HIV Outpatient Clinic Research Articles

Opposing associations of depression with sexual behaviour: implications for epidemiological investigation among gay, bisexual and other men who have sex with men

ObjectiveThe aim of this report is to investigate the nature of the relationship between depression and condomless sex (CLS) among gay, bisexual and other men who have sex with men...

Mediating Effects of Stigma and Depressive Symptoms in a Social Media-Based Intervention to Improve Long-term Quality of Life Among People Living With HIV: Secondary Analysis of a Randomized Controlled Trial.

BackgroundMobile health (mHealth) interventions have been shown to effectively improve the quality of life (QOL) among people living with HIV. However, little is known about the long-term effects of mHealth interventions.ObjectiveThis study aims to explore the intervention mechanisms of a social media–based intervention, Run4Love, on the QOL of people with HIV over across a 9-month follow-up period.MethodsWe recruited people living with HIV who were concurrently experiencing elevated depressive symptoms from an HIV outpatient clinic in South China. A total of 300 eligible participants were randomized either to the intervention group or the control group in a 1:1 ratio after they provided informed consent and completed a baseline survey. The intervention group received a 3-month WeChat-based intervention, comprising cognitive-behavioral stress management (CBSM) courses and physical activity promotion. The control group received a printed brochure on nutrition guidelines in addition to the usual care for HIV treatment. Neither participants nor the research staff were blinded to group assignment. All patients were followed at 3, 6, and 9 months. The primary outcome was depressive symptoms. Structural equation model (SEM) with longitudinal data was conducted to examine the sequential mediating effects of HIV-related stigma and depressive symptoms on the long-term intervention effects on participants’ QOL.ResultsAbout 91.3% (274/300), 88.3% (265/300), and 86.7% (260/300) of all participants completed follow-up surveys at 3, 6, and 9 months, respectively. Results showed that the intervention had significantly improved participants' QOL at 9 months, via complete mediating effects of reduced HIV-related stigma at 3 months and decreased depressive symptoms at 6 months. No adverse events were reported.ConclusionsThese findings underscore the critical roles of HIV-related stigma and depressive symptoms in an mHealth intervention with long-term effects on QOL improvements. We call for targeted mHealth interventions to improve QOL among people living with HIV, especially social media–based interventions that can address HIV-related stigma and alleviate depressive symptoms.Trial RegistrationChinese Clinical Trial Registry ChiCTR-IPR-17012606; https://www.chictr.org.cn/showproj.aspx?proj=21019

Predictive Factors of Detectable Viral Load in HIV-Infected Patients.

Despite availability of effective antiretroviral therapy (ART), many HIV patients still have a detectable viral load (VL). Predictive factors of detectable VL are not well documented. This study was done at two large multidisciplinary HIV outpatient clinics at the Centre hospitalier de l'Université de Montréal (CHUM) and the McGill University Health Centre (MUHC). This is a retrospective case-control study of patients treated between 2016 and 2018. Cases had a VL ≥50 copies/mL in 2018. Controls had an undetectable VL from 2016 to 2018. Matching was based on gender and year of HIV diagnosis. Primary objective was to identify predictive factors of detectable VL. Secondary objectives included to identify predictive factors of virologic failure, low persistent viremia, and viral blip. A forward stepwise model selection by the Akaike Information Criterion of the conditional logistic regression was used to identify predictive factors. Two hundred cases were identified and matched with 200 controls. The cohort was mostly male (68.0%) with a median age of 54 years (21-83 years). Among cases, viral blip was the most common type of detectable VL (43.0%). The strong predictive factors for a detectable VL were adherence to ART and seeking health care services. Asylum seekers were less at risk of detectable VL. Adherence to ART was the only strong predictive factor for virologic failure. Three main predictive factors of detectable VL were identified in two ambulatory clinic hospitals in Montreal. Ascertaining these factors will allow for identification of patients more at risk of detectable VL.

Alcohol, smoking, recreational drug use and association with virological outcomes among people living with HIV: cross-sectional and longitudinal analyses.

ObjectivesThere is increasing evidence to suggest that people living with HIV (PLWH) have significant morbidity from alcohol, recreational drug use and cigarette smoking. Our aim was to report associations of these factors with antiretroviral therapy (ART) non‐adherence, viral non‐suppression and subsequent viral rebound in PLWH.MethodsThe Antiretroviral Sexual Transmission Risk and Attitudes (ASTRA) study recruited PLWH attending eight outpatient clinics in England between February 2011 and December 2012. Data included self‐reported excessive drinking (estimated consumption of > 20 units of alcohol/week), alcohol dependency (CAGE score ≥ 2 with current alcohol consumption), recreational drug use (including injection drug use in the past 3 months), and smoking status. Among participants established on ART, cross‐sectional associations with ART non‐adherence [missing ≥2 consecutive days of ART on ≥2 occasions in the past three months] and viral‐non suppression [viral load (VL) > 50 copies/mL] were assessed using logistic regression. In participants from one centre, longitudinal associations with subsequent viral rebound (first VL > 200 copies/mL) in those on ART with VL ≤ 50 copies/mL at baseline were assessed using Cox regression during a 7‐year follow‐up.ResultsAmong 3258 PLWH, 2248 (69.0%) were men who have sex with men, 373 (11.4%) were heterosexual men, and 637 (19.6%) were women. A CAGE score ≥ 2 was found in 568 (17.6%) participants, 325 (10.1%) drank > 20 units/week, 1011 (31.5%) currently smoked, 1242 (38.1%) used recreational drugs and 74 (2.3%) reported injection drug use. In each case, prevalence was much more common among men than among women. Among 2459 people on ART who started at least 6 months previously, a CAGE score ≥ 2, drinking > 20 units per week, current smoking, injection and non‐injection drug use were all associated with ART non‐adherence. After adjusting for demographic and socioeconomic factors, CAGE score ≥ 2 [adjusted odds ratio (aOR) = 1.52, 95% confidence interval (CI): 1.09–2.13], current smoking (aOR = 1.58, 95% CI: 1.10–2.17) and injection drug use (aOR = 2.11, 95% CI: 1.00–4.47) were associated with viral non‐suppression. During follow‐up of a subset of 592 people virally suppressed at recruitment, a CAGE score ≥ 2 [adjusted hazard ratio (aHR) = 1.66, 95% CI: 1.03–2.74], use of 3 or more non‐injection drugs (aHR = 1.82, 95% CI: 1.12–3.57) and injection drug use (aHR = 2.73, 95% CI: 1.08–6.89) were associated with viral rebound.ConclusionsScreening and treatment for alcohol, cigarette and drug use should be integrated into HIV outpatient clinics, while clinicians should be alert to the potential for poorer virological outcomes.

Visit Trends and Factors Associated With Telemedicine Uptake Among Persons With HIV During the COVID-19 Pandemic.

BackgroundIn response to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, clinicians in outpatient HIV practices began to routinely offer telemedicine (video and/or phone visits) to replace in-person appointments. Video visits are preferred over phone visits, but determinants of video visit uptake in HIV care settings have not been well described.MethodsTrends in type of encounter (face-to-face, video, and phone) before and during the pandemic were reviewed for persons with HIV (PWH) at an urban, academic, outpatient HIV clinic in Seattle, Washington. Logistic regression was used to assess factors associated with video visit use including sociodemographic characteristics (age, race, ethnicity, language, insurance status, housing status) and electronic patient portal login.ResultsAfter an initial increase in video visits to 30% of all completed encounters, the proportion declined and plateaued at ~10%. A substantial proportion of face-to-face visits were replaced by phone visits (~50% of all visits were by phone early in the pandemic, now stable at 10%–20%). Logistic regression demonstrated that older age (>50 or >65 years old compared with 18–35 years old), Black, Asian, or Pacific Islander race (compared with White race), and Medicaid insurance (compared with private insurance) were significantly associated with never completing a video visit, whereas history of patient portal login was significantly associated with completing a video visit.ConclusionsSince the pandemic began, an unexpectedly high proportion of telemedicine visits have been by phone instead of video. Several social determinants of health and patient portal usage are associated with video visit uptake.

Childhood sexual abuse history amplifies the link between disease burden and inflammation among older adults with HIV

As they age, people living with HIV (PLWH) experience greater rates of inflammation-related health conditions compared to their HIV-negative peers. Because early life adversity can exaggerate proinflammatory effects of later physiological challenges, inflammation may be higher among PLWH with these combined risks, which could inform intervention approaches to mitigate multimorbidity. In this cross-sectional analysis, we investigated individual and combined effects of childhood sexual abuse (CSA) history and physiological burden (Veterans Aging Cohort Study Index scores) on serum cytokine and C-reactive protein (CRP) levels among PLWH. Participants (n ​= ​131; age 54 and older) were patients at an outpatient HIV clinic who completed a psychosocial survey and biomedical research visit as part of a larger study. 93% were virally suppressed, and 40% reported experiencing sexual abuse in childhood. Composite cytokine levels (summarizing IL-6, TNF-α, IFN-γ), CRP, and disease burden did not differ significantly between those who had a history of CSA and those who did not. Participants with greater disease burden had higher composite cytokine levels (r ​= ​0.29, p ​= ​0.001). The disease burden by CSA interaction effect was a significant predictor of composite cytokine levels (but not CRP), and remained significant after controlling for age, sex, race, BMI, anti-inflammatory medication use, selective serotonin reuptake inhibitor use, depressive symptoms, and smoking status (F(1, 114) ​= ​5.68, p ​= ​0.02). In follow-up simple slopes analysis, greater disease burden was associated with higher cytokine levels among those with CSA history (b ​= ​0.03, SE ​= ​0.008, p<0.001), but not among those without CSA history. Further, in the context of greater disease burden, individuals with a CSA history tended to have higher cytokine levels than those without a CSA history (b ​= ​0.38, SE ​= ​0.21, p ​= ​0.07). These data suggest that the physiological sequelae of childhood trauma may persist into older age among those with HIV. Specifically, links between physiological burden and inflammation were stronger among survivors of CSA in this study. The combined presence of CSA history and higher disease burden may signal a greater need for and potential benefit from interventions to reduce inflammation, an area for future work.

Comparative Efficacy of a High-Dose vs Standard-Dose Hepatitis B Revaccination Schedule Among Patients With HIV

Active immunization for hepatitis B virus (HBV) infection is recommended in patients living with HIV. Limited evidence is available about the most appropriate regimen of HBV vaccination among those who have not responded to an initial schedule. To determine the efficacy of a high-dose schedule compared with a standard dose of HBV vaccination. This double-masked, parallel-group, randomized controlled trial included patients living with HIV at a single outpatient HIV and hepatology clinic in Chile for whom previous HBV vaccination had failed. Patients with hepatitis B surface antibody (anti-HBs) titers less than 10 IU/L after an initial HBV vaccination regimen were included. Consecutive patients were recruited between December 2013 and March 2018. Data were analyzed in June 2018 using intention-to-treat analysis. The high-dose HBV vaccination group consisted of 3 doses of 40 μg recombinant hepatitis B vaccine at 0, 1, and 2 months. The standard-dose group received 3 doses 20 μg each at 0, 1, and 2 months. Primary outcome was the serologic response to HBV vaccination (anti-HBs greater than 10 IU/L) 4 to 8 weeks after completion of the schedule. Secondary outcomes were anti-HBs greater than 100 IU/L and seroprotective anti-HBs at 1 year follow up. A total of 107 patients underwent randomization (55 to the standard-dose group, 52 to the high-dose group); 81 (75.7%) were men, and the mean (SD) patient age was 47.0 (13.3) years. Nearly all patients were receiving antiretroviral therapy (105 patients [98%]) and 92 patients (86%) had an undetectable HIV viral load. Mean (SD) CD4 count was 418 (205) cells/mm3. There were no differences in baseline characteristics between groups. Serological response in the high-dose group was found in 36 of 50 patients (72%; 95% CI, 56.9%-82.9%) compared with 28 of 55 patients in the standard-dose group (51%; 95% CI, 37.1%-64.6%) (odds ratio, 2.48; 95% CI, 1.02-6.10; P = .03). Mean (SD) anti-HB levels were 398.0 (433.4) IU/L in the high-dose group and 158.5 (301.4) IU/L in the standard-dose group (P < .001). Of patients with a serological response in the high-dose group, 29 of 36 (80.6%) had anti-HBs titers greater than 100 IU/L compared with 14 of 28 responders (50.0%) in the standard-dose group (P = .02). At 1-year follow-up, 20 of 25 patients (80.0%) with a serological response in the high-dose group had protective anti-HBs vs 9 of 23 patients (39.1%) in the standard-dose group (P = .01). The results of this randomized clinical trial suggest that use of a high-dose regimen for HBV revaccination for patients with HIV achieves a higher and longer-lasting serological response as compared with a standard-dose regimen. ClinicalTrials.gov Identifier: NCT02003703.

Evaluation of a Clinic Dedicated to People Aging with HIV at Chelsea and Westminster Hospital: Results of a 10-Year Experience.

Successful management of HIV infection as a chronic condition has resulted in a demographic shift where the proportion of people living with HIV (PLWH) older than 50 years is steadily increasing. A dedicated clinic to PLWH older than 50 years was established at Chelsea and Westminster Hospital in January 2009 and then extended to HIV services across the directorate. We report the results of a service evaluation reviewing 10 years of activities of this clinic between January 2009 and 2019. We aimed to estimate the prevalence of major noninfectious comorbidities, polypharmacy (≥5 medications), and multimorbidity (≥2 non-HIV-related comorbidities) and describe algorithms devised for use in HIV outpatient clinics across the directorate. A cohort of 744 PLWH older than 50 years attending this service were analyzed (93% male; mean age of 56 ± 5.5 years; 84% white ethnicity); 97.7% were on antiretroviral treatment and 95.9% had undetectable HIV-RNA at the time of evaluation. The most common comorbidities diagnosed were dyslipidemia (50.1%), hypertension (21.5%), mental health disorders (depression and/or anxiety disorders, 15.7%), osteoporosis (12.2%), obesity (11.9%), chronic kidney disease (7.5%), and diabetes (5.8%). Low vitamin D levels were found in 62% of patients [43% with vitamin D deficiency (<40 mmol/liter) and 57% with vitamin D insufficiency (40-70 mmol/liter)]. The overall prevalence of polypharmacy and multimorbidity was 46.6% and 69.3%, respectively. This study showed significant rates of non-HIV-related comorbidities and polypharmacy in PLWH older than 50 years, leading on to the implementation of clinical care pathways and new joint HIV/specialty clinics (cardiology, nephrology, neurology, metabolic, menopause, and geriatric) to improve prevention, diagnosis, and management of major comorbidities in people aging with HIV.

Quality of life among people living with HIV in England and the Netherlands: a population-based study

BackgroundHIV is now considered a chronic condition, and people living with HIV, when treated, have a similar life expectancy as compared to the general population. Consequently, improving and ensuring a good health-related quality of life (HrQoL) among people living with HIV (people living with HIV) is increasingly important and has risen on the global agenda in recent years. A ‘fourth 90’ as 90% of people with viral load suppression have a good HrQoL should therefore be adopted alongside the other 90-90-90 targets. This study aims to report the progress on HrQoL as the ‘fourth 90’ and compare against the general population in the Netherlands and England.MethodsIn the Netherlands, individuals attending the HIV outpatient clinic of a tertiary hospital were asked to complete the EQ-5D-5L from June 2016 until December 2018. In England, individuals attending one of 73 HIV outpatient clinics were randomly sampled to complete the Positive Voices survey, which included the EQ-5D-5L, from January to September 2017. HrQoL scores were combined with demographic data and compared to general population data.FindingsThe EQ-5D-5L was filled-out by 895 people living with HIV in the NL and 4,137 in England. HrQoLutility was 0·85 among Dutch and 0·83 among English people living with HIV. This equated to 98% and 94% of the general population HrQoLutility in the Netherlands and England, respectively. Of the EQ-5D domains, anxiety/depression was mostly affected, with one-third in Dutch (35%) and almost half (47%) of English people living with HIV reporting symptoms. This was higher compared to their respective general populations (21% NL and 31% England).InterpretationOverall, HrQoLutility for people living with HIV was high in both countries and highly comparable to the general populations Nevertheless, there should be an increased focus on anxiety and depression in the people living with HIV population The EQ-5D-5L proved an easy HrQoL measurement tool and identified areas for improvement by social and behavioural interventions.FundingThe study received funding (unrestricted grants) from: Gilead sciences, ViiV Healthcare, MSD, and Jansen pharmaceuticals.

Patient perspectives on the implementation of routinised syphilis screening with HIV viral load testing: Qualitative process evaluation of the Enhanced Syphilis Screening Among HIV-positive Men trial

BackgroundSyphilis infections have been on the rise, affecting men living with HIV in urban centres disproportionately. Since individuals in HIV care undergo routine blood testing, HIV clinics provide practical opportunities to conduct regular and frequent syphilis testing. Following the implementation of a routine syphilis testing intervention in HIV outpatient clinics, we conducted a qualitative process evaluation of patient experiences to measure patient acceptability, barriers to implementation, and facilitators of successful uptake.MethodsUpon completion of the trial, which took place at four HIV outpatient clinics in Toronto and Ottawa, Canada, we recruited male patients attending these clinics from November 2017 to April 2018. Interviews were conducted on-site and were audio-recorded and transcribed verbatim. All participants provided written informed consent. Interview data were analyzed using grounded theory, assessing qualitative modulators of effective uptake of routinised syphilis testing.ResultsA total of 21 male patients were interviewed. Overall, interviewees found the clinical intervention acceptable, endorsing the practice of routinising syphilis testing alongside regular viral load bloodwork. Some men preferred, based on their self-assessment of syphilis risk, to opt out of testing; we considered this as a potential barrier to uptake of population-wide routinised syphilis testing. Interviewees also identified multiple facilitators of successful uptake, including the de-stigmatising of STI testing as a consequence of the universal nature of routinised testing. Participants recommended a routinised syphilis screening intervention to give patients peace of mind surrounding their sexual health. Participants identified HIV care clinics as comfortable and efficient locations to offer testing.ConclusionsOverall, most men were in support of implementing routinised syphilis testing as part of standard HIV care. From the patient perspective, HIV care clinics are convenient places to be tested for syphilis, and the routine approach was viewed to have a de-stigmatisng effect on syphilis testing.Trial registrationClinicalTrials.gov NCT02019043; registered December 23, 2013.

Oral health related quality of life among HIV positive patients attending two HIV outpatient clinics in Nigeria - a cross sectional study.

The human immunodeficiency virus infection remains a devastating disease of public health importance. To assess the association between oral health and quality of life and the factors affecting the oral health related quality of life among HIV positive patients in Nigeria. This was a cross sectional study of HIV positive patients attending two HIV outpatient clinics in Nigeria. Impact of oral health on quality of life was assessed using the OHIP-14. Oral health status was assessed by the DMFT and Simplified OHI indices. Level of significance was set at p< 0.05. Three hundred and fifty-two patients were seen, 64.2% being females. Prevalence of impact was 8.5%; and the mean OHIP scores was 8.05±9.54. Highest impact was "painful aching" 67(19.1%) with the domain of physical pain scoring the highest mean impact of 2.32. Most patients (88.6%) were on HAART. Following logistic regression, after controlling for potential confounders, independent factors associated with poor OHRQoL were perceived need for dental treatment, HAART use, and higher DMFT (p<0.05). The domain of physical pain had the highest impact, while perceived need for dental treatment, HAART use and higher caries index were contributory to poor OHRQoL.

Severe coronavirus disease 2019 in a patient with HIV-2 infection.

Around the globe, millions of people living with HIV-1 face the challenges posed to them by the current coronavirus disease 2019 (COVID-19) pandemic [1,2]. Thriving on health disparity, COVID-19 can overwhelm the same communities where HIV-1 prevalence is highest [3,4]. Despite the threat of insufficient public health support, it is vital to ensure a continuous provision of a good quality of care and the avoidance of treatment discontinuation [5]. Alarmingly, people living with an HIV-1 infection also seem to be at increased risk of COVID-19 mortality [3]. However, to the best of our knowledge, no data are available for people infected with HIV-2 infection. Here, we describe a unique case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (the virus that causes COVID-19), infection in a patient who is being treated for HIV-2. In April 2020, a 66-year-old patient presented at the emergency room with a 5-day history of fever, dry cough and shortness of breath. The episode started with complaints of unsteadiness upon which he had fallen on the ground of his bedroom. A review of systems was negative for chest pain, rhinorrhoea, altered smell or taste, sore throat or any gastrointestinal symptoms. Born in Burkina Faso, he was living in the Netherlands since 15 years. He was known at our outpatient HIV clinic because of a well controlled asymptomatic HIV-2 monoinfection diagnosed in 2014 for which he received a fixed combination of darunavir/cobicistat/emtricitabine/tenofoviralafenamide. His plasma HIV-2 RNA load was less than 50 copies/ml with a CD4+ cell count of 760 × 106/l and a CD8+ cell count of 510 × 106/l. In addition, he was known with obesity (BMI 32.8 kg/m2) and moderately controlled hypertension treated with losartan and hydrochlorothiazide. On presentation, he was hypoxemic with a SpO2 of 90% on 5 l/min oxygen. His temperature was 38.0 °C and his respiratory rate was 30/min. Blood pressure and pulse were normal. On auscultation, bibasal crackles was heard. The patient's full blood count demonstrated a normal white cell count (8.5 × 109/l) with a diminished lymphocyte (1.42 × 109/l) and platelets count (104 × 109/l). Haemoglobin was 13.7 g/l and the d-dimer level was strongly elevated at 13.15 mg/l. Biochemical markers demonstrated raised levels of C-reactive protein (242.3 mg/l), aspartate aminotransferase (879 IU/l), alanine aminotransferase (134 IU/l), creatine (2.32 mg/dl) and creatine phosphokinase (40.724 U/l). Lactate (1.5 mmol/l) and bicarbonate (23.1 mmol/l) levels were normal. The patient underwent thoracic computed tomography (CT) which demonstrated widespread bilateral areas of patchy consolidations, findings consistent with severe COVID-19 infection (classified as CO-RADS 5 and CT severity score 7). An ultrasound for lower extremity deep venous thrombosis was negative. The nasopharyngeal SARS-CoV-2 PCR was positive. The patient was admitted to a COVID-19 ward and received treatment with oxygen and empiric broad-spectrum antibiotics according to the then current guidelines [1]. For the presumptive diagnosis of acute renal failure secondary to rhabdomyolysis fluid, resuscitation was started. After 6 days, he was discharged from the hospital in good health. All abnormal laboratory values continued to normalize. In addition to persistent but waning complaints of shortness of breath for a period of approximately 4 months, his recovery was otherwise uneventful. A follow-up CT-scan 4 months after his initial presentation showed a clear decline of COVID-19-related lung abnormalities. Total SARS-CoV-2 antibodies (including IgG and IgM) became positive (Wantai ELISA) and his plasma HIV-2 RNA load remains undetectable. Now, 8 months after his original presentation, he is in good spirits and does not experience any long-term COVID-19-related adverse health outcomes. In conclusion, we present a first case report of a SARS-CoV-2 and HIV-2 coinfection in a patient who needed hospital admission for severe COVID-19 and experienced long lasting but self-limiting symptoms after discharge. His disease course was complicated by acute renal failure secondary to rhabdomyolysis which has been associated with COVID-19 in both HIV-1 positive and negative patients [6,7]. Most probably, the kidney injury is caused by pneumonia-induced rhabdomyolysis and direct effects of SARS-CoV-2 on the renal parenchyma [6]. After its first recognition in 1985, HIV-2 is now seen throughout West Africa with an exceptionally high prevalence in Burkina Faso [8]. It is estimated that approximately 1–2 million people live with HIV-2 worldwide [9]. Reported numbers of HIV-2 infections, however, may be a significant underestimation of actual numbers due to unrecognized or undiagnosed infections [8,9]. Our current case report highlights the potential challenges associated with HIV-2 infection in the current COVID-19 pandemic. Acknowledgements W.J.W. is currently receiving a Vidi grant (#91716475) from the Netherlands Organization for Scientific Research (NWO). M.v.d.V. has received consultancy fees paid to his institution by Gilead, MSD, ViiV and research support from Gilead, MSD, ViiV, Abbvie. Conflicts of interest There are no conflicts of interest.

‘I did not get this disease on the street; it was brought home as a gift’: Gender, violence and HIV vulnerability among Cuban women

While gay, bisexual and other men who have sex with men are most affected by HIV in Cuba, infections among women have increased over time, but there has been little research to contextualise their vulnerability to HIV. The purpose of this study was to explore the role of gender and violence in shaping vulnerability to HIV among Cuban women. Qualitative in-depth interviews were conducted with women living with HIV at an outpatient HIV clinic in Havana. Narrative and thematic technique were used to systematically analyse the data. Participants described negotiating sexual relationships in a context where traditional gender norms merge with the paradox of increasing professional opportunities for women alongside growing economic precarity. Interconnected economic and emotional dependence along with violence influenced the acceptance of certain behaviours that heightened vulnerability to HIV, including inconsistent condom use and infidelity. Gender transformative approaches that recognise the complex interplay between gender norms, economic precarity and violence are needed to address women’s vulnerability to HIV in the Cuban context. Such efforts can reinforce existing strategies to promote behaviourally focused prevention while creating an enabling environment for the integration and expansion of biomedical innovation in HIV prevention.

HPV vaccination to prevent recurrence of anal intraepithelial neoplasia in HIV+ MSM.

Objective:Anal cancer precursor lesions high-grade anal intraepithelial neoplasia (HGAIN) are highly prevalent among HIV+ MSM. Treatment of HGAIN is frustrated by high recurrence rates. We investigated the efficacy of the quadrivalent human papillomavirus (qHPV) vaccine as posttreatment adjuvant in preventing HGAIN recurrence in HIV+ MSM.Design:Randomized, double-blind, placebo-controlled, multicentre trial.Setting:Three HIV outpatient clinics in Amsterdam, the Netherlands.Subjects:HIV+ MSM with CD4+ cell count more than 350 cells/μl, biopsy-proven intra-anal HGAIN successfully treated in the past year, and lesions still in remission at enrolment, as assessed by high-resolution anoscopy (HRA).Intervention:Participants were randomized to three doses of qHPV (Gardasil-4, MSD) or placebo with vaccinations at 0, 2, and 6 months. HRA was repeated at 6, 12, and 18 months.Main outcome measure:The primary outcome was cumulative, biopsy-proven HGAIN recurrence rate at 18 months, evaluated in an intention-to-treat (ITT) (received all vaccinations) and per-protocol analysis (all vaccinations and complete follow-up).Results:We randomized 126 participants of which 64 (50.8%) received qHPV and 62 (49.2%) placebo. All participants received three vaccinations, and in both groups for two participants follow-up was incomplete. We found no difference (P = 0.38) in cumulative HGAIN recurrence rates between the qHPV (44/64, 68.8%) and placebo group (38/62, 61.3%) in the ITT analysis [absolute risk reduction −7.5 (95% confidence interval (CI) −24.1 to 9.2)]. This was similar in the per-protocol analysis.Conclusion:Despite adequate serological responses to qHPV vaccination, short-term recurrence of HGAIN was not prevented. These findings do not support qHPV vaccination as a treatment adjuvant to prevent HGAIN recurrence in HIV+ MSM.

Patterns of adverse drug reactions to approved HAART regimen in an HIV out-patient Clinic in Nigeria

Patterns of adverse drug reactions to approved HAART regimen in an HIV out-patient Clinic in Nigeria

Quality of Life Among People Living With HIV in England and the Netherlands Comparable to the General Population

Introduction: Nowadays, HIV is a chronic condition with a similar life expectancy as the general population. Consequently, improving and ensuring a good health-related quality of life (HrQoL) among people living with HIV (PLWH) is increasingly important and has risen on the global agenda in recent years. A ‘fourth 90’ as 90% of people with viral load suppression have a good HrQoL should therefore be adopted alongside the other 90-90-90 targets. This study aims to report the progress on HrQoL as the ‘fourth 90’ and compare against the general population in the Netherlands and England. Methods: In the Netherlands, individuals attending the HIV outpatient clinic of a tertiary hospital were asked to complete the EQ-5D-5L from June 2016 until December 2018. In England, individuals attending one of 73 HIV outpatient clinics were randomly sampled to complete the Positive Voices survey, which included the EQ-5D-5L, from January to September 2017. HrQoL scores were combined with demographic data and compared to general population data. Findings: The EQ-5D-5L was filled-out by 895 PLWH in the NL and 4,137 in England. HrQoLutility was 0.85 among Dutch and 0.83 among English PLWH. This equated to 98% and 94% of the general population HrQoLutility in the Netherlands and England, respectively. Of the EQ-5D domains, anxiety/depression was mostly affected, with one-third in Dutch (35%) and almost half (47%) of English PLWH reporting symptoms. This was significantly higher compared to their respective general populations (21% NL and 31% England). Interpretation: Overall, HrQoLutility for PLWH was high in both countries and highly comparable to the general populations Nevertheless, focus on anxiety and depression should be increased. The EQ-5D-5L proved an easy HrQoL measurement tool and identified areas for improvement by social and behavioural interventions. Funding Statement: The study received funding (unrestricted grants) from: Gilead sciences, ViiV Healthcare, MSD and MSD, Janssen pharmaceuticals. Declaration of Interests: SP reports an unrestricted educational grant from Gilead Sciences; DvdV reports unrestricted research grant from Gilead Sciences, MSD, ViiV and Janssen Pharmaceuticals; CAB reports personal fees from speaker honoraria from ViiV outside the submitted work; AvS reports grants from Dutch Ministry of Health, Welfare and Sport, during the conduct of the study; grants from European Centre for Disease Prevention and Control, outside the submitted work. MV: Dr. Versteegh reports grants from ZonMW, grants from EuroQoL Research Foundation, during the conduct of the study; grants from EuroQoL Research Foundation, outside the submitted work; MK, ES, BN, LV, VD, AV have nothing to disclose. Ethics Approval Statement: The Netherlands study was reviewed and approved by the local Medical Ethics Committee (MEC-2016-264). Additionally, all participants were asked to sign an informed consent form and all data were anonymized. The England study was reviewed and approved by the London – Harrow Research Ethics Committee (13/LO/0279).

Over a third of childbearing women with HIV would like to breastfeed: A UK survey of women living with HIV.

The World Health Organisation advice for post-partum women living with HIV (WLHs) in low- and middle-income countries is to breastfeed on suppressive antiretroviral treatment and use infant postnatal prophylaxis. In resource-rich settings, where formula feeding is safe, avoidance of breastfeed is advised. A questionnaire was created to survey attitudes to breastfeeding in WLHs in the United Kingdom. This was offered to all eligible pregnant women in the third trimester or within 3months post-partum who attended HIV outpatient clinics from 2017 to 2018. Ninety-four women completed the questionnaire, 69% were Black African and 92% had an undetectable HIV viral load. Thirty eight percent stated they would like to breastfeed and 89% said they would breastfeed if they were HIV negative. Sixty two percent had community members question why they did not breastfeed, and 66% felt forced to invent a reason why they were not breastfeeding. Current UK guidelines recommend formula feeding, proposing a harm reduction approach to support women with suppressed HIV who wish to breastfeed. Over a third of respondents said they would like to breastfeed because stigma and secrecy remain an issue for WLHs. This suggests that over time more women may choose this option.

Life expectancy of HIV-infected patients followed at the largest hospital in Guinea-Bissau is one-fourth of life expectancy of the background population.

To estimate the life expectancy (LE) of HIV-infected patients in the West African country Guinea-Bissau and compare it with the background population. Using data from the largest HIV outpatient clinic at the Hospital Nacional Simão Mendes in the capital Bissau, a retrospective observational cohort study was performed. The study included patients attending the clinic between June 2005 and January 2018. A total of 8958 HIV-infected patients were included. In the analysis of the background population, a total of 109,191 people were included. LE incorporating loss to follow-up (LTFU) was estimated via Kaplan-Meier estimators using observational data on adult HIV-infected patients and background population. The LE of 20-year-old HIV-infected patients was 9.8years (95% CI 8.3-11.5), corresponding to 22.3% (95% CI 18.5-26.7%) of the LE of the background population. (LE for 20-year-olds in the background population was 44.0years [95% CI 43.0-44.9].) Patients diagnosed with CD4 cell counts below 200 cells/µL had a LE of 5.7years (95% CI 3.6-8.2). No increase in LE with later calendar period of diagnosis was observed. LE was shown to be markedly lower among HIV-infected patients compared with the background population. While other settings have shown marked improvements in prognosis of HIV-infected patients in recent years, no improvement in Bissau was observed over time (9.8years (95% CI 7.6-12.2) and 9.9years (95% CI 7.6-12.1) for the periods 2005-2010 and 2014-2016, respectively).

Is age and not antiretroviral therapy the strongest risk factor for chronic pain in HIV-infected population?

BackgroundChronic pain in HIV-infected patients on effective antiretroviral therapy (ART) limits patients’ normal functioning both somatically and psychologically. The current state of knowledge on the topic is insufficient, with the underlying causes of this pain unexplained. Therefore we analyzed the frequency and factors associated with chronic pain in HIV-infected patients on ART.MethodsWe conducted a prospective, survey study, including consecutive HIV-infected patients under specialist care at the HIV Outpatient Clinic of the Hospital for Infectious Disease in Warsaw between February 2014 and December 2016. During their routine visit all patients who agreed to participate in the study were surveyed using a study questionnaire. For all patients reporting any pain the Brief Pain Inventory (BPI) form and Douleur Neuropathique 4 Questions form (DN4) were completed. Data on history and current ART and laboratory measurements were obtained from electronical database. Chi-squared and Kruskal-Wallis tests were used for group comparison. The potential factors associated with chronic pain were identified via logistic regression models.ResultsIn total 196 HIV-infected patients were included in the study, 57 (29,1%) of them reported chronic pain. The reported pain was mostly (75%) limited to a single area of the body. In univariable logistic regression model the odds of chronic pain were significantly higher with increasing age (OR 1.36 [95%CI:1.17–1.58]), time under specialist care (OR 2.25 [95%CI:1.42–35.7]), time on ART (OR2.96 [95%CI:1.60–5.49]), previous ART with zidovudine (OR 2.00[95%CI:1.06–1.55]) and previous treatment with ddI, ddC or d4T (OR4.13 [95%CI:1.92–8.91]). Homosexual route of HIV infection as compared to injecting drug use was decreasing the odds of chronic pain (OR0.33 [95%CI: 014–0.75]). In multivariable analyses, adjusting for all above the only factor associated with chronic pain was age (OR1.28 [95%CI:1.06–1.55]).ConclusionsThe prevalence of chronic pain in the studied population of HIV-infected Polish patients was high. The only risk factor for chronic pain identified was age. With ageing HIV population it is therefore imperative to develop cooperation protocols for specialist HIV treatment clinics, pain treatment clinics, and rehabilitation units.

Recreational drug use and use of drugs associated with chemsex among HIV-negative and HIV-positive heterosexual men and women attending sexual health and HIV clinics in England

BackgroundThere is little information on the prevalence of recreational drug use among UK heterosexual men and women, in particular on use of drugs associated with ‘chemsex’ within gay communities. The aim of this study was to examine among HIV-negative and HIV-positive heterosexual men and women in England: (i) the prevalence of recreational drug use (including use of drugs associated with chemsex), (ii) socio-economic/lifestyle correlates of drug use, and (iii) the association of drug use with sexual behavior measures and mental health symptoms. MethodsData are from the AURAH study of HIV-negative individuals attending sexual health clinics across England (2013–2014) and the ASTRA study of HIV-positive individuals attending HIV outpatient clinics in England (2011–2012). Prevalence of recreational drug use (past three months) and associations are presented separately among the four sample groups: HIV-negative (N = 470) and HIV-positive (N = 373) heterosexual men and HIV-negative (N = 676) and HIV-positive (N = 637) women. ResultsThe age standardized prevalence of any drug use was 22.9%, 17.1%, 15.3%, and 7.1% in the four sample groups respectively. In all groups, cannabis was the drug most commonly used (range from 4.7% to 17.9%) followed by cocaine (1.6% to 8.5%). The prevalence of use of drugs associated with chemsex was very low among HIV-negative participants (1.0% heterosexual men, 0.2% women) and zero among HIV-positive men and women. In age-adjusted analysis, factors linked to drug use overall and/or to cannabis and cocaine use specifically in the four sample groups included Black/mixed Caribbean and white (vs. Black/mixed African) ethnicity, lower level of education , cigarette smoking, and higher risk alcohol consumption. Associations of recreational drug use with measures of condomless sex, depression, and anxiety were observed in the four groups, but were particularly strong/apparent among women. ConclusionProviders need to be aware of cannabis and cocaine use and its potential link with sexual risk behavior and symptoms of depression and anxiety among heterosexual men and women attending sexual health and HIV clinics.