Adherence to antiretroviral therapy for HIV/AIDS in Latin America and the Caribbean: Systematic review and meta-analysis

Effectiveness of an intervention to improve ART adherence among men who have sex with men living with HIV: a randomized controlled trial in three public HIV clinics in Mexico

We conducted a parallel-group randomized controlled trial in three HIV clinics in Mexico to evaluate a user-centred habit-formation intervention to improve ART adherence among MSM living with HIV. We randomized 74 participants to the intervention group and 77 to the control group. We measured adherence at one, four, and ten months through medication possession ratio and self-reported adherence. Additionally, we measured viral load, CD4 cell count, major depression disorder symptoms, and alcohol and substance use disorder at baseline, fourth and tenth months. We found no statistically significant effect on adherence between groups. However, the intervention demonstrated positive results in major depression disorder symptoms (21% vs. 6%, p = 0.008) and substance use disorder (11% vs. 1%, p = 0.018) in the fourth month. The latter is relevant because, in addition to its direct benefit, it might also improve the chances of maintaining adequate adherence in the long term. This trial was retrospectively registered at ClinicalTrials.gov (trial number NCT03410680) on 8 January 2018.Trial registration: ClinicalTrials.gov identifier: NCT03410680.

Characterizing the "HIV Care Adherence Journey" for Persons With HIV in the Philippines: Conceptual Foundation for Person-Centered Intervention

ABSTRACT

Promoting adherence to HIV care among persons with HIV (PWH) is a key component to address the rising HIV epidemic in the Philippines. HIV care adherence is a complex process that may change throughout an individual's life course or "journey" living with HIV. This qualitative study aimed to explore the HIV care adherence journey of PWH. Maximum variation sampling was used in selecting 12 PWH and 3 health care providers for in-depth online interviews analyzed using thematic analysis. The four themes that emerged to describe the HIV care adherence journey are integration, relation, navigation, and manifestation. Each theme corresponds to a unique set of activities and goals related to PWH's lived experiences as they initiate, practice, and maintain care adherence. This study provides a preliminary framework to characterize the HIV care adherence journey as a dynamic, complex, and multifaceted phenomenon, which can help to inform holistic interventions to support PWH.

Pathways to Poor Adherence to Antiretroviral Therapy Among People Living with HIV: The Role of Food Insecurity and Alcohol Misuse

Daily adherence to antiretroviral therapy (ART) increases the length and quality of life of people living with HIV (PLHIV). We explored whether socioeconomic status directly impacts ART adherence and whether part of the effect is mediated by pathways through alcohol misuse or food insecurity. A cross-sectional study was conducted in Rio de Janeiro/Brazil (November/2019 to March/2020) with PLHIV aged ≥ 18 years. Validated instruments were used to measure alcohol use, food insecurity, and ART adherence. Using structural equation modeling we assessed the direct and indirect effects of variables on ART adherence. Participants reported significant challenges: hunger: 12%, alcohol use: 64%, and missing ART doses: 24%. Results showed that lower socioeconomic status increased poor adherence and that this effect was mediated through higher food insecurity. Alcohol misuse also increased poor adherence through a strong direct effect. Providing socio-economic support coupled with interventions to mitigate alcohol's harmful impact can aid HIV care.

Adherence to option B + antiretroviral therapy and associated factors in pregnant and breastfeeding women in Sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

To assess the adherence to option B + antiretroviral therapy (ART) and associated factors in pregnant and breastfeeding women in Sub-Saharan Africa (SSA).

METHODS

We conducted a comprehensive search from 01st January 2012 to 03rd October 2022, across four databases: PubMed, Scopus, Proquest Central, and Index Medicus Africain, to identify studies focused on pregnant and/or breastfeeding women living with HIV and receiving option B+ ART in SSA. Studies reporting adherence data were included in the meta-analysis. Were excluded studies published before 01st January 2012, grey literature, systematic reviews, and meta-analysis studies. Articles selection and data extraction were performed independently by two reviewers. We evaluated pooled adherence and pooled association between various factors and adherence using a random-effects model.

RESULTS

Overall, 42 studies involving 15,158 participants across 15 countries contributed to the meta-analysis. The overall pooled adherence was 72.3% (95% CI: 68.2-76.1%). Having high education level (pooled odds ratio (OR): 2.25; 95% CI: 1.57-3.21), living in urban area (pooled OR: 1.75; 95% CI: 1.10-2.81), disclosing status to a family/partner (pooled OR: 1.74; 95% CI: 1.27-2.40), having a support system (pooled OR: 3.19; 95% CI: 1.89-5.36), receiving counseling (pooled OR: 3.97; 95% CI: 2.96-5.34), initiating ART at early clinical HIV stage (pooled OR: 2.22; 95% CI: 1.08-4.56), and having good knowledge on PMTCT/HIV (pooled OR: 2.71; 95% CI: 1.40-5.25) were factors significantly associated with adherence to option B + ART.

CONCLUSIONS

Despite the implementation of option B+ ART, the level of adherence among pregnant and breastfeeding women in SSA falls short of meeting the critical thresholds for viral load suppression as outlined in the 95-95-95 objectives set for 2025. These objectives are integral for achieving HIV elimination, and in turn, preventing HIV mother-to-child transmission. To bridge this gap, urgent tailored interventions based on individual and structural factors are essential to enhance adherence within these subgroups of women. This targeted approach is crucial in striving towards the HIV elimination target in SSA.

Impact of Protease Inhibitor-Based Highly Active Antiretroviral Therapy on Fetal Subcutaneous Fat Tissue in HIV-Pregnant Women in a Middle-Income Country

BACKGROUND

HIV infection continues to be a global public health challenge, affecting approximately 1.7 million reproductive-aged women. Protease inhibitor-based highly active antiretroviral therapy (PI-HAART) has significantly reduced the risk of vertical transmission of HIV from mother to child. Nevertheless, concerns linger regarding the long-term effects, particularly on body composition, notably subcutaneous fat tissue (SFT). Although HIV-associated lipodystrophy syndrome (LS) has been well documented in adults and older children, its impact on fetuses exposed to PI-HAART remains underexplored. This study aims to evaluate SFT in the fetuses of HIV-pregnant women exposed to PI-HAART, assessing the potential clinical implications.

METHODS

We conducted a comparative study between HIV-pregnant women receiving PI-HAART and an HIV-negative control group. Fetometry measurements were obtained via 3D ultrasound. SFT in the fetal arm and thigh segments was assessed. Data were analyzed using lineal multivariate regression and receiver-operating characteristics (ROC)-curve analysis.

RESULTS

Fetuses exposed to PI-HAART exhibited a significant reduction in subcutaneous fat, particularly in the proximal third-middle union of the femur (coefficient: -2.588, p = 0.042). This reduction was correlated with lower newborn serum glucose levels (65.7 vs. 56.1, p = 0.007; coefficient: -1.277, p = 0.045).

CONCLUSIONS

Our study sheds light on the connection between PI-HAART, fetal subcutaneous fat, and neonatal health. These findings might reveal the long-lasting effects of PI-HAART on newborns and children's well-being. Our results emphasize the need for a more balanced approach to managing pregnant women with HIV in developing countries and open new venues for research on the impact of intrauterine PI-HAART exposure on energy metabolism and fetal programming.

Real-world effectiveness of WHO recommended first-line antiretroviral therapies: a cohort study from a middle-income country

We estimate the effectiveness of antiretroviral therapy (ART) among individuals receiving HIV care in Rio de Janeiro, Brazil. Adults (18y+) initiating ART between Jan/2008 and Dec/2018 (follow-up through Dec/2020) were included. First-line ART (two nucleoside reverse transcriptase inhibitors plus one antiretroviral from another class) was categorized into four categories: non-nucleoside reverse transcriptase inhibitor/NNRTI-based, protease inhibitor/PI-based, integrase strand transfer inhibitor/INSTI-based, and single-tablet regimen (STR, Tenofovir 300mg + Lamivudine 300mg + Efavirenz 600mg). Effectiveness (viral load ≤50 copies/µL) was evaluated at 6(3-9) and 12(9-15) months from ART initiation. Bayesian logistic regression models were used to quantify the association between exposure and outcomes while accounting for missing data. Overall, 1863(57%), 652(19.9%), 412(12.6%), and 342(10.5%) individuals used, respectively, NNRTI-based, PI-based, INSTI-based regimens, and STR. Compared to NNRTIs, the odds of viral suppression with INSTI-based regimens was 76% higher (adjusted OR:1.76, 95%CI:1.23-2.51) at six months but no higher at 12 months. Older age, higher education, CD4 count ≥500 cells/mm3 and viral load <100,000 copies/µL at ART initiation increased the odds of viral suppression. Viral suppression at six months was the strongest predictor of viral suppression at 12 months. These results highlight population groups that could benefit from close monitoring during the first year of ART.

Profile of the cohort of people being treated for HIV infection in the SUS, Brazil, 2015-2018

OBJECTIVE

To build an integrated database of individual and service data from the cohort of people who started antiretroviral therapy (ART), from 2015 to 2018, in Brazil.

METHODS

Open cohort study that includes people aged 15 years or older who started ART from 2015 to 2018, with follow-up in services of the Brazilian Unified Health System (SUS), and who responded to the 2016/2017 Qualiaids national survey. The source of individual data was the related HIV database, derived from the probabilistic linkage between data from the SUS systems of diagnostic information, medication, tests, and deaths. The data source for the services was the services' response database to the Qualiaids survey. After analysis of consistency and exclusions, the database of individuals was deterministically related to the database of services.

RESULTS

The cohort comprised 132,540 people monitored in 941 SUS services. Of these services, 59% are located in the Southeast region and 49% followed 51 to 500 cohort participants. The average performance of organization and management of patient care ranged from 29% to 75%. Most of the cohort participants are male, black and mixed, aged between 20 and 39 years old, and have between 4 and 11 years of schooling. Median baseline T-CD4 was 419 cells/mm3, 6% had an episode of tuberculosis, and 2% died of HIV disease.

CONCLUSION

For the first time in Brazil, this cohort provides the opportunity for a joint analysis of individual factors and services in the production of positive and negative clinical outcomes of HIV treatment.

Development, feasibility testing and perceived benefits of a new app to help with adherence to antiretroviral therapy in people living with HIV in Brazil

BACKGROUND

Despite the availability of antiretroviral therapy (ART) in many countries, people living with HIV still experience difficulties with treatment. We propose a new smartphone mobile application to assist in adherence to ART. This study aimed to describe this new mobile application's development (content construction and usability), feasibility testing (recruitment, retention rates [attendance], satisfaction) and primary perceived benefits.

METHODS

Two consecutive studies were conducted. First, people living with HIV, health care workers and experts in information technology provided feedback to improve the content and usability of the app. After changes in the app were implemented according to the feedback, a second study was performed to assess the feasibility and perceived benefits. Effects on self-reported adherence and perceived well-being were also assessed.

RESULTS

Scores of participants (N = 11) showed differences in adherence (effect size .43) and well-being (effect size .45) after using the app. However, the differences did not reach statistical significance. Observing scores individually, six out of 11 participants improved their overall adherence scores, and seven out of 11 participants improved their perceived well-being scores. Recruitment was 95%, and attendance at sessions was 62.5%. In general, the participants were satisfied with the intervention and viewed the app as an informative tool.

CONCLUSION

The results are promising and allow us to recommend further studies with the app.

Adherence to option B+ PMTCT program and its predictors among HIV-positive women in Ethiopia. A systematic review and meta-analysis

Background

Previously, few studies investigated level of adherence to option B+ lifelong antiretroviral therapy (ART) in Ethiopia. However, their findings were inconsistent. Therefore, this review aimed to determine the pooled magnitude of adherence to option B+ lifelong ART and its predictors among human immune virus (HIV)-positive women in Ethiopia.

Methods

A comprehensive web-based search was conducted using PubMed, Cochrane Library, Science Direct, Google scholar, and African Journals Online databases to retrieve relevant articles. STATA 14 statistical software was used to carry out the meta-analysis. We used the random effects model to account for the large heterogeneity across included studies. Egger's regression test in conjunction with funnel plot and I ² statistics were utilized to assess publication bias and heterogeneity among included studies respectively.

Result

Twelve studies with a total of 2927 study participants were involved in this analysis. The pooled magnitude of adherence to option B+ lifelong ART was 80.72% (95% confidence interval [CI]: 77.05-84.39; I ² = 85.4%). Disclosure of sero-status (OR 2.58 [95% CI: 1.55-4.3]), receiving counseling (OR 4.93 [95% CI: 3.21-7.57]), attending primary school and above (OR 2.45 [95% CI: 1.31-4.57]), partner support (OR 2.24 [95% CI: 1.11, 4.52]), good knowledge about prevention of mother-to-child transmission (PMTCT) (OR 4.22 [95% CI: 2.02-8.84]), taking less time to reach health facility (OR 1.64 [95% CI: 1.13-2.4]), and good relation with care provider (OR 3.24 [95% CI: 1.96-5.34]) were positively associated with adherence. Whereas, fear of stigma and discrimination (OR 0.12 [95% CI: 0.06-0.22]) and advanced disease stage (OR 0.59 [95% CI: 0.37-0.92]) were negatively associated.

Conclusion

The level of adherence to option B+ lifelong ART was suboptimal. Strengthened comprehensive counseling and client education on PMTCT, HIV status disclosure, and male partner involvement are important to eliminate mother to child transmission and control the pandemic.

Factors Associated with Adherence to Treatment in Patients with HIV and Diabetes Mellitus

We aim to identify the factors that influence the therapeutic adherence of subjects with chronic disease. The design followed in this work was empirical, not experimental, and cross-sectional with a correlational objective. The sample consisted of a total of 400 subjects (199 patients with HIV and 201 patients with diabetes mellitus). The instruments applied for data collection were a sociodemographic data questionnaire, the 4-item Morisky Medication Adherence Scale (MMAS-4) and the Coping Strategies Questionnaire. In the group of subjects with HIV, that the use of emotional coping strategies was related to lower adherence to treatment. On the other hand, in the group of subjects with diabetes mellitus, the variable related to compliance with treatment was the duration of illness. Therefore, the predictive factors of adherence to treatment were different in each chronic pathology. In the group of subjects with diabetes mellitus, this variable was related to the duration of the disease. In the group of subjects with HIV, the type of coping strategy used predicted adherence to treatment. As a result of these results, it is possible to develop health programmes to promote, from nursing consultations to adherence to treatment of patients with HIV and diabetes mellitus.

Medición de adherencia a antirretrovirales con métodos múltiples en La Romana, República Dominicana

RESUMEN

Objetivo.

El objetivo fue desarrollar una herramienta para medir los niveles de adherencia al tratamiento antirretroviral (la TARV) en un entorno de escasos recursos, a partir de la combinación de cuatro métodos de medición de adherencia.

Métodos.

Revisión retrospectiva de 500 expedientes médicos de personas que viven con VIH, elegidos de manera aleatoria desde octubre del 2017 hasta enero del 2020. Se midió la adherencia a la TARV combinando cuatro métodos de medición (porcentaje de cobertura de la TARV recetada, recogida de la TARV en farmacia, nivel de carga viral y autoinforme de adherencia). Se realizaron pruebas de chi al cuadrado con P <0,05 para diferencias estadísticamente significativas y regresión binaria logística para identificar probabilidades de adherencia óptima y subóptima. Realizamos pruebas de Spearman para correlación de categorías y alfa de Cronbach para medir la consistencia interna de la herramienta.

Resultados.

Obtuvimos 497 calificaciones de adherencia. De estas, 307 (61,8%) usuarios se calificaron como adherentes, 141(28,4%) como semiadherentes y 49 (9,8%) como no adherentes. Se encontró una mayor probabilidad de adherencia óptima en grupos de 60 años o más (odds ratio [OR]: 1,6; IC95%: 0,8-3,5) sin diferencia entre hombres y mujeres (OR: 0,9; IC95%: 0,7-1,4). La prueba de Spearman informó una relación (r = 0,8) entre los niveles de carga viral y la calificación final, y la prueba alfa de Cronbach arrojó una modesta consistencia interna (α = 0,7).

Conclusiones.

Se desarrolló una herramienta para medir adherencia en un entorno de escasos recursos. La herramienta presenta niveles modestos de consistencia interna y una correlación fuerte en la categoría de carga viral y adherencia.

Elucidating the Gene Signatures and Immune Cell Types in HIV-Infected Immunological Non-Responders by Bioinformatics Analyses

Objective

Numerous studies have reported on the pathogenesis of poor immune reconstitution (PIR) after antiretroviral treatment in human immunodeficiency virus (HIV) patients. However, fewer studies focused on both immune-related genes (IRGs) and immune cells, and the correlation between IRGs and immune cells was evaluated via bioinformatics analyses.

Methods

Gene expression profiling of GSE143742 from the Gene Expression Omnibus (GEO) database was analyzed to get differentially expressed immune-related genes (DEIRGs). The enrichment analysis and protein-protein interaction (PPI) networks of DEIRGs were established. The relative fractions of 22 immune cell types were detected using the "CIBERSORT". The correlation analysis between DEIRGs and immune cells was constructed to discover the potential IRGs associated with immune cells. A logistic regression diagnostic model was built, and a receiver operating characteristic (ROC) curve was performed to evaluate the model's diagnostic efficacy. The CMap database was used to find molecules with therapeutic potential. RT-qPCR was used to verify the expression of the hub DEIRGs.

Results

We identified eight types of significantly changed immune cells and five hub IRGs in INRs. The DEIRGs were mainly enriched in lymphocyte activation, receptor-ligand activity, and T cell receptor signaling pathway. The correlation analysis showed that the expression of TNF, CXCR4 and TFRC correlate with CD8 cells, resting mast cells, activated NK cells, and naïve CD4 cells in INRs. Meanwhile, TFRC and IL7R relate to activated NK cells and resting memory CD4 cells respectively in IRs. A diagnostic model was constructed using multiple logistic regression and nine small molecules were identified as possible drugs.

Conclusion

In this study, we suggested that the process of PIR might be related to TNF, CXCR4, TFRC, CD48, and IL7R. And these IRGs play roles in regulating immune-competent cells. And our constructed diagnostic model has excellent effectiveness. Moreover, some small-molecule drugs are screened to alleviate PIR.

Incorporating social determinants of health into the mathematical modeling of HIV/AIDS

Currently, it is estimated that 37.6 million people are living with the HIV/AIDS virus worldwide, placing HIV/AIDS among the ten leading causes of death, mostly among low- and lower-middle-income countries. Despite the effective intervention in the prevention and treatment, this reduction did not occur equally among populations, subpopulations and geographic regions. This difference in the occurrence of the disease is associated with the social determinants of health (SDH), which could affect the transmission and maintenance of HIV. With the recognition of the importance of SDH in HIV transmission, the development of mathematical models that incorporate these determinants could increase the accuracy and robustness of the modeling. This article aims to propose a theoretical and conceptual way of including SDH in the mathematical modeling of HIV/AIDS. The theoretical mathematical model with the Social Determinants of Health has been developed in stages. For the selection of SDH that were incorporated into the model, a narrative literature review was conducted. Secondly, we proposed an extended model in which the population (N) is divided into Susceptible (S), HIV-positive (I), Individual with AIDS (A) and individual under treatment (T). Each SDH had a different approach to embedding in the model. We performed a calibration and validation of the model. A total of 31 SDH were obtained in the review, divided into four groups: Individual Factors, Socioeconomic Factors, Social Participation, and Health Services. In the end, four determinants were selected for incorporation into the model: Education, Poverty, Use of Drugs and Alcohol abuse, and Condoms Use. the section "Numerical simulation" to simulate the influence of the poverty rate on the AIDS incidence and mortality rates. We used a Brazilian dataset of new AIDS cases and deaths, which is publicly available. We calibrated the model using a multiobjective genetic algorithm for the years 2003 to 2019. To forecast from 2020 to 2035, we assumed two lines of poverty rate representing (i) a scenario of increasing and (ii) a scenario of decreasing. To avoid overfitting, we fixed some parameters and estimated the remaining. The equations presented with the chosen SDH exemplify some approaches that we can adopt when thinking about modeling social effects on the occurrence of HIV. The model was able to capture the influence of the employment/poverty on the HIV/AIDS incidence and mortality rates, evidencing the importance of SDOH in the occurrence of diseases. The recognition of the importance of including the SDH in the modeling and studies on HIV/AIDS is evident, due to its complexity and multicausality. Models that do not take into account in their structure, will probably miss a great part of the real trends, especially in periods, as the current on, of economic crisis and strong socioeconomic changes.

Adherence to Antiretroviral Therapy in People Living with HIV/AIDS: A Cross-Sectional Study

Adherence to antiretroviral therapy (ART) is essential to suppress HIV replication, preserve immune competence, and ensure quality of life for people living with HIV/AIDS. This is a cross-sectional study to assess adherence to ART in HIV-infected adults and its associated factors in São Carlos, SP, Brazil, from June 2018 to January 2019. Standardized interviews were conducted covering demographic, clinical, and laboratory characteristics and instruments to assess compliance to treatment (CEAT-VIH), HIV/AIDS-targeted quality of life (HAT-QoL), and self-efficacy expectations of adherence (SEA-ART). Each variable was analyzed for association with adherence to ART, by refilling at least 90% of the prescribed doses in the 6 months before the interview date. The study consisted of 220 participants, with a mean age of 43 years, 60.5% male, and 24.5% men who have sex with men. Previous consumption of alcohol or illicit drugs was reported by 44.1% of participants and current or previous smoking by 34.1%. The most common regimen was two nucleoside reverse transcriptase inhibitors combined with one non-nucleoside reverse transcriptase inhibitor (37.3%). The adherence to ART was 62%, and the factors associated with it were living alone [adjusted odds ratio (aOR) 2.79], not having an active sexual life (aOR 0.43), not being a smoker (aOR 0.36), having a CD4 count ≥350 cells/mm³ (aOR 2.50), and having a SEA-ART Score >100 (aOR 1.94). The fear of disclosing HIV status could make adherence to treatment difficult. This could be the reason that living alone and not having an active sexual life have been associated with better adherence. Encouraging healthy lifestyle habits and promoting self-efficacy tools can also improve adherence.

New diagnosis of mother-to-child transmission of HIV in 8 Latin-American countries during 2018

Background

Important prevention efforts have led to a reduction in mother-to-child transmission of HIV (MTCT) globally. However, new cases of paediatric HIV infections still occur. Early diagnosis of new HIV infections is essential to start an appropriate antiretroviral treatment to avoid childhood morbidity and mortality related to infection. The aim of this study was to describe the new cases of MTCT in Latin-American referral hospitals.

Methods

A retrospective, multicentre and descriptive study of the new cases of MTCT diagnosed during 2018 in 13 referral hospitals from 8 Latin-American countries (Costa Rica, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, and Panama) belonging to PLANTAIDS (Paediatric Network for Prevention, Early Detection and Treatment of HIV in Children), was conducted. PLANTAIDS is included in CYTED (Ibero-American Programme of Science and Technology for Development).

Results

Eighty-one children (40.7% males) were included, median age at diagnosis of 2.33 years (IQR:0.7–4.7). Less than 3% of women knew their HIV diagnosis before pregnancy. More than 80% of them were diagnosed after delivery, 8.7% during pregnancy, and 2.9% at delivery. Only one patient underwent antiretroviral therapy (ART) prior to pregnancy. At diagnosis, 50.0% of the children presented with an advanced stage of disease (stage C following the current CDC classification for HIV infection), and 34.4% had less than 15% CD4⁺ cells/mm³. The time elapsed between delivery and the maternal diagnosis was correlated with the age of children at diagnosis, ρ = 0.760, p < 0.001. Younger age at diagnosis (p = 0.03), a smaller number of previous hospitalizations (p < 0.01), and better immunovirological status (p < 0.01) were found in children whose mothers knew their HIV status at delivery, compared to mothers who were not aware of it.

Conclusions

Although MTCT in Latin America has declined in recent years, our series shows there are still cases that indicate some failures in prevention, being a critical point to improve an earlier diagnosis of pregnant women. Half of the children were diagnosed in an advanced stage of disease and the delay in maternal diagnosis entailed a worse clinical and immunological child’ prognosis.

A conceptual model of alcohol use and adherence to antiretroviral therapy: systematic review and theoretical implications for mechanisms of action

Alcohol consumption is one of the most prevalent correlates of antiretroviral therapy (ART) adherence, yet causal processes underlying this association remain largely unexplored. The goal of this systematic review was to develop a conceptual model that describes the causal effect of alcohol consumption on ART nonadherence. We reviewed 230 studies that examined the association between alcohol consumption and ART adherence with three primary aims: (1) to replicate and extend previous reviews of the literature, (2) to summarize and critique study designs capable of answering questions about temporal overlap and (3) to summarize potential mechanisms of action. A model of alcohol-associated ART nonadherence was proposed to guide future work, integrating general theories of ART adherence and theory on the psychological and behavioral effects of alcohol intoxication. The conceptual model describes two mechanistic processes-prospective memory impairment and interactive toxicity beliefs/avoidance behaviors-involved in alcohol-associated intentional and unintentional nonadherence, respectively. This model can be used to guide future research on the causal processes involved in the frequently observed correlation between alcohol consumption and adherence.

Multilevel Analysis of Individual and Neighborhood Characteristics Associated with Viral Suppression Among Adults with HIV in Rio de Janeiro, Brazil

Understanding the impact of neighborhood context on viral suppression outcomes may help explain health disparities and identify future interventions. We assessed the relationship between individual characteristics, neighborhood socioeconomic context, and viral suppression using multilevel logistic regression models. Adults with HIV initiating antiretroviral therapy (ART) between 2000 and 2017, who resided in Rio de Janeiro and had an HIV-1 RNA level (viral load) measured 90-270 days after ART initiation were included. Overall, 83.9% achieved viral suppression. Participants who were older, had a higher level of education, and identified as heterosexual cisgender men and cisgender men-who-have-sex-with-men had increased odds of viral suppression. Later calendar year of ART initiation carried the strongest association with viral suppression, reflecting the increased effectiveness and tolerability of ART over time. Neighborhood socioeconomic indicators did not predict viral suppression in unadjusted or adjusted analyses, which may result from the integrated care provided in our health care facility together with Brazil's universal treatment.

A Technology-Based Intervention Among Young Men Who Have Sex With Men and Nonbinary People (The Conectad@s Project): Protocol for A Vanguard Mixed Methods Study

Background

In many parts of the world, including Brazil, uptake for biomedical interventions has been insufficient to reverse the HIV epidemic among key populations at high risk for HIV, including men who have sex with men. Young MSM (YMSM), particularly Black YMSM, have high HIV incidence, low viral suppression, and low preexposure prophylaxis (PrEP) uptake and adherence. Therefore, novel approaches to increase the HIV biomedical interventions uptake by YMSM are urgently needed.

Objective

We describe the Conectad@s Project, which aims to: (1) estimate the prevalence and incidence of HIV and other sexually transmitted infections, the onset of sexual risk behavior, and barriers to biomedical interventions among YMSM aged 18 to 24 years in Rio de Janeiro, Brazil; and (2) conduct a technology-based adherence intervention study to promote a rapid linkage of YMSM to HIV care or prevention, and support and sustain adherence.

Methods

A cross-sectional survey will be conducted with 400 YMSM recruited using respondent-driven sampling (RDS) adapted for social media-based sampling, preceded by a formative phase. HIV and sexually transmitted infections testing will be conducted, including early HIV infection biomarker detection. Behavioral, partnership, network, and structural measures will be collected through structured questionnaires. All individuals recruited for the survey will have access to HIV risk assessment, antiretroviral therapy (ART), PrEP, prevention counseling, and a technology-based adherence intervention. Those who accept the adherence intervention will receive weekly text messages via a social networking app (WhatsApp) for 24 weeks, with follow-up data collected over 48 weeks.

Results

The Conectad@s project has been approved by our local institutional review board (#CAAE 26086719.0.0000.4262) in accordance with all applicable regulations. Questionnaires for the RDS survey and intervention were developed and tested in 2020, formative interviews were conducted in January and February 2021 to guide the development of the RDS, and enrollment is planned to begin in early 2022.

Conclusions

The Conectad@s Project is a vanguard study that, for the first time, will apply digital RDS to sample and recruit YMSM in Brazil and rapidly connect them to ART, PrEP, or prevention counseling through a technology-based adherence intervention. RDS will allow us to estimate HIV prevalence among YMSM and measure HIV infection biomarkers in the context of the onset of risky behavior. The data will lay the groundwork to adapt and implement HIV prevention strategies, identify barriers to the earliest HIV infection diagnosis, immediate ART or PrEP initiation, and detect new clusters of HIV transmission.

International Registered Report Identifier (IRRID)

DERR1-10.2196/34885

Characteristics of psychosocial interventions to improve ART adherence in people living with HIV: A systematic review

The HIV/AIDS pandemic continues to be a significant global public health crisis. The main HIV/AIDS treatment is the antiretroviral therapy (ART), which is highly effective but depends on the patient's adherence to be successful. However, the adherence to antiretroviral therapy remains unsatisfactory across different populations, which raises considerable difficulties at both individual and collective levels. Suboptimal adherence to ART can be overcome through multidisciplinary management that includes evidence-based psychosocial interventions. Existing reviews on these interventions have focused mainly on studies with experimental designs, overlooking valuable interventions whose evidence comes from different study designs. Here, we aimed to carry out a comprehensive review of the current research on psychosocial interventions for ART adherence and their characteristics including studies with different designs. We conducted a systematic review following PRISMA guidelines. We searched five databases (Pubmed, EBSCO, LILACS, WoS and SCIELO) for articles reporting a psychosocial intervention to improve treatment adherence for people living with HIV (adults). The quality of each study was analyzed with standardized tools, and data were summarized using a narrative synthesis method. Twenty-three articles were identified for inclusion, and they demonstrated good to fair quality. Individual counseling was the most frequent intervention, followed by SMS reminders, education, and group support. Most interventions combined different strategies and self-efficacy was the most common underlying theoretical framework. This review provides insight into the main characteristics of current psychosocial interventions designed to improve ART treatment adherence. PROSPERO number: CRD42021252449.

Real-time Feedback to Improve HIV Treatment Adherence in Pregnant and Postpartum Women in Uganda: A Randomized Controlled Trial

We assessed an intervention aimed at improving adherence to antiretroviral therapy (ART) among pregnant and postpartum women living with HIV (PPWLH). We randomized 133 pregnant women initiating ART in Uganda to receive text reminders generated by real time-enabled electronic monitors and data-informed counseling through 3 months postpartum (PPM3) or standard care. Intention-to-treat analyses found low adherence levels and no intervention impact. Proportions achieving ≥95% adherence in PPM3 were 16.4% vs. 9.1% (t = -1.14, p = 0.26) in intervention vs. comparison groups, respectively; 30.9% vs. 29.1% achieved ≥80% adherence. Additional analyses found significant adherence declines after delivery, and no effect on disease progression (CD4-cell count, viral load), though treatment interruptions were significantly fewer in intervention participants. Per-protocol analyses encompassing participants who used adherence monitors as designed experienced better outcomes, suggesting potential benefit for some PPWLH. The study was registered on ClinicalTrials.Gov (NCT02396394).

Antiretroviral Treatment Adherence Level and Associated Factors Among Adult HIV-Positive Patients on Both HIV/AIDS Care Models: Comparative Study in Selected Hospitals of Western Ethiopia, 2019

Background

Many studies investigating antiretroviral treatment (ART) adherence found the majority of patients had suboptimal adherence for a variety of different reasons. The study aimed to compare the ART adherence level and associated factors among adult human immune deficiency virus (HIV) positive patients on both care models in selected hospitals.

Methods

An institution-based comparative cross-sectional study was conducted among 463 HIV positive patients on ART. The study samples were selected using systematic random sampling, and pretested semi-structured interviewer administered questionnaire was used to collect data. Binary and multivariable logistic regression analyses were used to see the association between outcome and predictors using odds ratio with a 95% confidence interval to estimate the strength of the association.

Results

The study had a response rate of 445 (96.1%). Of the study participants, 325 (73%) and 120 (27%) were from the routine and appointment spacing models, respectively. Patients on the appointment spacing model had higher levels of optimum adherence (87.5% vs 74.27%, respectively; p = 0.006). Patients’ satisfaction with health service delivery (OR = 0.31, 95%: CI 0.11–0.84), antiretroviral drug dosage taken per day (OR = 3, 95%: CI 1.16–8.1), disclosure of HIV status (OR = 0.30, 95%: CI 0.09–0.93), distance from patient residency to health facility (OR = 0.11, 95%: CI 0.03–0.34), the memory aids used (OR = 0.02, 95%: CI 0.01–0.05), and type of HIV/AIDS care model (OR= 0.24, 95%: CI 0.1–0.6) were factors significantly associated with ART adherence level.

Conclusion

ART patients on the appointment spacing model had higher optimum ART adherence levels than those on the routine schedule due to factors like satisfaction status, disclosure status, type of memory aid used, type of ART care model used, and distance from the care facility. Therefore, promoting adherence enablers and alleviating barriers of ART adherence will improve ART adherence levels.

The Relationship of Alcohol to ART Adherence Among Black MSM in the U.S.: Is it Any Different Among Black MSM in the South?

Alcohol-using Black MSM (Men who have sex with men) are disproportionately impacted by HIV in the U.S.-particularly in the southern U.S.-despite the availability of antiretroviral therapy (ART). The purpose of this study was to summarize the current evidence on alcohol use and ART adherence among Black MSM in the U.S. and in the South and to identify future research needs. A systematic review was conducted using eight databases to identify relevant peer-reviewed articles published between January 2010 and April 2021. The authors also snowballed remaining studies and hand-searched for additional studies. Including both quantitative and qualitative studies, five published studies examined alcohol and ART adherence among Black MSM in the U.S. The search identified 240 articles, the study team reviewed 114 in full-text and determined that only five met the inclusion criteria. Three of the five included studies identified alcohol use as a barrier to ART adherence. In conclusions, the general lack of literature on HIV disparities among alcohol-using Black MSM in the U.S. (specifically in the South) indicates a critical need for research on this population's unique risks and needs to inform the development of tailored interventions.

Factors associated with antiretroviral therapy adherence among people living with HIV in Haiti: a cross-sectional study

BACKGROUND

Socioeconomic, demographic and clinical factors can affect adherence to treatment among people living with HIV (PLH) and potentially have an impact on their prognosis and survival. The main objective of this study was to assess these factors as potential barriers to adherence among patients receiving care in central Haiti.

METHODS

A cross-sectional study was conducted among PLH receiving antiretroviral therapy (ART) at the TB/HIV clinic at St. Therese Hospital in Hinche, Haiti. A total of 426 potential participants were approached during their follow-up visits from June to August 2019, of whom 411 participated in the study. After giving informed consent, study participants completed a structured interview that included the Self-Report Item Scale (SRIS), a standard measure, to assess adherence. Socio-demographic, economic and clinical factors were assessed for their association with adherence.

RESULTS

The 411 participating patients represented 39% of the patient population at the TB/HIV clinic during the timeframe of the study. The mean age was 43.7 years (range: 19-80), 65.5% were female and 78.1% had only achieved a primary level of schooling. Nearly 78% had received ART for less than 10 years, 3.41% reported having poor adherence and 28% less than excellent adherence. Factors related to poor adherence in bivariate analysis were age less than 40 years (OR: 6.32, 95% CI 2.04-10.58, p < 0.01) and inability to meet basic needs (OR: 2.70, 95% CI 1.04-7.0, p = 0.03).

CONCLUSIONS

To improve medication adherence, the hospital should strengthen patient counselling of younger recipients of ART and provide financial assistance and other social service interventions. Studies should be implemented in other HIV management centers in Haiti and similar contexts to examine barriers to ART adherence with the goal of improving prognosis and survival in the long-term among PLH in resource-limited setting.

Factors associated with viremia in people living with HIV on antiretroviral therapy in Guatemala

INTRODUCTION

Viral suppression prevents HIV transmission and disease progression, but socio-economic and clinical factors can hinder the goal of suppression. We evaluated factors associated with viral non suppression (VNS) and persistent viremia (PV) in people living with HIV (PLHIV) receiving antiretroviral therapy (ART) in Guatemala.

METHODS

We conducted a cross sectional analysis using data from an ongoing cohort of PLHIV attending the largest HIV clinic in Guatemala. Univariable and multivariable analyses were conducted between PLHIV with viral suppression and detectable viremia. VNS was defined as most recent HIV RNA ≥ 200 copies/ml and PV as two consecutive HIV RNA ≥ 200 copies/ml.

RESULTS

Of 664 participants, 13.3% had VNS and 7.1% had PV. In univariable analysis disaggregated by gender, low income, poor education, perceived difficulty attending healthcare, and alcohol use were associated with VNS in men while low CD4 at diagnosis, multiple prior ART regimens and treatment interruptions were significant in both genders. Multiple prior ART regimens (adjusted Odds Ratio (aOR) 2.82, [95% confidence interval (CI) 1.59, 4.99], p < 0.01), treatment interruptions (aOR 4.51, [95% CI 2.13, 9.58], p < 0.01), excessive alcohol consumption (aOR 2.56, [95% CI 1.18, 5.54], p < 0.05) perceived difficulty attending healthcare (aOR 2.07, [ 95% CI 1.25, 3.42], p < 0.01) and low CD4 at diagnosis (aOR 2.34, 95% [CI 1.30, 4.20], p < 0.01) were independently associated with VNS on multivariable regression.

CONCLUSIONS

We conclude that socio-economic and clinical factors influence viral suppression in our cohort and vary between men and women. Gender specific approaches are necessary to achieve the 90% suppression goal.

HIV and antiretroviral treatment knowledge gaps and psychosocial burden among persons living with HIV in Lima, Peru

This study aims to describe knowledge on HIV and antiretroviral (ARV) treatment and psychosocial factors among people living with HIV (PLWH) in Lima, Perú, to explore characteristics associated to this knowledge, and determine its impact on sustained viral suppression. A cross-sectional survey was conducted among 171 PLWH at the largest referral health care center in Lima. The psychosocial factors measured were depression, risk of alcoholism, use of illegal drugs and disclosure. A participant had "poor knowledge" when less than 80% of replies were correct. Sustained viral suppression was defined as two consecutive viral loads under 50 copies/mL. A total of 49% and 43% had poor HIV and ARV knowledge respectively; 48% of the study population screened positive for depression and 27% reported feeling unsupported by the person they disclosed to. The largest gaps in HIV and ARV knowledge were among 98 (57%) that did not recognize that HIV increased the risk of cancer and among 57 (33%) participants that did not disagree with the statement that taking a double dose of ARV if they missed one. Moderate depression was significantly associated to poor HIV and ARV knowledge. Non-disclosure and being on ARVs for less than 6 months were associated with not achieving sustained viral suppression. Our findings highlight important HIV and ARV knowledge gaps of PLWH and a high burden of psychosocial problems, especially of depression, among PLWH in Lima, Peru. Increasing knowledge and addressing depression and disclosure could improve care of PLWH.

Effect of pharmacist care on clinical outcomes among people living with HIV/AIDS: A systematic review and meta-analysis

BACKGROUND

Pharmacists play a significant role in the multidisciplinary care of people living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) (PLWHA). However, there is less evidence to clarify the impact of pharmacist as an individual team member on HIV care.

OBJECTIVE

This study aims to determine the effects of pharmacist intervention on improving adherence to antiretroviral therapy (ART), viral load (VL) suppression, and change in CD4-T lymphocytes in PLWHA.

METHODS

We identified relevant records from six databases (Pubmed, EMBASE, ProQuest, Scopus, Cochrane, and EBSCOhost) from inception till June 2020. We included studies that evaluated the impact of pharmacist care activities on clinical outcomes in PLWHA. A random-effect model was used to estimate the overall effect [odds ratio (OR) for dichotomous and mean difference (MD) for continuous data] with 95% confidence intervals (CIs). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to evaluate the quality of evidence. The review protocol was published on PROSPERO (CRD42020167994).

RESULTS

Twenty-five studies involving 3206 PLWHA in which pharmacist-provided intervention either in the form of education with or without pharmaceutical-care either alone or as an interdisciplinary team member were included. Eight studies were randomized controlled trials (RCTs), while 17 studies were non-RCTs. Pooled-analyses showed a significant impact of pharmacist care compared to usual care group on adherence outcome (OR: 2.70 [95%, CI 1.80, 4.05]), VL suppression (OR: 4.13 [95% CI 2.27, 7.50]), and rise of CD4-T lymphocytes count (MD: 66.83 cells/mm³ [95% CI 44.08, 89.57]). The strength of evidence ranged from moderate, low to very low.

CONCLUSION

The findings suggest that pharmacist care improves adherence, VL suppression, and CD4-T lymphocyte improvement in PLWHA; however, it should be noted that the majority of the studies have a high risk of bias. More research with more rigorous designs is required to reaffirm the impact of pharmacist interventions on clinical and economic outcomes in PLWHA.

Factors associated with self-reported adherence to daily oral pre-exposure prophylaxis among men who have sex with man and transgender women: PrEP Brasil study

Understanding the factors associated with pre-exposure prophylaxis (PrEP) adherence may help in the development of strategies to support, motivate and sustain PrEP use. This study estimated self-reported adherence, described perceived barriers and facilitators and investigated factors associated with adherence to daily oral PrEP among men who have sex with man (MSM) and transgender women after 1 year of PrEP use in Brazil. PrEP Brasil was a prospective, multicentre, open-label demonstration study with MSM and transgender women at high risk for HIV infection. We used logistic regression to evaluate factors associated with complete adherence (not forgetting to take any pills in the past 30 days) at week 48. Of 338 participants included in this analysis, 60% reported complete adherence to daily oral PrEP at week 48. Perceived barriers and facilitators to daily oral PrEP were reported by 38.2% and 98.5%, respectively. The most reported barrier and facilitator were 'I forgot to take my pills' (19.2%) and 'Associate PrEP with a daily activity/task' (58.6%), respectively. In final multivariable analysis, living in Rio de Janeiro (aOR: 0.38; 95% CI: 0.20-0.73), being transgender women (aOR: 0.22; 95% CI: 0.07-0.73), reporting stimulant use (a OR: 0.40; 95% CI: 0.20-0.80) and having any perceived barriers to daily oral PrEP (aOR: 0.12; 95% CI: 0.07-0.23) were associated with decreased odds of complete adherence. Our findings provide information for developing the best practices to promote PrEP adherence in the Brazilian context.

Evaluation of the Sociodemographic, Behavioral and Clinical Influences on Complete Antiretroviral Therapy Adherence Among HIV-Infected Adults Receiving Medical Care in Houston, Texas

Introduction

Few studies have estimated complete antiretroviral therapy (ART) adherence following HIV infection since the advent of the new ART guidelines in 2012. This study determined the prevalence and influence of sociodemographic, behavioral, and clinical factors on complete ART adherence among people living with HIV (PLWH) receiving medical care in Houston/Harris County, Texas.

Methods

Data from the Houston Medical Monitoring Project survey collected from 2009 to 2014 among 1073 participants were used in this study. The primary outcome evaluated was combined adherence, defined as complete, partial, and incomplete combined adherence based on three ART adherence types—dose, schedule, and instruction adherence. The duration living since initial HIV diagnosis was classified as <5, 5–10 and >10 years. Rao–Scott Chi-square test and multivariable proportional-odds cumulative logit regression models were employed to identify the sociodemographic, behavioral, and clinical characteristics of complete combined adherence among the three groups of PLWH living with HIV infection.

Results

More than one-half (54.4%) of PLWH had complete, 37.4% had partial, and 8.3% had incomplete combined adherence. Among these PLWH, 52.2% had been infected with HIV for >10 years, and 26.5% and 21.4% were infected for <5 years and 5–10 years, respectively. PLWH who were diagnosed <5 and 5–10 years were two times (aOR=1.71, 95% CI=1.13–2.57; aOR=1.69, 95% CI=1.10–2.59; respectively) more likely to experience complete combined adherence than those with >10 years of infection. Multiple sociodemographic, behavioral, and clinical characteristics were significantly associated with complete adherence and varied by the duration of HIV infection.

Conclusion

Measures of adherence should include all adherence types (dose, schedule, instruction), as utilizing a single adherence type will overestimate adherence level in PLWH receiving medical care. Intervention efforts to maintain adherence should target recently infected PLWH, while those aimed at improving adherence should focus on longer infected PLWH.

Barriers to HIV treatment adherence among adults living with HIV in the eastern Dominican Republic

Despite access to nationally supplied antiretroviral treatment, viral load suppression rates remain suboptimal in the Dominican Republic. Counseling and support services are available but mainly targeted to those identified as having the most need. At Clínica de Familia La Romana (CFLR) in La Romana, all patients undergo a structured baseline interview including exploration of expected barriers to care. We conducted a retrospective cohort study of a random sample of patients at CFLR with treatment initiation between 1 January 2015 and 1 December 2017 to determine if self-identified barriers to HIV care predict viral load suppression. Viral load suppression occurred in 63% of the 203 patients evaluated. Lack of food (n = 19) was significantly associated with lack of viral suppression (OR 3.0, 95% CI 1.14-7.87). Nondisclosure of HIV status (n = 24) showed evidence for a protective effect (OR 0.33; 95% CI 0.11-1.0). Further steps should be taken to address food insecurity as well as to understand associated barriers to care among individuals with food insecurity.

Poor quality of life and incomplete self-reported adherence predict second-line ART virological failure in resource-limited settings

We evaluated health-related quality of life (QoL) and self-reported incomplete adherence as predictors of early second-line antiretroviral (ART) virological failure (VF). ACTG A5273 study participants completed the ACTG SF-21 measure which has 8 QoL domains. We used exact logistic regression to assess the association of QoL at baseline and week 4 with early VF adjusted for self-reported adherence. Of 500 individuals (51% women, median age 39 years) in this analysis, 79% and 75% self-reported complete adherence (no missing doses in the past month) at weeks 4 and 24, respectively. Early VF was experienced by 7% and more common among those who self-reported incomplete adherence. Participants with low week 4 QoL scores had higher rates of early VF than participants with high scores. After adjusting for self-reported adherence at week 4, VL and CD4 at baseline, cognitive functioning, pain and mental health domains were significantly associated with subsequent early VF. In this post-hoc analysis, poorer QoL adds to self-reported incomplete adherence after 4 weeks of second-line ART in predicting VF at week 24. Evaluation is needed to assess whether individuals with poorer QoL might be targeted for greater support to reduce risk of VF.Trial registration: ClinicalTrials.gov identifier: NCT01352715.

Impact of COVID-19 Pandemic on Sexual Minority Populations in Brazil: An Analysis of Social/Racial Disparities in Maintaining Social Distancing and a Description of Sexual Behavior

We conducted a web-based survey to understand the impact of social distancing measures on Brazilian MSM and transgender/non-binary lives. A total of 3486 respondents were included in this analysis and the great majority were cismen (98%). The median age was 32 years (IQR: 27-40), 44% non-white, 36% low schooling and 38% low income. Most of participants reported HIV negative/unknown status (77%). Participants on-PrEP reported more condomless anal sex than those off-PrEP. Conversely, 24% off-PrEP were at substantial HIV-risk. PrEP/ART continuation were reported by the majority, despite reports of impediments to medication refill. Transgender/non-binary reported more mental health problems and challenges to access health care. Social and racial disparities were associated with unattainability of maintaining social distancing. Tailored social and economic support policies during COVID-19 pandemic should be made available to these populations. Challenges for PrEP/ART access will demand the implementation of innovative solutions to avoid the expansion of the HIV epidemic.

Adherence to Adjuvant Tamoxifen in Mexican Young Women with Breast Cancer

BACKGROUND

Breast cancer (BC) in young women is characterized by an unfavorable prognosis in hormone receptor-positive/HER2-negative tumors, which may be explained by low rates of tamoxifen adherence. In Mexico, up to 14% of all BC diagnoses occur in young women and no data on tamoxifen adherence has been reported.

OBJECTIVE

To estimate the rate of adherence to adjuvant tamoxifen in Mexican young women with BC (YWBC).

METHODS

A cross-sectional survey was conducted at the National Cancer Institute in Mexico City, among YWBC (≤40 years at diagnosis) receiving adjuvant tamoxifen. Adherence was measured subjectively, through self-reported surveys, and objectively, through medication possession ratio (MPR). Descriptive statistics were used to analyze sociodemographic characteristics. To compare associations between patients' characteristics and adherence, Chi-square test was used for categorical variables and Student's t-test or Mann-Whitney U-test for quantitative variables.

RESULTS

A total of 141 YWBC receiving adjuvant tamoxifen were included. Regarding subjective adherence, 95% expressed taking tamoxifen regularly, 70% reported missing 0 doses in the past 30 days, and 71.6% reported having adverse effects. Regarding objective adherence, 74.8% of patients had an MPR ≥80%. The association between subjective and objective adherence was statistically significant (p = 0.004). Subjective adherence was associated with not skipping tamoxifen doses when feeling worse. Objective adherence was associated with having a stable job, not skipping tamoxifen doses when feeling worse, taking additional medications, and time on tamoxifen treatment. Fifty-six percent considered the information on tamoxifen to be insufficient and 37% not understandable.

CONCLUSION

In our study, high subjective and objective adherence rates to adjuvant tamoxifen were reported, although an important proportion of women reported high rates of adverse effects and not fully understanding the benefits of tamoxifen. Strategies to increase tamoxifen adherence may be even more important now that longer durations of treatment or further ovarian function suppression have become the standard of care in YWBC.

Gender differences in the association between childhood sexual abuse and risk behaviors among people living with HIV in Haiti

Research shows that in the Caribbean one-third of people living with HIV continue to engage in unprotected sexual practices. Childhood sexual abuse (CSA) and HIV-related risk behaviors have been found to play a contributory role in HIV transmission. We aimed to analyze gender differences in the association between CSA and substance use and sexual risk behaviors among Haitians living with HIV. A total of 276 HIV-positive individuals participated in this study with 56% experiencing sexual abuse during childhood. Results showed that participants who experienced CSA had increased odds of hazardous drinking compared to those who did not experience CSA; men (OR 2.9, 95% CI 1.2-7.3) and women (OR 2.5, 95% CI 1.2-5.6). While, marijuana use was only significantly associated in women (OR 5.2, 95% CI 2.1-13.5). For sexual risk behaviors, unprotected sex was significantly associated in both men (OR 3.0, 95% CI 1.3-7.1) and women (OR 2.0, 95% CI 1.5-7.7) who experienced CSA. Results of this study underscore the need for further research to better understand the role of gender in the relationship between CSA and risky behaviors among PLWH.

Translation and validation of the Short HIV Stigma scale in Brazilian Portuguese

BACKGROUND

HIV-related stigma, or the degree to which people living with HIV endorse negative stereotypes associated with HIV, is associated with poor continuum of care outcomes. We translated the 12-item Short HIV Stigma scale and evaluated its psychometric properties in a Brazilian context with regard to construct validity and reliability.

METHODS

The first step included translation, back-translation, evaluation, peer review, and pre-testing of the Short HIV Sigma scale developed by Reinius et al. (Health Qual Life Outcomes 15(1):115, 2017). The second step involved piloting the scale in three convenience samples of adults recruited online through advertisements on different platforms: Grindr (October/2019) and Hornet (February-March/2020), geospatial network apps for sexual encounters for gay, bisexuals and other men who have sex with men, and social media apps (Facebook and WhatsApp, October/2019). The psychometric evaluation included confirmatory factor analysis, differential item functioning using the Multiple-Indicator Multiple-Cause model, and correlations between subscale scores and antiretroviral treatment use and adherence. Reliability was assessed using Cronbach's alpha, and ordinal alpha and omega from the polychoric correlation matrix.

RESULTS

In total, 114, 164, and 1824 participants completed the measure items through Grindr, social media, and Hornet, respectively. We confirmed a 4-factor structure with factors for personalized stigma (3 items), disclosure concerns (3 items), concerns with public attitudes (3 items), and negative self-image (3 items). Small differential item functioning with respect to sample was found for one item ("I feel guilty because I have HIV"), which did not substantively influence estimates of latent factor scores. Grindr and Hornet's participants scored significantly higher than social media participants on all factors except personalized stigma. Higher subscale scores correlated with antiretroviral treatment use among participants from Hornet and with lower treatment adherence in participants from Grindr and Hornet. Reliability as measured by Cronbach's alpha, ordinal alpha and omega were 0.83, 0.88 and 0.93 for the entire scale.

DISCUSSION

The Brazilian Portuguese version of the Short HIV Stigma scale had satisfactory psychometric properties with present results suggesting that scores from different samples may be compared without concern that measurement differences substantively influence results though further studies with greater representation of women and heterosexual men are warranted.

The HIV epidemic in Latin America: accomplishments and challenges on treatment and prevention

Purpose of review

To describe how countries in Latin America and the Caribbean are (or are not) meeting 2016 WHO guidelines on the use of antiretroviral drugs for treating and preventing HIV infection, that is, their progress on the adoption of ‘Treat All’ and of preexposure prophylaxis (PrEP) as an additional prevention tool for people at substantial risk of HIV infection.

Recent findings

The HIV epidemic in the region continues largely concentrated in vulnerable populations with MSM and transgender women (TGW) suffering the highest burden. On treatment, the challenges of late initiation as well as suboptimal adherence persist. On prevention, recent studies on PrEP willingness in key populations show promising results, meanwhile PrEP implementation projects as well as actual PrEP adoption by national health systems is expanding. A glimpse of real-world PrEP uptake is shown through Brazil's first-year experience of offering PrEP in multiple cities in all regions of the country.

Summary

In conclusion, accomplishments have been made though challenges for fully addressing the HIV epidemic persist. The impact of both treatment and PrEP will be limited by the availability and prompt use of all services, including HIV testing.

Adherence to Antiretroviral Therapy Among HIV Patients in India: A Systematic Review and Meta-analysis

We conducted a systematic review and meta-analysis to estimate the prevalence of adherence to antiretroviral therapy (ART) in India, the third largest HIV epidemic in the world. We identified peer reviewed literature published between 2007 and 2017 to extract data on ART adherence. We estimated pooled prevalence of adherence to ART using a random-effects model. Thirty-two eligible studies (n = 11,543) were included in the meta-analysis. Studies were mostly clustered in the southern and western Indian states. Overall, 77% (95% Confidence Interval 73-82; I² = 96.80%) of patients had optimum adherence to ART. Women had higher prevalence of optimum adherence compared to men. Depression or anxiety were significant risk factors in seven of the fifteen studies reporting determinants of nonadherence. Studies should be performed to explore the reasons for gender gap in ART adherence and HIV program in India should prioritize mental health issues among HIV patients to improve ART adherence.

HIV understanding, experiences and perceptions of HIV-positive men who have sex with men in Amazonian Peru: a qualitative study

BACKGROUND

HIV-related incidence and mortality is increasing across Peru, with highest mortality rates recorded in the Amazonian region of Loreto. This epidemic is concentrated in men who have sex with men, a population with 14% HIV treatment adherence despite free national provision. This study investigates barriers and facilitators to following healthcare advice through experiences and perceptions of HIV-positive men who have sex with men and healthcare professionals in Loreto.

METHODS

Twenty qualitative interviews with HIV-positive men who have sex with men and one focus group with HIV-specialist healthcare professionals were conducted in Loreto, January-February 2019. Interviews were transcribed per verbatim. Thematic content analysis and deviant case analysis were used.

RESULTS

A culture of isolation and discrimination was identified, propagated by poor public knowledge surrounding HIV transmission and treatment. Employment potential was hampered and 7/20 patients had suicidal thoughts post-diagnosis. Barriers to care included: shame, depression, travel cost/times, a preference for traditional plant-based medicine and side-effects of antiretroviral therapy. Facilitators included: education, family and clinic support, disease acceptance and lifestyle changes.

CONCLUSION

More effective, focussed community education and workplace discrimination investigations are recommended to reduce stigma and increase adherence to treatment in this population.

Rapid initiation of antiretroviral therapy at HIV diagnosis: definition, process, knowledge gaps

Initiating antiretroviral therapy (ART) as early as the day of HIV diagnosis is a strategy of increasing global interest to control the HIV epidemic and optimize the health of people living with HIV (PLWH). No detrimental effects of rapid-start ART have been identified in randomized controlled trials undertaken in low- or middle-income countries, or in cohort studies performed in high-income countries. Rapid-start ART may be a key approach in reaching the 2020 Joint United Nations Programme on HIV/AIDS goal of 90% of all PLWH knowing their status, 90% of those diagnosed receiving sustained ART, and 90% of those receiving ART achieving viral suppression; it may also be important for achieving the suggested fourth "90%" goal: improving health-related quality-of-life in PLWH. Presently there is insufficient broad evidence for guidelines to recommend universal test-and-treat strategies for all people, in all settings, at HIV diagnosis; consequently, there is a pressing need to conduct high-quality studies that investigate immediate ART initiation. This article evaluates global evidence regarding rapid-start ART, including same-day start, with particular focus on the implementation of this strategy in high-income countries.

Correlates of and barriers to ART adherence among adherence-challenged people living with HIV in southern India

Suboptimal adherence to Antiretroviral Therapy (ART) regimens can lead to the development of drug resistance, virologic and clinical failure, and, on the community level, the spread of drug-resistant HIV. To design effective interventions, it is crucial to understand locally specific barriers to optimal adherence. Self-report data from a cross-sectional sample of 527 adherence-challenged people living with HIV (PLWH) in the South-Indian state of Karnataka showed that they took on average 68% of prescribed doses in the past month. Large majorities of participants encountered individual (95%), social/structural (88%), and clinic/regimen (80%) adherence barriers. Multivariate linear regression analyses of past month adherence showed that disclosure to all adults in the household was positively related to adherence, as was employing a larger number of adherence strategies, perceiving more benefits of ART, and having been on ART for longer. Fears of stigmatization upon disclosure of HIV-status to friends and people at work were negatively related to adherence. These results suggest that some barriers, especially individual-level barriers like forgetfulness are very common and can be targeted with relatively simple individual-level strategies. Other barriers, related to fear of stigma and lack of disclosure may require family- or community-level interventions.

Adherence to Antiretroviral Regimens in Australia: A Nationwide Cohort Study

The lifetime use of combination antiretroviral therapy (cART) highlights the need to understand patterns of and factors associated with adherence to cART. In this cohort study using a 10% random sample of dispensing claims data for eligible Australians, we identified 2042 people dispensed cART between January 2016 and December 2017 (mean age 48.0 ± 12.0 years old, 88.6% male, and 85.9% treatment experienced). We considered people to be adherent if the proportion of treatment coverage days was ≥80% in the 360 days after their first observed cART dispensing. We also used group-based trajectory modeling (GBTM) to examine different patterns of adherence for 360 days from first observed cART dispensing. Most commonly, people receiving cART were treated with two nucleoside/nucleotide reverse transcriptase inhibitors with an integrase strand transfer inhibitors (INSTI-46.6%). Overall, 1708 people [83.6% (95% confidential interval 82.0-85.3%)] remained adherent over 360 days. GBTM identified three distinct adherence patterns: nearly always adherent [67.8% (63.7-71.9%) of the cohort], moderate adherence [26.6% (23.0-30.1%)], and low adherence [5.6% (4.1-7.2%)]. People were more likely to belong to the "nearly always adherent" trajectory if they were older (per additional year of age), treated with an INSTI regimen, and on treatment for more than 6 months. Our study demonstrates that the 360-day adherence to cART is generally high, but approximately one-third maintain a moderate or low adherence pattern. The use of INSTI regimens and additional support of treatment adherence, especially among younger people and those initiating therapy, may further improve adherence.

Adherence to antiretroviral therapy among people living with HIV/AIDS in northeastern Brazil: a cross-sectional study

BACKGROUND

Nonadherence to antiretroviral therapy (ART) may lead to viral replication and development of antiretroviral resistance.

OBJECTIVE

To identify the factors associated with nonadherence to ART among people living with the human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) (PLWHA).

DESIGN AND SETTING

Cross-sectional study in a tertiary-level hospital in northeastern Brazil.

METHODS

Intake of less than 90% of the antiretroviral drugs prescribed in the last week prior to the interview was defined as nonadherence. Intake was evaluated using a questionnaire. Descriptive and multivariate analyses were conducted on the study population, with estimation of the respective odds ratios and 95% confidence intervals.

RESULTS

The prevalence of nonadherence was 28.4%. Significant associations were found regarding the following variables: age less than 35 years, smoking, sedentary lifestyle, lack of medication and lack of knowledge regarding the patient's HIV status, on the part of the patient's partner or family.

CONCLUSIONS

Encouragement of adherence to antiretroviral therapy is one of the fundamental pillars of treatment for HIV-infected patients. The high proportion of nonadherence (28.4%) and the predictive factors related to this indicate that it is necessary to improve patients' adherence to antiretroviral therapy.

A global bibliometric analysis of antiretroviral treatment adherence: implications for interventions and research development (GAPRESEARCH)

The introduction of antiretroviral therapy (ART) has helped HIV population to live longer, but they could face not only AIDS-related morbidity but also other non-communicable diseases. Paying attention to ART adherence requires a system thinking with the life-long factors, individual-environment interactions and contextualized dynamics. Although several quantitative research had been conducted, they were not able to fully demonstrate the development of research approaches and scopes of previous studies. Essential and practical public health policy should be based on the most accessible and strategically analyzed evidence. Therefore, our study uses a scientometric approach to supplement previous reviews research covering until the end of 2017. Using a combination of two quantitative approaches to supplement previous reviews, we attempt to identify the research trends and potential research gaps which could be very helpful for policies and practices enhancements to inform evidence-based strategies. Our result indicates countries tend to collaborate in traditional models rather than prioritize severity and characteristics of HIV epidemics. Further ART research should highlight the incorporation of newly developed technology to examine long-term impacts, combine multiple measures, address contextual factors, and involve available technologies and resources, e.g., family, community.

A Qualitative Study to Identify Perceptual Barriers to Antiretroviral Therapy (ART) Uptake and Adherence in HIV Positive People from UK Black African and Caribbean Communities

To inform the development of interventions to increase uptake and adherence to antiretroviral therapy (ART), we explored perceptions of ART in semi-structured interviews with 52 men and women from UK black African and black Caribbean communities. Verbatim transcripts were analyzed using framework analysis. Perceptions of ART could be grouped into two categories: doubts about the personal necessity for ART and concerns about potential adverse effects. Doubts about necessity stemmed from feeling well, doubts about the efficacy of ART, religious beliefs and the belief that treatment was futile because it could not cure HIV. Concerns about adverse effects included the fear that attending HIV services and taking treatment would lead to disclosure of HIV, feeling overwhelmed at the prospect of starting treatment soon after diagnosis, fears about side effects and potential long-term effects, and physical repulsion. The findings will facilitate the development of interventions to increase uptake and adherence to ART.

Adherence to antiretroviral therapy and the associated factors among people living with HIV/AIDS in Northern Peru: a cross-sectional study

Background

There are approximately 72,000 people living with HIV/AIDS (PLHIV) in Peru. Non-adherence to antiretroviral therapy (ART) is the most important factor for therapeutic failure and the development of resistance. Peru has achieved moderate progress in meeting the 90-90-90 targets, but only 60% of PLHIV receiving ART are virally suppressed. The purpose of this study was to understand ART adherence in the Peruvian context, including developing sociodemographic and clinical profiles, evaluating the clinical management strategies, and analyzing the relationships between the variables and adherence of PLHIV managed at a regional HIV clinic in Lambayeque Province (Northern Peru).

Methods

This was a cross-sectional study with 180 PLHIV adults, non-randomly but consecutively selected with self-reported ART compliance (78.2% of the eligible population). The PLHIV profile (PLHIV-Pro) and the Simplified Medication Adherence Questionnaire (SMAQ) were used to collect sociodemographic information, clinical variables, and data specific to ART adherence. Descriptive analysis of sociodemographic and clinical characteristics was performed. Bivariate analysis was performed with the Mann–Whitney test, Chi square test, and Yates correction.

Results

The 180 PLHIV sample included 78.9% men, 49.4% heterosexual, 45% with a detectable HIV-1 viral load less than 40 copies/ml, 58.3% not consistently adherent, and only 26.1% receiving Tenofovir + Lamivudine + Efavirenz. Risk factors significant for non-adherence included concurrent tuberculosis, discomfort with the ART regime, and previous pauses in ART. Multivariate analysis of nested models indicated having children is a protector factor for adherence.

Conclusions

Self-reported adherence appeared to be low and the use of first-line therapy is not being prescribed homogeneously. Factors associated with nonadherence are both medical and behavioral, such as having tuberculosis, pausing ART, or experiencing discomfort with ART. The Peruvian government needs to update national technical standards, monitor medication availability, and provide education to health care professionals in alignment with evidence-based guidelines and international recommendations. Instruments to measure adherence need to be developed and evaluated for use in Latin America.

Evaluating cabotegravir/rilpivirine long-acting, injectable in the treatment of HIV infection: emerging data and therapeutic potential

Cabotegravir and rilpivirine long-acting injectable antiretroviral therapy for the treatment of HIV-1 infection brings promise of a new mode of delivery and potential solutions to some problems of oral therapy, but also new challenges and unanswered questions. Adding to the increasing body of evidence for newer two-drug combinations, phase II and phase III trial data to date demonstrate cabotegravir and rilpivirine combination injectable therapy to be non-inferior to selected oral triple-therapy alternatives. Most importantly, this therapy is reported to be acceptable to individuals taking the 4-weekly or 8-weekly injections, despite frequent injection-site reactions. Key outstanding questions include management of missed or delayed dosing, drug interactions and management of virological failure, as well as the efficacy of cabotegravir and rilpivirine in all HIV-1 subtypes. We describe clinical evidence to date and efficacy and challenges in selected populations, including women; those with prior virological failure; individuals with a history of difficulty adhering to oral therapy and individuals with co-infections. We await real-world data and longer-term evidence while moving forward to this new era of antiretroviral therapy.

Adherence to antiretroviral therapy for HIV/AIDS in Latin America and the Caribbean: Systematic review and meta-analysis

INTRODUCTION

Optimal adherence to antiretroviral therapy is closely related with suppression of the HIV viral load in plasma, slowing disease progression and decreasing HIV transmission rates. Despite its importance, the estimated proportion of people living with HIV in Latin America and the Caribbean with optimal adherence has not yet been reported in a meta-analysis. Moreover, little is known of the factors leading to poor adherence which may be setting-specific. We present a pooled estimate of adherence to antiretroviral therapy (ART) of people living with HIV in Latin America and Caribbean, report the methods used to measure adherence and describe the factors associated with poor adherence among the selected studies.

METHODS

We electronically searched published studies up to July 2016 on the PubMed, Web of Science and Virtual Health Library (Latin America and the Caribbean Regional Portal); considering the following databases: MEDLINE, LILACS, PAHO and IBECS. Two independent reviewers selected and extracted data on ART adherence and study characteristics. Pooled estimate of adherence was derived using a random-effects model. Risk of bias in individual studies was assessed independently by two investigators using the Risk of Bias Assessment tool for Non-randomized Studies (RoBANS).

RESULTS AND DISCUSSION

The meta-analysis included 53 studies published between 2005 and 2016, which analysed 22,603 people living with HIV in 25 Latin America and Caribbean countries. Overall adherence in Latin America and Caribbean was 70% (95% CI: 63-76; I²  = 98%), similar to levels identified by studies conducted in high-income regions. Self-report was the most frequently used method to measure adherence. Subgroup analysis showed that adherence was higher for the shortest recall time frame used, as well as in countries with lower income level, Gross National Income (GNI) per capita and Human Development Index (HDI). Studies reported diverse adherence barriers, such as alcohol and substance misuse, depression, unemployment and pill burden.

CONCLUSIONS

Our study suggests that adherence to ART in Latin America and Caribbean may be below the sufficient levels required for a successful long-term viral load suppression.

Adherence to Highly Active Antiretroviral Therapy Among Children in Ethiopia: A Systematic Review and Meta-analysis

Adherence to highly active antiretroviral therapy (HAART) is the mainstay of the strategy in reducing morbidity and mortality of HIV-infected children. Different primary studies were conducted in Ethiopia. Thus, we aimed to conduct a meta-analysis of the national prevalence of optimal adherence to HAART in children. In addition, associated factors of HAART adherence were reviewed. A weighted inverse variance random-effects model was applied. The 88.7 and 93.7% of children were adhering to HAART at 07 and 03 days prior to an interview respectively. The subgroup analysis showed that HAART adherence was 93.4% in Amhara, 90.1% in Addis Ababa and 87.3% in Tigray at 07 days prior to an interview. Our study suggests that, within short window reported time, adherence to HAART in Ethiopian children may be in a good progress. Emphasis on specific adherence interventions need further based on individual predictors to improve overall HAART adherence of children.

Terapia com antirretrovirais: grau de adesão e a percepção dos indivíduos com HIV/Aids

Resumo Objetivo Apreender os aspectos relacionados ao grau de adesão de pessoas vivendo com HIV/aids aos antirretrovirais. Métodos Estudo com abordagem qualitativa desenvolvido em duas unidades de internação de um hospital universitário do interior paulista. A produção dos dados ocorreu no período de outubro de 2017 a abril de 2018 com 40 participantes entrevistados, cujo material produzido foi gravado e posteriormente transcrito. A análise e o processamento dos dados foram realizados com apoio na técnica da Classificação Hierárquica Descendente e base fundamentada no Discurso do Sujeito Coletivo. Resultados Após análise e processamento, obtiveram-se cinco classes de palavras: 1. Questões sócio-econômicas como motivos fundamentais da não adesão aos antirretrovirais; 2. O apoio familiar para o enfrentamento da condição e estímulo para a adesão ao tratamento; 3. Consequências do grau de adesão aos antirretrovirais; 4. Dificuldades de adesão à terapia antirretroviral relacionadas aos efeitos adversos e apresentação medicamentosa; e 5. Possíveis mudanças para melhorar a adesão ao tratamento do HIV. Conclusão As principais dificuldades enfrentadas por pessoas vivendo com HIV/aids hospitalizadas e que estão em adesão irregular são questões sócio-econômicas, apoio familiar e efeitos adversos.