Association of highly active antiretroviral therapy coverage, population viral load, and yearly new HIV diagnoses in British Columbia, Canada: a population-based study

Association Between Dynamic Viral Rebound and Longitudinal Measures of Viral Load/CD4 Counts Among People with HIV in South Carolina

Monitoring HIV viral rebound (VR) is crucial, as it indicates an increased risk of infection, transmission, disease progression, and drug resistance. This study aims to identify the association between dynamic VR and historical viral load (VL)/CD4 count measures. Fifteen-year South Carolina population-based electronic health record data were used for the study. VR was defined as the return of detectable levels of VL (>200 copies/mL) after stable viral suppression (VS) (two consecutive VS, i.e., VL ≤200 copies/mL). A generalized linear mixed model was used to evaluate the association between dynamic VR and historical time-dependent predictors, such as nadir CD4 count and comorbidities, within a year prior to each VR. Subgroup analysis for men who have sex with men (MSM) was also conducted. Among 8,185 people with HIV (PWH), 1,173 (14.3%) had a history of VR. Lower nadir CD4 count (≥500 vs. <200 cells/µL; adjusted odds ratio [aOR]: 0.51, 95% confidence interval [CI]: [0.43, 0.60]), younger age (>60 years old vs. 18-30 years old; aOR: 0.43, 95% CI: [0.29, 0.63]), and being Black (Black vs. White; aOR: 1.58, 95% CI: [1.34, 1.85]) were associated with a higher risk of VR, while MSM (MSM vs. heterosexual; aOR: 0.81, 95% CI: [0.67, 0.96]) were associated with decreased VR risk. The rate of VR among PWH in South Carolina is significant. Within-1-year VL/CD4 test is critical for identifying PWH at risk for VR. Tailored interventions are needed for PWH at risk for VR to achieve sustained suppression and better health outcomes.

Sociodemographic and Psychosocial Factors Influencing COVID-19 Testing Uptake: Insights from Urban and Rural Communities in South Africa

Access, demand, and acceptance of coronavirus disease 2019 (COVID-19) testing have varied globally. This study explored the sociodemographic and psychosocial risk factors that contribute to the uptake of COVID-19 testing in community settings in South Africa. This paper presents a cross-sectional secondary analysis using data from a cluster randomized controlled trial and a nested perception survey of COVID-19 antigen testing in communities located in urban (eThekwini, KwaZulu-Natal) and rural settings (Worcester, Eastern Cape) in South Africa. Individuals who were reluctant to get tested participated in the perception survey. Data were analyzed using descriptive statistics and multivariable logistic regression to assess linear associations and estimate adjusted odds ratios (ORs). The analysis was conducted on 3,074 individuals, of whom 2,509 (81.6%) provided consent for COVID-19 testing. Among those, 2,505 (81.5%) tested negative, and 4 (0.1%) tested positive for COVID-19. The mean age of participants was 38 (SD = 14.61), and 57% were male. Females (OR: 1.27; 95% CI = 1-1.6), individuals older than 56 years (OR: 1.95; 95% CI = 1.24-3.07), and those who were vaccinated (OR: 1.99; 95% CI = 1.53-2.60) were more likely to consent. Individuals who had previously tested positive for severe acute respiratory syndrome coronavirus 2 were less likely to consent to testing (OR: 0.64; 95% CI = 0.11-0.46). No link was found between depression, anxiety, substance use, and willingness to undergo COVID-19 testing. A perceptions survey involving 704 participants, which explored factors influencing testing willingness, found that older adults, and urban populations were less likely to undergo COVID-19 testing. Targeted health campaigns may improve testing rates. Larger-scale implementation research is required to explore best practices for improving testing rates and confidence in population-level detection within South Africa.

Evidence of zero-risk transmission of HIV in the era of antiretroviral therapy: A systematic review and meta-analyses

OBJECTIVE

This systematic review aimed to assess the evidence on sexual transmission of HIV in high-income settings between serodiscordant couples where the index partner infected with HIV is on antiretroviral therapy.

STUDY DESIGN

Systematic review and meta-analyses.

METHODS

We performed a systematic search in four databases: Embase, MEDLINE, The Cochrane Library, and Web of Science on September 24, 2022. We assessed the risk of bias with ROBINS-I and pooled estimates in meta-analyses using a Poisson regression model with a random effect of the study and population size. The study protocol was pre-registered at PROSPERO. The study involved high-income countries.

RESULTS

The search identified 6886 studies, of which six were included for review. Altogether, studies reported zero linked transmissions among 2383 couples, more than 160,000 acts of intercourse, and 3578 couple years. The risk estimate from overall meta-analyses was 0.000 95%CI (0.000-0.103) per 100 couple-years.

CONCLUSION

This systematic review and meta-analyses provide epidemiological evidence for a low risk of HIV transmission under antiretroviral therapy in high-income countries and thus cannot reject the theoretical "treatment as prevention" paradigm.

Association between population viral load surrogate indicator and HIV transmission potential: a prospective cohort study in Xinjiang, China

BACKGROUND

New indicators of potential human immunodeficiency virus (HIV) transmission are being actively explored. We aim to categorical testing of the viral load (VL) of persons living with HIV (PLWH) in order to explore new indicators to measure the intensity of the epidemic and the effectiveness of the response in the community.

METHODS

A dynamic cohort study was conducted in Yining to monitor the VL of all persons living with HIV from 2017 to 2019. Different population VL (PVL) surrogate indicators were measured and the strength of the associations of different PVL surrogates with HIV incidence, antiretroviral therapy (ART) coverage, virus unsuppression, and viremia prevalence was assessed. PVL surrogate indicators were used to describe the current status of HIV transmission in different populations and communities.

RESULTS

All PVL indicators decreased from 2017 to 2019 (P < 0.05). Arithmetic mean community viral load (CVL) (r = 1.000, P = 0.006) and geometric mean CVL (r = 1.000, P = 0.001) were positively associated with HIV incidence, ART coverage and viral unsuppression (P < 0.05). CVL was higher in the male, ≤ 25 years of age, primary school or below, other household registration, other medical insurance types, other source of sample, nonmarital and noncommercial heterosexual contact, and nonmarital and commercial heterosexual contact subgroups. Community-based cross-sectional analyses showed that CVL in community 10 was positively correlated with viral unsuppression rate and viremia prevalence but negatively correlated with ART coverage rate, suggesting that the community was a hotspot for HIV epidemics.

CONCLUSIONS

CVL can be used as an indicator for assessing HIV transmission and identifying high-risk populations and hotspot communities.

Success rates and adherence to antiretroviral therapy among treatment-naïve patients in Davao City, Philippines: A ten-year retrospective cohort study

Background

Antiretroviral therapy (ART) has significantly improved the prognosis and quality of life of HIV/AIDS patients. However, ART success is greatly influenced by patient adherence to the treatment regimens. This study aimed to assess the association between patient adherence to ART and the treatment success rate among antiretroviral-naïve patients in Davao City, Philippines.

Methods

This study utilized a 10-year retrospective cohort design, including 517 antiretroviral-naïve patients from an HIV treatment hub in Davao City, the Philippines. Using strict inclusion criteria, 183 antiretroviral-naïve patients were analyzed.

Findings

The study found significant associations between the type of ART (p = 0.011) and the timing of ART initiation (p = 0.006) with both patient adherence and the ART success rate. Specifically, patients who achieved sustained viral suppression were predominantly those who initiated ART early, with 71.6 % (n = 131) of them prescribed a regimen consisting of 2 NRTIs and 1 NNRTI. Moreover, 73.8 % of patients demonstrated good adherence (<50 HIV copies/mL). Importantly, patient adherence to ART was strongly correlated with treatment success rate.

Interpretation

This study highlights the significance of adherence to antiretroviral therapy (ART) for successful treatment outcomes among antiretroviral-naïve patients living with HIV/AIDS. Early initiation of ART and consistent adherence to treatment regimens are essential for achieving sustained viral suppression and improving treatment effectiveness.

Association between markers of hepatitis B virus infection and risk of virological rebound in people with HIV receiving antiretroviral therapy

OBJECTIVES

The aim of this analysis was to investigate the impact of hepatitis B virus (HBV) coinfection on the risk of HIV viral rebound (VR) after achieving suppression for the first time following initiation of antiretroviral therapy (ART) in the real-world setting.

DESIGN

Patients living with HIV (PLWH) who were enrolled in the ICONA Foundation Study cohort and achieved viral suppression ≤50 copies/mL for the first time after starting ART were prospectively evaluated and divided in three exposure groups according to serology test results: (a) HIV-monoinfected; (b) HIV-positive/HBcAb-positive/HBsAg-negative; (c) HIV-positive/HBsAg-positive. The occurrence of VR, defined as two consecutive HIV-RNA values >50 copies/mL after achieving viral suppression for the first time (baseline), was investigated.

METHODS

Standard survival analysis by means of Kaplan-Meier curves and Cox regression analysis with the serology exposure fitted as a time-fixed covariate measured at baseline was employed after controlling for key confounding factors.

RESULTS

Of a total of 5657 patients included, 4090 (72%) were HIV-monoinfected, 1342 (23.7%)were HBcAb-positive, and 225 (3.9%) were HbsAg-positive coinfected. Overall, 654 (11.5%) PLWH experienced VR > 50 copies/mL during follow-up. After controlling for all sources of measured confounding, coinfected PLWH showed an increased risk of experiencing VR compared with those who were HIV-monoinfected. In particular, the strongest associations were seen for the HIV/HBsAg-positive participants [adjusted hazard ratio (aHR) = 1.56, 95% confidence interval (CI): 1.03-2.38, p = 0.037] but an excess of risk was also seen in those who were HIV-positive/HBcAb-positive/HBsAg-negative (aHR = 1.25, 95% CI: 1.00-1.55, p = 0.047).

CONCLUSIONS

Coinfection with HBV seems to have an impact on the probability of maintaining HIV viral suppression achieved for the first time after ART initiation. Of note, even PLWH positive for HBcAb, a marker of inactive HBV infection, appeared to be at higher risk of VR compared with those who were HIV-monoinfected and their HIV-RNA should be carefully monitored.

Identification of antibody targets associated with lower HIV viral load and viremic control

BACKGROUND

High HIV viral loads (VL) are associated with increased morbidity, mortality, and on-going transmission. HIV controllers maintain low VLs in the absence of antiretroviral therapy (ART). We previously used a massively multiplexed antibody profiling assay (VirScan) to compare antibody profiles in HIV controllers and persons living with HIV (PWH) who were virally suppressed on ART. In this report, we used VirScan to evaluate whether antibody reactivity to specific HIV targets and broad reactivity across the HIV genome was associated with VL and controller status 1-2 years after infection.

METHODS

Samples were obtained from participants who acquired HIV infection in a community-randomized trial in Africa that evaluated an integrated strategy for HIV prevention (HPTN 071 PopART). Controller status was determined using VL and antiretroviral (ARV) drug data obtained at the seroconversion visit and 1 year later. Viremic controllers had VLs <2,000 copies/mL at both visits; non-controllers had VLs >2,000 copies/mL at both visits. Both groups had no ARV drugs detected at either visit. VirScan testing was performed at the second HIV-positive visit (1-2 years after HIV infection).

RESULTS

The study cohort included 13 viremic controllers and 64 non-controllers. We identified ten clusters of homologous peptides that had high levels of antibody reactivity (three in gag, three in env, two in integrase, one in protease, and one in vpu). Reactivity to 43 peptides (eight unique epitopes) in six of these clusters was associated with lower VL; reactivity to six of the eight epitopes was associated with HIV controller status. Higher aggregate antibody reactivity across the eight epitopes (more epitopes targeted, higher mean reactivity across all epitopes) and across the HIV genome was also associated with lower VL and controller status.

CONCLUSIONS

We identified HIV antibody targets associated with lower VL and HIV controller status 1-2 years after infection. Robust aggregate responses to these targets and broad antibody reactivity across the HIV genome were also associated with lower VL and controller status. These findings provide novel insights into the relationship between humoral immunity and viral containment that could help inform the design of antibody-based approaches for reducing HIV VL.

Diastereoselective Synthesis of the HIV Protease Inhibitor Darunavir and Related Derivatives via a Titanium Tetrachloride-Mediated Asymmetric Glycolate Aldol Addition Reaction

Darunavir is a potent HIV protease inhibitor that has been established as an effective tool in the fight against the progression of HIV/AIDS in the global community. The successful application of this drug has spurred the development of derivatives wherein strategic regions (e.g., P1, P1', P2, and P2') of the darunavir framework have been structurally modified. An alternate route for the synthesis of darunavir and three related P1 and P1' derivatives has been developed. This synthetic pathway involves the use of a Crimmins titanium tetrachloride-mediated oxazolidine-2-thione-guided asymmetric glycolate aldol addition reaction. The resultant aldol adduct introduces the P1 fragment of darunavir via an aldehyde. Transamidation with a selected amine (isobutylamine or 2-ethyl-1-butylamine) to cleave the auxiliary yields an amide wherein the P1' component is introduced. From this stage, the amide is reduced to the corresponding β-amino alcohol and the substrate is then bis-nosylated to introduce the requisite p-nitrobenzenesulfonamide component and activate the secondary alcohol for nucleophilic substitution. Treatment with sodium azide yielded the desired azides, and the deprotection of the p-methoxyphenoxy group is achieved with the use of ceric ammonium nitrate. Finally, hydrogenation to reduce both the aniline and azide functionalities with concurrent acylation yields darunavir and its derivatives.

Expanding access to healthcare for people who use drugs and sex workers: hepatitis C elimination implications from a qualitative study of healthcare experiences in British Columbia, Canada

BACKGROUND

Hepatitis C virus (HCV) is a major health threat in Canada. In British Columbia (BC) province, 1.6% of the population had been exposed to HCV by 2012. Prevalence and incidence of HCV are very high in populations of people who use drugs (PWUD) and sex workers (SW), who may experience unique barriers to healthcare. Consequently, they are less likely to be treated for HCV. Overcoming these barriers is critical for HCV elimination. This research sought to explore the healthcare experiences of PWUD and SW and how these experiences impact their willingness to engage in healthcare in the future, including HCV care.

METHODS

Interpretive Description guided this qualitative study of healthcare experiences in BC, underpinned by the Health Stigma and Discrimination framework. The study team included people with living/lived experience of drug use, sex work, and HCV. Twenty-five participants completed in-depth semi-structured interviews on their previous healthcare and HCV-related experiences. Thematic analysis was used to identify common themes.

RESULTS

Three major themes were identified in our analysis. First, participants reported common experiences of delay and refusal of care by healthcare providers, with many negative healthcare encounters perceived as rooted in institutional culture reflecting societal stigma. Second, participants discussed their choice to engage in or avoid healthcare. Many avoided all but emergency care following negative experiences in any kind of healthcare. Third, participants described the roles of respect, stigma, dignity, fear, and trust in communication in healthcare relationships.

CONCLUSIONS

Healthcare experiences shared by participants pointed to ways that better understanding and communication by healthcare providers could support positive change in healthcare encounters of PWUD and SW, who are at high risk of HCV infection. More positive healthcare encounters could lead to increased healthcare engagement which is essential for HCV elimination.

Self-Emulsifying Drug Delivery System for Enhanced Oral Delivery of Tenofovir: Formulation, Physicochemical Characterization, and Bioavailability Assessment

Tenofovir (TNF) is a common component of many antiretroviral therapy regimens, but it is associated with poor membrane permeability and low oral bioavailability. To improve its oral bioavailability and membrane permeability, a self-emulsifying drug delivery system (SEDDS) was developed and characterized, and its relative bioavailability was compared to the marketed tablets (Tenof). Based on solubility and ternary phase diagram analysis, eucalyptus oil was selected as an oil phase, Kolliphor EL, and Kollisolv MCT 70 were chosen as surfactant and cosurfactant, respectively, while glycerol was used as cosolvent in surfactant mixture. Optimized SEDDS formulation F6 showed an oil droplet size of 98.82 nm and zeta potential of -13.03 mV, indicating the high stability of oil droplets. Differential scanning calorimetry, X-ray diffraction, and scanning electron microscopy characterization studies were also carried out to assess the amorphous and morphological states of the drug in the prepared SEDDS formulation. The in vitro dissolution profile of SEDDS shows the rapid release of the drug. SEDDS F6 demonstrates a higher drug permeability than the plain TNF and TNF-marketed tablets (Tenof). A pharmacokinetic study in rats revealed that SEDDS F6 showed significantly higher Cmax and AUC0-t than the marketed tablets and pure drug suspension. In addition, the relative bioavailability of SEDDS formulation dramatically improved by 21.53-fold compared to marketed tablets and 66.27-fold compared to pure drugs. These findings show that SEDDS composed of eucalyptus oil, glycerol, Kolliphor EL, and Kollisolv MCT 70 could be a useful tool for enhancing physiochemical properties and oral TNF absorption. Therefore, SEDDS has shown promise in improving the oral bioavailability of poorly water-soluble drugs.

It's all about connection: Determinants of social support and the influence on HIV treatment interruptions among people living with HIV in British Columbia, Canada

BACKGROUND

Social support has previously been found to be associated with improved health outcomes of individuals managing chronic illnesses, including amongst people living with HIV (PLWH). For women and people who use injection drugs who continue to experience treatment disparities in comparison to other PLWH, social support may have potential in facilitating better treatment engagement and retention. In this analysis, we examined determinants of social support as measured by the Medical Outcomes Study - Social Support Survey (MOS-SSS) scale, and quantified the relationship between MOS-SSS and HIV treatment interruptions (TIs) among PLWH in British Columbia, Canada.

METHODS

Between January 2016 and September 2018, we used purposive sampling to enroll PLWH, 19 years of age or older living in British Columbia into the STOP HIV/AIDS Program Evaluation study. Participants completed a baseline survey at enrolment which included the MOS-SSS scale, where higher MOS-SSS scores indicated greater social support. Multivariable linear regression modeled the association between key explanatory variables and MOS-SSS scores, whereas multivariable logistic regression modeled the association between MOS-SSS scores and experiencing TIs while controlling for confounders.

RESULTS

Among 644 PLWH, we found that having a history of injection drug use more than 12 months ago but not within the last 12 months, self-identifying as Indigenous, and sexual activity in the last 12 months were positively associated with MOS-SSS, while being single, divorced, or dating (vs. married), experiences of lifetime violence, and diagnosis of a mental health disorder were inversely associated. In a separate multivariable model adjusted for gender, ethnicity, recent homelessness, sexual activity in the last 12 months, and recent injection drug use, we found that higher MOS-SSS scores, indicating more social support, were associated with a lower likelihood of HIV treatment interruptions (adjusted odds ratio: 0.90 per 10-unit increase, 95% confidence interval: 0.83, 0.99).

CONCLUSIONS

Social support may be an important protective factor in ensuring HIV treatment continuity among PLWH. Future research should examine effective means to build social support among communities that have potential to promote increased treatment engagement.

Exposure to Biological Fluids in Dental Practice-Narrative Review on Appropriate Risk Assessment to Guide Post-Exposure Management

Accidental exposure to blood or other biological fluids is a common occurrence in dentistry, and its post-exposure management is a key component of infection prevention and control programs designed to prevent the transmission of blood-borne pathogens such as hepatitis B and C viruses (HBV, HCV) and human immunodeficiency virus (HIV). This narrative review aims to comprehensively review the risk assessment process for each of these pathogens at all steps of the epidemiological process, i.e., source-exposure route-receptive person, in order to provide a better understanding of the delicate differences that influence the transmission risk and that drive the individualized post-exposure management.

Study protocol for data to suppression (D2S): a cluster-randomised, stepped-wedge effectiveness trial of a reporting and capacity-building intervention to improve HIV viral suppression in housing and behavioural health programmes in New York City

INTRODUCTION

With progress in the 'diagnose', 'link' and 'retain' stages of the HIV care continuum, viral suppression (VS) gains increasingly hinge on antiretroviral adherence among people with HIV (PWH) retained in care. The Centers for Disease Control and Prevention estimate that unsuppressed viral load among PWH in care accounts for 20% of onward transmission. HIV intervention strategies include 'data to care' (D2C)-using surveillance to identify out-of-care PWH for follow-up. However, most D2C efforts target care linkage, not antiretroviral adherence, and limit client-level data sharing to medical (versus support-service) providers. Drawing on lessons learnt in D2C and successful local pilots, we designed a 'data-to-suppression' intervention that offers HIV support-service programmes surveillance-based reports listing their virally unsuppressed clients and capacity-building assistance for quality-improvement activities. We aimed to scale and test the intervention in agencies delivering Ryan White HIV/AIDS Programme-funded behavioural health and housing services.

METHODS AND ANALYSIS

To estimate intervention effects, this study applies a cross-sectional, stepped-wedge design to the intervention's rollout to 27 agencies randomised within matched pairs to early or delayed implementation. Data from three 12-month periods (pre-implementation, partial implementation and full implementation) will be examined to assess intervention effects on timely VS (within 6 months of a report listing the client as needing follow-up for VS). Based on projected enrolment (n=1619) and a pre-implementation outcome probability of 0.40-0.45, the detectable effect size with 80% power is an OR of 2.12 (relative risk: 1.41-1.46).

ETHICS AND DISSEMINATION

This study was approved by the New York City Department of Health and Mental Hygiene's institutional review board (protocol: 21-036) with a waiver of informed consent. Findings will be disseminated via publications, conferences and meetings including provider-agency representatives.

TRIAL REGISTRATION NUMBER

NCT05140421.

The epidemiology of HIV population viral load in twelve sub-Saharan African countries

BACKGROUND

We examined the epidemiology and transmission potential of HIV population viral load (VL) in 12 sub-Saharan African countries.

METHODS

We analyzed data from Population-based HIV Impact Assessments (PHIAs), large national household-based surveys conducted between 2015 and 2019 in Cameroon, Cote d'Ivoire, Eswatini, Kenya, Lesotho, Malawi, Namibia, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe. Blood-based biomarkers included HIV serology, recency of HIV infection, and VL. We estimated the number of people living with HIV (PLHIV) with suppressed viral load (<1,000 HIV-1 RNA copies/mL) and with unsuppressed viral load (viremic), the prevalence of unsuppressed HIV (population viremia), sex-specific HIV transmission ratios (number female incident HIV-1 infections/number unsuppressed male PLHIV per 100 persons-years [PY] and vice versa) and examined correlations between a variety of VL metrics and incident HIV. Country sample sizes ranged from 10,016 (Eswatini) to 30,637 (Rwanda); estimates were weighted and restricted to participants 15 years and older.

RESULTS

The proportion of female PLHIV with viral suppression was higher than that among males in all countries, however, the number of unsuppressed females outnumbered that of unsuppressed males in all countries due to higher overall female HIV prevalence, with ratios ranging from 1.08 to 2.10 (median: 1.43). The spatial distribution of HIV seroprevalence, viremia prevalence, and number of unsuppressed adults often differed substantially within the same countries. The 1% and 5% of PLHIV with the highest VL on average accounted for 34% and 66%, respectively, of countries' total VL. HIV transmission ratios varied widely across countries and were higher for male-to-female (range: 2.3-28.3/100 PY) than for female-to-male transmission (range: 1.5-10.6/100 PY). In all countries mean log10 VL among unsuppressed males was higher than that among females. Correlations between VL measures and incident HIV varied, were weaker for VL metrics among females compared to males and were strongest for the number of unsuppressed PLHIV per 100 HIV-negative adults (R2 = 0.92).

CONCLUSIONS

Despite higher proportions of viral suppression, female unsuppressed PLHIV outnumbered males in all countries examined. Unsuppressed male PLHIV have consistently higher VL and a higher risk of transmitting HIV than females. Just 5% of PLHIV account for almost two-thirds of countries' total VL. Population-level VL metrics help monitor the epidemic and highlight key programmatic gaps in these African countries.

Laboratory diagnosis of HIV: a contemporary overview in the Australian context

Over the past decade there have been technical advances in human immunodeficiency virus (HIV) assays and updates to testing regulations that have substantially changed the landscape of laboratory testing for HIV. In addition, there have been significant changes in the epidemiology of HIV in Australia in the context of highly effective contemporary biomedical treatment and prevention strategies. Here, we provide an update on contemporary issues for the laboratory detection and confirmation of HIV in Australia. These include (1) the impact of early treatment and biological prevention strategies on the serological and virological detection of HIV; (2) the updated national HIV laboratory case definition and its interaction with testing regulations, public health and clinical guidelines; and (3) novel strategies for the laboratory detection of HIV, including the incorporation of HIV nucleic acid amplification tests (NAATs) into testing algorithms. These developments present an opportunity to develop a nationally consistent contemporary HIV testing algorithm that would result in optimisation and standardisation of HIV testing in Australia.

Structure based design and evaluation of benzoheterocycle derivatives as potential dual HIV-1 protease and reverse transcriptase inhibitors

The development of dual inhibitors of HIV-1 protease and reverse transcriptase is an attractive strategy for multi-target therapeutic of AIDS, which may be privileged in delaying the occurrence of drug resistance. We herein designed a novel kind of dual inhibitors with benzofuran or indole cores. Biological results showed that a number of inhibitors displayed significant activity against both HIV-1 protease and reverse transcriptase. Among which, inhibitor 10f exhibited a good correlation with an approximate ratio of 1: 2 between the two enzymes. Furthermore, the dual inhibitors illustrated similar potency against both the wild-type virus and drug-resistant mutant. In addition, the molecular dynamic simulation studies verified the dual actions of such inhibitors.

Design and Evaluation of Novel HIV-1 Protease Inhibitors Containing Phenols or Polyphenols as P2 Ligands with High Activity against DRV-Resistant HIV-1 Variants

With the increasing prevalence of drug-resistant variants, novel potent HIV-1 protease inhibitors with broad-spectrum antiviral activity against multidrug-resistant causative viruses are urgently needed. Herein, we designed and synthesized a new series of HIV-1 protease inhibitors with phenols or polyphenols as the P2 ligands and a variety of sulfonamide analogs as the P2' ligands. A number of these new inhibitors showed superb enzymatic inhibitory activity and antiviral activity. In particular, inhibitors 15d and 15f exhibited potent enzymatic inhibitory activity in the low picomolar range, and the latter showed excellent activity against the Darunavir-resistant HIV-1 variant. Furthermore, the molecular modeling studies provided insight into the ligand-binding site interactions between inhibitors and the enzyme cavity, and they sparked inspiration for the further optimization of potent inhibitors.

HIV proviral genetic diversity, compartmentalization and inferred dynamics in lung and blood during long-term suppressive antiretroviral therapy

The lung is an understudied site of HIV persistence. We isolated 898 subgenomic proviral sequences (nef) by single-genome approaches from blood and lung from nine individuals on long-term suppressive antiretroviral therapy (ART), and characterized genetic diversity and compartmentalization using formal tests. Consistent with clonal expansion as a driver of HIV persistence, identical sequences comprised between 8% to 86% of within-host datasets, though their location (blood vs. lung) followed no consistent pattern. The majority (77%) of participants harboured at least one sequence shared across blood and lung, supporting the migration of clonally-expanded cells between sites. The extent of blood proviral diversity on ART was also a strong indicator of diversity in lung (Spearman's ρ = 0.98, p<0.0001). For three participants, insufficient lung sequences were recovered to reliably investigate genetic compartmentalization. Of the remainder, only two participants showed statistically significant support for compartmentalization when analysis was restricted to distinct proviruses per site, and the extent of compartmentalization was modest in both cases. When all within-host sequences (including duplicates) were considered, the number of compartmentalized datasets increased to four. Thus, while a subset of individuals harbour somewhat distinctive proviral populations in blood and lung, this can simply be due to unequal distributions of clonally-expanded sequences. For two participants, on-ART proviruses were also phylogenetically analyzed in context of plasma HIV RNA populations sampled up to 18 years prior, including pre-ART and during previous treatment interruptions. In both participants, on-ART proviruses represented the most ancestral sequences sampled within-host, confirming that HIV sequences can persist in the body for decades. This analysis also revealed evidence of re-seeding of the reservoir during treatment interruptions. Results highlight the genetic complexity of proviruses persisting in lung and blood during ART, and the uniqueness of each individual's proviral composition. Personalized HIV remission and cure strategies may be needed to overcome these challenges.

A Comparative Analysis of Different HIV Viral Load Suppression Definitions Among Clients Receiving Care in the Miami-Dade Ryan White HIV/AIDS Program

The study's objective was to examine variations in viral load (VL) suppression definitions among clients in the Ryan White Program (RWP). Data from clients enrolled in the RWP during 2017 were examined to calculate the proportion of virally suppressed clients using three definitions: recent viral suppression, defined as having a suppressed VL (< 200 copies/mL) in the last test in 2017; maintained viral suppression, having a suppressed VL for both the first and last tests in 2017; and sustained viral suppression, having all tests in 2017 showing suppression. Relative differences across all three definitions were computed. Recent viral suppression measures were higher than maintained and sustained viral suppression measures by 7.0% and 10.1%, respectively. Significant relative differences in definitions by demographic, socioeconomic and clinical status were observed. It may be beneficial for care planning to report not only estimates of recent viral suppression but maintained and sustained viral suppression as well.

Determinants of long-term survival in late HIV presenters: The prospective PISCIS cohort study

Background

Late HIV diagnosis (i.e CD4≤350 cells/µL) is associated with poorer outcomes. However, determinants of long-term mortality and factors influencing immune recovery within the first years after antiretroviral treatment (ART) initiation are poorly defined.

Methods

From PISCIS cohort, we included all HIV-positive adults, two-year survivors after initiating ART between 2005-2019. The primary outcome was all-cause mortality according to the two-year CD4 count. We used Poisson regression. The secondary outcome was incomplete immune recovery (i.e., two-year CD4<500 cells/µL). We used logistic regression and propensity score matching.

Findings

We included 2,719 participants (16593·1 person-years): 1441 (53%) late presenters (LP) and 1278 non-LP (1145 non-LP with two-year CD4 count >500 cells/µL, reference population). Overall, 113 patients (4·2%) died. Mortality was higher among LP with two-year CD4 count 200-500 cells/µL (aMRR 1·95[95%CI:1·06-3·61]) or <200 cells/µL (aMRR 4·59[2·25-9·37]).Conversely, no differences were observed in participants with two-year CD4 counts >500 cells/µL, regardless of being initially LP or non-LP (aMRR 1·05[0·50-2·21]). Mortality rates within each two-year CD4 strata were not affected by the initial CD4 count at ART initiation (test-interaction, p = 0·48). The stronger factor influencing immune recovery was the CD4 count at ART initiation. First-line integrase-inhibitor-(INSTI)-based regimens were associated with reduced mortality compared to other regimens (aMRR 0·54[0·31-0·93]) and reduced risk of incomplete immune recovery in LP (aOR 0·70[0·52-0·95]).

Interpretation

Two-year immune recovery is a good early predictor of long-term mortality in LP after surviving the first high-risk 2 years. Nearly half experienced a favorable immune recovery with a life expectancy similar to non-LP. INSTI-based regimens were associated with higher rates of successful immune recovery and better survival compared to non-INSTI regimens.

Funding

Southern-Denmark University, Danish AIDS-foundation, and Region of Southern Denmark.

A kind of HIV-1 protease inhibitors containing phenols with antiviral activity against DRV-resistant variants

Based upon the preliminary design of enhancing genetic barrier to drug-resistant viral mutants by maximizing hydrogen-bonding or other van der Waals contacts, we have designed, synthesized and biologically evaluated a new class of HIV-1 protease inhibitors with phenol derived P2 ligands and nitro or halogens in P2' ligands. Results indicate that a majority of inhibitors exhibit robust enzyme inhibitory with IC₅₀ values in picomolar or single digit nanomolar ranges. Among which, compound 17d displays potency with IC₅₀ value of 21 pM and high protease selectivity. Of note, 17d exhibits greater antiviral activity against the DRV-resistant variant than the efficacy against the wild type virus. Furthermore, the molecular modeling studies demonstrate important interactions between 17d and the active sites of both the wild-type and DRV-resistant HIV-1 protease, as well as furnish insights for further optimization of new inhibitors.

Design, Synthesis and X-Ray Structural Studies of Potent HIV-1 Protease Inhibitors Containing C-4 Substituted Tricyclic Hexahydro-Furofuran Derivatives as P2 Ligands

The design, synthesis, X-ray structural, and biological evaluation of a series of highly potent HIV-1 protease inhibitors are reported herein. These inhibitors incorporate novel cyclohexane-fused tricyclic bis-tetrahydrofuran as P2 ligands in combination with a variety of P1 and P2' ligands. The inhibitor with a difluoromethylphenyl P1 ligand and a cyclopropylaminobenzothiazole P2' ligand exhibited the most potent antiviral activity. Also, it maintained potent antiviral activity against a panel of highly multidrug-resistant HIV-1 variants. The corresponding inhibitor with an enantiomeric ligand was significantly less potent in these antiviral assays. The new P2 ligands were synthesized in optically active form using enzymatic desymmetrization of meso-diols as the key step. To obtain molecular insight, two high-resolution X-ray structures of inhibitor-bound HIV-1 protease were determined and structural analyses have been highlighted.

Pocket-to-Lead: Structure-Based De Novo Design of Novel Non-peptidic HIV-1 Protease Inhibitors Using the Ligand Binding Pocket as a Template

A novel strategy for lead identification that we have dubbed the "Pocket-to-Lead" strategy is demonstrated using HIV-1 protease as a model target. Sometimes, it is difficult to obtain hit compounds because of the difficulties in satisfying the complex pharmacophoric features. In this study, a virtual fragment hit which does not match all of the pharmacophore features but has key interactions and vectors that could grow into remaining pharmacophore features was optimized in silico. The designed compound 9 demonstrated weak but evident inhibitory activity (IC₅₀ = 54 μM), and the design concept was proven by the co-crystal structure. Then, structure-based drug design promptly gave compound 14 (IC₅₀ = 0.0071 μM, EC₅₀ = 0.86 μM), an almost 10,000-fold improvement in activity from 9. The structure of the designed molecules proved to be novel with high synthetic feasibility, indicating the usefulness of this strategy to tackle tough targets with complex pharmacophore.

Provider preferences for delivery of HIV care coordination services: results from a discrete choice experiment

INTRODUCTION

The PROMISE study was launched in 2018 to assess and document the implementation of changes to an existing HIV Care Coordination Programme (CCP) designed to address persistent disparities in care and treatment engagement among persons with HIV in New York City. We evaluated provider endorsement of features of the CCP to understand drivers of engagement with the programme.

METHODS

We used a discrete choice experiment to measure provider endorsement of four CCP attributes, including: (1) how CCP helps with medication adherence, (2) how CCP helps with primary care appointments, (3) how CCP helps with issues other than primary care and (4) where CCP visits take place (visit location). Each attribute had three to four levels. Our primary outcomes were relative importance and part-worth utilities, measures of preference for the levels of the four CCP program attributes, estimated using a hierarchical-Bayesian multinomial logit model. All non-medical providers in the core CCP positions of patient navigator, care coordinator and programme director or other administrator from each of the 25 revised CCP-implementing agencies were eligible to participate.

RESULTS

We received responses from 152 providers, 68% of whom identified as women, 49% identified as Latino/a, 34% identified as Black and 60% were 30-49 years old. Visit location (28.6%, 95% confidence interval [CI] 27.0-30.3%) had the highest relative importance, followed by how staff help with ART adherence (24.3%, 95% CI 22.4-26.1%), how staff help with issues other than primary care (24.2%, 95% CI 22.7-25.7%) and how staff help with primary care appointments (22.9%, 95% CI 21.7-24.1%). Within each of the above attributes, respectively, the levels with the highest part-worth utilities were home visits 60 minutes from the program or agency (utility 19.9, 95% CI 10.7-29.0), directly observed therapy (utility 26.1, 95% CI 19.1-33.1), help with non-HIV specialty medical care (utility 26.5, 95% CI 21.5-31.6) and reminding clients about and accompanying them to primary care appointments (utility 20.8, 95% CI 15.6-26.0).

CONCLUSIONS

Ongoing CCP refinements should account for how best to support and evaluate the intensive CCP components endorsed by providers in this study.

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.

The Effect of Buprenorphine on Human Immunodeficiency Virus Viral Suppression

BACKGROUND

Opioid use is prevalent among people living with human immunodeficiency virus (HIV; PLWH) and adversely affects HIV outcomes. We assessed the effect of buprenorphine (BUP) initiation on subsequent HIV viral loads.

METHODS

We identified PLWH from the Johns Hopkins HIV Clinical Cohort who initiated BUP between 2002 and 2017. Poisson regression with robust variance was used to estimate the prevalence of viral suppression (<200 copies/mL) before and after BUP initiation. We matched individuals who initiated BUP with controls based on viral load measurement dates and used prior event rate ratio (PERR) methods to estimate the effect of BUP initiation on viral suppression. PERR methods account for unmeasured confounders.

RESULTS

We identified 279 PLWH who initiated BUP. After BUP initiation, PLWH were more likely to be virally suppressed (prevalence ratio [PR], 1.19; 95% confidence interval [CI], 1.03-1.37). After matching PLWH who initiated BUP to controls and accounting for measured and unmeasured confounders, BUP initiation increased viral suppression for both those on antiretroviral therapy (ART) at baseline (PERR PR, 1.08; 95% CI, 1.00-1.18) and those not on ART at baseline (PR, 1.31; 95% CI, 1.10-1.61).

CONCLUSIONS

Our results indicate that the initiation of BUP results in an increase in the probability of being virally suppressed after accounting for both measured and unmeasured confounders. Persons with opioid use disorder should initiate BUP to not only treat substance use but also to increase viral suppression allowing for treatment as prevention.

HIV incidence, viremia, and the national response in Eswatini: Two sequential population-based surveys

With the highest HIV incidence and prevalence globally, the government of Eswatini started a substantial scale-up of HIV treatment and prevention services in 2011. Two sequential large population-based surveys were conducted before and after service expansion to assess the impact of the national response. Cross-sectional, household-based, nationally representative samples of adults, ages 18 to 49 years, were sampled in 2011 and 2016. We measured HIV prevalence, incidence (recent infection based on limiting antigen ≤1.5 optical density units and HIV RNA ≥1000 copies/mL), viral load suppression (HIV RNA <1000 copies/mL among all seropositive adults) and unsuppressed viremia (HIV RNA ≥1000 copies/mL among all, regardless of HIV status) and assessed for temporal changes by conducting a trend analysis of the log ratio of proportions, using a Z statistic distribution. HIV prevalence remained stable from 2011 to 2016 [32% versus 30%, p = 0.10]. HIV incidence significantly declined 48% [2.48% versus 1.30%, p = 0.01]. Incidence remained higher among women than men [2011: 3.16% versus 1.83%; 2016: 1.76% versus 0.86%], with a smaller but significant relative reduction among women [44%; p = 0.04] than men [53%; p = 0.09]. The proportion of seropositive adults with viral load suppression significantly increased from 35% to 71% [p < .001]. The proportion of the total adult population with unsuppressed viremia decreased from 21% to 9% [p < .001]. National HIV incidence in Eswatini decreased by nearly half and viral load suppression doubled over a five-year period. Unsuppressed viremia in the total population decreased 58%. These population-based findings demonstrate the national impact of expanded HIV services in a hyperendemic country.

Incidence and Predictors of Hypertension Among HIV Patients Receiving ART at Public Health Facilities, Northwest Ethiopia: A One-Year Multicenter Prospective Follow-Up Study

Background

The introduction of highly active retroviral therapy has dramatically reduced mortality and improved survival among HIV patients. However, there is a possible risk of comorbid complications such as hypertension. Little evidence is available regarding the incidence of hypertension among HIV patients receiving anti-retroviral therapy in Ethiopia.

Purpose

To assess the incidence and predictors of hypertension among HIV positive patients receiving ART at Public Health Facilities, Northwest Ethiopia.

Patients and Methods

A one-year prospective follow-up study was conducted among a cohort of 302 new adult individuals initiating on a standard anti-retroviral therapy regimen with a median (IQR) age of 35 years (IQR=30-41). A pretested data extraction checklist was used to extract baseline patient records. The collected data were entered into Epi-Data version 3.1 and exported to STATA version 14 for analysis. The incidence rate was calculated, and a Kaplan-Meier survival curve was used to estimate the survival probabilities of developing hypertension. Cox proportional hazards model was fitted to identify the predictors of hypertension.

Results

About 40 (13.25) new hypertensive cases were observed during the follow-up period, and the remaining 262 (86.75%) were censored. The overall incidence rate of hypertension was 16.35 per 1000 person-month with 2447 patient-month observations. Male sex (AHR = 2.45, 95% CI: 1.02, 6.14), old age (AHR = 2.83, 95% CI: 1.08, 7.45), high BMI (AHR = 6.54, 95% CI: 2.03, 21.13), diabetic comorbidity (AHR = 2.36, 95% CI: 1.07, 5.22), and patients who were on Zidovudine (AZT)-based ART regimen (AHR =3.47, 95% CI: 1.10, 10.94) were significant predictors for the development of hypertension.

Conclusion

The findings of this study revealed that incident hypertension is a common problem among HIV patients receiving ART. Routine monitoring of blood pressure and screening and treating high blood pressure should be an integral part of follow-up for HIV patients in ART clinics.

Understanding patterns of HIV multi-drug resistance through models of temporal and spatial drug heterogeneity

Triple-drug therapies have transformed HIV from a fatal condition to a chronic one. These therapies should prevent HIV drug resistance evolution, because one or more drugs suppress any partially resistant viruses. In practice, such therapies drastically reduced, but did not eliminate, resistance evolution. In this article, we reanalyze published data from an evolutionary perspective and demonstrate several intriguing patterns about HIV resistance evolution - resistance evolves (1) even after years on successful therapy, (2) sequentially, often via one mutation at a time and (3) in a partially predictable order. We describe how these observations might emerge under two models of HIV drugs varying in space or time. Despite decades of work in this area, much opportunity remains to create models with realistic parameters for three drugs, and to match model outcomes to resistance rates and genetic patterns from individuals on triple-drug therapy. Further, lessons from HIV may inform other systems.

Tuberculosis incidence and mortality in people living with human immunodeficiency virus: a Danish nationwide cohort study

OBJECTIVES

To explore changes over time in the epidemiology of tuberculosis (TB) in Denmark in people living with human immunodeficiency virus (HIV) (PLWH).

METHODS

In this nationwide, population-based cohort study we included all adult PLWH from the Danish HIV Cohort Study (1995-2017) without previous TB. We estimated TB incidence rate (IR), all-cause mortality rate (MR), associated risk and prognostic factors using Poisson regression.

RESULTS

Among 6982 PLWH (73 596 person-years (PY)), we observed 217 TB events (IR 2.9/1000 PY, 95% CI 2.6-3.4: IR 6.7, 95% CI 5.7-7.9 among migrants and IR 1.4, 95% CI 1.1-1.7 among Danish-born individuals; p < 0.001). The IR of concomitant HIV/TB remained high and unchanged over time. The IR of TB diagnosed >3 months after HIV diagnosis declined with calendar time, longer time from HIV diagnosis, and CD4 cell recovery. Independent TB risk factors were African/Asian/Greenland origin (adjusted incidence rate ratio (aIRR) 5.2, 95% CI 3.5-7.6, aIRR 6.5, 95% CI 4.2-10.0, aIRR 7.0, 95% CI 3.4-14.6, respectively), illicit drug use (aIRR 6.9, 95% CI 4.2-11.2), CD4 <200 cells/μL (aIRR 2.7, 95% CI 2.0-3.6) and not receiving antiretroviral therapy (aIRR 3.7, 95% CI 2.5-5.3). Fifty-five patients died (MR 27.9/1000 PY, 95% CI 21.4-36.3), with no improvement in mortality over time. Mortality prognostic factors were Danish-origin (adjusted mortality rate ratio (aMRR) 2.3, 95% CI 1.3-4.3), social burden (aMRR 3.9, 95% CI 2.2-7.0), CD4 <100 cells/μL at TB diagnosis (aMRR 2.6, 95% CI 1.3-4.9), TB diagnosed >3 months after HIV versus concomitant diagnosis (aMRR 4.3, 95% CI 2.2-8.7) and disseminated TB (aMRR 3.3, 95% CI 1.1-9.9).

CONCLUSION

Late HIV presentation with concomitant TB remains a challenge. Declining TB rates in PLWH were observed over time and with CD4 recovery, highlighting the importance of early and successful antiretroviral therapy. However, MR remained high. Our findings highlight the importance of HIV and TB screening strategies and treatment of latent TB in high-risk groups.

Population Viral Load, Viremia, and Recent HIV-1 Infections: Findings From Population-Based HIV Impact Assessments (PHIAs) in Zimbabwe, Malawi, and Zambia

BACKGROUND

HIV population viral load (PVL) can reflect antiretroviral therapy program effectiveness and transmission potential in a community. Using nationally representative data from household surveys conducted in Zimbabwe, Malawi, and Zambia in 2015-16, we examined the association between various VL measures and the probability of at least one recent HIV-1 infection in the community.

METHODS

We used limiting-antigen avidity enzyme immunoassay, viral load suppression (VLS) (HIV RNA <1000 copies/mL), and antiretrovirals in the blood to identify recent HIV-1 cases.

RESULTS

Among 1510 enumeration areas (EAs) across the 3 surveys, 52,036 adults aged 15-59 years resided in 1363 (90.3%) EAs with at least one HIV-positive adult consenting to interview and blood draw and whose VL was tested. Mean HIV prevalence across these EAs was 13.1% [95% confidence intervals (CI) 12.7 to 13.5]. Mean VLS prevalence across these EAs was 58.7% (95% CI: 57.3 to 60.0). In multivariable analysis, PVL was associated with a recent HIV-1 case in that EA (adjusted odds ratio: 1.4, 95% CI: 1.2 to 1.6, P = 0.001). VLS prevalence was inversely correlated with recent infections (adjusted odds ratio: 0.3, 95% CI: 0.1 to 0.6, P = 0.004). The 90-90-90 indicators, namely, the prevalence of HIV diagnosis, antiretroviral therapy coverage, and VLS at the EA level, were inversely correlated with HIV recency at the EA level.

CONCLUSIONS

We found a strong association between PVL and VLS prevalence and recent HIV-1 infection at the EA level across 3 southern African countries with generalized HIV epidemics. These results suggest that population-based measures of VLS in communities may serve as a proxy for epidemic control.

Tracking elimination of HIV transmission in men who have sex with men in England: a modelling study

BACKGROUND

To manage the HIV epidemic among men who have sex with men (MSM) in England, treatment as prevention strategies based on test and treat were strengthened between 2011 and 2015, and supplemented from 2015 by scale-up of pre-exposure prophylaxis (PrEP). We examined the effect of these interventions on HIV incidence and investigated whether internationally agreed targets for HIV control and elimination of HIV transmission by 2030 might be within reach among MSM in England.

METHODS

We used a novel, age-stratified, CD4-staged Bayesian back-calculation model to estimate HIV incidence and undiagnosed infections among adult MSM (age ≥15 years) during the 10-year period between 2009 and 2018. The model used data on HIV and AIDS diagnoses routinely collected via the national HIV and AIDS Reporting System in England, and knowledge on the progression of HIV through CD4-defined disease stages. Estimated incidence trends were extrapolated, assuming a constant MSM population from 2018 onwards, to quantify the likelihood of achieving elimination of HIV transmission, defined as less than one newly aquired infection per 10 000 MSM per year, by 2030.

FINDINGS

The peak in HIV incidence in MSM in England was estimated with 80% certainty to have occurred in 2012 or 2013, at least 1 year before the observed peak in new diagnoses in 2014. Results indicated a steep decrease in the annual number of new infections among MSM, from 2770 (95% credible interval 2490-3040) in 2013 to 1740 (1500-2010) in 2015, followed by a steadier decrease from 2016, down to 854 (441-1540) infections in 2018. A decline in new infections was consistently estimated in all age groups, and was particularly marked in MSM aged 25-34 years, and slowest in those aged 45 years or older. Similar trends were estimated in the number of undiagnosed infections, with the greatest decrease after 2013 in the 25-34 years age group. Under extrapolation assumptions, we calculated a 40% probability of achieving the defined target elimination threshold by 2030.

INTERPRETATION

The sharp decrease in HIV incidence, estimated to have begun before the scale up of PrEP, indicates the success of strengthening treatment as prevention measures among MSM in England. To achieve the 2030 elimination threshold, targeted policies might be required to reach those aged 45 years or older, in whom incidence is decreasing at the slowest rate.

FUNDING

UK Medical Research Council, UK National Institute of Health Research Health Protection Unit in Behavioural Science and Evaluation, and Public Health England.

Immunogenetic determinants of heterosexual HIV-1 transmission: key findings and lessons from two distinct African cohorts

Immunogenetic studies in the past three decades have uncovered a broad range of human genetic factors that seem to influence heterosexual HIV-1 transmission in one way or another. In our own work that jointly evaluated both genetic and nongenetic factors in two African cohorts of cohabiting, HIV-1-discordant couples (donor and recipient pairs) at risk of transmission during quarterly follow-up intervals, relatively consistent findings have been seen with three loci (IL19, HLA-A, and HLA-B), although the effect size (i.e., odds ratio or hazards ratio) of each specific variant was quite modest. These studies offered two critical lessons that should benefit future research on sexually transmitted infections. First, in donor partners, immunogenetic factors (e.g., HLA-B*57 and HLA-A*36:01) that operate directly through HIV-1 viral load or indirectly through genital coinfections are equally important. Second, thousands of single-nucleotide polymorphisms previously recognized as "causal" factors for human autoimmune disorders did not appear to make much difference, which is somewhat puzzling as these variants are predicted or known to influence the expression of many immune response genes. Replicating these observations in additional cohorts is no longer feasible as the field has shifted its focus to early diagnosis, universal treatment, and active management of comorbidities.

Adherence to antiretroviral therapy among HIV positive men who inject drugs in Pakistan

BACKGROUND

People who inject drugs (PWID) living with HIV have poorer adherence to HIV antiretroviral therapy (ART) and elevated mortality compared to other populations. Little is known about factors associated with adherence among PWID in low-and middle-income countries, including in countries where opioid agonist therapy (OAT) is unavailable. We aimed to estimate ART adherence among men who inject drugs (MWID) living with HIV in Pakistan and identify factors independently associated with adherence.

METHODS

Nai Zindagi Trust (NZT) provides a range of HIV prevention, testing and treatment services to PWID in Pakistan. This study utilized data from HIV positive MWID who received ART refill/s from public sector ART Centres via NZT's Social Mobilizer Adherence Support Unit between September 2016 and December 2018. Multivariable logistic regression modelled factors independently associated with ART adherence.

RESULTS

Among 5,482 HIV positive MWID registered with NZT who had attended the AAU and were supplied with ART refills between September 2016 and December 2018., 55% were adherent to ART. Independent predictors of adherence were being married (AOR 1.38, 95% CI:1.23-1.55, p<0.001) and >5 years of education compared to those with no education (AOR 1.19, 95% CI:1.05-1.35, p = 0.005). MWID living on the street at night had lower adjusted odds of ART adherence (AOR 0.75, 95% CI:0.62-0.91, p = 0.003).

CONCLUSIONS

Findings indicate that MWID living with HIV continue to face barriers to ART adherence in Pakistan. Despite considerable evidence supporting the impact of OAT in increasing ART adherence among PWID, OAT remains illegal and inaccessible in Pakistan. Evidence-based interventions, including OAT, are needed to increase adherence and improve clinical outcomes, health equity and survival among PWID living with HIV in Pakistan.

Evidence of an Association of Increases in Pre-exposure Prophylaxis Coverage With Decreases in Human Immunodeficiency Virus Diagnosis Rates in the United States, 2012-2016

BACKGROUND

Annual human immunodeficiency virus (HIV) diagnoses in the United States (US) have plateaued since 2013. We assessed whether there is an association between uptake of pre-exposure prophylaxis (PrEP) and decreases in HIV diagnoses.

METHODS

We used 2012-2016 data from the US National HIV Surveillance System to estimate viral suppression (VS) and annual percentage change in diagnosis rate (EAPC) in 33 jurisdictions, and data from a national pharmacy database to estimate PrEP uptake. We used Poisson regression with random effects for state and year to estimate the association between PrEP coverage and EAPC: within jurisdictional quintiles grouped by changes in PrEP coverage, regressing EAPC on time; and among all jurisdictions, regressing EAPC on both time and jurisdictional changes in PrEP coverage with and without accounting for changes in VS.

RESULTS

From 2012 to 2016, across the 10 states with the greatest increases in PrEP coverage, the EAPC decreased 4.0% (95% confidence interval [CI], -5.2% to -2.9%). On average, across the states and District of Columbia, EAPC for a given year decreased by 1.1% (95% CI, -1.77% to -.49%) for an increase in PrEP coverage of 1 per 100 persons with indications. When controlling for VS, the state-specific EAPC for a given year decreased by 1.3% (95% CI, -2.12% to -.57%) for an increase in PrEP coverage of 1 per 100 persons with indications.

CONCLUSIONS

We found statistically significant associations between jurisdictional increases in PrEP coverage and decreases in EAPC independent of changes in VS, which supports bringing PrEP use to scale in the US to accelerate reductions in HIV infections.

Design and biological evaluation of cinnamic and phenylpropionic amide derivatives as novel dual inhibitors of HIV-1 protease and reverse transcriptase

Upon the basis of both possible ligand-binding site interactions and the uniformity of key residues in active sites, a novel class of HIV-1 PR/RT dual inhibitors was designed and evaluated. Cinnamic acids or phenylpropionic acids with more flexible chain and smaller steric hindrance were introduced into the inhibitors, giving rise to significant improvement in HIV-1 RT inhibitory activity by one or two orders of magnitude, with comparable or even improved potency against PR at the same time, compared with coumarin anologues in our previous studies. Among these inhibitors, 38d displayed a 19-fold improvement in anti-PR activity with IC₅₀ value of 0.081 nM compared to the control DRV. In addition, inhibitor 38c exhibited an excellent anti-RT IC₅₀ value of 0.43 μM, only a 4.7-fold less potent activity than the control EFV. More significantly, the disparate ratio between HIV-1 PR and RT inhibition became more reasonable with ratio of 1: 10.4, just as 37b. Furthermore, the assays on HIV-1 late stage and early stage supported the rationality of designing dual inhibitors. The SAR data as well as molecular modeling studies provided new insight for further optimization of more potent HIV-1 PR/RT dual inhibitors.

What gaps remain in the HIV cascade of care? Results of a population-based survey in Nsanje District, Malawi

INTRODUCTION

The Malawi Ministry of Health (MoH) has been in collaboration with Médecins sans Frontières (MSF) to increase access to quality HIV care through decentralization of antiretroviral therapy (ART) diagnosis and treatment from hospital to clinics in Nsanje District since 2011. A population-based household survey was implemented to provide information on HIV prevalence and cascade of care to inform and prioritize community-based HIV interventions in the district.

METHODS

A cross-sectional survey was conducted between September 2016 and January 2017. Using two-stage cluster sampling, eligible adult individuals aged ≥15 years living in the selected households were asked to participate. Participants were interviewed and tested for HIV at home. Those tested HIV-positive had their HIV-RNA viral load (VL) measured, regardless of their ART status. All participants tested HIV-positive at the time of the survey were advised to report their HIV test result to the health facility of their choice that MSF was supported in the district. HIV-RNA VL results were made available in this health facility.

RESULTS

Among 5,315 eligible individuals, 91.1% were included in the survey and accepted an HIV test. The overall prevalence was 12.1% (95% Confidence Interval (CI): 11.2-13.0) and was higher in women than in men: 14.0% versus 9.5%, P<0.001. Overall HIV-positive status awareness was 80.0% (95%CI: 76.4-83.1) and was associated with sex (P<0.05). Linkage to care was 78.0% (95%CI: 74.3-81.2) and participants in care 76.2% (95%CI: 72.4-79.5). ART coverage among participants aware of their HIV-positive status was 95.3% (95%CI: 92.9-96.9) and was not associated with sex (P = 0.55). Viral load suppression among participants on ART was 89.9% (95%CI: 86.6-92.4) and was not statistically different by sex (p = 0.40).

CONCLUSIONS

Despite encouraging results in HIV testing coverage, cascade of care, and UNAIDS targets in Nsanje District, some gap remains in the first 90, specifically among men and young adults. Enhanced community engagement and new strategies of testing, such as index testing, could be implemented to identify those who are still undiagnosed, particularly men and young adults.

Design and evaluation of novel piperidine HIV-1 protease inhibitors with potency against DRV-resistant variants

A novel class of HIV-1 protease inhibitors with flexible piperidine as the P2 ligand was designed with the aim of improving extensive interactions with the active subsites. Many inhibitors exhibited good to excellent inhibitory effect on enzymatic activity and viral infectivity. In particular, inhibitor 3a with (R)-piperidine-3-carboxamide as the P2 ligand and 4-methoxybenzenesulfonamide as the P2' ligand showed an enzyme K_i value of 29 pM and antiviral IC₅₀ value of 0.13 nM, more than six-fold enhancement of activity compared to DRV. Furthermore, there was no significant change in potency against DRV-resistant mutations and HIV-1_NL4-3 variant for 3a. Besides, inhibitor 3a exhibited potent antiviral activity against subtype C variants with low nanomole EC₅₀ values. In addition, the molecular modeling revealed important hydrogen bonds and other favorable van der Waals interactions with the backbone atoms of the protease and provided insight for designing and optimizing more potent HIV-1 protease inhibitors.

The opioid crisis and HIV in the USA: deadly synergies

The opioid epidemic is one of the greatest public health problems that the USA faces. Opioid overdose death rates have increased steadily for more than a decade and doubled in 2013-17, as the highly potent synthetic opioid fentanyl entered the drug supply. Demographics of new HIV diagnoses among people who inject drugs are also changing, with more new HIV diagnoses occurring among White people, young people (aged 13-34 years), and people who reside outside large central metropolitan areas. Racial differences also exist in syringe sharing, which decreased among Black people and Hispanic people but remained unchanged among White people in 2005-15. Recent HIV outbreaks have occurred in rural areas of the USA, as well as among marginalised people in urban areas with robust HIV prevention and treatment services (eg, Seattle, WA). Multiple evidence-based interventions can effectively treat opioid use disorder and prevent HIV acquisition. However, considerable barriers exist precluding delivery of these solutions to many people who inject drugs. If the USA is serious about HIV prevention among this group, stigma must be eliminated, discriminatory policies must change, and comprehensive health care must be accessible to all. Finally, root causes of the opioid epidemic such as hopelessness need to be identified and addressed.

Hepatitis C Virus Incidence in a Cohort in Medication-Assisted Treatment for Opioid Use Disorder in New York City

BACKGROUND

Hepatitis C virus (HCV) incidence has increased in the worsening opioid epidemic. We examined the HCV preventive efficacy of medication-assisted treatment (MAT), and geographic variation in HCV community viral load (CVL) and its association with HCV incidence.

METHODS

HCV incidence was directly measured in an open cohort of patients in a MAT program in New York City between 1 January 2013 and 31 December 2016. Area-level HCV CVL was calculated. Associations of individual-level factors, and of HCV CVL, with HCV incidence were examined in separate analyses.

RESULTS

Among 8352 patients, HCV prevalence was 48.7%. Among 2535 patients seronegative at first antibody test, HCV incidence was 2.25/100 person-years of observation (PYO). Incidence was 6.70/100 PYO among those reporting main drug use by injection. Female gender, drug injection, and lower MAT retention were significantly associated with higher incidence rate ratios. Female gender, drug injection, and methadone doses <60 mg were independently associated with shorter time to HCV seroconversion. HCV CVLs varied significantly by geographic area.

CONCLUSIONS

HCV incidence was higher among those with lower MAT retention and was lower among those receiving higher methadone doses, suggesting the need to ensure high MAT retention, adequate doses, and increased HCV prevention and treatment engagement. HCV CVLs vary geographically and merit further study as predictors of HCV incidence.

Primary HIV-1 infection in users of pre-exposure prophylaxis

Pre-exposure prophylaxis (PrEP) has proven to be a highly effective and safe way to prevent HIV infection. Seroconversion and primary HIV infection are exceptional if adherence to PrEP is good. However, primary HIV infection while using PrEP can occur, albeit rarely, and HIV drug resistance might develop. Furthermore, the scope of PrEP is expected to expand, and clinicians might face potential seroconversions and primary HIV infection in patients starting or taking PrEP. The characteristics of primary HIV infection in users of PrEP are poorly described. PrEP users present a lower viral load peak during primary HIV infection and, frequently, fewer symptoms than individuals not exposed to PrEP. Additionally, PrEP prolongs the stages of seroconversion, thus potentially complicating diagnosis of primary HIV infection. Drug resistance is rare, occurring mostly when PrEP is initiated in undiagnosed patients who are at an extremely early stage of infection, in whom detection of HIV-RNA was not used to rule out HIV infection. Therefore, careful exclusion of primary HIV infection before starting PrEP is crucial. In patients presenting with primary HIV infection while on PrEP, a drug with a high genetic barrier (or even two) should be added to tenofovir disoproxil fumarate-emtricitabine until test results for resistance are available.

HIV viral load trajectories of women living with HIV in Metro Vancouver, Canada

This study describes long-term viral load (VL) trajectories and their predictors among women living with HIV (WLWH), using data from Sexual Health and HIV/AIDS: Women's Longitudinal Needs Assessment (SHAWNA), an open prospective cohort study with linkages to the HIV/AIDS Drug Treatment Program. Using Latent Class Growth Analysis (LCGA) on a sample of 153 WLWH (1088 observations), three distinct trajectories of detectable VL (≥50 copies/ml) were identified: 'sustained low probability of detectable VL', characterized by high probability of long-term VL undetectability (51% of participants); 'high probability of delayed viral undetectability', characterized by a high probability VL detectability at baseline that decreases over time (43% of participants); and 'high probability of detectable VL', characterized by a high probability of long-term VL detectability (7% of participants). In multivariable analysis, incarceration (adjusted odds ratio (AOR) = 3.24; 95%CI:1.34-7.82), younger age (AOR = 0.96; 95%CI:0.92-1.00), and lower CD4 count (AOR = 0.82; 95%CI:0.72-0.93) were associated with 'high probability of delayed viral undetectability' compared to 'sustained low probability of detectable VL.' This study reveals the dynamic and heterogeneous nature of WLWH's long-term VL patterns, and highlights the need for early engagement in HIV care among young WLWH and programs to mitigate the destabilizing impact of incarceration on WLWH's HIV treatment outcomes.

Ending an HIV epidemic among persons who inject drugs in a middle-income country: extremely low HIV incidence among persons who inject drugs in Hai Phong, Viet Nam

OBJECTIVE

To determine whether it is possible to 'end an HIV epidemic' among persons who inject drugs (PWID) in a low/middle income country.

DESIGN

Serial cross-sectional surveys with a cohort of HIV seronegative participants with 6-month follow-up visits recruited from surveys.

METHODS

Surveys of PWID using respondent driven and snowball sampling were conducted in 2016, 2017, 2018, and 2019 (N = 1383, 1451, 1444, and 1268). HIV recency testing was used to identify possible seroconversions in the window period prior to study entry. Structured interviews covering drug use histories, current drug use, and use of HIV-related services were administered by trained interviewers. Urinalysis was used to confirm current drug use. HIV and hepatitis C virus testing were conducted. Electronic fingerprint readers were used to avoid multiple participation in each survey and to link participants across surveys. A cohort of HIV seronegative participants with 6-month follow-up visits was recruited from the surveys, 480 from 2016, 233 from 2017, and 213 from 2018.

RESULTS

Participants were predominantly male (95%), mean age approximately 40, all reported injecting heroin, HIV prevalence ranged between 26 and 30%. We had three seroconversions in 1483 person-years at risk (PYAR) in the cohort study, and 0 in 696 PYAR among repeat survey participants, and 0 seroconversions in 1344 PYAR in recency testing. Overall HIV incidence was 0.085/100 PYAR, 95% confidence interval 0.02-0.25/100 PYAR.

CONCLUSION

The data from Hai Phong clearly demonstrate that it is possible to achieve very low HIV incidence - 'end an HIV epidemic' - among PWID in a middle-income country.

Efficacy and Freedom: Patient Experiences with the Transition from Daily Oral to Long-Acting Injectable Antiretroviral Therapy to Treat HIV in the Context of Phase 3 Trials

Long-acting injectable antiretroviral therapy (LA ART) may be an alternative for people living with HIV (PLHIV) with adherence challenges or who prefer not to take pills. Using in-depth interviews, this study sought to understand the experiences of PLHIV (n = 53) participating in Phase 3 LA ART trials in the United States and Spain. The most salient consideration when contemplating LA ART was its clinical efficacy; many participants reported wanting to ensure that it worked as well as daily oral ART, including with less frequent dosing (every 8 versus 4 weeks). While injection side effects were often reported, most participants felt that regimen benefits outweighed such drawbacks. Participants described the main benefit of LA ART as the "freedom" it afforded both logistically and psychosocially, including through reduced HIV stigma. Findings highlight the importance of patient-provider communication related to weighing potential benefits and side effects and the continued need to address HIV stigma.

Human immunodeficiency virus prevention strategies in China

This paper reviews the current epidemics of human immunodeficiency virus (HIV) infection in China, particularly the globally available prevention strategies developed and implemented. This review focuses on HIV prevention measures in general, such as education, testing, and counseling and in specific responses to transmission modes, such as blood safety, harm reduction for people who inject drugs, and condom promotion to reduce sexual transmission. We also assess newly developed prevention measures, such as prevention treatment, pre-exposure prophylaxis, post-exposure prophylaxis, male circumcision, and promising potential future preventions, including microbicides and vaccines. Based on this assessment, we provide recommendations for their implementation in China. We conclude that there is no magic bullet for HIV prevention, particularly sexual transmission of the disease, but only a combination of these prevention strategies can control the HIV epidemic.

Preventing HIV outbreaks among people who inject drugs in the United States: plus ça change, plus ça même chose

: This editorial review covers current trends in the epidemiology of HIV among people who inject drugs (PWID) in the United States, including four recent HIV outbreaks. We discuss gaps in the prevention and treatment cascades for HIV and medications for opioid disorder and propose lessons learned to prevent future HIV outbreaks. Over the last decade, North America has been in the throes of a major opioid epidemic, due in part to over-prescribing of prescription opiates, followed by increasing availability of cheap heroin, synthetic opioids (e.g. fentanyl), and stimulants (e.g. methamphetamine). Historically, HIV infection among PWID in the US had predominantly affected communities who were older, urban and Black. More recently, the majority of these infections are among younger, rural or suburban and Caucasian PWID. All four HIV outbreaks were characterized by a high proportion of women who inject drugs and underlying socioeconomic drivers such as homelessness and poverty. We contend that the US response to the HIV epidemic among PWID has been fractured. A crucial lesson is that when evidence-based responses to HIV prevention are undermined or abandoned because of moral objections, untold humanitarian and financial costs on public health will ensue. Restructuring a path forward requires that evidence-based interventions be integrated and brought to scale while simultaneously addressing underlying structural drivers of HIV and related syndemics. Failing to do so will mean that HIV outbreaks among PWID and the communities they live in will continue to occur in a tragic and relentless cycle.