Recreational ART use among individuals living with HIV/AIDS in South Africa: Examining longitudinal ART initiation and viral suppression

Population prevalence of antiretroviral therapy sharing and its association with HIV viremia in rural Uganda: a cross-sectional population-based study

INTRODUCTION

Antiretroviral treatment (ART) sharing has been reported among fishermen and sex workers in Uganda and South Africa. However, no population-based studies have documented ART diversion prevalence (including sharing [giving/receiving], buying and selling) or its relationship with viremia among men and women living with HIV in Africa.

METHODS

In 2018-2020, we surveyed people living with HIV aged 15-49 years in 41 communities in the Rakai Community Cohort Study, a population-based cohort in south-central Uganda. We assessed the prevalence and correlates of self-reported lifetime and past-year ART diversion, stratifying by age and gender and documenting sources of diverted drugs. We used log-binomial regression to quantify the relationship between diversion patterns and viremia (viral load >40 copies/ml), reported as unadjusted and adjusted prevalence ratios (aPR) with 95% confidence intervals (CI).

RESULTS

Of 2852 people living with HIV and self-reporting current ART use, 266 (9.3%) reported lifetime ART diversion. Giving/receiving drugs were most common; few participants reported buying, and none reported selling. Men (12.9%) were more likely to report lifetime diversion than women (7.4%), with men aged 25-34 reporting high levels of sharing (18.9%). Friends were the most common sources of shared drugs, followed by spouses/sexual partners. Patterns of lifetime and past-year diversion were similar. Among participants with viral load results, 8.6% were viraemic. In adjusted analyses, people who reported only giving ART were nearly twice as likely to be viraemic than those who reported no diversion (aPR: 1.94, 95% CI: 1.10-3.44), and those reporting only receiving ART were less likely to exhibit viremia (aPR: 0.46, 95% CI: 0.12-1.79), although the latter was not statistically significant. Reporting both giving and receiving ART was not associated with viremia (aPR: 0.79, 95% CI: 0.43-1.46). Reporting buying ART, though rare, was also correlated with higher rates of viremia, but this relationship was not statistically significant (aPR: 1.98, 95% CI: 0.72-5.45).

CONCLUSIONS

ART sharing is common among persons reporting ART use in rural Uganda, particularly among men. Sharing ART was associated with viremia, and receiving ART may facilitate viral suppression. HIV programmes may benefit from considering ART sharing in counselling messages.

A Systematic Review of Risk Factors and Consequences of Nyaope Usage: The Illicit Street Drug Containing HIV Antiretrovirals

South Africa currently has the highest number of cases of HIV in the world. HIV antiretrovirals (ARVs) are publicly available across the country to address this crisis. However, a consequence of widely available ARVs has been the diversion of these drugs for recreational usage in a drug cocktail commonly known as "nyaope" or "whoonga," which poses a significant public health concern. To better understand nyaope, we conducted a systematic review investigating the risks and consequences associated with its usage. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searches were conducted in eight different databases and screened thereafter. Articles were eligible for inclusion if they included analysis of least one nyaope user and considered either demographics, risk factors, or consequences of usage. Data extracted included study characteristics and limitations, as well as demographic factors, risk factors for usage in the general population, and consequences. Quality assessments were performed using the Joanna Briggs Institute's tools. Searches produced a total of 228 articles and, after screening, a total of 19 articles were eligible for inclusion. There was a pooled total of 807 nyaope users, all in South Africa. Major risk factors for usage were being male, unemployed, not completing secondary education, pressure from peer groups, having HIV, prior use of cannabis, and to a lesser extent, usage of other substances such as alcohol and tobacco. While young adults tend to be at high-risk, evidence indicates that adolescents are also at-risk. Consequences of usage include high rates of infection, cortical atrophy, depression, and addiction. Addiction was shown to lead to individuals stealing from friends and family to pay for the drugs. HIV-positive nyaope users were more likely to partake in risk behaviours and tended to have high viral loads. Nyaope's rise has been linked to many health and social issues. Considering that this may also disrupt HIV control efforts in South Africa, there is an urgent need to address the rise of nyaope.

SARS-CoV-2/COVID-19: Clinical Course Among Subjects HIV-1-Infected in Sao Paulo

INTRODUCTION

People living with Human Immunodeficiency Virus (HIV) are under risk for co-infection with SARS-CoV-2. This population may be more prone to complications from COVID-19 due to persistent inflammation caused by HIV and higher incidence of metabolic syndromes, cardiovascular diseases, and malignancies, as well as being considered elderly at 50 years of age. The objective of this study was to report SARS-CoV-2 infection frequency, clinical evolution, and mortality in HIV-positive patients on antiretroviral therapy.

METHODS

The period of inquiry ranged from January to September 2020. Due to the social distance and the suspension of in-person medical care during the time of the investigation, we sent electronic questions about demographic, epidemiological, and clinical data to 403 HIV-infected patients.

RESULTS

Among 260 patients who answered the questionnaire, thirty-nine patients (15%) had suggestive symptoms and were tested for SARS-CoV-2 infection. Of this, 11 had positive results (32.4%) and no patient died of COVID-19 complications. Nine were male (3.4%), and the mean age of the patients with positive results was 43.2 years (± 9.6). 107 patients (41.1%) were over 50 years of age and their mean T-CD4+ cell count was 768. Eleven patients (4.2%) had a detectable HIV RNA viral load and 127 (48.8%) had comorbidities. These variables were not associated with an increased risk for infection.

CONCLUSION

The frequency of SARS-COV2 infection among HIV-infected is similar to the general population, and the clinical course is associated with the presence of comorbidities and not due to the HIV infection. However, new studies should be done to assess if this vulnerable population could answer the vaccine anti-SARS-Cov2.

Using a Syndemics Framework to Understand How Substance Use Contributes to Morbidity and Mortality among People Living with HIV in Africa: A Call to Action

Substance use is increasing throughout Africa, with the prevalence of alcohol, tobacco, cannabis, and other substance use varying regionally. Concurrently, sub-Saharan Africa bears the world’s largest HIV burden, with 71% of people living with HIV (PWH) living in Africa. Problematic alcohol, tobacco, and other substance use among PWH is associated with multiple vulnerabilities comprising complex behavioral, physiological, and psychological pathways that include high-risk behaviors (e.g., sexual risk-taking), HIV disease progression, and mental health problems, all of which contribute to nonadherence to antiretroviral therapy. Physiologically, severe substance use disorders are associated with increased levels of biological markers of inflammation; these, in turn, are linked to increased mortality among PWH. The biological mechanisms that underlie the increased risk of substance use among PWH remain unclear. Moreover, the biobehavioral mechanisms by which substance use contributes to adverse health outcomes are understudied in low- and middle-income countries (LMIC). Syndemic approaches to understanding the co-occurrence of substance use and HIV have largely been limited to high-income countries. We propose a syndemic coupling conceptual model to disentangle substance use from vulnerabilities to elucidate underlying disease risk for PWH. This interventionist perspective enables assessment of biobehavioral mechanisms and identifies malleable targets of intervention.

An Emerging Substance Use Epidemic: Recreational Use of HIV Pre-Exposure Prophylaxis and Treatment in South Africa

South Africa has the largest HIV burden and treatment program in the world. Diversion of HIV prevention and treatment medication for recreational use-or nonmedical use for psychoactive effects-is a public health concern globally and in South Africa. Few South African studies examine recreational use of HIV antiretrovirals (ARVs). The objective of this article is to evaluate the prevalence of recreational ARV use and to identify risk and protective factors associated with use. Data are drawn from a cross-sectional household survey of N = 4399 adolescent girls and young women (AGYW) aged 15-24 years in six districts across South Africa where an evaluation of a South African combination HIV prevention for girls and young women was implemented. The use of ARVs to "get high" was reported by 8.3% of AGYW across all districts. Logistic regressions showed that those engaging in transactional sex were at two times higher odds of recreational ARV use [adjusted odds ratio (aOR) = 2.01; confidence interval (95% CI): 1.51-2.68]. Recreational ARV use was more likely among those who used pre-exposure prophylaxis (PrEP) (aOR = 2.17; 95% CI: 1.36-3.48); HIV-positive participants who were not on ARVs for treatment (aOR = 0.36; 95% CI: 0.18-0.68); and those who were not virally suppressed (aOR, no vs. yes = 2.84; 95% CI: 1.21-6.66). As ARVs become more widely available for prevention and treatment, it will be important to monitor and address the possible emergence of ARVs as a substance for misuse or abuse.

Project Khanya: a randomized, hybrid effectiveness-implementation trial of a peer-delivered behavioral intervention for ART adherence and substance use in Cape Town, South Africa

BACKGROUND

Substance use is prevalent in South Africa and associated with poor HIV treatment outcomes, yet, it is largely unaddressed in HIV care. Implementing an evidence-based, task-shared intervention for antiretroviral therapy (ART) adherence and substance use integrated into HIV care may be a feasible and effective way to improve HIV treatment outcomes and reduce substance use in this population.

METHODS

Guided by the RE-AIM framework, a randomized, hybrid type 1 effectiveness-implementation trial (n = 60) is being used to evaluate a peer-delivered intervention that integrates evidence-based intervention components, including Life-Steps (problem solving and motivational skills for HIV medication adherence), behavioral activation to increase alternative, substance-free rewarding activities in one's environment, and relapse prevention skills, including mindfulness. The comparison condition is enhanced standard of care, which includes facilitating a referral to a local substance use treatment clinic (Matrix). Participants are followed for a period of 6 months. Implementation outcomes are defined by Proctor's model for implementation and include mixed methods evaluations of feasibility, acceptability, and fidelity, and barriers and facilitators to implementation. Primary patient-level effectiveness outcomes are ART adherence (Wisepill) and substance use (WHO-ASSIST and urinalysis); viral load is an exploratory outcome.

DISCUSSION

Results of this trial will provide important evidence as to whether peer delivery of an integrated intervention for ART adherence and substance use is feasible, acceptable, and effective. Implementation outcomes will provide important insight into using peers as an implementation strategy to extend task sharing models for behavioral health in resource-limited settings globally.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03529409. Trial registered on May 18, 2018.