Identifying subgroups within at-risk populations that drive late HIV diagnosis in a Southern U.S. state

Equity of PrEP uptake by race, ethnicity, sex and region in the United States in the first decade of PrEP: a population-based analysis

Background

PrEP was approved for HIV prevention in the US in 2012; uptake has been slow. We describe relative equity with the PrEP Equity Ratio (PER), a ratio of PrEP-to-Need Ratios (PnRs).

Methods

We used commercial pharmacy data to enumerate PrEP users by race and ethnicity, sex, and US Census region from 2012 to 2021. We report annual race and ethnicity-, sex-, and region-specific rates of PrEP use and PnR, a metric of PrEP equity, to assess trends.

Findings

PrEP use increased for Black, Hispanic and White Americans from 2012 to 2021. By 2021, the rate of PrEP use per population was similar in Black and White populations but slightly lower among Hispanic populations. PnR increased from 2012 to 2021 for all races and ethnicities and regions; levels of PrEP use were inconsistent across regions and highly inequitable by race, ethnicity, and sex. In all regions, PnR was highest for White and lowest for Black people. Inequity in PrEP use by race and ethnicity, as measured by the PER, grew early after availability of PrEP and persisted at a level substantially below equitable PrEP use.

Interpretation

From 2012 to 2021, PrEP use increased among Americans, but PrEP equity for Black and Hispanic Americans decreased. The US South lagged all regions in equitable PrEP use. Improved equity in PrEP use will be not only just, but also impactful on the US HIV epidemic; persons most at-risk of acquiring HIV should have the highest levels of access to PrEP. Prevention programs should be guided by PrEP equity, not PrEP equality.

Funding

National Institutes of Health, Gilead Sciences.

Delayed Diagnosis of Human Immunodeficiency Virus in the Latino Population at a Federally Qualified Community Health Center in New Jersey

Late diagnosis of human immunodeficiency virus (HIV) is associated with early progression to acquired immunodeficiency syndrome (AIDS). We examined racial/ethnic differences in presentation with advanced HIV/AIDS at a community health center in New Jersey. Records of patients diagnosed with HIV between 1990 and 2018 were reviewed. Odds ratios (OR) of presenting with AIDS at HIV diagnosis were computed in unadjusted and adjusted models. There were 182 (48.3%) Latino, 48 (12.7%) non-Latino White (NLW), 130 (34.5%) non-Latino Black, and 17 (4.5%) non-Latino of other race/ethnicity included in the analysis. Over 75% of the Latinos were foreign-born. Latino patients had higher odds of presentation with AIDS at time of HIV diagnosis than NLW in unadjusted (OR = 4.85, 95% confidence interval (95% CI): 2.28-10.31) and adjusted models (OR = 3.71, 95%CI: 1.60-8.59). Latino patients, particularly foreign-born and bisexual, had higher odds of being diagnosed with AIDS at presentation with HIV in this cohort.

Determinants of HIV late presentation among men who have sex with men in Portugal (2014-2019): who's being left behind?

Introduction

HIV late presentation (LP) remains excessive in Europe. We aimed to analyze the factors associated with late presentation in the MSM population newly diagnosed with HIV in Portugal between 2014 and 2019.

Methods

We included 391 newly HIV-1 diagnosed Men who have Sex with Men (MSM), from the BESTHOPE project, in 17 countrywide Portuguese hospitals. The data included clinical and socio-behavioral questionnaires and the viral genomic sequence obtained in the drug resistance test before starting antiretrovirals (ARVs). HIV-1 subtypes and epidemiological surveillance mutations were determined using different bioinformatics tools. Logistic regression was used to estimate the association between predictor variables and late presentation (LP).

Results

The median age was 31 years, 51% had a current income between 501-1,000 euros, 28% were migrants. 21% had never been tested for HIV before diagnosis, with 42.3% of MSM presenting LP. 60% were infected with subtype B strains. In the multivariate regression, increased age at diagnosis, higher income, lower frequency of screening, STI ever diagnosed and higher viral load were associated with LP.

Conclusion

Our study suggests that specific subgroups of the MSM population, such older MSM, with higher income and lower HIV testing frequency, are not being targeted by community and clinical screening services. Overall, targeted public health measures should be strengthened toward these subgroups, through strengthened primary care testing, expanded access to PrEP, information and promotion of HIV self-testing and more inclusive and accessible health services.

Geographic disparities in late HIV diagnoses in Tennessee: Opportunities for interventions in the rural Southeast

PURPOSE

Incident HIV remains an important public health issue in the US South, the region leading the nation in HIV incidence, rural HIV cases, and HIV-related deaths. Late diagnoses drive incident HIV and understanding factors driving late diagnoses is critical for developing locally relevant HIV testing and prevention interventions, decreasing HIV transmission, and ending the HIV epidemic.

METHODS

Retrospective cohort study utilizing Tennessee Department of Health (TDH) surveillance data and US Census Bureau data. Adults of ≥18-year old with a new HIV diagnosis between January 1, 2015 and December 31, 2019 identified in the TDH electronic HIV/AIDS Reporting System were included. Individuals were followed from initial HIV diagnosis until death, 90 days of follow-up for outcome assessment, or administrative censoring 90 days after study enrollment closed.

FINDINGS

We included 3652 newly HIV-diagnosed individuals; median age was 31 years (IQR: 25, 42), 2909 (79.7%) were male, 2057 (56.3%) were Black, 246 (6.7%) were Hispanic, 408 (11.2%) were residing in majority-rural areas at diagnosis, and 642 (17.6%) individuals received a late HIV diagnosis. Residents of majority-rural counties (adjusted risk ratios [aRR] = 1.39, 95% confidence intervals [CI]: 1.16-1.67) and Hispanic individuals (aRR = 1.87, 95% CI: 1.50-2.33) had an increased likelihood of receiving a late diagnosis after controlling for race/ethnicity, age, and year of HIV diagnosis.

CONCLUSIONS

Rural residence and Hispanic ethnicity were associated with an increased risk of receiving a late HIV diagnosis in Tennessee. Future HIV testing and prevention efforts should be adapted to the needs of these vulnerable populations.

A community health worker and mobile health app intervention to improve adherence to HIV medication among persons with HIV: the CHAMPS study protocol

BACKGROUND

Persons with HIV (PWH) can now achieve a near-normal life expectancy due to antiretroviral therapy (ART). Despite widespread availability of ART in the United States (US), many of the country's approximate 1.1 million PWH are not achieving viral suppression due to poor ART adherence. Viral suppression rates are particularly low in Alabama (AL, 62%) and New York City (NYC, 67%). There is mixed evidence on the efficacy of community health workers (CHW) and mHealth interventions for improving ART adherence and viral suppression in PWH thus, we sought to combine these interventions and test the efficacy for improving health outcomes in PWH.

METHODS

The CHAMPS study is a two-arm randomized controlled trial among 300 PWH with suboptimal primary care appointment adherence (n = 150 in AL and 150 in NYC) over the course of 12 months. Participants are randomly assigned to CHAMPS (intervention) or a standard-of-care (control) arm. Participants in the intervention arm are given a CleverCap pill bottle that syncs to the WiseApp to track medication adherence, reminds users to take their medication at a set time, and enables communication with CHW. All participants complete baseline, 6-month, and 12-month follow-up visits where surveys are administered and, CD4 and HIV-1 viral load are obtained through blood draw.

DISCUSSION

Maintaining ART adherence has significant implications in HIV management and transmission. mHealth technologies have been shown to optimize the provision of health services, produce positive changes in health behavior, and significantly improve health outcomes. CHW interventions also provide personal support to PWH. The combination of these strategies may provide the necessary intensity to increase ART adherence and clinic attendance among PWH at highest risk for low engagement. Delivering care remotely enables CHW to contact, assess, and support numerous participants throughout the day, reducing burden on CHW and potentially improving intervention durability for PWH. The adoption of the WiseApp coupled with community health worker sessions in the CHAMPS study has the potential to improve HIV health outcomes, and will add to the growing knowledge of mHealth and CHW efforts to improve PWH medication adherence and viral suppression.

TRIAL REGISTRATION

This trial was registered with Clinicaltrials.gov (NCT04562649) on 9/24/20.

Molecular Network Analysis Discloses the Limited Contribution to HIV Transmission for Patients with Late HIV Diagnosis in Northeast China

In the "treat all" era, the high rate of late HIV diagnosis (LHD) worldwide remains an impediment to ending the HIV epidemic. In this study, we analyzed LHD in newly diagnosed people living with HIV (PLWH) and its impact on HIV transmission in Northeast China. Sociodemographic information, baseline clinical data, and plasma samples obtained from all newly diagnosed PLWH in Shenyang, the largest city in Northeast China, between 2016 and 2019 were evaluated. Multivariate logistic regression analysis was performed to identify risk factors associated with LHD. A molecular network based on the HIV pol gene was constructed to assess the risk of HIV transmission with LHD. A total of 2882 PLWH, including 882 (30.6%) patients with LHD and 1390 (48.2%) patients with non-LHD, were enrolled. The risk factors for LHD were older age (≥ 30 years: p < .01) and diagnosis in the general population through physical examination (p < .0001). Moreover, the molecular network analysis revealed that the clustering rate (p < .0001), the fraction of individuals with ≥ 4 links (p = .0847), and the fraction of individuals linked to recent HIV infection (p < .0001) for LHD were significantly or marginally significantly lower than those recorded for non-LHD. Our study indicates the major risk factors associated with LHD in Shenyang and their limited contribution to HIV transmission, revealing that the peak of HIV transmission of LHD at diagnosis may have been missed. Early detection, diagnosis, and timely intervention for LHD may prevent HIV transmission.

Real-world data in late presentation of HIV infection in Suzhou, China: Results from four consecutive cross-sectional surveys, 2017-2020

Objectives

This study aimed to examine the real prevalence of late presentation of HIV infection and to identify factors associated with late HIV presentation among patients with newly diagnosed HIV/AIDS in Suzhou, China.

Methods

Patients with newly diagnosed HIV/AIDS who registered in national AIDS surveillance system from 2017 to 2020 were included in this study. Late presentation (LP) of HIV infection was defined as HIV diagnosis with a CD4 count < 350 cells/μL or an AIDS-defining event. Multivariable logistic regression analyses were used to identify factors associated with LP.

Results

A total of 2,300 patients were enrolled. 1,325 were classified as late presenters, showing a high percentage of 57.6% (95% CI: 54.5-60.7%) and a rise (P = 0.004) over the four-year period. Patients with newly diagnosed HIV/AIDS who were older than 24 years of age (aOR = 1.549, P = 0.001 for 25-39 years; aOR = 2.389, P < 0.001 for 40 years and older), were Suzhou registered residents (aOR = 1.259, P = 0.026), and were from inpatient and outpatient (aOR = 1.935, P < 0.001) were more likely to be late presentation.

Conclusions

This study showed a high percentage and a rise of late presentation of HIV infection among patients with newly diagnosed HIV/AIDS in Suzhou, China, which is a challenge for future prevention and control of AIDS. Targeted measures should be urgently implemented to reduce late HIV diagnosis.