Human Immunodeficiency Virus Medicine Research Articles

Australian consensus statement on doxycycline post-exposure prophylaxis (doxy-PEP) for the prevention of syphilis, chlamydia and gonorrhoea among gay, bisexual and other men who have sex with men.

Doxycycline post-exposure prophylaxis (doxy-PEP) involves consuming 200 mg of doxycycline up to 72 hours after a condomless sex act to reduce the risk of bacterial sexually transmitted infections (STIs). Recent clinical trials of doxy-PEP have demonstrated significant reductions in syphilis, chlamydia and, to a lesser degree, gonorrhoea among gay, bisexual and other men who have sex with men (GBMSM). There is a high level of interest in doxy-PEP in the GBMSM community and, in response, the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) held a national consensus conference with the aim of creating preliminary guidance for clinicians, community, researchers and policy makers. There was broad agreement that doxy-PEP should be considered primarily for the prevention of syphilis in GBMSM who are at risk of this STI, with a secondary benefit of reductions in other bacterial STIs. At the end of the consensus process, there remained some disagreement, as some stakeholders felt strongly that doxy-PEP should be considered only for the prevention of syphilis in GBMSM, and that the risk of increasing antimicrobial resistance outweighed any potential benefit from reductions in other bacterial STIs in the target population. The national roundtable made several other recommendations for clinicians, community, researchers and policy makers, as detailed in this article. ASHM will support the development of detailed clinical guidelines and education materials on doxy-PEP (www.ashm.org.au/doxy-pep). For GBMSM at high risk of syphilis, and perhaps other bacterial STIs, clinicians may consider prescribing doxy-PEP for a limited period of time, followed by a review of ongoing need. Unlike human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP), doxy-PEP may not be suitable as a population-level intervention and should instead be used more selectively.

Principles for Ending Human Immunodeficiency Virus as an Epidemic in the United States: A Policy Paper of the Infectious Diseases Society of America and the HIV Medical Association.

While we have the tools to achieve this goal, the persistent barriers to healthcare services experienced by too many individuals will need to be addressed to make significant progress and improve the health and quality of life of all people with human immunodeficiency virus (HIV). The necessary structural changes require actions by federal, state, and local policymakers and range from ensuring universal access to healthcare services to optimizing care delivery to ensuring a robust and diverse infectious diseases and HIV workforce. In this article, we outlines 10 key principles for policy reforms that, if advanced, would make ending the HIV epidemic in the United States possible and could have much more far-reaching effects in improving the health of our nation.

Serial surveys of Hong Kong medical students regarding attitudes towards HIV/AIDS from 2007 to 2017.

With widespread adoption of antiretroviral therapy, human immunodeficiency virus (HIV) epidemiology has changed since the late 2000s. Accordingly, attitudes towards the disease may also have changed. Because medical students are future physicians, their attitudes have important implications in access to care among patients with HIV/acquired immunodeficiency syndrome (AIDS). Here, we performed a survey to compare medical students' attitudes towards HIV/AIDS between the late 2000s (2007-2010) and middle 2010s (2014- 2017). From 2007 to 2010, we surveyed three cohorts of medical students at the end of clinical training to assess their attitudes towards HIV/AIDS. From 2014 to 2017, we surveyed three additional cohorts of medical students at the end of clinical training to compare changes in attitudes towards HIV/AIDS between the late 2000s and middle 2010s. Each set of three cohorts was grouped together to maximise sample size; comparisons were performed between the 2007-2010 and 2014-2017 cohorts. From 2007 to 2010, 546 medical students were surveyed; from 2014 to 2017, 504 students were surveyed. Compared with students in the late 2000s, significantly fewer students in the mid-2010s initially encountered patients with HIV during attachment to an HIV clinic or preferred to avoid work in a field involving HIV/AIDS; significantly more students planned to specialise in HIV medicine. Student willingness to provide HIV care remained similar over time: approximately 78% of students were willing to provide care in each grouped cohort. Although medical students had more positive attitudes towards HIV/AIDS, their willingness to provide HIV care did not change between the late 2000s and middle 2010s.

Fighting a Plague: Doctors' Stories of Challenge and Innovation Combatting the AIDS Epidemic in 1980s New York City.

The human immunodeficiency virus (HIV) has devastated the United States for forty years. Though there are highly effective treatments for HIV and acquired immune deficiency syndrome (AIDS) today, the early years of the HIV/AIDS epidemic in New York City (NYC) were filled with uncertainty, fear, and death—not unlike the period we are now experiencing in the COVID-19 era. Existing scholarship captures the political discourse of the HIV/AIDS era and the narratives of physicians who specialized in HIV medicine. This essay uses eight in-depth interviews of physicians of various specialties who worked in NYC to understand the uncertainties and fears in daily work during the early AIDS epidemic. Their stories provide unique perspectives into the realities of working as physicians in the epicenter of a highly politicized epidemic with limited support, information, and treatments. They illustrate that HIV/AIDS provided unique biomedical, social, and political challenges to the physicians working in NYC during the 1980s. Over the course of the decade, these physicians adapted to meet challenges using methods that have since become commonplace in their clinical practice.

Designing HIV Testing and Self-Testing Services for Young People in Nigeria: A Discrete Choice Experiment

A third of new human immunodeficiency virus (HIV) infections occur among young people and the majority of young people living with HIV are in sub-Saharan Africa. We examined the strength of Nigerian youth preferences related to HIV testing and HIV self-testing (HIVST). Discrete choice experiments were conducted among Nigerian youth (age 14-24 years). Participants completed one of two discrete choice experiments: (1) preferred qualities of HIV testing (cost, location of test, type of test, person who conducts the test, and availability of HIV medicine at the testing site) and (2) preferred qualities of HIVST kits (cost, test quality, type of test, extra items, and support if tested positive). A random parameter logit model measured the strength of preferences. A total of 504 youth participated: mean age 21 years (standard deviation 2 years), 38% male, and 35% had a higher than secondary school education. There was a strong preference overall to test given the scenarios presented, although male individuals were less likely to test for HIV or use HIVST kits. Youth preferred HIV testing services (with attributes in order of importance) that are free, blood-based testing, available in private/public hospitals or home, for HIV medications to be available in the same location as testing, and a doctor conducts the test. Participants preferred HIVST kits (with attributes in order of importance) that are available from community health centers, free, approved by the World Health Organization, include other sexually transmitted infection testing, have the option of an online chat, and oral-based HIVST. The HIV home testing was equally preferred to testing in a hospital, suggesting a viable market for HIVST if kits account for youth preferences. Male youth were less likely to choose to test for HIV or use HIVST kits, underscoring the need for further efforts to encourage HIV testing among young male individuals.

My PrEP Locator: PrEP directory in Malaysia

Background: A web-based directory of Human Immunodeficiency Virus (HIV) Pre-Exposure Prophylaxis (PrEP) providers in Malaysia was launched in January 2019 to increase public access to information on PrEP & provide a directory for PrEP providers in Malaysia. The PrEP provider database includes public and private clinics and hospitals that are prescribing PrEP. Providers listed in the database must complete the HIV Training Programme provided by Malaysian Society for HIV Medicine (MASHM) through HIV Connect to ensure adequate PrEP provision knowledge. My PrEP Locator is available in English, Malay and Chinese to cater to a multiracial Malaysian society. My PrEP Locator user data was analysed in order to strategically increase outreach and improve user-provider linkage. Methods & materials: There are three channels to be listed as provider in My PrEP Locator. Existing providers were approached and given a signup link. New providers who have completed their MASHM HIV Training Programme will be given e-flyer about the website; new providers who have signed up to be listed on the website, but have not completed their HIV Training Programme will be directed to the programme. User data was collected using Google Analytics. Results: Of the 20 PrEP currently listed providers, 5 are government clinics/hospitals and 15 are private clinics/hospitals, with 13 of them being general practitioner-led centre. Most of the providers are located in the states of Selangor and Kuala Lumpur. From May 2019, of the total of 1117 visitors to My PrEP Locator, 84.4% were new users and most of the users were located in Kuala Lumpur (64.04%). About 52.8% of the users are male, and the majority of the users are between the ages of 25–34 years old (59.2%), followed by 35–44 year old (18.0%). 84.0% of the users accessed the website via mobile phone, followed by 15.33% accessing via computer. Most of the users were referred through social media (44% from Twitter, 5% from Facebook) and 28.3% were direct visits to the website. Conclusion: My PrEP Locator requires continuous improvement, especially to increase the number of PrEP providers in Malaysia and to increase community outreach.

Primary Care Guidance for Persons With Human Immunodeficiency Virus: 2020 Update by the HIV Medicine Association of the Infectious Diseases Society of America.

Advances in antiretroviral therapy (ART) have made it possible for persons with human immunodeficiency virus (HIV) to live a near expected life span, without progressing to AIDS or transmitting HIV to sexual partners or infants. There is, therefore, increasing emphasis on maintaining health throughout the life span. To receive optimal medical care and achieve desired outcomes, persons with HIV must be consistently engaged in care and able to access uninterrupted treatment, including ART. Comprehensive evidence-based HIV primary care guidance is, therefore, more important than ever. Creating a patient-centered, stigma-free care environment is essential for care engagement. Barriers to care must be decreased at the societal, health system, clinic, and individual levels. As the population ages and noncommunicable diseases arise, providing comprehensive healthcare for persons with HIV becomes increasingly complex, including management of multiple comorbidities and the associated challenges of polypharmacy, while not neglecting HIV-related health concerns. Clinicians must address issues specific to persons of childbearing potential, including care during preconception and pregnancy, and to children, adolescents, and transgender and gender-diverse individuals. This guidance from an expert panel of the HIV Medicine Association of the Infectious Diseases Society of America updates previous 2013 primary care guidelines.

Advancing Digital Health Equity: A Policy Paper of the Infectious Diseases Society of America and the HIV Medicine Association.

The SARS-CoV-2 virus pandemic has revolutionized the practice of ambulatory medicine, triggering rapid dissemination of digital healthcare modalities, including synchronous video visits. However, social determinants of health, such as age, race, income, and others, predict readiness for telemedicine and individuals who are not able to connect virtually may become lost to care. This is particularly relevant to the practice of Infectious Diseases (ID) and HIV Medicine, as we care for high proportions of individuals whose health outcomes are affected by such factors. Furthermore, delivering high-quality clinical care in ID and HIV practice necessitates discussion of sensitive topics, which is challenging over video without proper preparation. We describe the “digital divide,” emphasize the relevance to ID and HIV practice, underscore the need to study the issue and develop interventions to mitigate its impact, and provide suggestions for optimizing telemedicine in ID and HIV clinics.

Innovations in Human Immunodeficiency Virus (HIV) Care Delivery During the Coronavirus Disease 2019 (COVID-19) Pandemic: Policies to Strengthen the Ending the Epidemic Initiative-A Policy Paper of the Infectious Diseases Society of America and the HIV Medicine Association.

The goal of the Ending the HIV Epidemic Initiative is to reduce new infections in the US by 90% by 2030. Success will require fundamentally changing HIV prevention and care delivery to engage more persons with HIV and at-risk of HIV in treatment. While the COVID-19 pandemic reduced in-person visits to care facilities and led to concern about interruptions in care, it also accelerated growth of alternative options, bolstered by additional funding support. These included the use of telehealth, medication delivery to the home and increased flexibility facilitating access to Ryan White HIV/AIDS Program services. While the outcomes of these programs must be studied, many have improved accessibility during the pandemic. As the pandemic wanes, long term policy changes are needed to preserve these options for those who benefit from them. These new care paradigms may provide a roadmap for progress for those with other chronic health issues as well.

Assessment of Post Exposure Prophylaxis (PEP) in Omdurman Voluntary Counselling and Testing Center (OVCTC)

PEP is taking human immunodeficiency virus medicine (HIV) within 72 hours after possible exposure to HIV to prevent the occurrence of the disease.
 Significance: exposure to the needle, surgical equipment, and rape is a life-threatening condition for hepatitis B virus (HBV), hepatitis C virus (HCV), HIV, acquired immunodeficiency syndrome (AIDS) infection, tetanus, and syphilis.
 The objective of this study was to assess the PEP.
 Methods: It was a descriptive-analytical study in OVCTC in September 2008.
 30 patients in study as the whole number. We included all patients attending the OVCTC and potential exposed either occupationally or through sexual intercourse and received antiretroviral therapy (ARV) agents as prophylaxis All cases diagnosed as HIV/AIDS and all persons need counseling were excluded in this study. Secondary data were collected from the records of the patients in OVCTC. Ethical considerations and clearance were taken from OVCTC and patients. It was accepted by the director.
 Results: In these study 30 cases fully described from the record and part of them were interviewed. Most cases (13) 43% in the age group 26 -35 years and the minority (2) 6% in age group (5 -15 years) and (2) 6% in age group (46-55years). Male (17)56.6% and Female (13)43.4%. Single (14) 46.6%, married (14)46.6%, widow (1)3.3% and divorced (1)3.3%. Most of them (21),70% are the health care professional, (27) 90% are educated and (26)86.3%lived in Khartoum. The equipment of exposure (28)93.3% due to needle stick, (1)3.3% due to rape and (1)3.3% due to rosary. (16)53.3%were expose in 2007, (12)40% in 2008 and (2)6.6% in 2006. All of them started needle stick protocol. The baseline of HIV testing is negative in all. All of them started Duovir according to world health organization guidelines and non-reported side effects or complications.
 Conclusion: Although PEP is offered in OVCTC according to world health organization (WHO) guidelines, pre and post-test counseling, ARV prophylaxis, and counseling including ARV side effects; the outcome is good, although the patients are not adherent to schedule follow-up in the center.

A Call to Action: The Role of Antiretroviral Stewardship in Inpatient Practice, a Joint Policy Paper of the Infectious Diseases Society of America, HIV Medicine Association, and American Academy of HIV Medicine.

Persons living with human immunodeficiency virus (HIV) and others receiving antiretrovirals are at risk for medication errors during hospitalization and at transitions of care. These errors may result in adverse effects or viral resistance, limiting future treatment options. A range of interventions is described in the literature to decrease the occurrence or duration of medication errors, including review of electronic health records, clinical checklists at care transitions, and daily review of medication lists. To reduce the risk of medication-related errors, antiretroviral stewardship programs (ARVSPs) are needed to enhance patient safety. This call to action, endorsed by the Infectious Diseases Society of America, the HIV Medicine Association, and the American Academy of HIV Medicine, is modeled upon the success of antimicrobial stewardship programs now mandated by the Joint Commission. Herein, we propose definitions of ARVSPs, suggest resources for ARVSP leadership, and provide a summary of published, successful strategies for ARVSP that healthcare facilities may use to develop locally appropriate programs.

Does Undetectable = Untransmissable?

Does Undetectable = Untransmissable?

Effectiveness of a Comprehensive 4-Week Course in HIV Medicine for Postgraduate Doctors at University of Nigeria: A Preservice Education Initiative.

There is a critical shortage of trained human immunodeficiency virus (HIV) providers in resource-limited settings. To strengthen preservice HIV training for postgraduate health care providers, University of Maryland’s Institute of Human Virology and Center for Clinical Care and Research Nigeria collaborated with University of Nigeria to plan and implement a comprehensive 4-week course in HIV medicine. The first course was piloted with 30 postgraduate doctors. Mean objective structured clinical examinations (OSCE), pretest, and posttest scores score were 51%, 53%, and 75%, respectively; follow-up examination at 6 months showed mean score of 74%. In multivariate regression analysis, pretest score was positively associated with posttest score (22.03, P < .001) and OSCE (0.29, P = .04), age negatively associated with pretest score (−0.94, P = .001), and female gender positively associated with OSCE score (6.15, P = .05). Six- and 18-month online surveys revealed trainees continued to apply knowledge and skills gained. North–south university collaborations to develop practicum-based preservice curricula offer a sustainable way to strengthen preservice evidence-based HIV medicine training with long-lasting retention of skills and knowledge.

2017 HIV Medicine Association of Infectious Diseases Society of America Clinical Practice Guideline for the Management of Chronic Pain in Patients Living With Human Immunodeficiency Virus.

Pain has always been an important part of human immunodeficiency virus (HIV) disease and its experience for patients. In this guideline, we review the types of chronic pain commonly seen among persons living with HIV (PLWH) and review the limited evidence base for treatment of chronic noncancer pain in this population. We also review the management of chronic pain in special populations of PLWH, including persons with substance use and mental health disorders. Finally, a general review of possible pharmacokinetic interactions is included to assist the HIV clinician in the treatment of chronic pain in this population.It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. The Infectious Diseases Society of American considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.

A Survey of Patients' Perspectives on Outpatient HIV Care in the Netherlands.

IntroductionResponding to patients’ needs and preferences is important in the delivery of outpatient care. Recent and systematically collected data reflecting human immunodeficiency virus (HIV)-infected patients’ opinions on how their outpatient care should be delivered are lacking. Our aim was to identify aspects of care that people with HIV in outpatient care in The Netherlands consider important and to evaluate the extent to which the received care meets their expectations.MethodsWe measured patient preferences and experiences in a nationwide sample of HIV-infected patients using a modified, previously validated questionnaire (QUOTE-HIV).ResultsThe aspects of care that were considered most important were specific expertise of the care provider in HIV medicine, the care provider taking the patient seriously and receiving adequate information about treatment options. In addition, confidentiality of HIV status at the outpatient clinic was a major concern. Patient experiences were positive, with the majority of the respondents indicating that they always or usually received care in accordance with their preferences.ConclusionHIV-infected patients greatly value having care providers with HIV-specific expertise. Safeguarding the privacy of HIV status and the provision of information about treatment options are matters that deserve continuous attention in the delivery of outpatient HIV care.Electronic supplementary materialThe online version of this article (doi:10.1007/s40121-017-0164-z) contains supplementary material, which is available to authorized users.

Should Human Immunodeficiency Virus Specialty Clinics Treat Patients With Hypertension or Refer to Primary Care? An Analysis of Treatment Outcomes.

Care for people with human immunodeficiency virus (HIV) increasingly focuses on comorbidities, including hypertension. Evidence indicates that antiretroviral therapy and opportunistic infections are best managed by providers experienced in HIV medicine, but it is unclear how to structure comorbidity care. Approaches include providing comorbidity care in HIV clinics ("consolidated care") or combining HIV care with comorbidity management in primary care clinics ("shared care"). We compared blood pressure (BP) control in HIV clinics practicing consolidated care versus shared care. We created a national cohort of Veterans with HIV and hypertension receiving care in HIV clinics in Veterans Administration facilities and merged these data with a survey asking HIV providers how they delivered hypertension care (5794 Veterans in 73 clinics). We defined BP control as BP ≤140/90 mmHg on the most recent measure. We compared patients' likelihood of experiencing BP control in clinics offering consolidated versus shared care, adjusting for patient and clinic characteristics. Forty-two of 73 clinics (57.5%) practiced consolidated care for hypertension. These clinics were larger and more likely to use multidisciplinary teams. The unadjusted frequency of BP control was 65.6% in consolidated care clinics vs 59.4% in shared care clinics (P < .01). The likelihood of BP control remained higher for patients in consolidated care clinics after adjusting for patient and clinic characteristics (odds ratio, 1.32; 95% confidence interval, 1.04-1.68). Patients were more likely to experience BP control in clinics reporting consolidated care compared with clinics reporting shared care. For shared-care clinics, improving care coordination between HIV and primary care clinics may improve outcomes.

Educational process management in HIV medicine in Saint Petersburg

The stages of the Department of socially significant infections formation, starting from the training course for laboratory diagnosis of acquired immunodeficiency syndrome (AIDS) at the Department of Infectious Diseases, scientific, educational and practical association «AIDS and AIDS-defining illnesses» at the Medical Academy of Postgraduate Education (nowadays - Northwest Medical University), approved by the order of Healthcare ministry of USSR №467 in 1987, which in 1992 came under the jurisdiction of Russia, headed by Professor A.G. Rakhmanova, up to creating the Department of the Pavlov First Saint Petersburg State Medical University. In the late 90s and early this century, Department of Infectious Diseases with the course of the AIDS laboratory diagnosis was virtually the only one in the country for training on human immunodeficiency virus (HIV) infection, its laboratory diagnostics and other related diseases. As a result of scientific, educational and practical association «AIDS and AIDS-defining illness» activity, for over 20 years scientific staff was trained on HIV Medicine and associated socially significant infections. As a part of that effort, more than 25 doctors of science and 60 PhDs who are currently teaching HIV medicine and associated co-infections: chronic viral hepatitides, tuberculosis, herpes and other diseases in Russia and countries of the former post-Soviet space, were trained. The next step was the establishment of «HIV Medicine» course in 2009 in the Pavlov First Saint Petersburg State Medical University, and later in 2013 - creation of an independent Department of socially significant diseases.

British HIV Association guidelines for the management of HIV infection in pregnant women 2012 (2014 interim review).

British HIV Association guidelines for the management of HIV infection in pregnant women 2012 (2014 interim review).

A Tool to Enhance Medical Care, Communication, and Patients’ Understanding of High-Resolution Anoscopy

To the Editor—In response to increasing rates of invasive anal cancer among persons infected with human immunodeficiency virus (HIV) [1], the most recent HIV Medicine Association of the Infectious Diseases Society of America primary care guidelines for management HIV recommend screening for anal cancer precursor using an anal cytology test [2]. A growing number of institutions have implemented screening programs modeled on procedures used in cervical cancer [1]. The equivalent screening procedure to cervical colposcopy is called high-resolution anoscopy (HRA) [3]. HRA is technically more challenging than colposcopy due to the uneven topography and collapsing nature of the anal canal [3]. There is variability in how HRA providers position the patient and document the location of visualized lesions, and little standardization of medical record documentation of HRA findings [4]. Consequently, referring physicians and patients frequently gain little understanding of the nature of findings and goals of the HRA procedure. We report a figure that has been designed and used at the University California, San Diego, Owen Clinic since March 2012. It illustrates the principal landmarks of the anal canal 3-dimensionally. The purpose of this graphical tool is to complement individual documentation practices and standardize nomenclature of HRA findings regardless of the position of the patient while undergoing HRA. In our institution, the HRA graphic is incorporated into the clinical notes of our electronic medical record system; it is thus available to any physician involved in the care of a patient who had a prior HRA. In Figure ​Figure1,1, we show an HRA graphic with findings of a patient in the left lateral decubitus position. The lesions identified are documented with respect to their relative position in the anal canal, and narrative descriptions are included at the bottom of the HRA graphic. The HRA graphic facilitates rapid review of prior documented lesions as well as their location. This tool complements 2-dimensional photographic images that may be captured in freestanding image management software. Finally, HRA providers can show the graphic to their patients and explain clearly concepts related to anal pathology including the types of lesions visualized, their locations, clinical significance, and their management implications. We believe this graphic offers a valuable adjunct that enhances documentation, care, and communication. Figure 1. High-resolution anoscopy schematic findings. Graphics such as this could help to standardize communication between medical providers and patients, and could be used in clinical research for documentation of HRA findings during screening for anal cancer precursors. Permission to copy this illustration for educational, research, and nonprofit purposes, without fee and without a written agreement, is granted provided that the following copyright notice is included: Copyright 2012. The Regents of the University of California. Commercial Rights Reserved.

Executive Summary: Primary Care Guidelines for the Management of Persons Infected With HIV: 2013 Update by the HIV Medicine Association of the Infectious Diseases Society of America

Abstract Evidence-based guidelines for the management of persons infected with human immunodeficiency virus (HIV) were prepared by an expert panel of the HIV Medicine Association of the Infectious Diseases Society of America. These updated guidelines replace those published in 2009. The guidelines are intended for use by healthcare providers who care for HIV-infected patients. Since 2009, new antiretroviral drugs and classes have become available, and the prognosis of persons with HIV infection continues to improve. However, with fewer complications and increased survival, HIV-infected persons are increasingly developing common health problems that also affect the general population. Some of these conditions may be related to HIV infection itself or its treatment. HIV-infected persons should be managed and monitored for all relevant age- and sex-specific health problems. New information based on publications from the period 2009–2013 has been incorporated into this document.