Young age predicts poor antiretroviral adherence and viral load suppression among injection drug users

A factorial experiment grounded in the multiphase optimization strategy to promote viral suppression among people who inject drugs on the Texas-Mexico border: a study protocol

BACKGROUND

People who inject drugs living with HIV (PWIDLH) suffer the lowest rates of HIV viral suppression due to episodic injection drug use and poor mental health coupled with poor retention in HIV care. Approximately 44% of PWIDLH along the US-Mexico border are retained in care and only 24% are virally suppressed. This underserved region faces a potential explosion of transmission of HIV due to highly prevalent injection drug use. This protocol describes an optimization trial to promote sustained viral suppression among Spanish-speaking Latinx PWIDLH.

METHODS

The multiphase optimization strategy (MOST) is an engineering-inspired framework for designing and building optimized interventions and guides this intervention. The primary aim is to conduct a 24 factorial experiment in which participants are randomized to one of 16 intervention conditions, with each condition comprising a different combination of four behavioral intervention components. The components are peer support for methadone uptake and persistence; behavioral activation therapy for depression; Life-Steps medication adherence counseling; and patient navigation for HIV care. Participants will complete a baseline survey, undergo intervention, and then return for 3-,6-,9-, and 12-month follow-up assessments. The primary outcome is sustained viral suppression, defined as viral loads of < 40 copies per mL at 6-,9-, and 12-month follow-up assessments. Results will yield effect sizes for each component and each additive and interactive combination of components. The research team and partners will make decisions about what constitutes the optimized multi-component intervention by judging the observed effect sizes, interactions, and statistical significance against real-world implementation constraints. The secondary aims are to test mediators and moderators of the component-to-outcome relationship at the 6-month follow-up assessment.

DISCUSSION

We are testing well-studied and available intervention components to support PWIDLH to reduce drug use and improve their mental health and engagement in HIV care. The intervention design will allow for a better understanding of how these components work in combination and can be optimized for the setting.

TRIAL REGISTRATION

This project was registered at clinicaltrials.gov (NCT05377463) on May 17th, 2022.

Digital directly observed therapy to monitor adherence to medications: a scoping review

Background: Technology-based directly observed therapy (DOT) is more cost-effective and efficient compared with in-person monitoring visits for medication adherence. While some evidence shows these technologies are feasible and acceptable, there is limited evidence collating information across medical conditions or in the context of HIV prevention, care, and treatment.Objectives: We conducted a scoping review to understand the current evidence on the acceptability, feasibility, and efficacy of digital DOT to improve medication adherence and, specifically, to determine if digital DOT had been used to improve adherence for HIV prevention, care, and treatmentMethods: We searched the electronic databases PubMed, Embase, and the Web of Science in January 2021 for any published studies with terms related to digital technologies and DOT. We included peer-reviewed studies in any population, from any country, for any outcome, and excluded conference abstracts. We included three types of digital DOT interventions: synchronous DOT, asynchronous DOT, and automated DOT. We provide an assessment of the current evidence, gaps in literature, and opportunities for intervention development regarding the use digital DOT to improve antiretroviral therapy (ART) adherence, specifically in the field of HIV.Results: We identified 28 studies that examined digital DOT. All studies found digital DOT to be acceptable and feasible. Patients using digital DOT had higher rates of treatment completion, observed doses, and adherence compared with in-person DOT, although data were limited on adherence. Only one study examined HIV prevention, and none examined ART adherence for HIV treatment.Conclusions: Digital DOT is acceptable and feasible but has not been used to remotely monitor and support ART adherence for people living with HIV.

Adherence to Antiretroviral Therapy Among HIV-Infected Clients Attending Opioid Treatment Program Clinics in Dar es Salaam, Tanzania

Background

Adherence to antiretroviral therapy (ART) among key populations like human immunodeficiency virus (HIV)-positive People Who Inject Drugs (PWID) could be challenging, especially in low and middle-income countries (LMICs). Therefore we conducted this study to assess the adherence to ART among HIV-positive PWID attending three methadone clinics in Dar es Salaam, Tanzania.

Methods

A cross-sectional study was conducted at three methadone clinics in Dar es Salaam, Tanzania. Adherence to ART was measured by using pharmacy refill and patient self-report methods. Bivariate and multivariable logistic regression was performed to determine the association between dependent and independent variables. A p-value of less than 0.05 was considered to be statistically significant.

Results

Of the 180 participants, 97.2% recorded good adherence to ART as per the pharmacy refill method. However, only 66.1% of the PWID were found to adhere to ART based on the patient self-report method. Upon associating the self-report method with a viral load of >1000 copies/mL, participants were 3.37 times more likely to have missed their ART dose at least once in the last three days before their refill visit compared to those with a viral load of <1000 copies/mL [Adjusted Odds ratio; 3.37, 95% Confidence Interval (95% CI); 1.35 - 8.45, p = 0.009].

Conclusion

The adherence to ART among HIV-infected PWID attending methadone clinics was high based on the pharmacy refill method but relatively much lower based on the patient self-report method. There was a strong correlation between viral load and the level of adherence measured by the patient self-report method.

Challenges to Antiretroviral Therapy Adherence and Coping Strategies to Overcome Them: Qualitative Investigations of Adolescents Living with HIV, their Caregivers, and Clinicians in Vietnam

Background:

Adolescents living with HIV (ALHIV) in Vietnam are known to struggle with adherence to Antiretroviral Therapy (ART).

Objective:

To examine treatment challenges and facilitators experienced by ALHIV from the perspective of adolescents, their caregivers, and providers, and to inform an adherence intervention.

Methods:

In-depth Interviews (IDIs) of adolescent/caregiver dyads and Focus Group Discussions (FGDs) with adolescents, caregivers, and clinicians were conducted in Hanoi, Vietnam. We used semi-structured guides to encourage open-ended responses. We queried the challenges adolescents experience taking ART medications and being adherent, their awareness of disease status, and facilitators to support high adherence. Audio-recorded IDIs were translated into English, and coded and analyzed in NVivo using a thematic approach.

Results:

A total of 78 individuals participated in the study. Forty individuals participated in IDIs (20 adolescents and 20 caregivers). All adolescents had acquired HIV perinatally. We conducted six FGDs: four with adolescents, and one each with caregivers and clinicians. We identified major themes regarding awareness of HIV status (most caregivers reported they had disclosed to their child, while few adolescents revealed the knowledge of their status); perceived barriers to adherence (medication-related challenges, stigma, school-associated issues, financial obstacles, system challenges, awareness of HIV status); and adherence facilitators (development of dose-taking habits, reminder systems, social support). Differences between adolescents and caregivers related to key issues were evident.

Conclusion:

Further research is needed to elucidate discrepancies in adolescent-caregiver viewpoints and develop interventions tailored to both ALHIV and their caregivers.

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.

Understanding adherence in virally suppressed and unsuppressed human immunodeficiency virus-positive urban patients on second-line antiretroviral treatment

Background

Understanding antiretroviral therapy (ART) adherence may assist in designing effective support interventions.

Objectives

This study elicited perspectives on how to promote treatment adherence from virologically suppressed and unsuppressed patients receiving second-line ART.

Methods

This was a cross-sectional study conducted with randomly selected patients active on second-line ART, from five public health facilities in the Johannesburg inner city. Data were collected on demographics, clinical information, participant’s experiences and ART knowledge. Virological failure was defined as exceeding 1000 copies/mL.

Results

The study sample comprised 149 participants; of which 47.7% (n = 71) were virally unsuppressed and 69.1% (n = 103) were women; the median age of the participants was 42 years (interquartile range [IQR] 36–47 years). Experiencing medication-related difficulties in taking second-line ART (p = 0.003), finding second-line regimen more difficult to take than a first-line regimen (p = 0.001) and experiencing side effects (p < 0.001) were all subjective predictors of virological failure. Participants’ recommendations for improving adherence included the introduction of a single tablet regimen (31.6%, n = 55), reducing the dosage to once daily (26.4%, n = 46) and reducing the pill size for second-line regimen (4.0%, n = 7).

Conclusion

The results of this study highlight the importance of improving patients’ knowledge about adherence and motivation to continue ART use despite the persistence of side effects and difficulties with taking medication.

Correlates of ART Use Among Newly Diagnosed HIV Positive Adolescent Girls and Young Women Enrolled in HPTN 068

Despite expanded access to HIV treatment worldwide, poor HIV care outcomes persist among adolescent girls and young women (AGYW). This study was conducted among AGYW recruited from the HPTN 068 cohort who had sero-converted to HIV during the main trial between 2011 and 2014. The aim was to examine correlates of anti-retroviral treatment (ART) use. Log binomial regression was used to estimate the crude associations between social support, stigma, and HIV status disclosure and current ART use. Adjusted analyses were also conducted controlling for age and time since diagnosis. Seventy-nine AGYW were included in this analysis. Median age of participants was 20 (range: 17 to 24) and time since diagnosis ranged from 0.5 to 4.8 years (median = 2.1). Over 75% of AGYW (n = 60) had sought HIV care at some point, with the same number reporting previous disclosure of their sero-status. However, just 43% (n = 34) of participants were on treatment at the time of the interview. Over half of participants (n = 44; 55.7%) reported social support was available to them most or all of the time, and the median stigma score was 90 (range 80-113). Adjusted analyses found higher current ART use among those who had disclosed their status (adjusted prevalence ratio (aPR): 3.19; 95% confidence interval (CI) 1.09, 9.32; p = 0.0339) and those with lower scores on the disclosure concern sub-scale of the Berger HIV Stigma Scale (aPR: 0.88; 95% CI 0.79, 0.98; p = 0.0236). ART use among AGYW living with HIV and enrolled in HPTN 068 was low despite relatively high linkage to care during the trial. Interventions aimed at minimizing individuals' concerns about disclosure and improving onward disclosure of one's status could further improve ART utilization among AGYW living with HIV in South Africa.

Magnitude of non-adherence to antiretroviral therapy and associated factors among adult people living with HIV/AIDS in Benishangul-Gumuz Regional State, Ethiopia

Introduction

Following global efforts to increase antiretroviral therapy (ART) access and coverage, Ethiopia has made significant achievement with a 6.3% annual decline in the HIV/AIDS incidence rate between 1990 and 2016. Such success depends not only on access to ART but also on attaining optimum treatment adherence. Emerging studies in Ethiopia has shown the increasing prevalence of poor adherence and lack of the desired viral suppression, but the extent and factors associated with non-adherence to ART are not well known, especially in the current study setup. In this study, we examined the magnitude and factors associated with treatment and non-adherence to ART among people living with HIV in Benishangul-Gumuz Regional State, northwest Ethiopia.

Methods

An institutional facility based cross-sectional descriptive study was carried out among adult people living with HIV/AIDS from mid-December 2016 to February 2017 with only 98.9% response rate. Sociodemographic factors (age, gender, marital status and residential area), economic factors (educational status, income, asset possession, employment status, dietary diversity, nutritional status and food security), and clinical characteristics (CD4 count, duration on ART and history of opportunistic infections) were explanatory variables. ART non-adherence was measured using a visual analogue scale (VAS). We used binary logistic regression and subsequent multivariate logistic regression analysis to determine the factors associated with ART non-adherence.

Result

Overall, 39.7% of the participants were found non-adherent to ART. Strong association was found between non-adherence to ART and young age below 25 years (AOR: 4.30, 95% CI [1.39-3.35]; p = 0.011), urban residential area (AOR: 2.78, CI [1.23-7.09], p = 0.043), lack of employment (AOR: 1.75, 95% CI [1.05-2.91], p = 0.032), food insecurity (AOR: 2.67, 95% CI [7.59-8.97]; p < 0.0001), malnutrition (AOR: 1.55, 95% CI [1.94-2.56]; p = 0.027) and opportunistic infections (AOR: 1.81, 95% CI [1.11-2.97]; p = 0.018).

Conclusion

The prevalence of non-adherence to ART in this study was high. Sociodemographic and economic factors such as young age of below 25 years, urban residential area, lack of employment, food insecurity, malnutrition and opportunistic infections were among the factors associated with non-adherence to ART.

Modeling Viral Suppression, Viral Rebound and State-Specific Duration of HIV Patients with CD4 Count Adjustment: Parametric Multistate Frailty Model Approach

INTRODUCTION

Combination antiretroviral therapy has become the standard care of human immunodeficiency virus (HIV)-infected patients and has further led to a dramatically decreased progression probability to acquired immune deficiency syndrome (AIDS) for patients under such a therapy. However, responses of the patients to this therapy have recorded heterogeneous complexity and high dynamism. In this paper, we simultaneously model long-term viral suppression, viral rebound, and state-specific duration of HIV-infected patients.

METHODS

Full-parametric and semi-parametric Markov multistate models were applied to assess the effects of covariates namely TB co-infection, educational status, marital status, age, quality of life (QoL) scores, white and red blood cell parameters, and liver enzyme abnormality on long-term viral suppression, viral rebound and state-specific duration for HIV-infected individuals before and after treatment. Furthermore, two models, one including and another excluding the effect of the frailty, were presented and compared in this study.

RESULTS

Results from the diagnostic plots, Akaike information criterion (AIC) and likelihood ratio test showed that the Weibull multistate frailty model fitted significantly better than the exponential and semi-parametric multistate models. Viral rebound was found to be significantly associated with many sex partners, higher eosinophils count, younger age, lower educational level, higher monocyte counts, having abnormal neutrophils count, and higher liver enzyme abnormality. Furthermore, viral suppression was also found to be significantly associated with higher QoL scores, and having a stable sex partner. The analysis result also showed that patients with a stable sex partner, higher educational levels, higher QoL scores, lower eosinophils count, lower monocyte counts, and higher RBC indices were more likely to spend more time in undetectable viral load state.

CONCLUSIONS

To achieve and maintain the UNAIDS 90% suppression targets, additional interventions are required to optimize antiretroviral therapy outcomes, specifically targeting those with poor clinical characteristics, lower education, younger age, and those with many sex partners. From a methodological perspective, the parametric multistate approach with frailty is a flexible approach for modeling time-varying variables, allowing for dealing with heterogeneity between the sequence of transitions, as well as allowing for a reasonable degree of flexibility with a few additional parameters, which then aids in gaining a better insight into how factors change over time.

Five-year survival analysis and predictors of death in HIV-positive serology patients attending the Military Hospital of Nampula, Mozambique

An observational retrospective study was conducted over a 5-year period to assess survival and predictors of death in people with HIV-positive serology undergoing antiretroviral treatment with first-line regimens at the Military Hospital of Nampula, Mozambique. We collected data from 332 patient records. Kaplan-Meier boundary product estimator, log-rank, Gehan-Breslow, Tarone-Ware, time-dependent Cox models and estimates of hazard ratios (HR), with 95% confidence interval (CI) were calculated. Meantime survival for females and males was 54.8 months [95% CI 50.32-55.40] and 49.7 months [95% CI 45.89-53.53], respectively. Cox regressions indicated higher death rates significantly or potentially associated with: male sex (HR = 1.3; [95% CI 0.7-2.39]); suspected diagnosis reported only by the physician (HR = 3.6; [95% CI 1.8-7.4]); disease stages III (HR=1.2 [95% CI 0.3-3.6]) or IV (HR 1.4 [95% CI 0.4-5.8]); first TCD4+ lymphocyte count lower than 350 cells per ml (HR = 3.2; [95% CI 0.9-11.2]) or between 350-500 cells per ml (HR = 1.3; [95% CI 0.3-5.8]); or do not present cells count (HR = 3.6; [95% CI 1.2-10.2]). The above variables were significant for HIV prognosis and as predictors of death and should be considered in the clinical care of these patients.

What do HIV-positive drug users' experiences tell us about their antiretroviral medication-taking? An international integrated literature review

BACKGROUND AND AIMS

HIV-positive drug users' poor adherence to antiretroviral regimens can pose a significant and negative impact on individual and global health. This review aims to identify knowledge gaps and inconsistencies within the current evidence base and to measure HIV-positive drug users' adherence rates and the factors that influence their adherence.

METHODS

A search of quantitative and qualitative studies in relation to HIV-positive drug users' adherence to antiretroviral treatment was performed using five databases: Applied Social Sciences Index and Abstract (ASSIA), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Embase and PsycINFO (Ovid interface). Relevant studies were retrieved based on the inclusion and exclusion criteria stated in the review. Findings were compared, contrasted and synthesized to provide a coherent account of HIV-positive drug users' adherence rates and the factors that influence their adherence.

RESULTS

The proportion of HIV-positive drug users who achieved ≥ 95% adherence across the studies varied widely, from 19.3 to 83.9%. Adherence rates changed over the course of HIV treatment. The factors that influenced adherence were reported as follows: stigmatization, motivation, active drug use, accessibility and conditionality of HIV and addiction care, side effects and complexity of treatment regimens, forgetfulness and non-incorporation of dosing times into daily schedules.

CONCLUSIONS

HIV-positive drug users' medication-taking is a dynamic social process that requires health professionals to assess adherence to HIV treatment on a regular basis.

A Multi-Site Study of Social Cognitive Factors Related to Adherence Among Youth Living With HIV in the New Era of Antiretroviral Medication

Objective

The goal of the current study was to determine how a set of social cognitive factors predict antiretroviral therapy (ART) medication adherence in youth living with HIV in an era of newer highly active ART medications using a conceptual model.

Methods

Behaviorally infected youth living with HIV ages 13-24 (N = 822) from 14 sites within the Adolescent Medicine Trials Unit (AMTU) were included in the study. Structural equation modeling was used to explore predictors of ART medication adherence.

Results

Results found that motivational readiness for ART was related to higher ART medication adherence, which was associated with lower viral load. Higher social support and higher self-efficacy had an indirect relationship with higher adherence through increased motivational readiness. Fewer psychological symptoms were associated with higher social support and higher self-efficacy. Lower substance use was directly associated with lower adherence.

Conclusions

The results provide insight into factors that may be related to adherence in youth living with HIV. Findings suggest focusing on motivational readiness to increase adherence. Improving the patients' ART self-efficacy and strengthening their social support networks during treatment can increase motivational readiness for ART treatment. Furthermore, programs maybe more effective with the inclusion of risk reduction components especially those related to substance use.

Viral Suppression and Its Associated Factors in HIV Patients on Highly Active Antiretroviral Therapy (HAART): A Retrospective Study in the Ho Municipality, Ghana

Background. The WHO targets to end HIV/AIDS as a public health problem by 2030. The introduction of the ambitious “90-90-90” strategy to attain this target is expected to be achieved by the year 2020. However, there is lack of regional data, especially on the third “90.” This study sought to assess the rate and associated factors of viral suppression among people living with HIV (PLWH) on highly active antiretroviral therapy (HAART) at the Antiretroviral Therapy (ART) Clinic in a Ghanaian health facility. Method. The study design was a retrospective analysis of secondary data of 284 HIV registrants on HAART for at least 6 months at the ART Clinic from July 2016 to April 2019. Data on sociodemography including age, gender, marital status, education, and occupation as well as pharmacological (type of medication and duration on medication) and laboratory variable (current viral load results) were extracted from patients’ folders. Viral suppression and failure were determined using the WHO definitions (viral suppression as viral load <1000 copies/ml and virologic failure ≥1000 copies/ml). Regular clinic attendance (used as a proxy measure for medication adherence) was defined as consistent monthly clinic attendance for HAART medication and other clinical management within the past 12 months. Results. Out of the 284 HIV patients, 195 (69%) achieved viral suppression. Of the 195 who were virally suppressed, 77 (39.5%) had undetectable levels, with a similar proportion (39.5%) achieving viral load results ranging from 20 to 200 copies/ml. Moreover, 27 (13.8%) patients had viral load ranging from 201 to 500 copies/ml while 14 (7.2%) recorded viral load from 501 to 1000 copies/ml. No clear pattern in the viral suppression rate was associated with the age groups (p=0.1152). However, regular clinic attendance (used as proxy for medication adherence) (p<0.0001) and being on HAART for more than three (3) years (p=0.03) were associated with viral suppression. Conclusion. The rate of viral suppression among PLWH on HAART in the Ho municipality fell short of the WHO target. However, the study identified regular ART clinic attendance and treatment >3 years as factors associated with viral suppression.

Durable HIV Suppression Among People Who Inject Drugs From a Community-Based Cohort Study in Baltimore, Maryland, 1997-2017

People who inject drugs (PWID) face disparities in human immunodeficiency virus (HIV) treatment outcomes and may be less likely to achieve durable viral suppression. We characterized transitions into and out of viral suppression from 1997 to 2017 in a long-standing community-based cohort study of PWID, the AIDS Link to Intravenous Experience (ALIVE) Study, analyzing HIV-positive participants who had made a study visit in or after 1997. We defined the probabilities of transitioning between 4 states: 1) suppressed, 2) detectable, 3) lost to follow-up, and 4) deceased. We used multinomial logistic regression analysis to examine factors associated with transition probabilities, with a focus on transitions from suppression to other states. Among 1,061 participants, the median age was 44 years, 32% were female, 93% were African-American, 59% had recently injected drugs, and 28% were virologically suppressed at baseline. Significant improvements in durable viral suppression were observed over time; however, death rates remained relatively stable. In adjusted analysis, injection drug use and homelessness were associated with increased virological rebound in earlier time periods, while only age and race were associated with virological rebound in 2012-2017. Opioid use was associated with an increased risk of death following suppression in 2012-2017. Despite significant improvements in durable viral suppression, subgroups of PWID may need additional efforts to maintain viral suppression and prevent premature mortality.

WYZ: a pilot study protocol for designing and developing a mobile health application for engagement in HIV care and medication adherence in youth and young adults living with HIV

INTRODUCTION

Youth and young adults bear a disproportionate share of the HIV burden and there is a critical need for interventions to curb health disparities experienced among these age groups. The purpose of our research is to build on our theory-guided model and formative research to develop a mobile health application, called WYZ, for improved engagement in HIV care and antiretroviral therapy adherence, and pilot test it among youth and young adults living with HIV (YLWH). In this paper, we explain the design and development of WYZ for YLWH, describe the design of a forthcoming pilot trial for evaluating the feasibility and acceptability of WYZ and compare WYZ with other mobile health applications being developed to improve engagement in HIV care and antiretroviral medication adherence.

METHODS AND ANALYSIS

We used an agile methodology, shown to be useful in software development, and elicited feedback during beta testing to develop WYZ. WYZ is a modular, adaptive and personalised intervention delivered via a mobile phone. It is grounded in the information, motivation, behaviouralskills model which has been valuable for understanding and guiding the development of interventions for complex health behaviours. WYZ was created in collaboration with YLWH aged 18-29 years using a human-centred design approach that emphasises understanding the perspective of the users of the technology. WYZ is intended to improve engagement in HIV care by: (1) enhancing medication adherence self-efficacy, (2) increasing awareness and use of community resources, (3) reducing barriers to communication between youth and their healthcare team, and (4) providing a secure platform for the formation of a private online community of YLWH. We will conduct a 6-month single-arm pilot study to examine feasibility and acceptability of WYZ among 76 YLWH who live or receive care in the San Francisco Bay Area. All study activities, including recruitment, screening, enrolment, study assessments, provision of incentives and exit interviews, will be conducted remotely. We will explore feasibility and acceptability outcomes of the intervention using quantitative and qualitative methods.

ETHICS AND DISSEMINATION

Study staff will obtain written consent for study participation from all participants. This study and its protocols have been approved by the University of California San Francisco (UCSF) Institutional Review Board. Study staff will work with the UCSF Center for AIDS Prevention Studies' Community Engagement Core and the Youth Advisory Panel to disseminate results to the participants and the community using presentations, community forums, journal publications and/or social media.

TRIAL REGISTRATION NUMBER

NCT03587857; Pre-results.

Systematic review of HIV treatment adherence research among people who inject drugs in the United States and Canada: evidence to inform pre-exposure prophylaxis (PrEP) adherence interventions

BACKGROUND

People who inject drugs (PWID) are at increased risk for HIV acquisition and could benefit from antiretroviral pre-exposure prophylaxis (PrEP). However, PrEP has been underutilized in this population, and PrEP adherence intervention needs are understudied.

METHODS

To inform PrEP intervention development, we reviewed evidence on antiretroviral therapy (ART) adherence among HIV-infected PWID. Guided by a behavioral model of healthcare utilization and using the PICOS framework, we conducted a systematic review in four electronic databases to identify original research studies of ART adherence in HIV-infected PWID in the United States and Canada between Jan 1, 2006-Dec 31, 2016. We synthesized and interpreted findings related to developing recommendations for PrEP adherence interventions for PWID.

RESULTS

After excluding 618 duplicates and screening 1049 unique records, we retained 20 studies of PWID (mean n = 465) with adherence-related outcomes (via pharmacy records: n = 9; self-report: n = 8; biological markers: n = 5; electronic monitoring: n = 2). Predisposing factors (patient-level barriers to adherence) included younger age, female sex, and structural vulnerability (e.g., incarceration, homelessness). Enabling resources (i.e., facilitators) that could be leveraged or promoted by interventions included self-efficacy, substance use treatment, and high-quality patient-provider relationships. Competing needs that require specific intervention strategies or adaptations included markers of poor physical health, mental health comorbidities (e.g., depression), and engagement in transactional sex.

CONCLUSIONS

HIV treatment adherence research carries important lessons for efforts to optimize PrEP adherence among PWID. Despite limitations, this systematic review suggests that strategies are needed to engage highly vulnerable and marginalized sub-groups of this underserved population (e.g., younger PWID, women who inject drugs) in PrEP adherence-related research and programming.

Trends in AIDS Mortality, Retention in Opioid Agonist Therapy, and HIV RNA Suppression in HIV-Infected People Who Injected Drugs from 2000 to 2015

AIDS is a major cause of preventable mortality in HIV-infected people who inject drugs (HIV-PWID). An observational study was conducted to examine trends in AIDS mortality and related factors among HIV-infected individuals who died between 2000 and 2015 at an urban hospital. Overall HIV-mortality was 6.5% (413/6307) with no changes over time (p 0.76). AIDS mortality dropped in HIV-PWID (p 0.02) although it represented 26.4% at the end of study period. Age (per one-year increase) [odds ratio (OR) 0.95], third study period (2010-2015) (OR 0.54), HIV-PWID on opioid agonist therapy (OAT) (OR 0.39), and HIV RNA suppression (OR 0.15) were associated with AIDS mortality. OAT was reported in 58.3% (161/276) and RNA suppression in 30.9% (85/276) of HIV-PWID. OAT non-retention was due to drop-outs [85.2% (98/115)] and rejection [14.8% (17/115)] in HIV-PWID. Therefore, additional strategies are required to improve OAT retention and HIV RNA suppression to continue reducing AIDS mortality.

The Prevalence of HIV Load Suppression and Related Factors Among Patients on ART at Phedisong 4 Clinic, Pretoria, South Africa

Background:

Globally, the benefits of viral load suppression in improving the lives of people living with HIV/AIDS have been established. In 2010, the South African Government decentralised ART to the primary care level. This study intended to determine the effect of this decentralisation in achieving viral load suppression among patients.

Objective:

To determine the prevalence of HIV viral load suppression and factors related to the suppression among patients initiated on ART at Pedisong 4 clinic, Tshwane District in Pretoria.

Methods:

A prospective cohort study was conducted on 98 patients initiated on ART between 01 November 2012 and 30 April 2013. Based on the viral load results, they were divided into those who achieved Viral Load Suppression (VLS), and those who did not (NVLS). Analyses were done using SAS® (version 9.2) for Microsoft software. A p < 0.05 was considered significant.

Results:

Ninety patients (91.8%; 95%CI, 84.7% – 95.8%) achieved viral load suppression while eight (8.2%; 95%CI, 4.2% – 15.3%), did not. Of the 98 patients, 63 (64%) were female. In the NVLS group, the female to male ratio was 7:1 (p = 0.038). There was no relationship between viral load suppression and patients’ baseline characteristics, behavioural characteristics and clinical characteristics (p > 0.05). ART adherence reported in both patient groups was ≥ 87.0%.

Conclusion:

There was good viral load suppression in patients initiated on ART at Pedisong 4 clinic. Patients’ baseline, behavioural and clinical characteristics were not related to viral load suppression, necessitating further large sample size studies in various health facilities.

Health Care Utilization Behaviors Predict Disengagement From HIV Care: A Latent Class Analysis

Background

The traditional definition of engagement in HIV care in terms of only clinic attendance and viral suppression provides a limited understanding of how persons living with HIV (PLWH) interact with the health care system.

Methods

We conducted a retrospective analysis of patients with ≥1 HIV clinic visits at the Duke Adult Infectious Diseases Clinic between 2008 and 2013. Health care utilization was characterized by 4 indicators: clinic attendance in each half of the year (yes/no), number of emergency department (ED) visits/year (0, 1, or 2+), inpatient admissions/year (0, 1, 2+), and viral suppression (never, intermittent, always). Health care engagement patterns were modeled using latent class/latent transition analysis.

Results 

A total of 2288 patients (median age, 46.4 years; 59% black, 71% male) were included in the analysis. Three care engagement classes were derived from the latent class model: "adherent" "nonadherent," and "sick." Patients age ≤40 years were more likely to be in the nonadherent class (odds ratio, 2.64; 95% confidence interval, 1.38-5.04) than other cohort members. Whites and males were more likely to transition from nonadherent to adherent the following year. Nonadherent patients were significantly more likely to disengage from care the subsequent year than adherent patients (23.6 vs 0.2%, P < .001).

Conclusions

A broader definition of health care engagement revealed distinct and dynamic patterns among PLWH that would have been hidden had only previous HIV clinic attendance had been considered. These patterns may be useful for designing engagement-targeted interventions.

Sub-optimal adherence to combination anti-retroviral therapy and its associated factors according to self-report, clinician-recorded and pharmacy-refill assessment methods among HIV-infected adults in Addis Ababa

Adherence to combination antiretroviral therapy (cART) is generally high in most resource-limited settings. However, sub-optimal adherence occurs in a sizable proportion of patients, and is independently predictive of detectable viremia. We investigated sub-optimal adherence according to self-report, clinician-recorded, and pharmacy-refill assessment methods, and their associated factors among HIV-infected adults receiving cART in Addis Ababa, Ethiopia. Eight-hundred seventy patients who initiated cART between May 2009 and April 2012 were randomly selected, and 664 patients who were alive, had remained in clinical care and were receiving cART for at least six-months were included. Sub-optimal adherence was defined as patients' response of less than "all-of the time" to the self-report adherence question, or any clinician-recorded poor adherence during the six most recent clinic visits, or a pharmacy-refill of <95% medication possession ratio (MPR). Logistic regression models were fitted to identify factors associated with sub-optimal adherence. The average adherence level to cART, expressed as MPR, was nearly 97%. However, sub-optimal adherence occurred in 12%, 4%, and 27% of patients according to self-report, clinician-recorded, and pharmacy-refill measures, respectively. More satisfaction with social support was significantly associated with less sub-optimal adherence according to self-report and clinician-record. Younger age, lower educational level, and lower CD4 cell count at cART initiation were significantly associated with sub-optimal refill-based adherence. Findings from our large multi-center study suggest that sub-optimal adherence was present in up to a quarter of the patients, despite a high degree of average adherence to cART. Interventions aimed at preventing sub-optimal adherence should focus on improving social support, on younger patients, on patients with lower educational level, and on those who started cART at a lower CD4 cell count.

The Use of Mobile Health Applications Among Youth and Young Adults Living with HIV: Focus Group Findings

The objective of this study was to conduct focus groups with youth (18-29 years old) living with HIV (YLWH) to better understand preferences for mobile applications in general and to inform the design of a mobile health application aimed at improving retention and engagement in healthcare and adherence to antiretroviral therapy. We conducted four focus groups with YLWH to elicit the names and characteristics of applications that they commonly used, reasons they deleted applications, and the features of an ideal mobile health application. A diverse sample of youth (N = 17) with a mean age of 25 years, 88.2% male, and 29.4% African American participated in four focus groups. Positive attributes of applications included informative, simple, allowing for networking, timely updates, little overlap with other applications, unlimited access to entertainment, and with ongoing advancement. Participants identified several reasons for deleting applications, including engaging in excessive behaviors (e.g., spending money), for hook ups only, too many notifications or restrictions, occupied too much space on device, or required wireless connectivity or frequent updates. Participants suggested that a mobile health application that they would find useful should have the ability to connect to a community of other YLWH, readily access healthcare providers, track personal data and information (such as laboratory data), and obtain health news and education. Privacy was a key factor in a mobile health application for all participants. Researchers can use the information provided by focus group participants in creating mobile health applications for YLWH.

Risk Factors for Loss to Follow-Up among People Who Inject Drugs in a Risk Reduction Program at Karachi, Pakistan. A Case-Cohort Study

INTRODUCTION

Retention of male people who inject drugs (PWIDs) is a major challenge for harm reduction programs that include sterile needle/syringe exchange in resource-limited settings like Pakistan. We assessed the risk factors for loss to follow-up among male PWIDs enrolled in a risk reduction program in Karachi, Pakistan.

METHODS

We conducted a prospective cohort study among 636 HIV-uninfected male PWIDs enrolled during March-June 2009 in a harm reduction program for the estimation of incidence rate. At 24 months post-enrollment, clients who had dropped out of the program were defined as lost to follow-up and included as cases for case-cohort study.

RESULTS

The median age of the participants was 29 years (interquartile range: 23-36). Active outreach accounted for 76% (483/636) of cohort recruits. Loss to follow-up at 24 months was 25.5% (162/636). In multivariable logistic regression, younger age (AOR: 0.97, 95% CI: 0.92-0.99, p = 0.028), clients from other provinces than Sindh (AOR: 1.49, 95% CI: 1.01-2.22, p = 0.046), having no formal education (AOR: 3.44, 95% CI: 2.35-4.90, p<0.001), a history of incarceration (AOR: 1.68, 95% CI: 1.14-2.46, p<0.008), and being homeless (AOR: 1.47, 95% CI: 1.00-2.19, p<0.049) were associated with loss to follow-up.

CONCLUSIONS

Our cohort retained 74.5% of male PWIDs in Karachi for 24 months. Its loss to follow up rate suggested substantial ongoing programmatic challenges. Programmatic enhancements are needed for the highest risk male PWIDs, i.e., younger men, men not from Sindh Province, men who are poorly educated, formerly incarcerated, and/or homeless.

Younger Age Predicts Failure to Achieve Viral Suppression and Virologic Rebound Among HIV-1-Infected Persons in Serodiscordant Partnerships

BACKGROUND

Antiretroviral therapy (ART) markedly reduces the risk of HIV-1 transmission in serodiscordant partnerships. We previously found that younger age and higher CD4 counts were associated with delayed initiation of ART by HIV-1-infected partners in serodiscordant partnerships. Among those initiating ART, we sought to explore whether those same factors were associated with failure to achieve viral suppression.

METHODS

In a prospective study of HIV-1-infected persons who had a known heterosexual HIV-1-uninfected partner in Kenya and Uganda [Partners Pre-Exposure Prophylaxis (PrEP) Study], we used Cox proportional hazards regression to evaluate correlates of viral nonsuppression (HIV-1 RNA >80 copies/ml).

RESULTS

Of 1,035 HIV-1-infected participants initiating ART, 867 (84%) achieved viral suppression: 77% by 6 months and 86% by 12 months. Younger age [adjusted hazard ratio (aHR) 1.05 for every 5 years younger; p = .006], lower pretreatment CD4 count (aHR 1.26; p = .009 for ≤250 compared with >250 cells/μl), and higher pretreatment HIV-1 RNA quantity (aHR 1.21 per log10; p < .001) independently predicted failure to achieve viral suppression. Following initial viral suppression, 8.8% (76/867) experienced virologic rebound (HIV-1 RNA >200 copies/ml): 6.3% and 11.5% by 6 and 12 months after initial suppression, respectively. Age was the only factor associated with increased risk of virologic rebound (aHR 1.33 for every 5 years younger; p = .005).

CONCLUSIONS

For HIV-1-infected persons in serodiscordant couples, younger age was associated with delayed ART initiation, failure to achieve viral suppression, and increased risk of virologic rebound. Motivating ART initiation and early adherence is a key to achieving and sustaining viral suppression.

High level of virological suppression among HIV-infected adults receiving combination antiretroviral therapy in Addis Ababa, Ethiopia

BACKGROUND

Plasma viral load (pVL) is a key indicator of therapeutic response in HIV-infected patients receiving combination antiretroviral therapy (cART), but is often unavailable in routine clinical care in resource-limited settings. Previous model-based simulation studies have suggested that the benefits of routine pVL monitoring among patients on first-line regimens in resource-limited settings are modest, but this needs corroboration in well-defined study populations.

METHODS

We investigated virological suppression levels and identified predictors of detectable viraemia among 870 randomly selected patients who started cART between May 2009 and April 2012 in 10 health-care facilities in Addis Ababa, Ethiopia. A total of 656 (75.4%) patients, who were alive, were retained in HIV care and receiving cART for at least 6 months provided a blood sample for pVL measurement. Predictors of detectable viraemia were identified in a multivariate logistic regression model.

RESULTS

In on-treatment analysis, 94.5% (95% CI 92.5, 96.1) of the patients achieved virological suppression below 400 copies/ml after a median (IQR) of 26 (17-35) months on cART. When patients who were lost to follow-up, dead or stopped were assumed to have had detectable viraemia, the proportion of patients with virological suppression <400 copies/ml decreased to 74.6% (95% CI 71.5%, 77.4%). Younger age, lower educational status, <95% medication adherence, lower CD4(+) T-cell count at cART initiation and/or the diagnosis of immunological failure thereafter significantly predicted detectable viraemia.

CONCLUSIONS

Virological suppression levels can be high in an established ART programme in a resource-limited setting, even without the availability of routine pVL monitoring. Efforts to improve treatment outcomes should focus on younger and illiterate patients, earlier detection of HIV-positive status and cART initiation before patients are severely immunocompromised, and improving retention in care.

Applying Triple-Matrix Masking for Privacy Preserving Data Collection and Sharing in HIV Studies

BACKGROUND

Many HIV research projects are plagued by the high missing rate of selfreported information during data collection. Also, due to the sensitive nature of the HIV research data, privacy protection is always a concern for data sharing in HIV studies.

METHODS

This paper applies a data masking approach, called triple-matrix masking [1], to the context of HIV research for ensuring privacy protection during the process of data collection and data sharing.

RESULTS

Using a set of generated HIV patient data, we show step by step how the data are randomly transformed (masked) before leaving the patients' individual data collection device (which ensures that nobody sees the actual data) and how the masked data are further transformed by a masking service provider and a data collector. We demonstrate that the masked data retain statistical utility of the original data, yielding the exactly same inference results in the planned logistic regression on the effect of age on the adherence to antiretroviral therapy and in the Cox proportional hazard model for the age effect on time to viral load suppression.

CONCLUSION

Privacy-preserving data collection method may help resolve the privacy protection issue in HIV research. The individual sensitive data can be completely hidden while the same inference results can still be obtained from the masked data, with the use of common statistical analysis methods.

Psychosocial factors in adherence to antiretroviral therapy among HIV-positive people who use drugs

OBJECTIVE

Suboptimal adherence to antiretroviral therapy (ART) among HIV-infected people who use illicit drugs (PWUD) remains a significant concern, and there is a lack of effective adherence interventions for this population. Therefore, we sought to identify psychosocial determinants of optimal adherence, including adherence self-efficacy and outcome expectancies, with the aim of informing interventions designed to improve adherence among PWUD.

METHOD

From December 2005 to November 2013, we collected data from the AIDS Care Cohort to evaluate Exposure to Survival Services (ACCESS), a prospective cohort of PWUD in Vancouver, Canada. We used multivariable generalized estimating equations (GEE) analysis to identify longitudinal factors independently associated with 95% or greater adherence to ART.

RESULTS

Among 667 participants, including 220 (33%) women, 391 (59%) had 95% or greater ART adherence at baseline. In multivariable GEE analysis, adherence self-efficacy, adjusted odds ratio (AOR) = 1.16, 95% confidence interval (CI) [1.11, 1.21] per 10-point increase, was independently and positively associated with adherence, while negative outcome expectancy, AOR = 0.95, 95% CI [0.93, 0.98], was negatively associated.

CONCLUSION

In light of the ongoing challenges associated with ART adherence among HIV-positive PWUD, and our findings of associations between adherence, self-efficacy, and outcomes expectancies, tailored intervention strategies based on constructs of social learning theory should be implemented and evaluated to improve adherence among HIV-infected PWUD.

Effectiveness of first-line antiretroviral therapy in HIV/AIDS patients: A 5-year longitudinal evaluation in Fujian Province, Southeast China

The aim of this study was to evaluate the long-term effectiveness of first-line antiretroviral therapy in HIV/AIDS patients in Southeast China. A total of 450 eligible patients were selected to initiate first-line antiretroviral therapy from February 2005 through August 2009. During the study period from 2009 through 2013, each subject received clinical and laboratory monitoring for effectiveness, safety and toxicity once every 3 months in the first year, and once every 6 months in the following years. The response to first-line antiretroviral therapy was evaluated through body weight gain and immunological and virological outcomes. During the mean follow-up period of 70.86 ± 28.9 months, the overall mortality was 14.2%. The mean body weight and CD4(+) counts increased significantly following antiretroviral therapy as compared to baselines across the follow-up period, and the rate of immunological effectiveness was over 85% in all subjects at 2 to 5 years of treatment. The rate of inhibition of HIV virus was 87.67%, 89.32%, 91.73%, 92.8% and 91.63% across the study period. In addition, significant differences were detected after treatment as compared to baselines, and Pearson correlation analysis revealed a positive correlation between immunological effectiveness and viral inhibition. Forty-eight percent of the subjects changed antiretroviral drugs once, and 16.22% twice, and 31 patients switched from first-line to second-line antiretroviral therapy. Long-term antiretroviral therapy remains effective for treatment of HIV/AIDS, resulting in higher mean body weight, effective viral inhibition and a higher CD4 count. Immunological effectiveness of antiretroviral therapy positively correlates with HIV viral inhibition.

Childhood Sexual Abuse and Syringe Sharing Among People Who Inject Drugs

Childhood sexual abuse is associated with adverse health outcomes. However, the impact of sexual abuse on HIV risk behaviors among people who inject drugs (IDU) has not been thoroughly characterized. We therefore sought to identify whether childhood sexual abuse was associated with syringe sharing among a sample of IDU in Vancouver, Canada. We assessed sexual abuse among two cohorts of IDUs via the Childhood Trauma Questionnaire. Multivariate logistic regression was used to estimate the relationship between childhood sexual abuse and syringe sharing. In total, 1380 IDU were included in the study, and 426 (30.9 %) IDU reported childhood sexual abuse. Syringe sharing (Adjusted Odds Ratio = 1.83, 95 % Confidence Interval 1.28-2.60) remained independently associated with childhood sexual abuse after adjustment for potential confounders. Given that a history of childhood sexual abuse appears to be elevated among IDU who engage in HIV risk behaviors (i.e., syringe sharing), HIV prevention efforts should include efforts to address historical trauma in this population.

Review: an urgent need for research on factors impacting adherence to and retention in care among HIV-positive youth and adolescents from key populations

INTRODUCTION

The 50% increase in HIV-related deaths in youth and adolescents (aged 10-24) from 2005 to 2012 highlights the need to improve HIV treatment and care in this population, including treatment adherence and retention. Youth and adolescents from key populations or young key populations (YKP) in particular are highly stigmatized and may face additional barrier(s) in adhering to HIV treatment and services. We reviewed the current knowledge on treatment adherence and retention in HIV care among YKP to identify gaps in the literature and suggest future directions to improve HIV care for YKP.

METHODS

We conducted a comprehensive literature search for YKP and their adherence to antiretroviral therapy (ART) and retention in HIV care on PsycInfo (Ovid), PubMed and Google Scholar using combinations of the keywords HIV/AIDS, ART, adolescents, young adults, adherence (or compliance), retention, men who have sex with men, transgender, injection drug users, people who inject drugs and prisoners. We included empirical studies on key populations defined by WHO; included the terms youth and adolescents and/or aged between 10 and 24; examined adherence to or retention in HIV care; and published in English-language journals. All articles were coded using NVivo.

RESULTS AND DISCUSSION

The systematic search yielded 10 articles on YKP and 16 articles on behaviourally infected youth and adolescents from 1999 to 2014. We found no studies reporting on youth and adolescents identified as sex workers, transgender people and prisoners. From existing literature, adherence to ART was reported to be influenced by age, access to healthcare, the burden of multiple vulnerabilities, policy involving risk behaviours and mental health. A combination of two or more of these factors negatively impacted adherence to ART among YKP. Collectively, these studies demonstrated that future programmes need to be tailored specifically to YKP to ensure adherence.

CONCLUSIONS

There is an urgent need for more systematic research in YKP. Current limited evidence suggests that healthcare delivery should be tailored to the unique needs of YKP. Thus, research on YKP could be used to inform future interventions to improve access to treatment and management of co-morbidities related to HIV, to ease the transition from paediatric to adult care and to increase uptake of secondary prevention methods.

Providing comprehensive health services for young key populations: needs, barriers and gaps

INTRODUCTION

Adolescence is a time of physical, emotional and social transitions that have implications for health. In addition to being at high risk for HIV, young key populations (YKP) may experience other health problems attributable to high-risk behaviour or their developmental stage, or a combination of both.

METHODS

We reviewed the needs, barriers and gaps for other non-HIV health services for YKP. We searched PubMed and Google Scholar for articles that provided specific age-related data on sexual and reproductive health; mental health; violence; and substance use problems for adolescent, youth or young sex workers, men who have sex with men, transgender people, and people who inject drugs.

RESULTS

YKP experience more unprotected sex, sexually transmitted infections including HIV, unintended pregnancy, violence, mental health disorders and substance use compared to older members of key populations and youth among the general population. YKP experience significant barriers to accessing care; coverage of services is low, largely because of stigma and discrimination experienced at both the health system and policy levels.

DISCUSSION

YKP require comprehensive, integrated services that respond to their specific developmental needs, including health, educational and social services within the context of a human rights-based approach. The recent WHO Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations are an important first step for a more comprehensive approach to HIV programming for YKP, but there are limited data on the effective delivery of combined interventions for YKP. Significant investments in research and implementation will be required to ensure adequate provision and coverage of services for YKP. In addition, greater commitments to harm reduction and rights-based approaches are needed to address structural barriers to access to care.

Correlation between use of antiretroviral adherence devices by HIV-infected youth and plasma HIV RNA and self-reported adherence

Our objective was to investigate antiretroviral adherence device use by HIV-infected youth and assess associations of device use with viral suppression and self-reported adherence. This cross-sectional, multisite, clinic-based study included data from 1,317 HIV-infected individuals 12-24 years of age that were prescribed antiretroviral therapy. Mean adherence in the past 7 days was 86.1 % and 50.5 % had an undetectable HIV RNA. Pillbox was the most commonly endorsed device. No specific device was independently associated with higher odds of 100 % adherence. Paradoxically, having an undetectable HIV RNA was inversely associated with use of adherence devices (OR 0.80; p = 0.04); however, among those with <100 % adherence, higher adherence was associated with use of one or more adherence devices (coefficient = 7.32; p = 0.003). Our data suggest that adolescents who experienced virologic failure often used adherence devices which may not have been sufficiently effective in optimizing adherence. Therefore, other tailored adherence-enhancing methods need to be considered to maximize virologic suppression and decrease drug resistance and HIV transmission.

Factors associated with retention and viral suppression among a cohort of HIV+ women of color

Access to sustained HIV medical care is critical to achieving viral suppression. However, a variety of factors may impede or facilitate retention in care or becoming virally suppressed. Though retention and suppression are often treated separately, this study examined both in a cohort of 921 HIV+ women of color who participated in eight demonstration programs across the US. For women who met the inclusion criteria, 83% (n = 587) were retained and 73% (n = 357) were virally suppressed. Average age of women retained was 40.9, and 41.9 for those virally suppressed. The majority were African American/Black or Hispanic/Latina, single, and had no children less than 18 years of age, had health insurance, a high school degree or higher, were stably housed, and unemployed. Some factors associated with retention in care were indecision about seeking HIV medical care (AOR = 0.42) and having children under the age of 18 (AOR = 0.59). Some factors associated with being virally suppressed were living with others (AOR = 0.58), current substance abuse (AOR = 0.38), and fair/poor health (AOR = 0.40). The findings suggest different processes and social mechanisms may influence retention and viral suppression. Interventions seeking to improve retention in care may require tailored program components and strategies that focus on improving viral suppression.

High-intensity cannabis use and adherence to antiretroviral therapy among people who use illicit drugs in a Canadian setting

Cannabis is increasingly prescribed clinically and utilized by people living with HIV/AIDS (PLWHA) to address symptoms of HIV disease and to manage side effects of antiretroviral therapy (ART). In light of concerns about the possibly deleterious effect of psychoactive drug use on adherence to ART, we sought to determine the relationship between high-intensity cannabis use and adherence to ART among a community-recruited cohort of HIV-positive illicit drug users. We used data from the ACCESS study, an ongoing prospective cohort study of HIV-seropositive illicit drug users linked to comprehensive ART dispensation records in a setting of universal no-cost HIV care. We estimated the relationship between at least daily cannabis use in the last 6 months, measured longitudinally, and the likelihood of optimal adherence to ART during the same period, using a multivariate linear mixed-effects model accounting for relevant socio-demographic, behavioral, clinical and structural factors. From May 2005 to May 2012, 523 HIV-positive illicit drug users were recruited and contributed 2,430 interviews. At baseline, 121 (23.1 %) participants reported at least daily cannabis use. In bivariate and multivariate analyses we did not observe an association between using cannabis at least daily and optimal adherence to prescribed HAART (Adjusted Odds Ratio = 1.12, 95 % Confidence Interval [95 % CI]: 0.76-1.64, p value = 0.555.) High-intensity cannabis use was not associated with adherence to ART. These findings suggest cannabis may be utilized by PLWHA for medicinal and recreational purposes without compromising effective adherence to ART.

Synergistic effects of food insecurity and drug use on medication adherence among people living with HIV infection

Food insecurity and drug use are closely connected in the context of poverty, and both have been suggested to interfere with HIV medication adherence among people living with HIV/AIDS (PLWH). Yet the potential interaction between the two factors on adherence has not been examined. For this study we collected longitudinal data on HIV medication adherence among PLWH in Atlanta, GA, to assess a possible synergistic effect between the two factors on HIV medication adherence. People informed about the study came to the research site and completed an audio computer-assisted self-interview and instructions for pill counting. Over the next 5 weeks participants received three unscheduled follow-up phone assessments conducted 2 weeks apart to collect pill counts of their HIV medication. The prevalence of food insecurity was 60 % (488) and that of drug use was 33 % (274) in the sample of 809 participants. Among 770 participants who completed follow-up phone assessments, both food insecurity and drug use were associated with HIV medication adherence after adjusting for socio-demographic characteristics. The negative association between drug use and adherence persisted after further adjusting for health-related characteristics. Moreover, drug use appeared to moderate the effect of food insufficiency on adherence, with drug users who were food insufficient being the least likely to achieve 85 % adherence. Results from the current study demonstrate a synergism between food insecurity and drug use that may impede adherence among PLWH. The findings imply that the disruptive effects of food insecurity and drug use on adherence are likely to be intensified with the presence of each other, and encourage interventions to address the problem of HIV medication adherence from a multi-faceted perspective that takes into account detrimental combination of problem factors.

Adherence to antiretroviral therapy during pregnancy and the first year postpartum among HIV-positive women in Ukraine

Background

Poor adherence to antiretroviral therapy (ART) is associated with HIV disease progression and, during pregnancy, increased mother-to-child transmission risk. In Ukraine, access to combination ART is expanding but data on adherence are scarce.

Methods

Cross-sectional surveys of HIV-positive women were conducted i) at delivery (on antenatal ART adherence) and ii) during the first year postpartum (on ART adherence in the preceding four weeks). Factors associated with a score ≤11 on the self-report Case Adherence Support Evaluation (CASE) index or ≥1 self-reported missed dose were assessed using Fisher’s exact test.

Results

Of 185 antenatal participants and 102 postnatal participants, median ages were 27.5 and 29.5 years respectively: 28% (50/180) and 27% (26/98) reported an unplanned pregnancy, and 13% (24/179) and 17% (17/98) an illicit drug-use history (excluding marijuana). One quarter (49/180 antenatally, 27/101 postnatally) screened positive for depression. The proportion reporting ‘low’ ART-related self-efficacy (i.e. unable to do ≥1/5 ART-taking activities) was 20% (28/141) antenatally and 17% (11/66) postnatally. Antenatally, 14% (95% CI 10-21%) had a CASE score ≤11 and 35% (95% CI 28-42%) reported missing ≥1 dose. Factors associated with a CASE score ≤11 were unplanned pregnancy (25% (12/48) vs. 11% (13/120) where planned, p = 0.03) and living with extended family (23% (13/57) vs. 10% (12/125) living with partner/alone, p = 0.04). Self-report of ≥1 missed dose antenatally was additionally associated with younger age (p = 0.03) and lower self-efficacy (50% (14/28) reported ≥1 missed dose vs. 28% (30/108) of those with high self-efficacy, p = 0.04). Of 102 postnatal participants, 8% (95% CI 4-15%) had a CASE score ≤11 and 31% (95% CI 22-41%) reported ≥1 missed dose. Of 11 women with low self-efficacy, 3 (27%) had a CASE score ≤11 compared with 3/55 (5%) of those with high self-efficacy (p = 0.05). Current smokers more commonly reported ≥1 missed dose postnatally (50% (13/26) vs. 25% (18/72) of non-smokers, p = 0.03).

Conclusions

Our results highlight unmet needs for counselling and support. We identify some groups at risk of poor ART adherence, including women with markers of social vulnerability and those with low ART-related self-efficacy, who may benefit from targeted interventions.

Decisional capacity among youth with HIV: results from the MacArthur Competence Tool for Treatment

We assessed the decisional capacity (DC) of 72 youth with HIV, ages 13-24, using the MacArthur Competence Tool for Treatment, a structured interview that assesses DC along the following dimensions: understanding, appreciation, reasoning, and the ability to express a choice. Using previously established cutoff scores, results suggested 100% of youth were competent in the area of appreciation, but only 62% and 60% were competent in the areas of understanding and reasoning, respectively. Additional descriptive analyses reveal more detailed information regarding specific strengths and weaknesses within each of the dimensions of decisional capacity. These findings have important implications for health literacy initiatives, medical education, and treatment for youth with HIV, and support the need for adherence and secondary prevention interventions that include a decisional capacity component.

Abriendo Puertas: baseline findings from an integrated intervention to promote prevention, treatment and care among FSW living with HIV in the Dominican Republic

Female sex workers (FSW) are often the focus of primary HIV prevention efforts. However, little attention has been paid to the prevention, treatment, and care needs of FSW living with HIV. Based on formative research, we developed an integrated model to promote prevention and care for FSW living with HIV in Santo Domingo, Dominican Republic, including (1) individual counseling and education; (2) peer navigation; (3) clinical provider training; and (4) community mobilization. We enrolled 268 FSW living with HIV into the intervention and conducted socio-behavioral surveys, sexually transmitted infection (STI) testing, and viral load (VL) assessments. We used multivariate logistic regression to identify behavioral and socio-demographic factors associated with detectable VL (>50 copies/mL) and STI prevalence. Over half of all participants (51.9%) had a detectable VL, even though most received HIV-related care in the last 6 months (85.1%) and were currently on anti-retroviral treatment (ART) (72.4%). Factors positively associated with a detectable VL included being 18-35 years of age (Adjusted Odds Ratio [AOR] 2.46, 95% CI 1.31-4.60), having ever used drugs (AOR 2.34, 95% CI 1.14-4.79), and having ever interrupted ART (AOR 3.09, 95% CI 1.44-6.59). Factors protective against having a detectable VL included being single (AOR 0.45, 95% 0.20-0.98) and being currently on ART (AOR 0.17, 95% CI 0.07-0.41). Nearly one-quarter (23.1%) had an STI, which was associated with being single (AOR 3.21, 95% CI 1.27-8.11) and using drugs in the last 6 months (AOR 3.54, 95% CI 1.32-9.45). Being on ART was protective against STI (AOR 0.51, 95% CI 0.26-1.00). Baseline findings indicate significant barriers to VL suppression and STI prevention among FSW living with HIV and highlight gaps in the continuum of HIV care and treatment. These findings have important implications for both the individual health of FSW and population-level HIV transmission dynamics.

Suboptimal plasma HIV-1 RNA suppression and adherence among sex workers who use illicit drugs in a Canadian setting: an observational cohort study

OBJECTIVE

Studies have demonstrated the central function of plasma HIV-1 RNA viral load (pVL) levels on determining the risk of HIV disease progression and transmission. However, there is limited empirical research on virologic outcomes among sex workers who use illicit drugs (SW-DU).

METHODS

Data were derived from the AIDS Care Cohort to evaluate Exposure to Survival Services, a cohort of HIV-positive illicit drug users. Using generalised estimating equations, we studied the longitudinal relationship between sex work and pVL suppression. We also tested whether adherence to antiretroviral therapy (ART) mediated the relationship between sex work and pVL suppression.

RESULTS

Between May 1996 and May 2012, 587 ART-exposed participants (2224 person-years of observation) were included in the study, among whom 127 (21.6%) reported sex work. In a time-updated multivariate model adjusted for various demographic, socioeconomic and clinical confounders (eg, gender, incarceration, CD4 cell count), SW-DU had an independently reduced odds of pVL suppression compared to non-SW-DU (adjusted OR (AOR)=0.66; 95% CI 0.45 to 0.96). However, adding ART adherence to the multivariate model eliminated this association (p>0.05), suggesting adherence mediated the relationship between sex work and pVL suppression.

CONCLUSIONS

Evidence-based interventions to improve adherence to ART among SW-DU are urgently needed to help produce the maximum HIV treatment and prevention benefit of ART among this highly vulnerable population.

Prevalence and indicators of viral suppression among persons with diagnosed HIV infection retained in care - Georgia, 2010

Advances in treatment have led to dramatic improvements in the health of persons infected with human immunodeficiency virus (HIV). Moreover, treatment can reduce HIV transmission because suppressed levels of circulating virus makes HIV-infected persons less infectious. Until recently, antiretroviral therapy (ART) was recommended only for HIV patients with advanced disease (stages 2 and 3), and was optional for patients with early disease (stage 1). In March 2012, national HIV treatment guidelines were changed to recommend ART at all disease stages. To establish a baseline for care and treatment outcomes among persons with HIV, the Georgia Department of Public Health (DPH) examined whether viral suppression among HIV patients in Georgia varied by disease stage at diagnosis before implementation of the new guidelines. Disease stage at diagnosis was assessed as an indicator of viral suppression several months after diagnosis, adjusting for age, sex, and race/ethnicity among patients who were reported to DPH with HIV infections newly diagnosed during 2010 and retained in care. This report describes the results of that analysis, which indicated that disease stage at diagnosis was a significant indicator of viral suppression; viral suppression was significantly less frequent among persons with earlier disease stage at diagnosis. Compared with viral suppression among 80.5% of persons with stage 3 HIV disease, only 72.3% with stage 2 disease (prevalence ratio [PR] = 0.9; 95% confidence interval [CI] = 0.8-1.0) and 64.5% with stage 1 disease (PR = 0.8; CI = 0.7-0.9) met criteria for viral suppression, likely resulting from lack of initiating treatment or inadequate adherence to treatment regimens, as suggested in previous studies. These data can serve as a baseline to determine the impact of the guideline change in the future, and can be used to emphasize the importance of implementing the guidelines by expanding treatment to persons at all disease stages to reach the goal of viral suppression for all persons with HIV, thus closing the gap in viral suppression among persons diagnosed at disease stages 1 and 2. Health-care providers and community-based organizations should inform patients of the recommendation for ART initiation at all disease stages.

Incarceration is associated with used syringe lending among active injection drug users with detectable plasma HIV-1 RNA: a longitudinal analysis

Background

Informed by recent studies demonstrating the central role of plasma HIV-1 RNA viral load (VL) on HIV transmission, interventions to employ HIV antiretroviral treatment as prevention (TasP) are underway. To optimize these efforts, evidence is needed to identify factors associated with both non-suppressed VL and HIV risk behaviours. Thus, we sought to assess the possible role played by exposure to correctional facilities on VL non-suppression and used syringe lending among HIV-seropositive people who use injection drugs (PWID).

Methods

We used data from the ACCESS study, a community-recruited prospective cohort. We used longitudinal multivariate mixed-effects analyses to estimate the relationship between incarceration and plasma HIV-1 RNA > 500 copies/mL among antiretroviral therapy (ART)-exposed active PWID and, during periods of non-suppression, the relationship between incarceration and used syringe lending.

Results

Between May 1996 and March 2012, 657 ART-exposed PWID were recruited. Incarceration was independently associated with higher odds of VL non-suppression (Adjusted Odds Ratio [AOR] = 1.54, 95% Confidence Interval [95% CI]: 1.10, 2.16). In a separate multivariate model restricted to periods of VL non-suppression, incarceration was independently associated with lending used syringes (AOR = 1.81, 95% CI: 1.03, 3.18).

Conclusions

The current findings demonstrate that incarceration is associated with used syringe lending among active PWID with detectable plasma HIV-1 RNA. Our results provide a possible pathway for the commonly observed association between incarceration and increased risk of HIV transmission. Our results suggest that alternatives to incarceration of non-violent PWID and evidence-based combination HIV prevention interventions for PWID within correctional facilities are urgently needed.

HIV and hepatitis C virus test uptake at methadone clinics in Southern China: opportunities for expanding detection of bloodborne infections

Background

HIV and hepatitis C (HCV) co-infection is highly common among Chinese injection drug users but it is difficult to reach IDUs at traditional VCT (Voluntary HIV counseling treatment) clinics. A new national model integrating HIV/HCV testing with methadone maintenance treatment was started in 2006. The purpose of this study was to investigate HIV and HCV test uptake and associated factors at methadone clinics in Guangdong Province, China.

Methods

A cross-sectional design using routine surveillance data and laboratory testing confirmation was applied to determine rates of HIV and HCV test uptake. Multi-level modeling was used to examine individual-level and clinic-level correlates of increased test uptake.

Results

45 out of 49 methadone clinics in Guangdong Province agreed to participate in the study. Among all 13,270 individuals, 10,046 (75.7%) had HIV test uptake and 10,404 (78.4%) had HCV uptake. At the individual level, methadone clients 30 years or older were more likely to have HIV and HCV test uptake (p <0.001 for both). At the clinic level, methadone clinics with greater health care personnel were more likely to have HIV (p =0.01) and HCV (p = 0.044) test uptake. HIV test uptake significantly correlated with HCV test uptake (correlation coefficient=0.64).

Conclusion

Methadone clinics provide an opportunity for routine integrated HIV and HCV screening among drug users in China. Increased test uptake in young drug users and increased health care personnel at clinics may further improve screening.

A pilot study to engage and counsel HIV-positive African American youth via telehealth technology

Abstract Antiretroviral nonadherence is a strong determinant of virologic failure and is negatively correlated with survival. HIV-positive African American youth have lower antiretroviral adherence and treatment engagement than other populations. We assessed the feasibility and acceptability of a telehealth (remote videoconferencing) medication counseling intervention as an innovative approach to address these disparities. HIV-positive African American youth (18-29 years old) on antiretrovirals were enrolled in a telehealth medication counseling session, followed by a semi-structured qualitative interview to explore likes/dislikes of the format, modality, and content; potential impact on adherence; privacy issues; and interaction quality. Fourteen participants with a mean age of 24 years, who were 86% male, and had a mean self-reported adherence in the past month of 89%, were interviewed. Participants stated that they liked telehealth, would use it if offered in clinic/research settings, and indicated that their privacy was maintained. Participants described telehealth as convenient and efficient, with positive impact on their knowledge. Telehealth provided a modality to interact with providers that participants described as less intimidating than in-person visits. Telehealth is feasible and acceptable for delivering medication counseling to HIV-positive African American youth when conducted in a controlled clinical setting and may improve quality of patient-provider dialogue. Use of telehealth may lead to more disclosure of treatment difficulties, increased patient comfort, and improved health education.

Initiation of antiretroviral therapy in youth with HIV: a U.S.-based provider survey

In 2009, the Department of Health and Human Services (DHHS) recommended initiating antiretroviral therapy (ART) for youth with HIV at higher CD4 counts (≤500 cells/mm³) than previously recommended (≤350 cells/mm³). Barriers experienced by providers regarding ART initiation in this population have not been assessed. From 12/2011-01/2012, we asked providers from the American Academy of HIV Medicine (AAHIVM) [corrected] listserv who prescribed ART to youth (ages 13-25 years) with behaviorally-acquired HIV to complete a web-based survey. We presented a clinical vignette to explore potential barriers for initiating ART. Overall, 274/290 (94%) respondents completed the survey. Most felt confident that evidence supported initiating ART at higher CD4 counts (94%), and that benefits outweighed the risks of long-term toxicity (98%) or developing resistance (88%). Most (96%) initiated ART in the patient vignette (age 19 years, CD4 count ~400). Patient characteristics (e.g., unstable housing or drug use) were perceived as large barriers to ART initiation. Low response rate (13%) was a limitation. Respondents were knowledgeable about relevant DHHS guidelines, believed sufficient evidence supported ART initiation at higher CD4 counts, and would provide treatment to those with CD4 counts ≤500cells/mm³. Understanding and overcoming barriers to initiation of ART perceived by providers is important to ensure implementation of ART treatment guidelines.

Trends and disparities in antiretroviral therapy initiation and virologic suppression among newly treatment-eligible HIV-infected individuals in North America, 2001-2009

BACKGROUND

Since the mid-1990s, effective antiretroviral therapy (ART) regimens have improved in potency, tolerability, ease of use, and class diversity. We sought to examine trends in treatment initiation and resulting human immunodeficiency virus (HIV) virologic suppression in North America between 2001 and 2009, and demographic and geographic disparities in these outcomes.

METHODS

We analyzed data on HIV-infected individuals newly clinically eligible for ART (ie, first reported CD4+ count<350 cells/µL or AIDS-defining illness, based on treatment guidelines during the study period) from 17 North American AIDS Cohort Collaboration on Research and Design cohorts. Outcomes included timely ART initiation (within 6 months of eligibility) and virologic suppression (≤500 copies/mL, within 1 year). We examined time trends and considered differences by geographic location, age, sex, transmission risk, race/ethnicity, CD4+ count, and viral load, and documented psychosocial barriers to ART initiation, including non-injection drug abuse, alcohol abuse, and mental illness.

RESULTS

Among 10,692 HIV-infected individuals, the cumulative incidence of 6-month ART initiation increased from 51% in 2001 to 72% in 2009 (Ptrend<.001). The cumulative incidence of 1-year virologic suppression increased from 55% to 81%, and among ART initiators, from 84% to 93% (both Ptrend<.001). A greater number of psychosocial barriers were associated with decreased ART initiation, but not virologic suppression once ART was initiated. We found significant heterogeneity by state or province of residence (P<.001).

CONCLUSIONS

In the last decade, timely ART initiation and virologic suppression have greatly improved in North America concurrent with the development of better-tolerated and more potent regimens, but significant barriers to treatment uptake remain, both at the individual level and systemwide.