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An editorial is presented in which the authors discuss support efforts for HIV-positive individuals who inject drugs during the COVID-19 pandemic in the U.S. and St. Petersburg, Russia. It examines the various challenges for people who inject drugs (PWID) with HIV, the reduction of impediments to care, and social stigma against PWID.

Background: HIV prevalence in correctional facilities may be 2 to 10 times higher than in the general adult population. Antiretroviral therapy (ART) interruption is frequent after an incarceration. This, in combination with post-release high-risk behaviors, may have detrimental consequences on the epidemic. Although return to care after release from correctional facilities has been described in many North American settings, data from South America seemed scarce. French Guiana is the only French territory located in South America. In 2014, HIV prevalence was estimated at 1.2% among pregnant women and oscillated around 4% in the only correctional facility.Method: HIV-infected adults released from the French Guiana correctional facility between 2007 and 2013 were included in a retrospective cohort survey. The first objective was to describe the cascade of care in the 4 years following release. The secondary objectives were to describe contacts with care and to identify factors associated with return to HIV care, 1 year after release.Results: We included 147 people, mostly males (81.6%). The median time before the first ambulatory consultation was 1.8 months. Within 1 year after release, 27.9% came for unscheduled emergency consultations, 22.4% were hospitalized. Within 4 years after release, 40.0-46.5% were in care, 22.4% archieved virological success. Being on ART when incarcerated was associated with HIV care (aIRR: 2.0, CI: 1.2-3.0), whereas being HIV-diagnosed during the last incarceration was associated with poor follow-up (aIRR: 0.3, CI: 0.1-0.9).Conclusion: The risk of HIV-follow-up interruption is high, after an incarceration with HIV. ART supply should be sufficient to cover the timespan following release, several months if possible. Those not on ART at the time of incarceration may require special attention, especially those newly HIV-diagnosed while in custody. Comprehensive programs are necessary to support ex-offenders to stay on ART after incarceration. [ABSTRACT FROM AUTHOR]

Background: A gender gap exists in knowledge regarding persons living with HIV/AIDS in Ghana. Women living with HIV/AIDS (WLHIV) greatly outnumber males living with HIV/AIDS (MLHIV) in Ghana and Sub-Saharan Africa generally. This necessitates more gender-nuanced evidence-based information on HIV/AIDS to guide individuals, healthcare workers, and other stakeholders in Ghana particularly. This paper undertook a gender-focused analysis of the experiences of WLHIV and MLHIV in a municipal area in Ghana which has been most impacted by HIV/AIDS.Methods: In-depth interviews of 38 HIV-positive persons recruited using combined purposive and random sampling for one month, were tape recorded and analyzed using thematic content analysis. Participants were out-patients who were receiving routine care for co-morbidities at two specially equipped HIV/AIDS Voluntary Counseling and Testing Centers in the Lower Manya Krobo Municipality (LMKM), Eastern Region, Ghana.Results: Our data yielded three major themes: characteristics of participants, health status and health seeking behavior, and challenges encountered living with HIV/AIDS. Except for feeling of sadness due to their HIV/AIDS-positive status, there were significant differences in the experiences of MLHIV, compared to WLHIV. WLHIV were more likely to be housing insecure, unemployed due mostly to stigmatization/self-stigmatization, less likely to have revealed their HIV-positive status to multiple family members, and had more profound challenges regarding their healthcare. Most MLHIV expected, demanded, and had support from their wives; WLHIV were mostly single-never married, divorced or widowed (mostly due to HIV/AIDS). The vast majority of WLHIV complained of near-abject poverty, including for most of them, lack of food for taking their anti-retroviral medicines and/or taking it on time.Conclusions: The experiences of the MLHIV and WLHIV with living and coping with the virus mostly differed. These experiences were unequivocally shaped by differential socio-cultural tenets and gendered nuances; WLHIV had more negative experiences. Public education on the extra burden of HIV/AIDS on WLHIV, more social support, and affirmative action in policy decisions in favor of WLHIV in the study district are needed to seek public sympathy and improve health outcomes and livelihoods of WLHIV particularly. Further studies using multiple sites to explore these differences are warranted. [ABSTRACT FROM AUTHOR]

The US Department of Health and Human Services has launched a large-scale plan that aims to "End the HIV Epidemic" (EtHE) in America, including ambitious goals and targets over the next 5 to 10 years. To be successful, the EtHE Plan will require timely dissemination of relevant metrics to inform the broad array of stakeholders who are in a position to act in support of the plan's goals. Metrics should include both population health outcome metrics and implementation metrics that track the deployment and uptake of specific intervention delivery strategies. In addition to the usual HIV care continuum metrics that include all people living with HIV in the denominator, metrics dedicated to those not yet reached (i.e., as the denominator) are essential to help target EtHE implementation efforts. Special attention is required around metrics and targets that inform and drive action on HIV-related health disparities. Well-chosen metrics and a well-designed dissemination system can serve as important tools to assess the progress of the EtHE Plan, and to identify and disseminate lessons learned quickly within and across jurisdictions aiming to end HIV as a local public health threat. [ABSTRACT FROM AUTHOR]

Background: Private health facilities are increasingly being recognized as the neglected partner in the provision of HIV services. The non-adherence rate in the study sites ranged from 19 to 22%. This study explored the factors associated with non-adherence from antiretroviral therapy (ART) among adult patients accessing ART services at two privately owned urban health facilities in Malawi.Methods: We conducted a descriptive qualitative approach employing in-depth interviews among adults who either defaulted or were retained in HIV care in two privately owned facilities in Malawi from March to July 2017. We purposively selected participants and interviewed a total of 6 ART providers and 24 ART clients. Data were analyzed manually using a thematic approach.Results: Overall, participants identified four facilitators for retention in care and four broad categories of barriers namely individual, psychological, drug related and human resource related factors. The factors that facilitated retention in care included follow up visits after missing a visit, adequate information education and counseling, and supportive relationships.Conclusion: The main reason for defaulting from antiretrovirals (ARVs) was fear of disclosing an HIV status to avert potential stigma and discrimination. In implementing ART clinics due consideration and strategies need to be adopted to ensure that privacy and confidentiality is preserved. Although adoption of all the key Malawi Implementing strategies like expert clients and a guardian may optimize retention in care, there is need for prior analysis of how those may lead to unintended disclosure which inadvertently affects adherence. Furthermore, private facilities should orient their clients to the public facilities within the catchment area so that clients have an option for alternative access to HIV care in the event of financial constraints. [ABSTRACT FROM AUTHOR]

Osteonecrosis of the jaws has recently been associated with HIV infection and requires surgical and prosthetic intervention. The prosthetic management of an HIV patient with a maxillary lesion, as well as medical status-related treatment considerations, are discussed in this article. [ABSTRACT FROM AUTHOR]

The article discusses historical inequities concerning the prevention and treatment of HIV among Hispanic American women. It presents statistics about the disproportionate incidence of HIV and AIDS among Hispanic American women, U.S. government policy, and social determinants of the health of Hispanic Americans.

Background: Men who have sex with men (MSM) are a priority group in Malawi's national response to Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS). There are limited data on service providers' acceptability to deliver appropriate sexual health services in relation to HIV prevention, care and treatment targeting the MSM. We assessed attitudes of healthcare providers already working, health professions students and faculty at health professions training institutions regarding the provision of MSM focused HIV related health services.Methods: We conducted a qualitative study between April and May 2017 in Lilongwe, Malawi. We purposively recruited 15 participants (5 health service providers, 5 health professions students and 5 faculty of tertiary health training institutions) among whom individual in-depth interviews were conducted. Interviews were audio recorded, transcribed and analysed thematically.Results: Participants recognized MSM as having health needs and rights. Participants generally expressed willingness to deliver appropriate healthcare because they perceived this as their professional responsibility. Participants suggested that it was the responsibility for MSM to disclose their sexual orientation and or preferences when they access care such that healthcare providers better anticipate their care needs. They suggested a need to increase the availability of MSM-centered and friendly health services as well as trained providers that are non-judgmental, non-discriminatory and have respect for people's right to health care access.Conclusion: Despite widespread poor attitudes against MSM in Malawi, health service providers and health professions students and faculty accepted and were willing to provide MSM-focused health services. The acceptability and willingness of health service providers, health professions students and faculty to provide health services to MSM offer hope and scope for efforts to strengthen the delivery of health services and quality of care to MSM in Malawi. [ABSTRACT FROM AUTHOR]

Introduction: Many people living with human immunodeficiency virus (HIV) do not enter healthcare until late in their infection course. We analysed the trends in baseline CD4 count among HIV patients in Sungai Buloh Hospital, Malaysia. Material and methods: A retrospective cohort study was conducted from the Malaysian AIDS Treatment Cohort (MATCH) database of HIV-positive patients registered in our HIV clinic between 2007 and 2016. Results: Out of 8757 patients, 84.5% were male. Heterosexual (38.2%) and homosexual (36.4%) contacts were the predominant HIV risk factors. Approximately 44% of patients presented late to care (CD4 < 200 cells/µl). The overall median baseline CD4 cell count was 235 cells/µl. The yearly median baseline CD4 cell count increased steadily from 176 cells/µl in 1997 to a peak of 271 cells/µl in 2015 (p for trend < 0.001). By HIV exposure risks, homosexual risk group consistently had the highest median baseline CD4 cell count, followed by heterosexual and intravenous drug use (IVDU) risk groups. The proportion of late presenters significantly decreased over time from 57.0% in 2007 to 44.0% in 2016 (p for trend < 0.001). Conclusions: The trends in baseline CD4 cell counts are improving, but the proportion of late presenters is still significant. Innovative strategies are imperative to identify HIV infected individuals early and link them promptly to HIV care. [ABSTRACT FROM AUTHOR]

Introduction: Considering the high prevalence of depression and the positive effects of physical activity on human immunodeficiency virus (HIV)-positive patients, the current study was conducted. The aim was to determine the prevalence of depression and to investigate its association with physical activity among people living with HIV (PLWH). Material and methods: This descriptive-analytic study was conducted on 122 PLWH aged over 18 years. The participants referred to the Counselling Centre for Behavioural Diseases in Kerman City, Iran in 2018. The data collection tools were the Beck Depression Inventory and the Baecke Physical Activity Inventory. Results: The mean scores of physical activity were 6.97 and 7.03 in depressed and non-depressed people, respectively. However, no significant relationship was observed between physical activity and depression. More than 70% of patients were affected by different types of depression; mild, moderate, and severe. Except the education and occupation factors (p = 0.01), no statistically significant difference was observed between participants' demographic characteristics and depression status. Conclusions: Considering the high prevalence of depression and low levels of physical activity among PLWH, and in order to achieve the 90-90-90 goals, serious measures should be taken in this regard. The PLWH are required to pay more attention to their physical activity along with their medicines. Furthermore, sports facilities should be provided for these patients. It is also recommended that they use the instructions provided by the psychologists and sports specialists in the Counselling Centres for Behavioural Diseases. [ABSTRACT FROM AUTHOR]

Introduction: While increased healthcare engagement and antiretroviral therapy (ART) adherence occurs during pregnancy, women living with HIV (WLWH) are often lost to follow-up after delivery. We sought to evaluate postpartum retention in care and viral suppression and to identify associated factors among WLWH in a large public hospital in Atlanta, Georgia.Methods: Data from the time of entry into prenatal care until 24 months postpartum were collected by chart review from WLWH who delivered with ≥20 weeks gestational age from 2011 to 2016. Primary outcomes were retention in HIV care (two HIV care visits or viral load measurements >90 days apart) and viral suppression (<200 copies/mL) at 12 and 24 months postpartum. Obstetric and contraception data were also collected.Results: Among 207 women, 80% attended an HIV primary care visit in a mean 124 days after delivery. At 12 and 24 months, respectively, 47% and 34% of women were retained in care and 41% and 30% of women were virally suppressed. Attending an HIV care visit within 90 days postpartum was associated with retention in care at 12 months (aOR 3.66, 95%CI 1.72-7.77) and 24 months (aOR 4.71, 95%CI 2.00-11.10) postpartum. Receiving ART at pregnancy diagnosis (aOR 2.29, 95%CI 1.11-4.74), viral suppression at delivery (aOR 3.44, 95%CI 1.39-8.50), and attending an HIV care visit within 90 days postpartum (aOR 2.40, 95%CI 1.12-5.16) were associated with 12-month viral suppression, and older age (aOR 1.09, 95% CI 1.01-1.18) was associated with 24-month viral suppression.Conclusions: Long-term retention in HIV care and viral suppression are low in this population of postpartum WLWH. Prompt transition to HIV care in the postpartum period was the strongest predictor of optimal HIV outcomes. Efforts supporting women during the postpartum transition from obstetric to HIV primary care may improve long-term HIV outcomes in women. [ABSTRACT FROM AUTHOR]

Health workers in 21 government health facilities in Zambia and South Africa linked spatial organisation of HIV services and material items signifying HIV-status (for example, coloured client cards) to the risk of People Living with HIV (PLHIV) 'being seen' or identified by others. Demarcated HIV services, distinctive client flow and associated-items were considered especially distinguishing. Strategies to circumvent any resulting stigma mostly involved PLHIV avoiding and/or reducing contact with services and health workers reducing visibility of PLHIV through alterations to structures, items and systems. HIV spatial organisation and item adjustments, enacting PLHIV-friendly policies and wider stigma reduction initiatives could combined reduce risks of identification and enhance the privacy of health facility space and diminish stigma. [ABSTRACT FROM AUTHOR]

Objectives: To report the efavirenz serum concentrations in TB/HIV-coinfected Ugandan adults on concomitant anti-TB treatment and analyse factors associated with elevated concentrations in this specific population.Methods: Serum efavirenz concentrations in TB/HIV-coinfected Ugandan adults on efavirenz-based ART (600 mg daily) were measured onsite at 2, 8, 12 and 24 weeks of concomitant anti-TB treatment, including rifampicin. Genetic analysis was done retrospectively through real-time PCR by allelic discrimination (CYP2B6 516G>T, rs3745274). Univariable and multivariable logistic regression analyses were done to assess factors potentially associated with elevated efavirenz serum concentrations.Results: A total of 166 patients were included in the analysis. The median age was 34 (IQR = 30-40) years, 99 (59.6%) were male, the median CD4 cell count was 195 (IQR = 71-334) cells/mm3 and the median BMI was 19 (IQR = 17.6-21.5)  kg/m2. Almost half of all patients (82, 49.4%) had at least one efavirenz serum concentration above the reference range of 4 mg/L. The serum efavirenz concentrations of patients with genotype CYP2B6 516 TT were consistently above 4 mg/L and significantly higher than those of patients with GG/GT genotypes: CYP2B6 516 TT 9.6 mg/L (IQR = 7.3-13.3) versus CYP2B6 516 GT 3.4 mg/L (IQR = 2.1-5.1) and CYP2B6 516 GG 2.6 mg/L (IQR = 1.3-4.0) (Wilcoxon rank-sum test: P < 0.0001).Conclusions: A large proportion of our study participants had at least one efavirenz serum concentration >4 mg/L. The CYP2B6 516 TT genotype was the strongest predictor of high concentration. Physicians should be vigilant that efavirenz serum concentrations may be elevated in patients on concomitant anti-TB treatment and that individualized care is warranted whenever possible. [ABSTRACT FROM AUTHOR]

Objectives. To examine the effect of patient navigation models on changes in housing status and its subsequent effects on HIV outcomes for 700 people living with HIV (PLWH) who were unstably housed with co-occurring substance use and psychiatric disorders across 9 demonstration sites in the United States between the years of 2013 and 2017. Methods. Self-reported housing status was collected at baseline, and at 6 and 12 months during the intervention. HIV outcomes included linkage and retention in care, antiretroviral therapy prescription, and viral suppression collected via chart review. Results. In the 12 months after the intervention, 59.6% transitioned to more stable housing. Compared with those who became or remained unstably housed, participants with greater stability achieved significantly higher rates of retention (adjusted odds ratio [AOR] = 2.12; 95% confidence interval [CI] = 1.11, 4.05), were more likely to be prescribed antiretroviral therapy (AOR = 2.06; 95% CI = 1.62, 2.63), and had higher rates of viral suppression (AOR = 1.62; 95% CI = 1.03, 2.55). Conclusions. The use of patient navigators to create a network of services for PLWH who are unstably housed can improve housing stability and lead to improvements in HIV-related outcomes. [ABSTRACT FROM AUTHOR]

Objective: To measure linkage to care and antiretroviral therapy (ART) initiation among newly diagnosed individuals with HIV in a rural Tanzanian community.Methods: We included all new HIV diagnoses of adults made between 2014 and 2017 during community- or facility-based HIV testing and counselling (HTC) in a rural ward in northwest Tanzania. Community-based HTC included population-level HIV serological testing (sero-survey), and facility-based HTC included a stationary, voluntary HTC clinic (VCT) and an antenatal clinic (ANC) offering provider-initiated HTC (ANC-PITC). Cox regression models were used to compare linkage to care rates by testing modality and identify associated factors. Among those in care, we compared initial CD4 cell counts and ART initiation rates by testing modality.Results: A total of 411 adults were newly diagnosed, of whom 10% (27/265 sero-survey), 18% (3/14 facility-based ANC-PITC) and 53% (68/129 facility-based VCT) linked to care within 90 days. Individuals diagnosed using facility-based VCT were seven times (95% CI: 4.5-11.0) more likely to link to care than those diagnosed in the sero-survey. We found no difference in linkage rates between those diagnosed using facility-based ANC-PITC and sero-survey (P = 0.26). Among individuals in care, 63% of those in the sero-survey had an initial CD4 count >350 cells/mm3 vs. 29% of those using facility-based VCT (P = 0.02). The proportion who initiated ART within 1 year of linkage to care was similar for both groups (94% sero-survey vs. 85% facility-based VCT; P = 0.16).Conclusions: Community-based sero-surveys are important for earlier diagnosis of HIV-positive individuals; however, interventions are essential to facilitate linkage to care. [ABSTRACT FROM AUTHOR]

Since September 2015, the World Health Organization has recommended antiretroviral therapy (ART) for all persons with human immunodeficiency virus (HIV) infection, regardless of clinical stage or CD4 count (1). This Treat All policy was based on evidence that ART initiation early in HIV infection as opposed to waiting for the CD4 count to decline to certain levels (e.g., <500 cells/mm3, per previous guidelines), was associated with reduced morbidity, mortality, and HIV transmission (2-4). Further, approximately half of persons enrolled in non-ART care that included monitoring for HIV disease progression (i.e., in pre-ART care) were lost to follow-up before becoming ART-eligible (5). India, the country with the third largest number of persons with HIV infection in the world (2.1 million), adopted the Treat All policy on April 28, 2017. This report describes implementation of Treat All during May 2017-June 2018, by India's National AIDS Control Organization (NACO) and partners, by facilitating ART initiation among persons previously in pre-ART care at 46 ART centers supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR)* in six districts in the states of Maharashtra and Andhra Pradesh. Partners supported these 46 ART centers in identifying and attempting to contact persons who were enrolled in pre-ART care during January 2014-April 2017, and educating those reached about Treat All. ART center-based records were used to monitor implementation indicators, including ART initiation. A total of 9,898 (39.6%) of 25,007 persons previously enrolled in pre-ART care initiated ART; among these 9,898 persons, 6,315 (63.8%) initiated ART after being reached during May 2017-June 2018, including 1,635 (16.5%) who had been lost to follow-up before ART initiation. NACO scaled up efforts nationwide to build ART centers' capacity to implement Treat All. Active tracking and tracing of persons with HIV infection enrolled in care but not on ART, combined with education about the benefits of early HIV treatment, can facilitate ART initiation. [ABSTRACT FROM AUTHOR]

Background: Because HIV viral suppression is essential for optimal outcomes and prevention efforts, understanding trends and predictors is imperative to inform public health policy. Objective: To evaluate viral suppression trends in people living with HIV (PLWH), including the relationship of associated factors, such as demographic characteristics and integrase strand transfer inhibitor (ISTI) use. Design: Longitudinal observational cohort study. Setting: 8 HIV clinics across the United States. Participants: PLWH receiving clinical care. Measurements: To understand trends in viral suppression (≤400 copies/mL), annual viral suppression rates from 1997 to 2015 were determined. Analyses were repeated with tests limited to 1 random test per person per year and using inverse probability of censoring weights to address loss to follow-up. Joint longitudinal and survival models and linear mixed models of PLWH receiving antiretroviral therapy (ART) were used to examine associations between viral suppression or continuous viral load (VL) levels and demographic factors, substance use, adherence, and ISTI use. Results: Viral suppression increased from 32% in 1997 to 86% in 2015 on the basis of all tests among 31 930 PLWH. In adjusted analyses, being older (odds ratio [OR], 0.76 per decade [95% CI, 0.74 to 0.78]) and using an ISTI-based regimen (OR, 0.54 [CI, 0.51 to 0.57]) were associated with lower odds of having a detectable VL, and black race was associated with higher odds (OR, 1.68 [CI, 1.57 to 1.80]) (P  < 0.001 for each). Similar patterns were seen with continuous VL levels; when analyses were limited to 2010 to 2015; and with adjustment for adherence, substance use, or depression. Limitation: Results are limited to PLWH receiving clinical care. Conclusion: HIV viral suppression rates have improved dramatically across the United States, which is likely partially attributable to improved ART, including ISTI-based regimens. However, disparities among younger and black PLWH merit attention. Primary Funding Source: National Institutes of Health. Understanding trends and predictors of HIV viral suppression is essential for optimal outcomes and prevention efforts and is imperative to inform public health policy. This observational cohort study of patients treated at 8 HIV clinics across the United States evaluated viral suppression trends in people living with HIV, including the relationship of associated factors, such as demographic characteristics and use of integrase strand transfer inhibitors. [ABSTRACT FROM AUTHOR]

Background Dolutegravir (DTG) is a next-generation HIV integrase inhibitor (INI) with an increased genetic barrier to resistance with respect to raltegravir (RAL) or elvitegravir (EVG). Few data are available on the durability of DTG-containing regimens. Objectives We aimed at investigating the duration of the DTG-containing regimen, the occurrence of an HIV-1 RNA blip, and factors associated with DTG virological response. Study design From the Antiviral Response Cohort Analysis database, we selected 89 HIV-1-positive four-class-experienced subjects who started DTG after receiving RAL or EVG. Factors associated with durability and virological response were analysed by logistic regression. Results After a median duration of 18.8 [0.4–76.2] months, 79/89 (88.8%) subjects were still on DTG. All subjects remaining on DTG at the end of follow-up had undetectable HIV-1 RNA, compared to 5/10 subjects who discontinued DTG. DTG discontinuation was less frequent in patients who had experienced ≥10 regimens (HR 0.11, p = 0.040). The probability of having an HIV-1 RNA positive value at the last follow-up significantly increased in patients with non-B HIV-1 subtype (HR 5.77, p < .001) and significantly decreased in patients with CD4 nadir >200/μL (HR 0.29, p = 0.038), with more than 10 previous regimens (HR 0.27, p = 0.040), and who harbored virus with IN mutations (HR 0.12, p = 0.023) at DTG start. Conclusions After previous exposure to first-generation INIs, treatment with DTG showed long durability and did not show virological rebound after virological suppression. Subjects infected with a non-B HIV-1 subtype had a greater risk of having detectable HIV-1 RNA at the last observation. [ABSTRACT FROM AUTHOR]

In the U.S. Black women with HIV face numerous psychosocial challenges, particularly trauma, racism, HIV-related discrimination, and gender role expectations, that are associated with negative HIV health outcomes and low medical treatment adherence. Yet many of these factors are unaddressed in traditional cognitive behavioral approaches. This study presents a case series of a tailored cognitive behavioral treatment approach for Black women living with HIV. Striving Towards EmPowerment and Medication Adherence (STEP-AD) is a 10-session treatment aimed at improving medication adherence for Black women with HIV by combining established cognitive behavioral strategies for trauma symptom reduction, strategies for coping with race- and HIV-related discrimination, gender empowerment, problem-solving techniques for medication adherence, and resilient coping. A case series study of five Black women with HIV was conducted to evaluate the preliminary acceptability and feasibility of the treatment and illustrate the approach. Findings support the potential promise of this treatment in helping to improve HIV medication adherence and decrease trauma symptoms. Areas for refinement in the treatment as well as structural barriers (e.g., housing) in the lives of the women that impacted their ability to fully benefit from the treatment are also noted. [ABSTRACT FROM AUTHOR]

Improved survival achieved by HIV-infected patients has complicated their medical care, as increasing numbers of comorbidities have led to polypharmacy and a higher risk of drug-drug interactions. Here, evidence is provided that weight-loss drugs should be used with caution in HIV-infected patients treated with lipophilic antiretroviral drugs because of the risk of virologic failure. This is particularly relevant considering that these agents are available on the market as over-the-counter medications, thus escaping the control of the physician. [ABSTRACT FROM AUTHOR]

To achieve epidemic control of human immunodeficiency virus (HIV) infection, sub-Saharan African countries are striving to diagnose 90% of HIV infections, initiate and retain 90% of HIV-diagnosed persons on antiretroviral therapy (ART), and achieve viral load suppression* for 90% of ART recipients (90-90-90) (1). In Eswatini (formerly Swaziland), the country with the world's highest estimated HIV prevalence (27.2%), achieving 90-90-90 depends upon improving access to early ART for men and young adults with HIV infection, two groups with low ART coverage (1-3). Although community-based strategies test many men and young adults with HIV infection in Eswatini, fewer than one third of all persons who test positive in community settings enroll in HIV care within 6 months of diagnosis after receiving standard referral services (4,5). To evaluate the effectiveness of peer-delivered linkage case management† in improving early ART initiation for persons with HIV infection diagnosed in community settings in Eswatini, CDC analyzed data on 651 participants in CommLink, a community-based, mobile HIV-testing, point-of-diagnosis HIV care, and peer-delivered linkage case management demonstration project, and found that after diagnosis, 635 (98%) enrolled in care within a median of 5 days (interquartile range [IQR] = 2-8 days), and 541 (83%) initiated ART within a median of 6 days (IQR = 2-14 days), including 402 (74%) on the day of their first clinic visit (same-day ART). After expanding ART eligibility to all persons with HIV infection on October 1, 2016, 96% of 225 CommLink clients initiated ART, including 87% at their first clinic visit. Compared with women and adult clients aged ≥30 years, similar high proportions of men and persons aged 15-29 years enrolled in HIV care and received same-day ART. To help achieve 90-90-90 by 2020, the United States President's Emergency Plan for AIDS Relief (PEPFAR) is supporting the national scale-up of CommLink in Eswatini and recommending peer-delivered linkage case management as a potential strategy for countries to achieve >90% early enrollment in care and ART initiation after diagnosis of HIV infection (6). [ABSTRACT FROM AUTHOR]

Background: Systematic reviews have described high rates of attrition in patients with HIV receiving antiretroviral therapy (ART). However, migration and clinical transfer may lead to an overestimation of attrition (death and loss to follow-up). Using a newly linked national laboratory database in South Africa, we assessed national retention in South Africa's national HIV program.Methods and Findings: Patients receiving care in South Africa's national HIV program are monitored through regular CD4 count and viral load testing. South Africa's National Health Laboratory Service has maintained a database of all public-sector CD4 count and viral load results since 2004. We linked individual laboratory results to patients using probabilistic matching techniques, creating a national HIV cohort. Validation of our approach in comparison to a manually matched dataset showed 9.0% undermatching and 9.5% overmatching. We analyzed data on patients initiating ART in the public sector from April 1, 2004, to December 31, 2006, when ART initiation could be determined based on first viral load among those whose treatment followed guidelines. Attrition occurred on the date of a patient's last observed laboratory measure, allowing patients to exit and reenter care prior to that date. All patients had 6 potential years of follow-up, with an additional 2 years to have a final laboratory measurement to be retained at 6 years. Data were censored at December 31, 2012. We assessed (a) national retention including all laboratory tests regardless of testing facility and (b) initiating facility retention, where laboratory tests at other facilities were ignored. We followed 55,836 patients initiating ART between 2004 and 2006. At ART initiation, median age was 36 years (IQR: 30-43), median CD4 count was 150 cells/mm3 (IQR: 81-230), and 66.7% were female. Six-year initiating clinic retention was 29.1% (95% CI: 28.7%-29.5%). After allowing for transfers, national 6-year retention was 63.3% (95% CI: 62.9%-63.7%). Results differed little when tightening or relaxing matching procedures. We found strong differences in retention by province, ranging from 74.2% (95% CI: 73.2%-75.2%) in Western Cape to 52.2% (95% CI: 50.6%-53.7%) in Mpumalanga at 6 years. National attrition was higher among patients initiating at lower CD4 counts and higher viral loads, and among patients initiating ART at larger facilities. The study's main limitation is lack of perfect cohort matching, which may lead to over- or underestimation of retention. We also did not have data from KwaZulu-Natal province prior to 2010.Conclusions: In this study, HIV care retention was substantially higher when viewed from a national perspective than from a facility perspective. Our results suggest that traditional clinical cohorts underestimate retention. [ABSTRACT FROM AUTHOR]

In light of the chronic shortage of health professionals willing to care for HIV/AIDS patients, and rising epidemics in many Muslim countries, this qualitative study examined susceptibility and resistance to courtesy stigma as experienced by nurses, doctors, and social workers in Morocco. Forty-nine in-depth interviews provided rich insights into the process of courtesy stigma and how it is managed, within the context of interactions with Islam, interactions within the workplace (patients, other health professionals), and interactions outside the workplace (the general public, friends, and family). Theoretically, the findings extend understanding of courtesy stigma and the dirty work literature. The findings also offer practical suggestions for the development of culturally appropriate strategies to reduce susceptibility to courtesy stigmatization. This study represents the first to explore courtesy stigma as a process experienced by health professionals providing HIV/AIDS care in an Islamic country. [ABSTRACT FROM AUTHOR]

Human immunodeficiency virus (HIV) care engagement post hospital discharge is often suboptimal. Strategies to improve follow-up are needed. A quasi-experimental study was conducted among hospitalized HIV-infected patients between the period from 1 January 2013 to 30 June 2014 (preintervention period) and 1 July 2014 to 31 December 2015 (intervention period). During the intervention period, an HIV care team consisting of an Infectious Diseases physician, a nurse, a pharmacist, a social worker, and an HIV-infected volunteer made daily inpatient rounds. Prior to discharge, patients received a structured HIV education session and an outpatient appointment was scheduled for them with two telephone reminder calls following discharge. There were 240 HIV-infected patients enrolled (120 in each study period), of which the median age was 37 years (interquartile range [IQR] 28-44 years), 58% were male, 39% were newly diagnosed with HIV infection, 46% were hospitalized because of AIDS-related conditions, and the median CD4 cell count on admission was 158 cells/µl (IQR 72-382 cells/µl). The rate of HIV care engagement within 30 days after discharge was significantly higher in the intervention period compared to the preintervention period (95% versus 69%; P < 0.001). Independent factors associated with no care engagement within 30 days were patients in the preintervention period (adjusted odds ratio [aOR] 6.36; P < 0.001) and new diagnosis of HIV infection (aOR 2.77; P = 0.009). The study findings suggest that enhanced inpatient rounds, appointment reminders, and patient education were shown to be associated with improved HIV care engagement after hospital discharge. Patients with a new diagnosis of HIV infection benefit from more intense outreach. ClinicalTrials.gov Identifier: NCT02578654. [ABSTRACT FROM AUTHOR]

The Department of Veteran Affairs (VA) is the largest health care provider for individuals with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), with >28,000 Veterans with HIV/AIDS enrolled in care. Advances in medical treatment have improved the life-limiting effects of the disease, though many chronic symptoms persist. Comprehensive care is critical to manage the diverse constellation of symptoms. However, many patients face challenges to receiving optimal care due to limited resources, mistrust of health care providers, and/or co-occurring medical, psychiatric, and substance use disorders. The VA is a leader in developing integrated models of care to address these barriers. The inclusion of subspecialty mental health and substance abuse treatment in HIV care has been implemented across many VAs, with evidence of improved patient outcomes. However, neuropsychology has not traditionally been included, despite the fact that cognitive dysfunction represents one of the most ubiquitous complications of HIV/AIDS. Cognitive impairment is associated with myriad negative outcomes including medication non-adherence, reduced quality of life, and increased mortality. We contend that neuropsychologists are uniquely equipped to contribute to the comprehensive care of patients with HIV/AIDS. Neuropsychologists understand the range of factors that can impact cognition and have the requisite knowledge and skills to assess and treat cognitive dysfunction. Although we focus on HIV/AIDS, neuropsychologists often play critical roles in the provision of care for other infectious diseases (e.g. hepatitis C). [ABSTRACT FROM AUTHOR]

Mississippi has some of the most pronounced racial disparities in HIV infection in the country; African Americans comprised 37% of the Mississippi population but represented 80% of new HIV cases in 2015. Improving outcomes along the HIV care continuum, including linking and retaining more individuals and enhancing adherence to medication, may reduce the disparities faced by African Americans in Mississippi. Little is understood about clergy's views about the HIV care continuum. We assessed knowledge of African American pastors and ministers in Jackson, Mississippi about HIV and the HIV care continuum. We also assessed their willingness to promote HIV screening and biomedical prevention technologies as well as efforts to enhance linkage and retention in care with their congregations. Four focus groups were conducted with 19 African American clergy. Clergy noted pervasive stigma associated with HIV and believed they had a moral imperative to promote HIV awareness and testing; they provided recommendations on how to normalize conversations related to HIV testing and treatment. Overall, clergy were willing to promote and help assist with linking and retaining HIV positive individuals in care but knew little about how HIV treatment can enhance prevention or new biomedical technologies such as pre-exposure prophylaxis (PrEP). Clergy underscored the importance of building coalitions to promote a collective local response to the epidemic. The results of this study highlight important public health opportunities to engage African American clergy in the HIV care continuum in order to reduce racial disparities in HIV infection. [ABSTRACT FROM AUTHOR]

Background: As the number of HIV-infected women initiating lifelong antiretroviral therapy (ART) during pregnancy increases globally, concerns have emerged regarding low levels of retention in HIV services and suboptimal adherence to ART during the postpartum period. We examined the impact of integrating postpartum ART for HIV+ mothers alongside infant follow-up within maternal and child health (MCH) services in Cape Town, South Africa.Methods and Findings: We conducted a randomised trial among HIV+ postpartum women aged ≥18 years who initiated ART during pregnancy in the local antenatal care clinic and were breastfeeding when screened before 6 weeks postpartum. We compared an integrated postnatal service among mothers and their infants (the MCH-ART intervention) to the local standard of care (control)-immediate postnatal referral of HIV+ women on ART to general adult ART services and their infants to separate routine infant follow-up. Evaluation data were collected through medical records and trial measurement visits scheduled and located separately from healthcare services involved in either arm. The primary trial outcome was a composite endpoint of women's retention in ART care and viral suppression (VS) (viral load < 50 copies/ml) at 12 months postpartum; secondary outcomes included duration of any and exclusive breastfeeding, mother-to-child HIV transmission, and infant mortality. Between 5 June 2013 and 10 December 2014, a total of 471 mother-infant pairs were enrolled and randomised (mean age, 28.6 years; 18% nulliparous; 57% newly diagnosed with HIV in pregnancy; median duration of ART use at randomisation, 18 weeks). Among 411 women (87%) with primary endpoint data available, 77% of women (n = 155) randomised to the MCH-ART intervention achieved the primary composite outcome of retention in ART services with VS at 12 months postpartum, compared to 56% of women (n = 117) randomised to the control arm (absolute risk difference, 0.21; 95% CI: 0.12-0.30; p < 0.001). The findings for improved retention in care and VS among women in the MCH-ART intervention arm were consistent across subgroups of participants according to demographic and clinical characteristics. The median durations of any breastfeeding and exclusive breastfeeding were longer in women randomised to the intervention versus control arm (6.9 versus 3.0 months, p = 0.006, and 3.0 versus 1.4 months, p < 0.001, respectively). For the infants, overall HIV-free survival through 12 months of age was 97%: mother-to-child HIV transmission was 1.2% overall (n = 4 and n = 1 transmissions in the intervention and control arms, respectively), and infant mortality was 1.9% (n = 6 and n = 3 deaths in the intervention and control arms, respectively), and these outcomes were similar by trial arm. Interpretation of these findings should be qualified by the location of this study in a single urban area as well as the self-reported nature of breastfeeding outcomes.Conclusions: In this study, we found that integrating ART services into the MCH platform during the postnatal period was a simple and effective intervention, and this should be considered for improving maternal and child outcomes in the context of HIV.Trial Registration: ClinicalTrials.gov NCT01933477. [ABSTRACT FROM AUTHOR]

Background: Linkage to and retention in care for US persons living with HIV (PLWH) after release from jail usually declines. We know of no rigorously evaluated behavioral interventions that can improve this. We hypothesized that a strengths-based case management intervention that we developed for PLWH leaving jail would increase linkage/retention in care (indicated by receipt of laboratory draws) and a suppressed HIV viral load (VL) in the year following release. Methods and findings: We conducted a quasi-experimental feasibility study of our intervention for PLWH jailed in Atlanta. We recruited 113 PLWH in jail starting in 2014. “SUCCESS” (ustained, nbroken onnection to are, ntry ervices, and uppression) began in jail and continued post-release. Subjects who started the intervention but subsequently began long-term incarcerations were excluded from further analysis. Persons who were retained in the intervention group were compared to contemporaneously incarcerated PLWH who did not receive the intervention. Identities were submitted to an enhanced HIV/AIDS reporting system (eHARS) at the state health department to capture all laboratories drawn. Both community engagement and care upon jail return were assessed equally. For 44 intervention participants released to Atlanta, 50% of care occurred on subsequent jail stays, as documented with EventFlow software. Forty-five receiving usual services only were recruited for comparison. By examining records of jail reentries, half of participants and 60% of controls recidivated (range: 1–8 returns). All but 6 participants in the intervention and 9 subjects in the comparison arm had ≥1 laboratory recorded in eHARS post-release. Among the intervention group, 52% were retained in care (i.e., had two laboratory studies, > = 3 months apart), versus 40% among the comparison group (OR = 1.60, 95% CI (0.71, 3.81)). Both arms showed improved viral load suppression. Conclusions: There was a trend towards increased retention for PLWH released from jail after SUCCESS, compared to usual services. Measuring linkage at all venues, including jail-based clinics, fully captured engagement for this frequently recidivating population. Trial registration: ClinicalTrials.gov [ABSTRACT FROM AUTHOR]

Background: Failure to keep people living with HIV engaged in life-long care and treatment has serious implications for individual and population-level health. Nested within a four-province study of HIV care and treatment outcomes, we explored the dynamic role of social and service-related factors influencing retention in HIV care in Zambia. Methods: From a stratified random sample of 31 facilities, eight clinics were selected, one urban and one rural from each province. Across these sites we conducted a total of 69 in-depth interviews, including with patients (including pregnant women) engaged in-care (n = 28), disengaged from care (n = 15), engaged facility transferee (n = 12), and friends/family of deceased patients (n = 14). At the same sites we conducted 24 focus group discussions with a total of 192 lay and professional healthcare workers (HCWs). Two-day observations in each of the eight facilities helped triangulate data on operational context, provider relations and patient-provider interactions. We ordered and analysed data using an adapted version of Ewart’s Social Action Theory. Results: Three overarching findings emerged. First, the experience of living with HIV and engaging in HIV care in Zambia is a social, not individual experience, influenced by social and gendered norms and life goals including financial stability, raising family and living stigma-free. Second, patients and their networks act collectively to negotiate and navigate HIV care. Anticipated responses from social network influenced patients’ willingness to engage in care, while emotional and material support from those networks influenced individuals’ capacity to remain in HIV care. Lastly, health system factors were most influential where they facilitated or undermined peoples’ collective approach to health service use. Participants living with HIV reported facilitation of both their initial and continued engagement in care where services involved social networks, such as during couples testing and community outreach. Conversely, service features that were poorly aligned with respondents’ social reality (e.g. workplace obligations) hindered long-term engagement. Conclusions: This study moves beyond listing barriers or socio-ecological groupings, to explain how social and health systems interact to produce HIV care outcomes. Our findings challenge the implicit assumption of individual agency underpinning many retention studies to highlight the social nature of illness and healthcare utilization for HIV in Zambia. This understanding of collective action for accessing and remaining in HIV care should underpin future efforts to revise and reform HIV and potentially other chronic service models and systems. [ABSTRACT FROM AUTHOR]

Background: South Africa has the largest HIV epidemic in the world, with 19% of the global number of people living with HIV, 15% of new infections and 11% of AIDS-related deaths. Even though HIV testing is mandated in all hospital-based facilities in South Africa (SA), it is rarely implemented in the Emergency Department (ED). The ED provides episodic care to large volumes of undifferentiated who present with unplanned injury or illness. Thus, the ED may provide an opportunity to capture patients with undiagnosed HIV infection missed by clinic-based screening programs. Methods and findings: In this prospective exploratory study, we implemented the National South African HIV testing guidelines (counselor initiated non-targeted universal screening with rapid point of care testing) for 24-hours a day at Frere Hospital in the Eastern Cape from September 1st to November 30th, 2016. The purpose of our study was to quantify the burden of undiagnosed HIV infection in a South African ED setting. Furthermore, we sought to evaluate the effectiveness of the nationally recommended HIV testing strategy in the ED. All patients who presented for care in the ED during the study period, and who were clinically stable and fully conscious, were eligible to be approached by HIV counseling and testing (HCT) staff to receive a rapid point-of-care HIV test. A total of 2355 of the 9583 (24.6%) patients who presented to the ED for care during the study period were approached by the HCT staff, of whom 1714 (72.8%) accepted HIV testing. There was a high uptake of HIV testing (78.6%) among a predominantly male (58%) patient group who mostly presented with traumatic injuries (70.8%). Four hundred (21.6%) patients were HIV positive, including 115 (6.2%) with newly diagnosed HIV infection. The overall prevalence of HIV infection was twice as high in females (29.8%) compared to males (15.4%). Both sexes had a similar prevalence of newly diagnosed HIV infection (6.0% for all females and 6.4% for all males) in the ED. Conclusions: Overall there was high HIV testing acceptance by ED patients. A non-targeted testing approached revealed a high HIV prevalence with a significant burden of undiagnosed HIV infection in the ED. Unfortunately, a counselor-driven HIV testing approach fell short of meeting the testing needs in this setting, with over 75% of ED patients not approached by HCT staff. [ABSTRACT FROM AUTHOR]

Objectives: A number of studies have been conducted to identify the self-care strategies that are used by persons living with chronic illnesses to manage their symptoms, but little work has been done to identify the primary information source for these self-care strategies.Methods: We conducted an anonymous online survey with 1373 persons living with HIV to identify the self-care strategies they use to manage 28 commonly experienced symptoms. Following their report of their symptoms and self-care strategies, we asked an open-ended question to identify where the participant obtained the information. We applied iterative content analysis of the narrative data and multi-nominal regression to identify which demographic factors were significantly related to each information source category.Results: Respondents reported a total of 8539 information sources for their self-care strategies categorized as follows: Common sense/Self-experience, Healthcare professional, Internet, Literature, Multiple Sources, Social Support, and TV ads.Conclusions: We found that respondents with no college education were significantly more likely to report the use of the Internet as the information source for their self-care strategies. On the other hand, males as compared to females were significantly less likely to use the Internet and significantly more likely to use TV ads. [ABSTRACT FROM AUTHOR]

Background: Different forms of HIV-related stigma are now firmly established in all HIV-affected countries across the world, including Thailand. These stigmas adversely affect access to care and other types of support needed by people living with HIV [PLHIV]. Data specific to differences in HIV-related attitudes, behaviors and beliefs between Thai PLHIV and health care workers [HCWs] are scarce. Objective: To investigate and compare differences in HIV-related attitudes, behaviors and beliefs between PLHIV and HCWs. This study aimed at comparing stigma-related attitudes among PLHIV and HCWs in Thailand. Materials and Methods: This questionnaire-based study was conducted in June 2014 in HCWs employed at and PLHIV receiving care from Siriraj Hospital, Thailand's largest university-based national tertiary referral center. Results: Ninety-one HCWs and 61 PLHIV were included. Counseling for safe sex practice and appropriate family planning were considered as stigma at higher proportion among PLHIV than did HCWs (p = 0.006 and 0.012, respectively). Moreover, attending special clinic was also a stigma issue concerned by PLHIV (p = 0.006). Issues including sexually promiscuous, people avoiding interaction with PLHIV, gossiped by others, expelled from their places of residency, and stigmatized by mass media appeared to be a concern by only small proportion of PLHIV (less than 25% of PLHIV). Conclusion: The present study emphasized the differences in attitude among HCWs and PLHIV regarding HIV-related stigma in Thailand health care setting. Safe sex advice, appropriate family planning counseling, and setting special clinic for PLHIV were considered HIV stigma-influenced behaviors in a higher proportion of PLHIV than HCWs. [ABSTRACT FROM AUTHOR]

The HPTN 065 (TLC-Plus) study tested the feasibility and effectiveness of using financial incentives (FIs) to increase linkage to care (L2C) among individuals with newly diagnosed HIV and those out of care in the Bronx, NY and Washington, DC. Qualitative data collection with a subset of participating patients and staff focused on experiences with and attitudes about the FI intervention. Semi-structured interviews were conducted with 15 patients and 14 site investigators. Four focus group discussions were conducted with a total of 15 staff members. The use of FIs for L2C was generally viewed favorably. Patients were grateful and benefited financially, but sites had some challenges implementing the program. Challenges included the timing and sensitive introduction of the intervention immediately after an HIV diagnosis, negative attitudes towards paying people for health behaviors, and the existence and strength of existing linkage programs. Future programs should consider optimal timing and presentation of FIs. [ABSTRACT FROM AUTHOR]

Effective antiretroviral therapy (ART) reduces plasma HIV RNA viral load (VL) to undetectable levels and its effectiveness depends on consistent adherence. Consistent adherence and use of safe sex practices may substantially decrease the risk of HIV transmission. We sought to explore the potential association between self-reported nonadherence to ART and engaging in unsafe sexual practices capable of transmitting HIV. Using clinical and audio computer-assisted self-interview data from the prospective HIV Outpatient Study from 2007 to 2014, we assessed the frequency of self-reported ART nonadherence during the three days prior to the survey among HIV-infected persons in care and factors associated with self-reported ART nonadherence. Of 1729 patients included in this analysis (median age = 48 years, 74.3% men who have sex with men), 17% were nonadherent, 15% had a detectable VL, and 42% reported condomless anal or vaginal sex in the past six months. In multivariable analysis, self-reported nonadherence was independently associated with younger age (adjusted odds ratio [aOR] 0.8 per additional ten years, [95% CI] 0.7-1.0), non-Hispanic black race/ethnicity (aOR 1.9; 95% CI 1.4-2.6 versus white), public health insurance (aOR 1.6, 95% CI 1.2-2.3 compared with private), survey date in 2011-2014 versus 2007-2010 (aOR 0.7, 95% CI 0.5-0.9), CD4 cell count ≥ 500 versus < 200 cells/mm3 (aOR 0.3, 95% CI 0.2-0.5), greater number of ART regimen doses (aOR 1.6, 95% CI 1.3-2.2), and binge drinking (aOR 1.4, 95% CI, 1.1-1.9). In this analysis, self-reported nonadherence was not associated with engaging in condomless sex. [ABSTRACT FROM AUTHOR]

As people living with HIV (PLWH) live longer, increased understanding of individuals' values and perceptions of successful aging can assist health providers in working with PLWH to set meaningful goals as they age. The purpose of this qualitative study was to understand how PLWH define successful aging and their perceptions of contributors to successful aging. Fourteen men and ten women over the age of 50 years (mean age 57 years; mean time since diagnosis 18 years) participated in individual interviews. Interviews were analyzed using directed content analysis. Six themes emerged: accepting limitations, staying positive, maintaining social supports, taking responsibility, living a healthy lifestyle, and engaging in meaningful activities. The participants emphasized individual control. This highlights the importance of working with PLWH to understand their values and aspirations, and create patient-centered goals. From a research perspective this reinforces calls to include the subjective experiences of older adults in developing successful aging criteria. [ABSTRACT FROM AUTHOR]

Reports of sexualised drug taking (chemsex) have increased significantly in recent years. There is currently limited intelligence on chemsex outside of London. An anonymous survey was promoted via several sources including voluntary services and a sexual health clinic in order to establish the risks associated with chemsex, and how support services can best be tailored to meet the needs of those in Greater Manchester, UK. Quantitative and qualitative data were collected on demographics, drug use, sexual practices and barriers and facilitators to accessing support. Fifty-two men who have sex with men completed the online survey. Thirty-nine (75%) were HIV-positive and 11 (21%) were hepatitis C virus (HCV) positive, all of whom were HIV/HCV co-infected. The most commonly used drugs were mephedrone (81%) and gamma hydroxybutyrate/gamma butyrolactone (79%). Nineteen (37%) reported ever injecting drugs. High-risk sexual practices were reported by respondents. Barriers to accessing support included a fear of being recognised. Findings demonstrate those engaging in chemsex are participating in a number of high-risk sexual practices, taking substances with significant risks and administering these substances in potentially high-risk ways. Results demonstrate the need for promotion of existing services, with key areas to target where chemsex sessions are most commonly arranged. Results may be useful in other metropolitan cities, both for commissioning and tailoring of chemsex support services. [ABSTRACT FROM AUTHOR]

Lung infection in human immunodeficiency virus (HIV)-positive individuals remains an important cause of morbidity and mortality, even in the current antiretroviral therapy era. Pneumonia is the most common cause of admission in HIV-positive individuals in our centre as reported in a previously published study. The objective of this retrospective observational study was to further characterize these admissions, with respect to index of disease severity at presentation, organisms identified, and investigations pursued including bronchoalveolar lavage (BAL). There were 123 unique patients accounting for a total of 209 admissions from 2005 to 2015. An organism was isolated in only 33% of all admissions (68/209). The most common organism was Pneumocystis jirovecii with a frequency of 29% of all admissions. Eighty-seven percent of presentations were mild, and 13% were moderate by CURB-65 criteria. A total of 39 BALs were performed, of which 27 yielded an organism (69%). Considering the burden of disease, low diagnostic yield of the current diagnostic strategy and increased morbidity and mortality caused by pneumonia in HIV-positive individuals, further methods are needed to more accurately target therapy. The preponderance of mild disease in this study suggests that better diagnostic tests may identify individuals that can be candidates for outpatient therapy. [ABSTRACT FROM AUTHOR]

Background: Early presentation for HIV care is vital as an initial tread in the UNAIDS 90-90-90 targets. However, late presentation for HIV care (LP) challenges achieving the targets. This study assessed the prevalence, trends, outcomes and risk factorsfor LP.Methods: A 12 year retrospective cohort study was conducted using electronic medical records extracted from an antiretroviral therapy (ART) clinic at Jimma University Teaching Hospital. LP for children refers to moderate or severe immune-suppression, or WHO clinical stage 3 or 4 at the time of first presentation to the ART clinics. LP for adults refers to CD4 lymphocyte count of < 200 cells/ μl and < 350 cells/μl irrespective of clinical staging, or WHO clinical stage 3 or 4 irrespective of CD4 count at the time of first presentation to the ART clinics. Binary logistic regression was used to identify factors that were associated with LP, and missing data were handled using multiple imputations.Results: Three hundred ninety-nine children and 4900 adults were enrolled in ART care between 2003 and 15. The prevalence of LP was 57% in children and 66.7% in adults with an overall prevalence of 65.5%, and the 10-year analysis of LP showed upward trends. 57% of dead children, 32% of discontinued children, and 97% of children with immunological failure were late presenters for HIV care. Similarly, 65% of dead adults, 65% of discontinued adults, and 79% of adults with immunological failure presented late for the care. Age between 25- < 50 years (AOR = 0.4,95% CI:0.3-0.6) and 50+ years (AOR = 0.4,95% CI:0.2-0.6), being female (AOR = 1.2, 95% CI: 1.03-1.5), having Tb/HIV co-infection (AOR = 1.6, 95% CI: 1.09-2.1), having no previous history of HIV testing (AOR = 1.2, 95% CI: 1.1-1.4), and HIV care enrollment period in 2012 and after (AOR = 0.8, 95% CI: 0.7-0.9) were the factors associated with LP for Adults. For children, none of the factors were associated with LP.Conclusions: The prevalence of LP was high in both adults and children. The majority of both children and adults who presented late for HIV care had died and developed immunological failure. Effective programs should be designed and implemented to tackle the gap in timely HIV care engagement. [ABSTRACT FROM AUTHOR]

Background: Engagement with HIV medical care is critical to successful HIV treatment and prevention efforts. However, in Ukraine, delays in the timely initiation of HIV treatment hamper viral suppression. By January 01, 2016, only 126,604 (57.5%) of the estimated 220,000 people living with HIV (PLWH) had registered for HIV care, and most (55.1%) of those who registered for HIV care in 2015 did that at a late stage of infection. In the US, Anti-Retroviral Treatment and Access to Services (ARTAS) intervention successfully linked newly diagnosed PLWH to HIV services using strengths-based case management with a linkage coordinator. To tailor the ARTAS intervention for Ukraine, we conducted a qualitative study with patients and providers to understand barriers and facilitators that influence linkage to HIV care.Methods: During September-October 2014, we conducted 20 in-depth interviews with HIV-positive patients and two focus groups with physicians in infectious disease, sexually transmitted infection (STI), and addiction clinics in Dnipropetrovsk Region of Ukraine. Interviews and focus groups were audio-recorded and transcribed verbatim. We translated illustrative quotes into English. We used thematic analysis for the data analysis.Results: Participants (20 patients and 14 physicians) identified multiple, mostly individual-level factors influencing HIV care initiation. Key barriers included lack of HIV knowledge, non-acceptance of HIV diagnosis, fear of HIV disclosure, lack of psychological support from health providers, and HIV stigma in community. Responsibility for one's health, health deterioration, and supportive provider communication were reported as facilitators to linkage to care. Expected benefits from the case management intervention included psychological support, HIV education, and help with navigating the segmented health system.Conclusions: The findings from the study will be used to optimize the ARTAS for the Ukrainian context. Our findings can also support future linkage-to-care strategies in other countries of Eastern Europe and Central Asia. [ABSTRACT FROM AUTHOR]

Characterizing HIV genetic diversity and evolution during antiretroviral therapy (ART) provides insights into the mechanisms that maintain the viral reservoir during ART. This review describes common methods used to obtain and analyze intra-patient HIV sequence data, the accumulation of diversity prior to ART and how it is affected by suppressive ART, the debate on viral replication and evolution in the presence of ART, HIV compartmentalization across various tissues, and mechanisms for the emergence of drug resistance. It also describes how CD4+ T cells that were likely infected with latent proviruses prior to initiating treatment can proliferate before and during ART, providing a renewable source of infected cells despite therapy. Some expanded cell clones carry intact and replication-competent proviruses with a small fraction of the clonal siblings being transcriptionally active and a source for residual viremia on ART. Such cells may also be the source for viral rebound after interrupting ART. The identical viral sequences observed for many years in both the plasma and infected cells of patients on long-term ART are likely due to the proliferation of infected cells both prior to and during treatment. Studies on HIV diversity may reveal targets that can be exploited in efforts to eradicate or control the infection without ART. [ABSTRACT FROM AUTHOR]

Cell-associated (CA) HIV RNA has received much attention in recent years as a surrogate measure of the efficiency of HIV latency reversion and because it may provide an estimate of the viral reservoir size. This review provides an update on some recent insights in the biology and clinical utility of this biomarker. We discuss a number of important considerations to be taken into account when interpreting CA HIV RNA measurements, as well as different methods to measure this biomarker. [ABSTRACT FROM AUTHOR]

Introduction: Although several studies have explored factors associated with loss to follow-up (LTFU) from HIV care, there remains a gap in understanding how these factors vary by setting, volume of patient and patients’ demographic and clinical characteristics. We determined rates and factors associated with LTFU in HIV care Lilongwe, Malawi. Methods: We conducted a retrospective cohort study of HIV-infected individuals aged 15 years or older at the time of registration for HIV care in 12 ART facilities, between April 2012 and March 2013. HIV-positive individuals who had not started ART (pre-ART patients) were clinically assessed to determine ART eligibility at registration and during clinic follow-up visits. ART-eligible patients were initiated on triple antiretroviral combination. Study data were abstracted from patients’ cards, facility ART registers or electronic medical record system from the date of registration for HIV care to a maximum follow-up period of 24 months. Descriptive statistics were undertaken to summarize characteristics of the study patients. Separate univariable and multivariable poisson regression models were used to explore factors associated with LTFU in pre-ART and ART care. Results: A total of 10,812 HIV-infected individuals registered for HIV care. Of these patients, 1,907 (18%) and 8,905 (82%) enrolled in pre-ART and ART care, respectively. Of the 1,907 pre-ART patients, 490 (26%) subsequently initiated ART and were included in both the pre-ART and ART analyses. The LTFU rates among patients in pre-ART and ART care were 48 and 26 per 100 person-years, respectively. Of the 9,105 ART patients with reasons for starting ART, 2,451 (27%) were initiated on ART because of pregnancy or breastfeeding (Option B+) status. Multivariable analysis showed that being ≥35 years and female were associated with decreased risk of LTFU in the pre-ART and ART phases of HIV care. However, being in WHO clinical stage 3 (adjusted risk ratio (aRR) 1.35, 95% confidence interval (CI): 1.20–1.51) and stage 4 (aRR 1.87, 95% CI: 1.62–2.18), body mass index ≤ 18.4 (aRR 1.24, 95% CI: 1.11–1.39) at ART initiation, poor adherence to clinic appointments (aRR 4.55, 95% CI: 4.16–4.97) and receiving HIV care in rural facilities (aRR 2.32, 95% CI: 1.94–2.87) were associated with increased risk of LTFU among ART patients. Being re-initiated on ART once (aRR 0.20, 95% CI: 0.17–0.22), more than once (aRR 0.06, 95% CI: 0.05–0.07), and being enrolled at a low-volume facility (aRR 0.25, 95% CI: 0.20–0.30) were associated with decreased risk of LTFU from ART care. Conclusion: A sizeable proportion of ART LTFU occurred among women enrolled during pregnancy or breast-feeding. Non- compliance to clinic and receiving ART in a rural facility or high-volume facility were associated with increased risk of LTFU from ART care. Developing effective interventions that target high-risk subgroups and contexts may help reduce LTFU from HIV care. [ABSTRACT FROM AUTHOR]

Background: The World Health Organization now recommends initiating all pregnant women on life-long antiretroviral therapy (ART), yet there is limited information about the characteristics and program outcomes of pregnant women already on ART in Africa. Our hypothesis was that pregnant women comprised an increasing proportion of those starting ART, and that sub-groups of these women were at higher risk for program attrition. Methods and findings: We used the International Epidemiology Databases to Evaluate AIDS- East Africa (IeDEA-EA) to conduct a retrospective cohort study including HIV care and treatment programs in Kenya, Uganda, and Tanzania. The cohort consecutively included HIV-infected individuals 13 years or older starting ART 2004–2014. We examined trends over time in the proportion pregnant, their characteristics and program attrition rates compared to others initiating and already receiving ART. 156,474 HIV-infected individuals (67.0% women) started ART. The proportion of individuals starting ART who were pregnant women rose from 5.3% in 2004 to 12.2% in 2014. Mean CD4 cell counts at ART initiation, weighted for annual program size, increased from 2004 to 2014, led by non-pregnant women (annual increase 20 cells/mm3) and men (17 cells/mm3 annually), with lower rates of change in pregnant women (10 cells/mm3 per year) (p<0.0001). There was no significant difference in the cumulative incidence of program attrition at 6 months among pregnant women starting ART and non-pregnant women. However, healthy pregnant women starting ART (WHO stage 1/2) had a higher rate of attrition rate (9.6%), compared with healthy non-pregnant women (6.5%); in contrast among women with WHO stage 3/4 disease, pregnant women had lower attrition (8.4%) than non-pregnant women (14.4%). Among women who initiated ART when healthy and remained in care for six months, subsequent six-month attrition was slightly higher among pregnant women at ART start (3.5%) compared to those who were not pregnant (2.4%), (absolute difference 1.1%, 95% CI 0.7%-1.5%). Conclusions: Pregnant women comprise an increasing proportion of those initiating ART in Africa, and pregnant women starting ART while healthy are at higher risk for program attrition than non-pregnant women. As ART programs further expand access to healthier pregnant women, further studies are needed to better understand the drivers of loss among this high risk group of women to optimize retention. [ABSTRACT FROM AUTHOR]

Little is known about the prevalence of and factors that influence retention in HIV-related care among Indonesian men who have sex with men (MSM) and transgender women (transwomen, or waria in Indonesian term). Therefore, we explored the driving factors of retention in care among HIV-positive MSM and waria in Indonesia. This cross-sectional study involved 298 self-reported HIV-positive MSM (n = 165) and waria (n = 133). Participants were recruited using targeted sampling and interviewed using a structured questionnaire. We applied a four-step model building process using multivariable logistic regression to examine how sociodemographic, predisposing, enabling, and reinforcing factors were associated with retention in care. Overall, 78.5% of participants were linked to HIV care within 3 months after diagnosis or earlier, and 66.4% were adequately retained in care (at least one health care visit every three months once a person is diagnosed with HIV). Being on antiretroviral therapy (adjusted odds ratio [AOR] = 6.00; 95% confidence interval [CI]: 2.93–12.3), using the Internet to find HIV-related information (AOR = 2.15; 95% CI: 1.00–4.59), and having medical insurance (AOR = 2.84; 95% CI: 1.27–6.34) were associated with adequate retention in care. Involvement with an HIV-related organization was associated negatively with retention in care (AOR = 0.47; 95% CI: 0.24–0.95). Future interventions should increase health insurance coverage and utilize the Internet to help MSM and waria to remain in HIV-related care, thereby assisting them in achieving viral suppression. [ABSTRACT FROM AUTHOR]

In this study, we explore how individuals living with HIV in the Dominican Republic strive to live a ‘normal’ life and the consequences of this pursuit of normalcy. We conducted qualitative in-depth interviews with men (n= 20) and women (n= 20) living with HIV and receiving care at two urban clinics in Santo Domingo. We analysed the data using a combination of narrative analysis and thematic coding. We aimed to identify how fears and/or lived experiences with social rejection and HIV-related stigma and discrimination shaped participants’ abilities to maintain social relationships, be economically productive and manage HIV within the context of sexual relationships. Participants used the discourse ofuna vida normal(a normal life) to frame their response to HIV. This pursuit of normality was driven by the social and economic pressures of living with a chronic condition in a context of HIV-related stigma; trying to keep things ‘normal’ further added to these pressures. We argue that the normal life discourse fails to recognise the dynamic and complex nature of negotiating this condition and may also create additional burdens for individuals living with HIV that could impact their wellbeing and preventive behaviours. [ABSTRACT FROM PUBLISHER]

Introduction: The intent was to evaluate time to match initial investment of a new, statewide correctional system telehealth program based upon cumulative savings by avoidance of transportation and custody-related costs. Materials and Methods: The setting was a statewide correctional system where prisoners received medical care through enhanced telemedicine technology supported by newly recruited specialty providers delivered through an open architecture system. The patients were incarcerated persons requiring nonemergent consultations in 10 specialties. A financial model was created to estimate transportation expenses, including vehicular use and custody staff, during the out of prison travel for traditional face-to-face care. Cost savings were then estimated by multiplying transportation expenses by the number of telehealth encounters (avoided cost) and summed cumulatively. Savings were mapped monthly. Private sector specialists were recruited, provided security clearance, trained in the use of the technology, and provided a secure site to provide services. Measurements and Main Results: Based on the financial model, 1.2 million dollars in savings, equaling the initial capital investment, were achieved at 32 months. The total number of patient telemedicine encounters increased from 2,365 (±98/month) to 3,748 during the first 32 months of operation (July 2013 through January 2016: ±117/month) with 89% of the established specialties performed by telemedicine technologies. Discussion: It was initially estimated to require 48 months to achieve the investment savings, but savings were achieved in 32 months, demonstrating greater adoption than expected. While finances were quantifiable, enhanced public safety by avoidance of out of prison time is unquantifiable, but judged to be significant. [ABSTRACT FROM AUTHOR]

Background Routine HIV clinical monitoring is vital for people living with HIV (PLHIV) after treatment initiation. The relationship between clinical visits during the first 6 months after initial antiretroviral therapy (ART) and long-term, HIV-related mortality and service retention was investigated.Methods: A retrospective ART observational research database was established based on de-identified data extracted from 6959 records of adult HIV-positive registrants held by Hunan CDC (Center for Disease Control and Prevention) between 2003 and 2013.Results: During the first 6 months of initiation into ART, 2364 (34.0%) of PLHIV had completed four scheduled visits, meeting the Chinese ART clinical monitoring standards. From 6 months onwards (up to 36 months), this group had the lowest HIV-related mortality (4.4%) compared with those who had more or less than four kept visits in the first 6 months [one visit only: adjusted hazards ratio (AHR)=3.15, 95% CI 2.24-3.88; two visits: AHR=2.24, 95% CI 1.80-3.01; three visits: AHR=1.86, 95% CI 1.69-2.05; and >4 visits: AHR=1.37, 95% CI 1.11-1.72]. Those with less than three kept visits were also at increased risk of cohort loss to follow up (ART discontinuation, prolonged service disengagement or death). A myriad of personal, clinical and social factors are identified to be associated with increased HIV-related mortality and clinical retention.Conclusions: Enabling PLHIV to complete four scheduled clinical visits during the first 6 months of ART initiation, as recommended by the Chinese CDC, is critical. [ABSTRACT FROM AUTHOR]

Background: Organization of HIV care and treatment services, including clinic staffing and services, may shape clinical and financial outcomes, yet there has been little attempt to describe different models of HIV care in sub-Saharan Africa (SSA). Information about the relative benefits and drawbacks of different models could inform the scale-up of antiretroviral therapy (ART) and associated services in resource-limited settings (RLS), especially in light of expanded client populations with country adoption of WHO's test and treat recommendation.Methods: We characterized task-shifting/task-sharing practices in 19 diverse ART clinics in Tanzania, Uganda, and Zambia and used cluster analysis to identify unique models of service provision. We ran descriptive statistics to explore how the clusters varied by environmental factors and programmatic characteristics. Finally, we employed the Delphi Method to make systematic use of expert opinions to ensure that the cluster variables were meaningful in the context of actual task-shifting of ART services in SSA.Results: The cluster analysis identified three task-shifting/task-sharing models. The main differences across models were the availability of medical doctors, the scope of clinical responsibility assigned to nurses, and the use of lay health care workers. Patterns of healthcare staffing in HIV service delivery were associated with different environmental factors (e.g., health facility levels, urban vs. rural settings) and programme characteristics (e.g., community ART distribution or integrated tuberculosis treatment on-site).Conclusions: Understanding the relative advantages and disadvantages of different models of care can help national programmes adapt to increased client load, select optimal adherence strategies within decentralized models of care, and identify differentiated models of care for clients to meet the growing needs of long-term ART patients who require more complicated treatment management. [ABSTRACT FROM AUTHOR]

Objective The goal of this pharmacist-led study was to utilize two validated instruments, Beers Criteria and Screening Tool of Older Persons' Potentially Inappropriate Prescriptions ( STOPP), to assess potentially inappropriate prescribing ( PIP) in older patients infected with the human immunodeficiency virus ( HIV) and evaluate pharmacist interventions. Design Prospective randomized interventional trial. Setting Large urban clinic providing interdisciplinary primary and HIV care for ~2700 HIV-positive publicly insured patients. Data Source A computerized electronic record search was conducted for all patients who met the two search criteria: 50 years and older, and a primary care appointment within the last 12 months. Patients After identification of 857 patients meeting the search criteria, 324 patients were randomly selected and contacted, resulting in 248 patients assessed. Measurements and Main Results Patients had a mean age of 58 years, 71% male, 44% white, and a mean CD4 count of 536 cells/mm3. Common comorbidities included hypertension (56%), depression (52%), asthma/chronic obstructive pulmonary disease (48%), dyslipidemia (39%), coronary artery disease (27%), and diabetes (22%). Patients sampled were prescribed a mean of 11.6 ± 5.7 concomitant medications (excluding antiretrovirals) with 35% receiving at least 16 medications. PIP was identified in 54% and 63% of patients using the STOPP and Beers Criteria, respectively. Twenty-five contraindicated drug interactions were identified in 20 patients. After the pharmacist visit, at least 69% of patients had at least one medication discontinued with almost 10% having six or more medications discontinued. More than 40% of patients had at least one Beers or STOPP criteria that required immediate correction by the pharmacist. Conclusions Results suggest that targeting individuals with 11 or more chronic medications would have the highest yield and greatest impact. Pharmacist-led review of medication prescribing using Beers and STOPP criteria revealed a large number of PIP, many amenable to immediate clinical pharmacist intervention. [ABSTRACT FROM AUTHOR]