When is Enough, Enough? How the Absence of Dose-Determination Trials Impedes Implementation of HIV Behavioral Interventions

Effects of Behavioral Intervention Components for African American/Black and Latino Persons Living with HIV with Non-suppressed Viral Load Levels: Results of an Optimization Trial

There is an urgent need for efficient behavioral interventions to increase rates of HIV viral suppression for populations with serious barriers to engagement along the HIV care continuum. We carried out an optimization trial to test the effects of five behavioral intervention components designed to address barriers to HIV care continuum engagement for African American/Black and Latino persons living with HIV (PLWH) with non-suppressed HIV viral load levels: motivational interviewing sessions (MI), focused support groups (SG), peer mentorship (PM), pre-adherence skill building (SB), and navigation with two levels, short (NS) and long (NL). The primary outcome was HIV viral suppression (VS) and absolute viral load (VL) and health-related quality of life were secondary outcomes. Participants were 512 African American/Black and Latino PLWH poorly engaged in HIV care and with detectable HIV viral load levels in New York City, recruited mainly through peer referral. Overall, VS increased to 37%, or 45% in a sensitivity analysis. MI and SG seemed to have antagonistic effects on VS (z = - 1.90; p = 0.057); the probability of VS was highest when either MI or SG was assigned, but not both. MI (Mean Difference = 0.030; 95% CI 0.007-0.053; t(440) = 2.60; p = 0.010) and SB (Mean Difference = 0.030; 95% CI 0.007-0.053; t(439) = 2.54; p = 0.012) improved health-related quality of life. This is the first optimization trial in the field of HIV treatment. The study yields a number of insights into approaches to improve HIV viral suppression in PLWH with serious barriers to engagement along the HIV care continuum, including chronic poverty, and underscores challenges inherent in doing so.

Suubi + Adherence4Youth: a study protocol to optimize the Suubi Intervention for Adherence to HIV treatment for youth living with HIV in Uganda

BACKGROUND

Suubi is an evidenced based multi-component intervention that targets psychosocial and economic hardships to improve ART adherence, viral suppression, mental health, family financial stability, and family cohesion for adolescents living with HIV (ALHIV) in Uganda. Suubi was originally tested as a combined package of four components: 1) Financial Literacy Training; 2) incentivized matched Youth Savings Accounts with income-generating activities; 3) a manualized and visual-based intervention for ART adherence and stigma reduction; and 4) engagement with HIV treatment-experienced role models. However, it is unknown if each component in Suubi had a positive effect, how the components interacted, or if fewer components could have produced equivalent effects. Hence, the overall goal of this new study is to identify the most impactful and sustainable economic and psychosocial components across 48 health clinics in Uganda.

METHODS

A total of 576 ALHIV (aged 11-17 years at enrollment) will be recruited from 48 clinics and each clinic will be randomized to one of 16 study conditions. Each condition represents every possible combination of the 4 components noted above. Assessments will be conducted at baseline, 12, 24, 36 and 48- months post-intervention initiation. Using the multi-phase optimization strategy (MOST), we will identify the optimal combination of components and associated costs for viral suppression, as well as test key mediators and moderators of the component-viral suppression relationship.

DISCUSSION

The study is a shift in the paradigm of research to use new thinking to build/un-pack highly efficacious interventions that lead to new scientific knowledge in terms of understanding what drives an intervention's success and how to iterate on them in ways that are more efficient, affordable and scalable. The study advances intervention science for HIV care outcomes globally.

TRIAL REGISTRATION

This project was registered at clinicaltrials.gov (NCT05600621) on October, 31, 2022. https://clinicaltrials.gov/ct2/show/NCT05600621.

Randomized Community Trial Comparing Telephone versus Clinic-Based Behavioral Health Counseling for People Living with HIV in a Rural Setting

PURPOSE

To test the efficacy of a theory-based behavioral intervention delivered via telephone versus clinic-based counseling to improve HIV outcomes and reduce alcohol consumption for people at-risk for treatment failure in a rural setting.

METHODS

Patients receiving HIV care (N = 240) were randomized using a computer-generated scheme to one of three conditions: (a) telephone behavioral health counseling, (b) clinic-based behavioral health counseling, or (c) attention control nutrition education. Behavioral counseling was delivered by either a community nurse or a paraprofessional patient navigator, with differences examined. Participants were followed for 12 months to assess medication adherence using unannounced pill counts and alcohol use measured by electronic daily text message assessments, and 18 months for HIV viral load and retention in care extracted from medical records.

FINDINGS

There was evidence for telephone and office-based counseling demonstrating greater medication adherence than the control condition but only in the short term. Clinic-based behavioral counseling significantly reduced alcohol use to a greater degree than telephone counseling and the control condition. There were no other differences between conditions. There were also no discernable differences between counseling delivered by the community nurse and the patient navigator.

CONCLUSIONS

Telephone and clinic-based counseling demonstrated improved medication adherence in the short term, while clinic-based counseling demonstrated reductions in alcohol use. The modest outcomes suggest that intensive intervention strategies are needed for patients that clinicians identify as at-risk for treatment discontinuation and treatment failure.

Undetectable viral load and HIV transmission dynamics on an individual and population level: where next in the global HIV response?

PURPOSE OF REVIEW

To examine recent literature on the efficacy and effectiveness of HIV treatment in preventing HIV transmission through sexual exposure, at both an individual and at a population level.

RECENT FINDINGS

Two recent studies on the individual-level efficacy of treatment as prevention (TasP) have added to the now conclusive evidence that HIV cannot be transmitted sexually when the virus is suppressed. However, four large cluster-randomized population-level trials on universal HIV testing and treatment in Africa have not delivered the expected impact in reducing HIV incidence at a population level. Two of these trials showed no differences in HIV incidence between the intervention and control arms, one demonstrated a nonsignificant lower incidence in the intervention arm, and the fourth trial found a reduction between the communities receiving a combination prevention package and the control arm, but no difference between the immediate treatment plus the prevention package and the control arm. Factors contributing to the disconnect between individual high-level efficacy and population-level effectiveness of TasP include undiagnosed infection, delays in linkage to care, challenges in retention and adherence to antiretroviral therapy (ART), time between ART initiation and viral suppression, and stigma and discrimination.

SUMMARY

Suppressive ART renders people living with HIV sexually noninfectious. However, epidemic control is unlikely to be achieved by TasP alone.