Human Immunodeficiency Virus Care Continuum Research Articles

PSYCHOSOCIAL CORRELATES OF PREVENTION, CARE, AND WELL-BEING AMONG OLDER WOMEN LIVING WITH HIV

Abstract There are over 4.2 million older adults (ages 50+ years) living with human immunodeficiency virus (HIV) globally. Older women continue to make up a significant proportion of this population. Advances in antiretroviral therapy treatments have allowed HIV+ individuals to live longer, healthier lives. However, compared to all persons living with HIV, women have lower viral suppression rates and are less likely to be retained in care. While older women living with HIV (WLWH) face unique challenges with HIV prevention and care, such as caregiving responsibilities, gender discrimination, and ageism, there is a dearth of research focusing on their experiences. As the population of older WLWH continues to increase, understanding barriers and facilitators to HIV prevention and care among this population is a public health priority. This symposium will provide insight into psychosocial factors that influence HIV prevention, care, and well-being among older WLWH. Our first presentation highlights a qualitative study identifying sources of strength and concerns about aging with HIV among older women. Our second presentation examines social support networks and interpersonal strain in relation to loneliness among older WLWH. Our third presentation highlights the impact of patient-provider communication regarding HIV/AIDs on sexual health communication between older WLWH and their partners. Our fourth presentation examines mental health vulnerabilities and strengths of older WLWH during the humanitarian crisis in Ukraine. Discussant Dr. Anna Rubtsova will contextualize these findings and offer suggestions for future research to enhance well-being of older women across the continuum of HIV prevention and care.

Human immunodeficiency virus diagnosis and care among adults with intellectual and developmental disabilities who are publicly insured.

This study aimed to assess the prevalence of human immunodeficiency virus (HIV) testing, HIV diagnosis and receipt of HIV care among adults with intellectual and developmental disabilities (IDDs) who are publicly insured in the USA. This study is a cross-sectional analysis of Medicare-Medicaid linked data of adults with IDD who were publicly insured in 2012 (n=878186). We estimated adjusted prevalence ratios of HIV testing, diagnosis and receipt of antiretroviral therapy (ART). We also identified the relationship between predisposing (age, gender, race and ethnicity), enabling (Medicare, Medicaid or both; rural status; geographical location; and county income) and need-related characteristics (IDD diagnosis and other co-occurring conditions) associated with these outcomes. Only 0.12% of adults with IDD who had no known HIV diagnosis had received an HIV test in the past year. The prevalence of HIV diagnosis among adults with IDD was 0.38%, although differences by type of IDD diagnosis were observed. Prevalence of HIV diagnosis differed by type of IDD. Among adults with IDD who were living with HIV, approximately 71% had received ART during 2012. The adjusted analyses indicate significant racial disparities, with Black adults with IDD making up the majority (59.11%) of the HIV-positive IDD adult population. Adults with IDD are a unique priority population at risk for HIV-related disparities, and the level of risk is differential among subtypes of IDD. People with IDD, like other people with disabilities, should be considered in prevention programming and treatment guidelines to address disparities across the HIV care continuum.

Acceptability of integration of cervical cancer screening into routine HIV care, associated factors and perceptions among HIV-infected women: a mixed methods study at Mbarara Regional Referral Hospital, Uganda

BackgroundIntegrating cervical cancer screening into routine Human Immunodeficiency Virus (HIV) care has been endorsed as an effective strategy for increasing uptake of cervical cancer screening, facilitating early detection and treatment of pre-cancerous lesions among HIV-infected women. In Uganda, this strategy has not been implemented yet in most HIV clinics. Assessing acceptability of this intervention among HIV-infected women is of great relevance to inform implementation. We assessed acceptability of integration of cervical cancer screening into routine HIV care, associated factors and perceptions among HIV-infected women enrolled in the HIV clinic at Mbarara Regional Referral Hospital.MethodologyA mixed methods study utilizing explanatory sequential approach was conducted among 327 eligible HIV-infected women. Acceptability of integration of cervical cancer screening into routine HIV care was measured based on Theoretical Framework of Acceptability. Quantitative data was collected using a pre-tested questionnaire. We conducted focus group discussions to explore perceptions regarding the intervention among purposively selected HIV-infected women. Modified Poisson regression with robust variance analysis was utilized to determine factors associated with acceptability of the intervention. Statistical significance was determined at p-value <0.05. Thematic analysis utilizing inductive coding was applied to analyse qualitative data.ResultsThe majority of HIV-infected women (64.5%) accepted integration of cervical cancer screening into routine HIV care. Religion, perceived risk of developing cervical cancer and ever screened for cervical cancer were statistically significantly associated with acceptability of integration of cervical cancer screening into routine HIV care. Perceived benefits of the proposed intervention were: convenience to seek for cervical cancer screening, motivation to undergo cervical cancer screening, improved archiving of cervical cancer screening results, confidentiality of HIV patient information, and preference to interact with HIV clinic health workers. Shame to expose their privacy to HIV clinic health workers and increased waiting time were the only perceived challenges of the integrated strategy.ConclusionStudy findings highlight the need to take advantage of this acceptability to prioritize implementation of integration of cervical cancer screening into routine HIV care. HIV-infected women should be reassured of confidentiality and reduced waiting time to increase uptake of integrated cervical cancer screening and HIV services among HIV-infected women along the continuum of HIV care and treatment services.

The YGetIt? Program: A Mobile Application, PEEP, and Digital Comic Intervention to Improve HIV Care Outcomes for Young Adults.

In New York State (NYS), young adults account for the largest number of new human immunodeficiency virus (HIV) infections and struggle to seek and remain in HIV care. Digital interventions and access to peer support have demonstrated positive influences on the HIV care continuum and health outcomes. The New York State Department of Health (NYS DOH) developed YGetIt? (YGI) that combines a mobile application, GET!, peer navigation (PEEPs), and a compelling digital comic series, "Tested," to facilitate the timely entry of young people into HIV care, to prevent vulnerable youth from dropping out of care, and to achieve sustained viral load suppression among those in care. This article describes the development and early implementation of the YGI digital intervention. Intervention Design. GET! provided a high level of confidentiality and security, ease of access, and Wi-Fi accessibility. YGI enrolled 113 HIV-positive participants from a clinical setting who were individually randomized at a 1:1 ratio to receive access to GET! plus PEEPs (n = 53) or the app alone (n = 60). For recruitment, staff and organization buy-in was essential to the success of the intervention, and building relationships was critical. GET! development was an iterative process. Peer Engagement Educator Professionals (PEEPs) who were tech savvy, representative of the priority population, and had shared life experience with participants were most impactful. Interest in apps declines over time and participants in the APP alone arm were less engaged. GET! is a communication and engagement tool that supports HIV care and may serve as a model for like digital interventions.

Adolescent and young adult research across the HIV prevention and care continua: an international programme analysis and targeted review

Human immunodeficiency virus (HIV) continues to rise in young people among low- and middle-income countries (LMIC). The US National Institutes of Health (NIH) supports the largest public investment in HIV research globally. Despite advancements in the last decade, adolescents and young adults (AYA) remain underrepresented in research to improve HIV prevention and care. We undertook a programme analysis of NIH grants and conducted a targeted review of linked publications on international AYA research across the HIV prevention and care continuum (HPCC) to inform new initiatives to address the needs of AYA in these settings. NIH-funded grants from 2012 to 2017, pertaining to AYA in LMIC, and evaluating areas of HIV prevention, care and/or treatment were identified. A systematic review of publications limited to funded grants was performed in two waves: 2012-2017 and 2018-2021. The review included a landscape assessment and an evaluation of NIH-defined clinical trials, respectively. Data on outcomes across the HPCC were abstracted and analysed. Among grant applications, 14% were funded and linked to 103 publications for the analytic database, 76 and 27 from the first and second waves, respectively. Fifteen (15%) wave 1 and 27 (26%) wave 2 publications included an NIH-defined clinical trial. Among these, 36 (86%) did not target a key population (men who have sex with men, drug users and sex workers) and 37 (88%) were exclusively focused on sub-Saharan Africa. Thirty (71%) publications addressed at least one HPCC milestone. Specific focus was on milestones in HIV prevention, care or both, for 12 (29%), 13 (31%) and five (12%) of publications, respectively. However, few addressed access to and retention in HIV care (4 [14%]) and none included microbicides or treatment as prevention. More focus is needed in crucial early steps of the HIV care continuum and on biomedical HIV prevention interventions. Research gaps remain in this portfolio across the AYA HPCC. To address these, NIH launched an initiative entitled Prevention and Treatment through a Comprehensive Care Continuum for HIV-affected Adolescents in Resource Constrained Settings (PATC3 H) to generate needed scientific innovation for effective public health interventions for AYA affected by HIV in LMIC.

The role of community pharmacies in the HIV and HCV care continuum

IntroductionIn 2019, there were over 1.1 million people living with human immunodeficiency virus (HIV) and 2.4 million people living with hepatitis C virus (HCV) in the United States. One in seven (14%) are unaware of their HIV infection and almost half of all HCV infections are undiagnosed. People with unstable housing are disproportionately affected by HIV and HCV. The present study will evaluate interventions by community pharmacists that may reduce HIV and HCV transmission and promote linkage to care. MethodsThis study was conducted in an independent community pharmacy in Spokane, Washington. Eligible study participants were walk-in patients of the pharmacy, over the age of 18, and experiencing homelessness. Pharmacy patients were excluded if they had a history of HIV or HCV diagnosis, received a screening for HIV or HCV in the last six months or were unable to give informed consent. The intervention included administration of HIV and HCV point-of-care testing (POCT) using a blood sample, risk determination interview, comprehensive HIV and HCV education, and personalized post-test and risk mitigation counseling followed by referral to partnering health clinics. ResultsFifty participants were included in the final data analysis. Twenty-two participants (44%) had a reactive HCV POCT, and one participant had a reactive HIV POCT. Of the 94% of participants who reported illicit drug use, 74% reported injection drug use. Seventy-six percent (n = 38) qualified for PrEP. Pharmacist referrals were made for 28 participants and 71% were confirmed to have established care. ConclusionIndividuals experiencing homelessness are at an increased risk for acquiring HIV and HCV due to risky sexual behaviors and substance misuse. PrEP is underutilized in the U.S. and pharmacist involvement in the HIV and HCV care continuum may have a significant impact in improving linkage and retention in care of difficult to treat populations.

The Story and Implications of the Korean Health Care Facility Counseling Project on People Living with HIV.

In 2005, the Korea Disease Control and Prevention Agency (KDCA) launched "Health Care Facility Counseling Project on People Living with human immunodeficiency virus (HIV)" funded by the private-subsidy project for the prevention of acquired immune deficiency syndrome (AIDS) and sexually transmitted diseases to provide people living with HIV (PLWH) psychological support and counsel them about the disease and antiretroviral therapy (ART). Currently, 38 counseling nurse specialists work at 28 healthcare facilities for patient care. Of all PLWH in Korea, 71.9% received benefits from the Counseling Project. Adherence to ART medication (>95.0%), level of depression or anxiety, counseling coverage, and viral load status were monitored as common project indicators. Various specialized programs have been implemented in diverse facilities. This project has played a pivotal role in HIV care continuum and viral suppression policies, resulting in 95.9% of PLWH maintaining undetectable status (<40 copies/ml) in 2021. In this review, we present the chronology and fulfillment of this project, which will be an essential step for future planning in the context of aging and the chronic comorbid nature of HIV/AIDS.

Perceptions and attitudes regarding HIV pre-exposure prophylaxis (PrEP) among dermatology clinicians and trainees.

In 2020, over 1.2 million people were at risk of acquiring human immunodeficiency virus (HIV), though only 25% were prescribed pre-exposure prophylaxis (PrEP). Given the multitude of dermatologic manifestations of HIV and other sexually transmitted infections, dermatologic care can serve as the entry point to the HIV care continuum. Currently, there is limited data on specialists' perspectives on HIV PrEP prescribing. We aimed to survey clinicians and trainees in an academic dermatology department about HIV PrEP-related knowledge, attitudes, and practices. Survey questions were adapted from existing literature on HIV stigma and PrEP-related knowledge, attitudes, and practices. Composite scores for each domain were averaged and compared between clinicians and trainees using Wilcoxon's signed rank test or Fisher's exact test. Of 135 providers invited, 31 (23%) completed the survey (11 clinicians and 20 trainees). Of the 31 participants, 16 (52%) had specialized HIV experience and training. When asked about discriminatory beliefs, nine participants (29%) agreed that HIV infection is a "consequence of irresponsible behavior." PrEP knowledge was low, with 13 (42%) participants answering zero out of 3 PrEP knowledge questions correctly. Additionally, 10 (91%) clinicians reported poor knowledge of PrEP side effects, and eight clinicians (73%) indicated they were "not comfortable at all" in prescribing PrEP. No participant had prescribed PrEP, and 22 (70%) participants had never discussed PrEP with patients. Dermatology clinicians and trainees reported some levels of HIV stigma. Substantial gaps in PrEP knowledge and discussion were reported despite prior HIV discrimination training and HIV-related practice experience. Study limitations include a small sample size and a modest response rate. Addressing stigma among dermatologists and improving HIV PrEP education is vital to enhancing the healthcare outcomes of people living with HIV.

Hazardous alcohol use and HIV indicators in six African countries: results from the Population-based HIV Impact Assessments, 2015-2017.

Hazardous alcohol use (HAU), defined as a pattern of alcohol consumption that increases the risk of harmful consequences for the user or others, is associated with an elevated risk of human immunodeficiency virus (HIV) infection and poor health outcomes. We describe the association between people living with HIV (PLHIV) who report HAU and key HIV indicators. Gaps in current literature in estimating HAU on HIV outcomes at the regional level of Eastern and Southern Africa still exist and our analysis aims to address this issue. We used weighted pooled data (2015-2017) from the nationally representative Population-based HIV Impact Assessments among adults who provided written consent aged 18-59 years from Eswatini, Malawi, Namibia, Tanzania, Zambia and Zimbabwe. We estimated differences in the prevalence of HIV infection and The Joint United Nations Programme on HIV and AIDS (UNAIDS) 90-90-90 indicators between PLHIV by HAU status using log-binomial regression, stratified by sex.HAU was determined using the Alcohol Use Identification Test-Consumption. Among the 9755 women and 4444 men who tested HIV positive, 6.6% of women and 21.8% of men engaged in HAU. Women who reported HAU were more likely to be HIV positive (adjusted prevalence ratio [aPR] = 1.31, 95% CI: 1.18-1.46) compared to those who did not report HAU. For the UNAIDS 90-90-90 targets, women who engaged in HAU were more likely to be unaware of their HIV-positive status (aPR = 1.22, 95% CI: 1.01-1.47) and not on antiretroviral therapy (ART) (aPR = 1.73, 95% CI: 1.26-2.37). Men who engaged in HAU were more likely to be unaware of their HIV-positive status (aPR = 1.56, 95% CI 1.39-1.76) and not on ART (aPR = 1.72, 95% CI: 1.30-2.29). No difference in viral load suppression, defined as <1000 copies/ml of HIV RNA, was seen by sex. PLHIV who engage in HAU were more likely to have suboptimal outcomes along the HIV care continuum when compared to those who did not engage in HAU. Targeted interventions, such as alcohol screening for HAU in HIV testing and treatment settings and HIV prevention efforts in alcohol-based venues, may help countries reach HIV epidemic control by 2030.

A Call to Action: Integration of Buprenorphine Prescribing Into the Care of Persons With Human Immunodeficiency Virus and Opioid Use Disorder.

During the coronavirus disease 2019 (COVID-19) pandemic, we also experienced a worsening opioid overdose epidemic. Untreated opioid use disorder (OUD) in persons with human immunodeficiency virus (HIV) is associated with worse HIV-related outcomes. Buprenorphine is a safe, evidence-based medication for OUD and is effective in reducing opioid craving and overdose and improving outcomes along the HIV care continuum. Despite the longstanding evidence supporting the benefits of buprenorphine, there remains an implementation gap in the uptake of buprenorphine prescribing in HIV care settings. To improve integration of OUD care and HIV primary care, we recommend (1) all HIV clinicians obtain a buprenorphine waiver, (2) teaching on OUD should be integrated into infectious diseases and HIV continuing medical education, and (3) previously validated models of integrated care should be leveraged to urgently expand access to buprenorphine for persons with HIV and OUD.

The role of online social networks in improving health literacy and medication adherence among people living with HIV/AIDS in Iran: Development of a conceptual model

Online social networks have been used to enhance human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) prevention, diagnosis, and treatment programs worldwide. This study aimed to develop a conceptual model of using online social networks in improving health literacy and medication adherence among people living with HIV/AIDS in Iran. This mixed-method sequential exploratory study was conducted in three phases. Firstly, a series of semi-structured interviews with a purposive sample of 29 HIV-positive patients were conducted to investigate the perceptions and experiences of HIV-positive patients about using online social networks to support health literacy and medication adherence. Thematic analysis was used to analyse qualitative interviews, extract potential components, and design a conceptual model. Then, a Delphi study with 27 HIV-positive patients was subsequently conducted to examine the consensus of patients on the proposed model. Finally, the trustworthiness and credibility of the proposed model were reviewed and evaluated by expert panel members from epidemiology and public health. Seven themes and 24 sub-themes emerged from the qualitative interviews. Five themes encompassed components of online social networks that supported communication and information-seeking behaviour of people living with HIV/AIDS. The two other themes encompassed social support and health-related outcomes including medication adherence. The credibility of the proposed conceptual model was confirmed methodologically using the expert panel and Delphi technique. Our findings highlighted that using online social networks has empowered Iranian people living with HIV/AIDS, making them more connected, safe, and able to access HIV/AIDS-related information and services. The role of online social networks in improving health literacy and medication adherence was also demonstrated in a conceptual model to understand the supportive components of online social networks in the HIV care continuum as well as customized interventions to improve the success of antiretroviral therapies.

Exploring the Impact of Alcohol and Other Drug Use on HIV Care Among African American Older Adults Living with HIV/AIDS

For people living with HIV, there are multiple barriers to engagement with care. This study qualitatively examines the role of use of alcohol and other drugs (AOD) on the health and management of Human Immunodeficiency Virus (HIV) disease among older African Americans (≥50 years). It draws on interviews conducted with twenty-seven older African Americans living with HIV in the Louisville, Kentucky area. Interviews were transcribed verbatim and then analyzed using constructivist grounded theory analytic techniques. Participants’ understandings of their AOD use fell on a continuum of problematic use to use for self-care. Regardless of where participants fell on this continuum, they faced a) environmental impacts of AOD use and b) current or historic discrimination from the health care system. The analysis focused on gaining a deeper understanding of the intersection of AOD use and engagement in the HIV care continuum. This revealed six major phases, which occurred at various stages of the continuum: (1) Linking AOD use as the cause of HIV diagnosis (2) Having AOD use facilitate denial of HIV, (3) Experiencing problematic use, (4) “Testing the Waters,” (5) Relying on AIDS Service Organizations (ASO) and medical providers and (6) Maintaining health and/or using AOD for self-care. We discuss the ways that stigma along the lines of race, gender, and age intersect with co-occurring conditions such as substance use disorders in complex and multifaceted ways. Recommendations include assessing a patients’ AOD use in relationship to the HIV care continuum to assess patients’ experiences and barriers within systems of care.

Different Trends of Distinct Time Points of AIDS Events Following HIV Diagnosis in Various At-risk Populations: A Retrospective Nationwide Cohort Study in Taiwan.

IntroductionAcquired immune deficiency syndrome (AIDS) events at distinct time points after human immunodeficiency virus (HIV) diagnosis require various AIDS prevention strategies. However, no nationwide epidemiological surveillance studies have been conducted to explore the trends of distinct AIDS event time points in various at-risk populations. The aim of this study was to explore the issues and characterize the determinants of AIDS status after HIV diagnosis.MethodsThis nationwide cohort study enrolled HIV-positive Taiwanese during 1984–2016. AIDS events were classified into three time points (≤ 3, 4–12, > 12 months) by their occurrence time after HIV diagnosis. The periods of HIV/AIDS diagnosis were divided into six categories according to the calendar year of HIV/AIDS diagnosis: 1984–1991, 1992–1996, 1997–2001, 2002–2006, 2007–2011, and 2012–2016. HIV-positive Taiwanese during 1984–2011 were then selected to determine the factors associated with four AIDS statuses within 5 years after HIV diagnosis (no AIDS, AIDS ≤ 3 months, within 4–12 months, > 12 months) using multinomial logistic regression.ResultsOf 33,142 cases, we identified 15,254 (46%) AIDS events. The overall AIDS incidence (events/100 person-years) peaked during 1992–1996 (20.61), then declined, and finally stabilized from 2002 (8.96–9.82). The evolution of the proportion of distinct time points of AIDS events following HIV diagnosis changed significantly in heterosexuals and intravenous drug users (IDUs) during 1984–2016 (decline at ≤ 3 months in IDUs, decline at 4–12 months in IDUs, and increase at > 12 months in heterosexuals and IDUs) but not among men who have sex with men (MSM). Time points at ≤ 3 months remained at > 50% among MSM and at > 55% among heterosexuals. In multinomial logistic regression, IDUs (vs. men who have sex with men; MSM) had a lower risk of all AIDS statuses; heterosexuals (vs. MSM) had a higher risk of AIDS events ≤ 3 months after HIV diagnosis.ConclusionThe magnitude of AIDS in Taiwan has been stable since 2002. Enhancing early diagnosis among people with sexual contact and optimizing the HIV care continuum among heterosexuals and IDUs should be priorities for further AIDS prevention strategies.

Significant Impact of Coronavirus Disease 2019 (COVID-19) on Human Immunodeficiency Virus (HIV) Care in Hospitals Affecting the First Pillar of the HIV Care Continuum.

During COVID-19 lockdown, the in-hospital number of HIV indicator conditions decreased disproportionally compared to other non-COVID-19 diseases which was accompanied by reduced HIV testing rates, number and proportion of positive HIV tests, and new HIV referrals with more late presentation after lockdown cessation, indicating a significantly impacted HIV care continuum.

Assessment of Human Immunodeficiency Virus Care Continuum in Korea using the National Health Insurance System Data.

BackgroundAntiretroviral therapy (ART) has been shown to significantly reduce the likelihood of transmission to other people as well as promoting the health of people living with Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (PLH). The purpose of this study was to assess the HIV care continuum of PLH in Korea using the national health insurance system (NHIS) database.Materials and MethodsFrom 2006 to 2015, ART prescription/laboratory test claim data and enlisted accompanying comorbidities were extracted from the NHIS database. Utilizing these data, proportion of PLH on ART among those who registered to Korea Disease Control and Prevention Agency (KDCA), HIV viral load testing, prescription trends of ART, medication possession ratio (MPR) of ART, and accompanying comorbidities were reviewed. Factors related with MPR <90% was also investigated among demographic factors, ART prescription, and accompanying comorbidities.ResultsDuring the observation period, the number of people receiving ART prescription increased from 2,076 in 2006 to 9,201 in 2015. Considering the number of PLHs reported by the KDCA, the proportion of PLHs who received ART prescription increased from 55.4% to 87.6% during the study period. The median value of ART MPR increased from 76.4% to 94.2% and the proportion of patients with MPR >90% increased from 54.3% to 78.2%. The most commonly accompanying comorbidities were dyslipidemia (55.7%), osteoporosis (16.3%), hypertension (15.7%) and diabetes (13.7%), respectively. The proportion of PLH with two or more comorbid conditions increased from 22.0% to 31.6%. Regarding the factors associated with suboptimal compliance, age less than 50 years old, under support of National Medical Aid, alcoholic liver disease, mental and behavioral disorders due to use of alcohol, and ART regimen of protease inhibitor and non-single table regimen integrase strand transfer inhibitor were related with MPR <90%.ConclusionThe proportion of PLHs who received ART prescription and median MPR of ART increased during the study period. However, proportion of patients with MPR >90% was 78.2% in 2015 and there are still much room for improvement in the aspect of compliance.

Immediate Antiretroviral Therapy: The Need for a Health Equity Approach.

Immediate antiretroviral therapy (iART), defined as same-day initiation of ART or as soon as possible after diagnosis, has recently been recommended by global and national clinical care guidelines for patients newly diagnosed with human immunodeficiency virus (HIV). Based on San Francisco’s Rapid ART Program Initiative for HIV Diagnoses (RAPID) model, most iART programs in the US condense ART initiation, insurance acquisition, housing assessment, and mental health and substance use evaluation into an initial visit. However, the RAPID model does not explicitly address structural racism and homophobia, HIV-related stigma, medical mistrust, and other important factors at the time of diagnosis experienced more poignantly by African American, Latinx, men who have sex with men (MSM), and transgender patient populations. These factors negatively impact initial and subsequent HIV care engagement and exacerbate significant health disparities along the HIV care continuum. While iART has improved time to viral suppression and linkage to care rates, its association with retention in care and viral suppression, particularly in vulnerable populations, remains controversial. Considering that in the US the HIV epidemic is sharply defined by healthcare disparities, we argue that incorporating an explicit health equity approach into the RAPID model is vital to ensure those who disproportionately bear the burden of HIV are not left behind.

Human Immunodeficiency Virus Continuum of Care in 11 European Union Countries at the End of 2016 Overall and by Key Population: Have We Made Progress?

BackgroundHigh uptake of antiretroviral treatment (ART) is essential to reduce human immunodeficiency virus (HIV) transmission and related mortality; however, gaps in care exist. We aimed to construct the continuum of HIV care (CoC) in 2016 in 11 European Union (EU) countries, overall and by key population and sex. To estimate progress toward the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 target, we compared 2016 to 2013 estimates for the same countries, representing 73% of the population in the region.MethodsA CoC with the following 4 stages was constructed: number of people living with HIV (PLHIV); proportion of PLHIV diagnosed; proportion of those diagnosed who ever initiated ART; and proportion of those ever treated who achieved viral suppression at their last visit.ResultsWe estimated that 87% of PLHIV were diagnosed; 92% of those diagnosed had ever initiated ART; and 91% of those ever on ART, or 73% of all PLHIV, were virally suppressed. Corresponding figures for men having sex with men were: 86%, 93%, 93%, 74%; for people who inject drugs: 94%, 88%, 85%, 70%; and for heterosexuals: 86%, 92%, 91%, 72%. The proportion suppressed of all PLHIV ranged from 59% to 86% across countries.ConclusionsThe EU is close to the 90-90-90 target and achieved the UNAIDS target of 73% of all PLHIV virally suppressed, significant progress since 2013 when 60% of all PLHIV were virally suppressed. Strengthening of testing programs and treatment support, along with prevention interventions, are needed to achieve HIV epidemic control.

Human Immunodeficiency Virus Prevention for People Who Use Drugs: Overview of Reviews and the ICOS of PICOS.

This article summarizes the results from systematic reviews of human immunodeficiency virus (HIV) prevention interventions for people who use drugs (PWUD). We performed an overview of reviews, meta-analysis, meta-epidemiology, and PROSPERO Registration CRD42017070117. We conducted a comprehensive systematic literature search using the Centers for Disease Control and Prevention HIV/AIDS Prevention Research Synthesis Project database to identify quantitative systematic reviews of HIV public heath interventions with PWUD published during 2002-2017. We recombined results of US studies across reviews to quantify effects on HIV infections, continuum of HIV care, sexual risk, and 5 drug-related outcomes (sharing injection equipment, injection frequency, opioid use, general drug use, and participation in drug treatment). We conducted summary meta-analyses separately for reviews of randomized controlled trials (RCTs) and quasi-experiments. We stratified effects by 5 intervention types: behavioral-psychosocial (BPS), syringe service programs (SSP), opioid agonist therapy (OAT), financial and scheduling incentives (FSI), and case management (CM). We identified 16 eligible reviews including >140 US studies with >55 000 participants. Summary effects among US studies were significant and favorable for 4 of 5 outcomes measured under RCT (eg, reduced opioid use; odds ratio [OR] = 0.70, confidence interval [CI] = 0.56-0.89) and all 6 outcomes under quasi-experiments (eg, reduced HIV infection [OR = 0.42, CI = 0.27-0.63]; favorable continuum of HIV care [OR = 0.68, CI = 0.53-0.88]). Each intervention type showed effectiveness on 1-6 outcomes. Heterogeneity was moderate to none for RCT but moderate to high for quasi-experiments. Behavioral-psychosocial, SSP, OAT, FSI, and CM interventions are effective in reducing risk of HIV and sequelae of injection and other drug use, and they have a continuing role in addressing the opioid crisis and Ending the HIV Epidemic.

A realist systematic review of stigma reduction interventions for HIV prevention and care continuum outcomes among men who have sex with men.

While stigma associated with human immunodeficiency virus (HIV) infection among men who have sex with men (MSM) is well recognized, there remains relatively limited intervention data on effective stigma reduction strategies. This systematic review was conducted to highlight the mechanisms through which sexual and HIV stigma is reduced in relation to HIV prevention and care engagement. Search of PubMed and Scopus resulted in 11 tested interventions to include in our preliminary model constructed from programme frameworks and recommendations. We refined the preliminary programme theory to identify whether, why, or how mitigation strategies produce observed outcomes. Our review showed that the interventions produced stigma reduction through three groups of mechanisms: (1) Self-acceptance, leadership, and motivational activation for behaviour change from intrapersonal strategies, such as education and mobile health strategies, which intervene on internalized and anticipated stigma; (2) socialization, knowledge sharing, and social empowerment from interpersonal strategies, such as peer support and training for care providers; and (3) community introspection, self-reflection, and humanistic activation from structural strategies such as community leaders' sensitization, which intervene on both anticipated and enacted stigma. Interventions mechanisms act complementarily and can be activated in different contexts in which MSM exposed to and infected with HIV are living.

The Relationship Between the Human Immunodeficiency Virus-1 Transmission Network and the HIV Care Continuum in Los Angeles County.

Public health action combating human immunodeficiency virus (HIV) includes facilitating navigation through the HIV continuum of care: timely diagnosis followed by linkage to care and initiation of antiretroviral therapy to suppress viral replication. Molecular epidemiology can identify rapidly growing HIV genetic transmission clusters. How progression through the care continuum relates to transmission clusters has not been previously characterized. We performed a retrospective study on HIV surveillance data from 5226 adult cases in Los Angeles County diagnosed from 2010 through 2014. Genetic transmission clusters were constructed using HIV-TRACE. Cox proportional hazard models were used to estimate the impact of transmission cluster growth on the time intervals between care continuum events. Gamma frailty models incorporated the effect of heterogeneity associated with genetic transmission clusters. In contrast to our expectations, there were no differences in time to the care continuum events among individuals in clusters with different growth dynamics. However, upon achieving viral suppression, individuals in high growth clusters were slower to experience viral rebound (hazard ratio 0.83, P = .011) compared with individuals in low growth clusters. Heterogeneity associated with cluster membership in the timing to each event in the care continuum was highly significant (P < .001), with and without adjustment for transmission risk and demographics. Individuals within the same transmission cluster have more similar trajectories through the HIV care continuum than those across transmission clusters. These findings suggest molecular epidemiology can assist public health officials in identifying clusters of individuals who may benefit from assistance in navigating the HIV care continuum.