Use Of HIV Treatment Research Articles

Reducing stigma and promoting HIV wellness/mental health of sexual and gender minorities: RCT results from a group-based programme in Nigeria.

High levels of HIV stigma as well as stigma directed towards sexual and/or gender minorities (SGMs) are well documented in the African setting. These intersecting stigmas impede psychosocial wellbeing and HIV prevention and care. Yet, there are few if any evidence-based interventions that focus on reducing internalized stigma and promoting mental health and HIV wellness for SGMs in Africa. We developed and evaluated a group-based intervention drawing on cognitive behavioural therapy (CBT) strategies for men who have sex with men (MSM) and transgender women (TGW) at risk for or living with HIV in Lagos, Nigeria. The intervention comprised four weekly in-person group sessions facilitated by community health workers. We conducted a delayed intervention group randomized controlled trial (April-September 2022), with pre-post surveys plus 3-month follow-up (immediate group only), as well as qualitative research with participants and programme staff. Outcomes included internalized stigma related to SGM and HIV status, depression, resiliency/coping and pre-exposure prophylaxis (PrEP)/HIV treatment use. Mean age of the 240 participants was 26 years (range 18-42). Seventy-seven percent self-identified as MSM and 23% TGW; 27% were people with HIV. Most (88%) participants attended all four sessions, and 98% expressed high intervention satisfaction. There was significant pre-post improvement in each psychosocial outcome, in both the immediate and delayed arms. There were further positive changes for the immediate intervention group by 3-month follow-up (e.g. in intersectional internalized stigma, depression). While baseline levels of ever-PrEP use were the same, 75% of immediate-group participants reported currently using PrEP at 3 months post-intervention versus 53% of delayed-group participants right after the intervention (p<0.01). Participants post-intervention described (in qualitative interviews) less self-blame, and enhanced social support and resilience when facing stigma, as well as motivation to use PrEP, and indicated that positive pre-intervention changes in psychosocial factors found in the delayed group mainly reflected perceived support from the study interviewers. This study demonstrated the feasibility and acceptability of a group-based CBT model for MSM and TGW in Nigeria. There were also some indications of positive shifts related to stigma, mental health and PrEP, despite issues with maintaining the randomized design in this challenging environment.

LGBTQ+ AFFIRMING CARE AND UNDETECTABLE=UNTRANSMITTABLE: EVIDENCE FOR OLDER GAY AND BISEXUAL MEN IN THE US SOUTH

Abstract One of the most significant innovations in HIV prevention is the use of HIV treatment to prevent HIV transmission. This information has been disseminated as the “Undetectable = Untransmittable” (U=U) message. Despite evidence of effectiveness, U=U awareness, belief, and understanding remain limited in some communities. In this study we examine whether having an LGBTQ affirming healthcare provider increases U=U awareness, belief, and understanding among midlife and older gay and bisexual men in the US South, an understudied and underserved population and region where new HIV infections are increasing. We use data from the Vanderbilt University Social Networks Aging and Policy Study (VUSNAPS) on sexual minority men aged 50 to 76 from four Southern US states collected in 2020-2021. We find that only one in four men report prior awareness of U=U, but awareness is higher among HIV-negative and HIV-positive men who have an LGBTQ-affirming provider. Having an affirming provider significantly increases U=U belief and understanding, improves risk perception accuracy, and increases the likelihood of having ever tested for HIV among HIV-negative men. Improving access to LGBTQ affirming healthcare may improve U=U awareness, belief, and understanding, which could help to curb HIV transmission in the US South.

LGBTQ+ Affirming Care May Increase Awareness and Understanding of Undetectable = Untransmittable among Midlife and Older Gay and Bisexual Men in the US South.

One of the most significant innovations in HIV prevention is the use of HIV treatment to prevent HIV transmission. This information has been disseminated as the “Undetectable = Untransmittable” (U = U) message. Despite evidence of effectiveness, U = U awareness, belief, and understanding remains limited in some communities. In this study, we examine whether having an LGBTQ affirming healthcare provider increases U = U awareness, belief, and understanding among midlife and older gay and bisexual men in the US south, an understudied and underserved population and region where new HIV infections are increasing. We used data from the Vanderbilt University Social Networks Aging and Policy Study (VUSNAPS) on sexual minority men aged 50 to 76 from four southern US states collected in 2020–2021. We found that only one in four men reported prior awareness of U = U, but awareness was higher among men who have an LGBTQ affirming provider. Among HIV negative men, those with an affirming provider were more likely to believe and understand U = U, have more accurate risk perception, and have ever tested for HIV. Improving access to LGBTQ affirming healthcare may improve U = U awareness, belief, and understanding, which could help to curb HIV transmission in the US south.

Pre-exposure prophylaxis (PrEP) uptake and adherence experiences of gay and bisexual men who engage in chemsex: A qualitative study.

Pre-exposure prophylaxis (PrEP) is the use of HIV antiretroviral medications to reduce the risk of HIV acquisition. PrEP is highly effective when used during periods of potential HIV exposure. Gay and bisexual men (GBM) who engage in unprotected chemsex (without condoms or PrEP) are at high-risk of acquiring HIV. Substance use has been shown to detrimentally impact on the effective use of HIV treatment among GBM living with HIV. This study aims to qualitatively explore PrEP uptake and adherence among GBM who engage in chemsex in the United Kingdom. Nineteen semi-structured in-depth telephone interviews were conducted with self-identifying HIV-negative GBM who reported recently engaging in chemsex and currently using or had recently used PrEP. We explored the ways in which chemsex influenced GBM's motivation to use, access to and effective use of PrEP. Interviews were audio recorded, transcribed, and coded using thematic analysis. Most of the men identified as gay, were of white ethnicity and had a median age of 41. Eighteen men were still using PrEP at the time of the interview and most used daily dosing. The perception of being at high risk of HIV acquisition was a key factor influencing PrEP initiation and after initiation, continued to influence high levels of adherence which was reported by the majority of participants. The few individuals who reported sub-optimal adherence, explained that psychosocial stressors or periods of impaired mental health led to more frequent or intense chemsex sessions, which in turn contributed to occasional non-adherence. Most participants used a variety of strategies to help them adhere, which included restricting the amount or intensity of chemsex they engaged in, strategic placement of PrEP and external triggers to remind them to take PrEP. In this study, the majority of GBM who engaged in chemsex, initiated PrEP in recognition of their potential risk of HIV acquisition and reported high levels of PrEP adherence. They used multiple strategies to support effective PrEP access and adherence. These findings support a growing body of evidence that PrEP is a viable prevention tool for GBM who engage in chemsex, and that chemsex does not negatively impact PrEP adherence.

What are we learning about HIV testing in informal settlements in KwaZulu-Natal, South Africa? Results from a randomized controlled trial.

BackgroundRecent evidence highlighting high HIV incidence and prevalence in informal settlements suggests that they are environments that foster HIV risk. Given growing urbanization in sub-Saharan Africa, there is a critical need to assess the successes and challenges of implementing HIV testing, prevention and treatment interventions in these contexts.MethodsWe randomly selected a household-based sample of 1528 adult men (18–35) and women (18–24) living in 18 randomly selected communities in KZN, South Africa. After the baseline interview, communities were randomized to one of three intervention rollout arms in a stepped wedge design. At approximately 8-month intervals, the Asibonisane Community Responses Program (and in particular the implementation of Stepping Stones, a participatory HIV prevention program focused on strengthening relationships and communication) was rolled at by intervention phase. Using data from this evaluation, we describe levels and trends in HIV testing and treatment during follow-up, and we use fixed effects models to estimate the effects of participation in the program on testing.ResultsStudy respondents reported high levels of economic insecurity and mobility, and men report various HIV risk behaviors including about 50% reporting multiple partnerships. About two-thirds of respondents (73% of women, 63% of men) had been tested for HIV in the last six months. Among those living with HIV, treatment levels were high at baseline, and almost universal by endline in 2019. Program participation led to a 17% increase in the probability of testing for women (p<0.05) but had no effect on testing for men due, in part, to the fact that the program did not reach men who were least likely to be tested, including those who had migrated recently, and those who had never been tested at baseline.ConclusionsNear universal HIV treatment use demonstrates positive trends in access to some HIV services (including treatment as prevention) in these communities. Stepping Stones had positive effects on HIV testing for women, yet barriers to HIV testing remain, especially for men. Redoubled efforts to reach men with testing are vital for improving HIV outcomes for both men and their partners.

Increasing HIV treatment access, uptake and use among men who have sex with men in urban Indonesia: evidence from a qualitative study in three cities.

Men who have sex with men make up one of four key populations identified as critical to a successful HIV response in Indonesia. Despite international policies supporting HIV treatment in low- and middle-income countries, Indonesia is one of the few countries experiencing low coverage of HIV treatment and little decrease in HIV incidence. There is poor retention in care and low viral suppression rates among key populations such as men who have sex with men. The national government has committed to increasing treatment access and uptake for people with HIV but little is known about how these men themselves view, use and experience these medications. Drawing on qualitative data collected in 2015-16 from 24 HIV-positive men who have sex with men living in three Indonesian cities, we observed multiple intersecting social and contextual factors that can influence effective HIV treatment use. Although shared stories of strong side effects and fear of unwanted disclosure inhibited treatment uptake, social support from 'buddies' helped to navigate healthcare systems and sharing medication among peers enabled adherence. In order to improve treatment uptake and adherence among Indonesian men who have sex with men living with HIV, these divergent effects of the social meanings and practices associated with HIV treatments in Indonesia must be better acknowledged. A more comprehensive understanding of social and community practices within key populations can strengthen national efforts to improve treatment access and increase adherence. Ongoing decentralization of healthcare in Indonesia, and differentiated care models that enable initiation of treatment in community settings and involve non-medical, community-based organizations in the provision of treatment services have the potential to address the needs of individuals who fall into a key population category such as men who have sex with men.

Accessing HIV treatment and care services in fishing communities around Lake Victoria in Uganda: mobility and transport challenges

Qualitative research exploring the influence of community-level factors on access to and use of HIV treatment and care services among people living in fishing communities is limited, especially with respect to those already in receipt of HIV care and on treatment. To enhance understanding of these issues, semi-structured in-depth interviews were conducted with 42 HIV-positive fisherfolk and 15 health care providers from two HIV clinics located in two fishing communities in Uganda. Fisherfolk’s mobility and poor transport systems were significant barriers to access to and use of HIV treatment and care. Mobility, which involved regular movement between communities, sometimes led to fisherfolk’s inability to access HIV treatment and care. A poor transport system in fishing communities – characterised by irregular transport services and boats in a poor condition – was reported to force both fisherfolk and health care providers sometimes to cancel journeys to centres providing treatment and support. Community-level factors such as these, which relate to the organisation and provision of transport in local community settings, are significant influences on access to HIV treatment and care. Interventions that address these challenges are needed to improve access to and use of HIV treatment and care in fishing communities.

Navigating HIV citizenship: identities, risks and biological citizenship in the treatment as prevention era

The use of HIV Treatment as Prevention (TasP) has radically changed our understandings of HIV risk and revolutionised global HIV prevention policy to focus on the use of pharmaceuticals. Yet, there has been little engagement with the very people expected to comply with a daily pharmaceutical regime. We employ the concept of HIV citizenship to explore responses by people living with HIV in the UK to TasP. We consider how a treatment-based public health strategy has the potential to reshape identities, self-governance and forms of citizenship, domains which play a critical role not only in compliance with new TasP policies, but in how HIV prevention, serodiscordant relationships and (sexual) health are negotiated and enacted. Our findings disrupt the biomedical narrative which claims an end to HIV through scaling up access to treatment. Responses to TasP were framed through shifting negotiations of identity, linked to biomarkers, cure and managing treatment. Toxicity of drugs – and bodies – were seen as something to manage and linked to the shifting possibilities in serodiscordant environments. Finally, a sense of being healthy and responsible, including appropriate use of resources, meant conflicting relationships with if and when to start treatment. Our research highlights how HIV citizenship in the TasP era is negotiated and influenced by intersectional experiences of community, health systems, illness and treatment. Our findings show that the complexities of HIV citizenship and ongoing inequalities, and their biopolitical implications, will intimately shape the implementation and sustainability of TasP.

Factors associated with optimal pharmacy refill adherence for antiretroviral medications and plasma HIV RNA non-detectability among HIV-positive crack cocaine users: a prospective cohort study.

BackgroundCrack cocaine use is known to contribute to poor adherence to antiretroviral medications; however, little is known about facilitators of or barriers to effective HIV treatment use among HIV-infected crack cocaine users. We sought to identify correlates of optimal pharmacy refill adherence for antiretroviral medications and plasma HIV RNA viral load (pVL) suppression among this population.MethodsData from a prospective cohort of HIV-positive people who use illicit drugs in Vancouver, Canada, were linked to comprehensive HIV clinical monitoring and pharmacy dispensation records. We used multivariable generalized linear mixed-effects modelling to longitudinally identify factors associated with ≥95 % adherence to pharmacy refills for antiretroviral medications and pVL <50 copies/mL among crack cocaine users exposed to highly-active antiretroviral therapy (HAART).ResultsAmong 438 HAART-exposed crack cocaine users between 2005 and 2013, 240 (54.8 %) had ≥95 % pharmacy refill adherence in the previous 6 months at baseline. In multivariable analyses, homelessness (adjusted odds ratio [AOR]: 0.58), ≥daily crack cocaine smoking (AOR: 0.64), and ≥ daily heroin use (AOR: 0.43) were independently associated with optimal pharmacy refill adherence (all p < 0.05). The results for pVL non-detectability were consistent with those of medication adherence, except that longer history of HAART (AOR: 1.06), receiving a single tablet-per-day regimen (AOR: 3.02) and participation in opioid substitution therapies was independently associated with pVL non-detectability (AOR: 1.55) (all p < 0.05).ConclusionsHomelessness, and daily crack cocaine and/or heroin use were independently and negatively associated with optimal HAART-related outcomes. With the exception of opioid substitution therapies, no addiction treatment modalities assessed appeared to facilitate medication adherence or viral suppression. Evidence-based treatment options for crack cocaine use that also confer benefits to HAART need to be developed.

The uncertainty of treatment: Women's use of HIV treatment as prevention in Malawi

In countries throughout sub-Saharan Africa, antiretroviral therapy is seen as the solution to not only treat existing patients, but also to prevent the future spread of HIV. New policies for the prevention of mother-to-child transmission place women on lifelong treatment as soon as they are tested HIV positive. This article looks at how women understand this prescription for lifelong treatment. Drawing on interviews with HIV-positive women in Lilongwe, Malawi (N = 65) during July–September 2014, I examine the process of making treatment decisions, and why – despite increased access – women refuse or stop treatment. Using treatment for preventative purposes transforms the experience of HIV from an acute to a chronic condition where both the symptoms of disease and the efficacy of treatment are unclear. Women look for evidence of the cost and benefit of treatment through their personal experiences with illness and drug-taking. For some women, the benefits were clearer: they interpreted past illnesses as signs of HIV infection, and felt healthier and more economically productive afterwards. For others, taking treatment sometimes led to marital problems, and side effects made them feel worse and disrupted their ability to work. While women understand the health benefits of antiretroviral therapy, taking treatment does not always make sense in their present circumstances when there are costly physical and economic repercussions. This study builds on existing sociological research on medical decision-making by situating decisions in a broader political economy of changing HIV policies, economic conditions, and everyday uncertainty.

Key factors in the acceptability of treatment as prevention (TasP) in Scotland: a qualitative study with communities affected by HIV.

ObjectivesThere is a clear need to understand the factors that might prevent and/or facilitate the effective use of HIV treatment as prevention (TasP) at an individual level. This paper reports on findings from the first qualitative study in the UK exploring the acceptability of TasP among gay, bisexual and/or men who have sex with men (MSM) and migrant African communities in Scotland.MethodsWe conducted seven exploratory focus group discussions (FGDs) with convenience samples of MSM (five FGDs, n=22) and mixed-gender African (two FGDs, n=11) participants. Of these, three FGDs were conducted with HIV-positive MSM (n=14) and one FGD with HIV-positive Africans (n=8). We then conducted 34 in-depth interviews (IDIs) with a purposive sample of MSM (n=20) and Africans (n=14, women=10). Half were HIV-positive (MSM, n=10; African, n=7). FGD and IDI data were analysed thematically drawing on predetermined and emergent themes.ResultsWe found that inequalities in HIV literacy could be a barrier to TasP, as could social constraints, such as criminalisation of transmission, increased risk of sexually transmitted infection and increased burden of treatment. We also identified psychological barriers such as perceptions of risk. However, relationships and shared decision making were identified as potential facilitators for TasP.ConclusionsOur results suggest that potential use and management of TasP may not be straightforward. It could be contingent on reducing inequalities in HIV literacy, minimising the perceived burden of treatment and other potential risks, and addressing the dynamics of existing and socially acceptable risk management strategies, especially in relation to long-term serodiscordant relationships.

HIV-1 treatment as prevention: the good, the bad, and the challenges.

This work focuses on the use of antiretroviral agents to prevent the sexual transmission of HIV-1. Two randomized clinical trials demonstrated that antiretroviral agents provided before exposure to HIV-1 offer substantial protection, ostensibly directly proportional to the concentration of antiretroviral therapy (ART) in the genital secretions. Intense focus on the use of HIV treatment as prevention has led to publication of modeling exercises, ecological studies, and observational studies, most of which support the potential benefits of ART. However, the logistical requirements for successful use of ART for prevention are considerable. ART will serve as a cornerstone of combination prevention of HIV-1. Continued research will be essential to measure anticipated benefits and to detect implementation barriers and untoward consequences of such a program, especially increases in primary ART resistance.

Honing the Test-and-Treat HIV Strategy

In his News Focus story (“Treatment as prevention,” 5 March, p. [1196][1]), J. Cohen reviews ideas presented at the 17th Conference on Retroviruses and Opportunistic Infections about the use of HIV treatment as prevention. Enthusiasm for the treatment-as-prevention approach has grown in recent years as (i) the drugs have become safer, better tolerated, and more widely available; (ii) widespread testing has become cheaper and more efficient; (iii) earlier therapy has become desirable; and (iv) mathematical modeling by some ([ 1 ][2]) (but by no means all) has suggested that a test-and-treat strategy could control the spread of HIV. Cohen cites an observational analysis, by Donnell et al. , that reported considerable reduction of HIV transmission in HIV discordant couples when ART was provided to the HIV-infected index partner ([ 2 ][3]). This finding—similar to work from Sullivan et al. presented at Conference on Retroviruses and Opportunistic Infections in 2009 ([ 3 ][4])—helps to support the key assumption that ART reduces infectiousness. However, these studies report only short-term observations; they do not address the durability of this effect or the risk of transmitted drug-resistant HIV strains, two critical considerations for the test-and-treat strategy. 1. [↵][5] 1. R. M. Granich, 2. C. F. Gilks, 3. C. Dye, 4. K. M. De Cock, 5. B. G. Williams , Lancet 373, 48 (2009). [OpenUrl][6][CrossRef][7][PubMed][8][Web of Science][9] 2. [↵][10] 1. D. Donnell 2. et al ., abstract 136, presented at the 17th Conference on Retroviruses and Opportunistic Infections, San Francisco, CA, 16 to 19 February 2010. 3. [↵][11] 1. P. Sullivan 2. et al ., abstract 52bLB, presented at the 16th Conference on Retroviruses and Opportunistic Infections, Montreal, Canada, 8 to 11 February 2009. [1]: /lookup/doi/10.1126/science.327.5970.1196-b [2]: #ref-1 [3]: #ref-2 [4]: #ref-3 [5]: #xref-ref-1-1 View reference 1 in text [6]: {openurl}?query=rft.jtitle%253DLancet%26rft.stitle%253DLancet%26rft.aulast%253DGranich%26rft.auinit1%253DR.%2BM.%26rft.volume%253D373%26rft.issue%253D9657%26rft.spage%253D48%26rft.epage%253D57%26rft.atitle%253DUniversal%2Bvoluntary%2BHIV%2Btesting%2Bwith%2Bimmediate%2Bantiretroviral%2Btherapy%2Bas%2Ba%2Bstrategy%2Bfor%2Belimination%2Bof%2BHIV%2Btransmission%253A%2Ba%2Bmathematical%2Bmodel.%26rft_id%253Dinfo%253Adoi%252F10.1016%252FS0140-6736%252808%252961697-9%26rft_id%253Dinfo%253Apmid%252F19038438%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [7]: /lookup/external-ref?access_num=10.1016/S0140-6736(08)61697-9&link_type=DOI [8]: /lookup/external-ref?access_num=19038438&link_type=MED&atom=%2Fsci%2F328%2F5981%2F976.atom [9]: /lookup/external-ref?access_num=000262183800031&link_type=ISI [10]: #xref-ref-2-1 View reference 2 in text [11]: #xref-ref-3-1 View reference 3 in text