HIV-1 superinfection in the antiretroviral therapy era: are seroconcordant sexual partners at risk?

AIDS mortality in Brazil, 2012-2022: a time series study

BACKGROUND

Human immunodeficiency virus (HIV) infection is a health problem in Brazil and worldwide. Without treatment, the infection can progress to Acquired Immunodeficiency Syndrome (AIDS), with a high mortality potential. The objective of this study was to analyze the time trend of AIDS mortality in Brazil, macro-regions, federal units and their respective capitals, from 2012 to 2022.

METHODS

This is a time-series study of all AIDS deaths in Brazil from 2012 to 2022. The study included the annual number of deaths and the crude and standardized mortality rates. The Joinpoint regression model was used for the time analysis of the standardized rates. Annual percentage change (APC) and average annual percentage change (AAPC) were calculated. A 95% confidence interval (CI) and a 5% significance level were used.

RESULTS

During the period analyzed, 128,678 AIDS deaths were recorded in Brazil, with a crude mortality rate of 6.3/100,000 and a standardized mortality rate of 5.3/100,000. From 2012 to 2020, three regions showed a declining trend in AIDS mortality: Central-West (AAPC - 2.3%; 95%CI -4.3 to -0.21; p = 0.03), Southeast (AAPC - 5.6%; 95%CI -6.8 to -4.0; p < 0.001), and South (AAPC - 4.4%; 95%CI -5.27 to -3.6; p < 0.001). There was also a downward trend in 10 states and 10 capitals. There was an increase in the number of deaths from 2020 onwards in the North, Northeast and Southeast regions compared to 2019.

CONCLUSION

There was a downward trend in AIDS mortality from 2012 to 2020 and an upward trend from 2020 to 2022. The regional differences observed could reflect the social disparities that exist in Brazil. In addition, the Covid-19 pandemic has had an impact on the process of dealing with HIV in Brazil.

Dual Contraceptive Method Utilization and Associated Factors Among HIV Positive Women Attending ART Clinic in Finote-Selam Hospital: Cross-Sectional Study

Worldwide, the human immune deficiency virus is the leading cause of death for women of childbearing age. Around two-thirds of all pregnant women living with the human immune deficiency virus experience an unintended pregnancy. The correct and consistent use of dual contraceptive methods is important to prevent unintended pregnancy and transmission of sexually transmitted infections. However, little is known about the utilization of dual contraceptive methods among HIV-infected women. Thus, this study aimed to assess dual contraceptive utilization and associated factors among HIV-positive women attending antiretroviral therapy (ART) in Finote Selam Hospital, Northwest Ethiopia. Facility-based cross-sectional study design was conducted from September 1 to October 30, 2019, in Finote Selam Hospital among HIV-positive women. A systematic random sampling technique was used to select study participants and the data were gathered by an interviewer-administered structured pretested questionnaire. Factors associated with dual contraceptive use were identified through binary logistic regression. Finally, a p-value < 0.05 was taken as a cutoff point to declare a significant association, and the direction and strength of the association were determined by the adjusted odds ratio. The study showed that 21.8% of HIV-positive women attending ART care in Finote Selam Hospital utilize dual contraceptive methods. Dual contraceptive utilization was significantly associated with having a child (AOR: 3.29; CI 1.45, 7.47), having family support to use dual contraceptives (AOR: 3.02; CI 1.39, 6.54), having multiple sexual partners (AOR: 0.11; CI 0.05, 0.22), and urban residence (AOR: 3.64; 1.82, 7.3). The study revealed that low utilization of dual contraceptive methods. This will continue major public health problems in the study area unless future interventions conducted.

High level risky sexual behavior among persons living with HIV in the urban setting of the highest HIV prevalent areas in Ethiopia: Implications for interventions

INTRODUCTION

Data on the sexual behavior among people living with human immunodeficiency virus (PLHIV) dwelling at HIV prevalent setting located at the periphery of Ethiopia is lacking. Therefore, this study was designed to investigate sexual practice of patients following their antiretroviral therapy (ART) service and factors affecting their behavior.

MATERIALS AND METHODS

A facility based cross-sectional study design was employed to assess risky sexual practice and associated factors among HIV positive adults attending ART clinics in Gambella town, Southwest Ethiopia. Risky sexual practice is defined as a custom of getting in at least one of the following practices such as condom-unprotected sex with any partner, having two or more sexual partners and practicing casual sex in the last three months. A total of 352 randomly selected clients were interviewed by using a structured questionnaire. The multivariable logistic regression model was used to examine the association between covariates and the outcome variable.

RESULTS

Majority of the study participants were engaged at least in one of the risky sexual practices (79.8% confidence interval (CI): 75.3% - 83.9%). The multivariable analysis found that the odds of risky sexual practice were higher among individuals who use substances ('khat' users (AOR: 3.82, 95%CI:1.30-11.22), smoke cigarette (AOR:4.90, 95%CI:1.19-12.60), consume alcohol (AOR: 2.59, 95%CI:1.28-5.21)); those who never discuss about safe sex with their partner/s (AOR: 2.21, 95%CI:1.16-4.21); those who have been in attachment for longer duration (more than four years) with their partner (AOR: 3.56, 95%CI: 1.32-9.62); and groups who desire to bear children in their future life (AOR: 3.15, 95%CI:1.40-7.04) as compared to their respective comparison groups.

CONCLUSIONS

A significant number of participants were engaged at least in one of the risky sexual practices which potentially result in super infection by a new or/and drug resistant viral strain/s, and onward transmission of the virus. Thus, an HIV intervention program which focuses on the identified factors has to be implemented to mitigate risk of unsafe sexual behavior of this population group and move towards ending the HIV/Acquired Immunodeficiency Syndrome (AIDS) epidemic.

Partner HIV Serostatus Impacts Viral Load, Genital HIV Shedding, and Immune Activation in HIV-Infected Individuals

Studies of seronegative individuals in HIV discordant relationships provide important insights into the effects of HIV exposure on the seronegative partner, but few have examined the impact of partner serostatus on disease progression in seropositive individuals. We investigated the impact of HIV serostatus on clinical and biological factors influencing HIV disease progression in 337 HIV-infected heterosexual individuals in stable long-term HIV-seroconcordant or HIV-serodiscordant relationships. Seroconcordant individuals had significantly higher plasma viral loads (pVLs) than HIV-infected partners in serodiscordant partnerships [4.4 log10 copies RNA/mL (interquartile range 3.7-5.0) versus 3.9 (3.3-4.5), P < 0.0001], irrespective of gender. pVLs correlated inversely with CD4 T-cell counts, although CD4 counts did not differ significantly between seroconcordant and serodiscordant individuals. HIV+ seroconcordant individuals had higher frequencies of CCR5 CD4 and CD8 T cells (P = 0.03 and P = 0.02, respectively) than HIV+ individuals in serodiscordant relationships and higher concentrations of plasma IL-1β (P = 0.04), TNF-α (P = 0.02), and IL-10 (P = 0.02). Activated CD4 T-cell frequencies and TNF-α were the most influential in determining variation in pVLs, independently of CD4 counts. In addition, HIV+ seroconcordant women had significantly higher genital VLs (gVLs) than HIV+ women in serodiscordant relationships (P < 0.001), with pVLs correlating significantly with gVLs (Rho = 0.65, P < 0.0001). Cervical and blood T-cell activation tended to correlate positively, although partner seroconcordance did not influence genital T-cell activation. We conclude that HIV+ seroconcordant individuals have higher frequencies of activated, CCR5-expressing T cells in blood and higher pVLs and gVLs than their HIV+ counterparts in discordant relationships, which could translate to faster disease progression or larger viral reservoir.

Contraceptive, condom and dual method use at last coitus among perinatally and horizontally HIV-infected young women in Atlanta, Georgia

Objective

To evaluate factors within the social-ecological framework associated with most or moderately effective contraception, condom and dual method use at last coitus among young, HIV-infected women in Atlanta.

Methods

This is a cross-sectional study conducted from November, 2013 until August, 2015 at the Grady Infectious Disease Clinic in Atlanta, Georgia. We recruited perinatally and horizontally HIV-infected women of ages 14–30 years to complete an audio computer-assisted self-interview. We evaluated factors within a social-ecological framework associated with most or moderately effective contraceptive use (hormonal contraception or an IUD), condom use, and dual method use (use of condom and most or moderately effective contraceptive) at last coitus.

Results

Of 103 women enrolled, 74 reported a history of sexual activity. The average age was 22.1; 89% were African American, 52% were perinatally infected, 89% received combination antiretroviral therapy, and 63% had undetectable viral loads. At last coitus, 46% reported most or moderately effective contraception, 62% reported condom use and 27% reporting dual-method use. The odds of most or moderately effective contraceptive use was significantly reduced among those with detectable viral loads (versus undetectable viral loads; aOR 0.13 [0.04, 0.38]). Older age (aOR 0.85 [0.74, 0.98] and more frequent coitus (>once/week versus < = once/week; aOR 0.24 [0.08, 0.72]) was significantly associated with reduced condom use. Having a detectable viral load (versus undetectable viral loads; aOR 0.13 [0.03, 0.69]) and more frequent coitus (>once/week versus < = once/week; aOR 0.14 [0.03,0.82]), was associated with reduced dual method use, while being enrolled in school (aOR 5.63 [1.53, 20.71]) was significantly associated with increased dual method use.

Conclusions

Most or moderately effective contraception, condom and dual method use remained inadequate in this cohort of young HIV-infected women. Individual-level interventions are needed to increase the uptake of dual methods with user-independent contraceptives.

Examining the contraceptive decisions of young, HIV-infected women: A qualitative study

This study qualitatively examined factors that influenced contraceptive choices in a sample of young, HIV-infected women. Individual qualitative interviews were conducted among 30 vertically and horizontally HIV-infected women (n = 26 African American) from the ages of 14 to 24 years (Mean age = 20.9 years). We recruited sample groups with the following characteristics: (a) current contraceptive/condom use with ≥1 child (n = 11); (b) current contraceptive/condom use with no children (n = 12); and (c) no current contraceptive/condom use with no children (n = 7). A semi-structured interview guide was used to ask participants about factors influencing past and current contraceptive choices. Individual interviews were digitally recorded and transcribed verbatim; analyses to identify core themes were informed by the Grounded Theoretical approach. Young, HIV-infected women did not identify their HIV serostatus or disease-related concerns as influential in their contraceptive decisions. However, they reported that recommendations from health-care providers and input from family and friends influenced their contraceptive choices. They also considered a particular method's advantages (e.g., menstrual cycle improvements) and disadvantages (e.g., increased pill burden) when selecting a method. Findings suggested that HIV-infected young women's contraceptive decisions were influenced by factors other than those related to their infection.

Immunological and virological characteristics of human immunodeficiency virus type 1 superinfection: implications in vaccine design

Superinfection is frequently detected among individuals infected by human immunodeficiency virus type I (HIV-1). Superinfection occurs at similar frequencies at acute and chronic infection stages but less frequently than primary infection. This observation indicates that the immune responses elicited by natural HIV-1 infection may play a role in curb of superinfection; however, these responses are not sufficiently strong to completely prevent superinfection. Thus, a successful HIV-1 vaccine likely needs to induce more potent and broader immune responses than those elicited by primary infection. On the other hand, potent and broad neutralization responses are more often detected after superinfection than during monoinfection. This suggests that broadly neutralizing antibodies are more likely induced by sequential immunization of multiple different immunogens than with only one form of envelope glycoprotein immunogens. Understanding why the protection from superinfection by immunity induced by primary infection is insufficient and if superinfection can lead to cross-reactive immune responses will be highly informative for HIV-1 vaccine design.

First Canadian Case Report of Kidney Transplantation From an HIV-Positive Donor to an HIV-Positive Recipient

RATIONALE

Kidney transplantation has become standard of care for carefully selected patients living with human immunodeficiency virus (HIV) and end-stage renal disease (ESRD) in the highly active antiretroviral therapy (HAART) era. American and European prospective cohort studies have reported similar patient and graft survival compared with HIV-negative kidney transplant recipients. Despite an increased rate of acute rejection, partially due to drug interactions, HIV immunovirologic parameter generally remains under control during immunosuppression. A few cases of kidney transplantation between HIV-infected patients were done in South Africa and showed favorable results. No cases of kidney transplantation from an HIV-positive donor in Canada have previously been reported.

PRESENTING CONCERNS OF THE PATIENT

A 60-year-old Canadian man with HIV infection presented in 2007 with symptoms compatible with acute renal failure secondary to IgA nephropathy. Chronic kidney disease resulted after the acute episode.

DIAGNOSES

Hemodialysis was started in 2012. The patient was referred for a kidney transplantation evaluation.

INTERVENTIONS

The patient underwent kidney transplantation from an HIV-positive donor in January 2016. The recipient's antiretroviral regimen consisted of abacavir, lamivudine, and dolutegravir. No drug interactions have been reported between these antiretrovirals and the maintenance immunosuppressive regimen used.

OUTCOMES

The outcome at 7 months post transplantation was excellent, with good graft function and adequate control of HIV replication, in the absence of opportunistic infections at a time when immunosuppression is at its highest intensity. No acute rejection was reported. An episode of bacteremic graft pyelonephritis due to Enterococcus faecalis was successfully treated after transplantation.

NOVEL FINDING

With careful selection of patient, kidney transplantation between HIV-infected patients is a viable option. The use of antiretroviral drugs free of interactions simplified the dosing and management of the immunosuppressive drugs.

Challenges and Clinical Decision-Making in HIV-to-HIV Transplantation: Insights From the HIV Literature

Life expectancy among HIV-infected (HIV+) individuals has improved dramatically with effective antiretroviral therapy. Consequently, chronic diseases such as end-stage liver and kidney disease are growing causes of morbidity and mortality. HIV+ individuals can have excellent outcomes after solid organ transplantation, and the need for transplantation in this population is increasing. However, there is a significant organ shortage, and HIV+ individuals experience higher mortality rates on transplant waitlists. In South Africa, the use of organs from HIV+ deceased donors (HIVDD) has been successful, but until recently federal law prohibited this practice in the United States. With the recognition that organs from HIVDD could fill a critical need, the HIV Organ Policy Equity (HOPE) Act was passed in November 2013, reversing the federal ban on the use of HIV+ donors for HIV+ recipients. In translating this policy into practice, the biologic risks of using HIV+ donors need to be carefully considered. In this mini-review, we explore relevant aspects of HIV virology, antiretroviral treatment, drug resistance, opportunistic infections and HIV-related organ dysfunction that are critical to a transplant team considering HIV-to-HIV transplantation.

The transplantation of solid organs from HIV-positive donors to HIV-negative recipients: ethical implications

HIV-positive individuals have traditionally been barred from donating organs due to transmission concerns, but this barrier may soon be lifted in the USA in limited settings when recipients are also infected with HIV. Recipients of livers and kidneys with well-controlled HIV infection have been shown to have similar outcomes to those without HIV, erasing ethical concerns about poorly chosen beneficiaries of precious organs. But the question of whether HIV-negative patients should be disallowed from receiving an organ from an HIV-positive donor has not been adequately explored. In this essay, we will discuss the background to this scenario and the ethical implications of its adoption from the perspectives of autonomy, beneficence/non-maleficence and justice.

Connecting the dots: examining transgender women's utilization of transition-related medical care and associations with mental health, substance use, and HIV

Findings on access to general healthcare for transgender people have emerged, but little is known about access to transition-related medical care for transwomen (i.e., hormones, breast augmentation, and genital surgery). Transgender women have low access to general medical care and are disproportionately at risk for substance use, mental illness, and HIV. We conducted an analysis to determine if utilization of transition-related medical care is a protective factor for health risks to transgender women and to investigate if care differs by important demographic factors and HIV status. A secondary analysis was conducted using data from a 2010 HIV surveillance study using respondent-driven sampling to recruit 314 transwomen in San Francisco. Survey-corrected logistic regression models were used to estimate odds ratios for six psychosocial health problems-binge drinking, injection drug use, anxiety, depression, suicidal ideation, and high-risk intercourse-comparing various levels of utilization of transition-related medical care. Odds ratios were also calculated to determine if utilization of transition-related medical care was related to less overlap of risk domains. We found that Latina and African American transwomen had significantly lower estimated utilization of breast augmentation and genital surgery, as did transwomen who identified as transgender rather than female. Overall, utilization of transition-related medical care was associated with significantly lower estimated odds of suicidal ideation, binge drinking, and non-injection drug use. Findings suggest that utilization of transition-related medical care may reduce risk for mental health problems, especially suicidal ideation, and substance use among transwomen. Yet, important racial/ethnic and gender identity disparities in utilization of transition-related medical care need to be addressed.

Attitude of patients with HIV infection towards organ transplant between HIV patients. A cross-sectional questionnaire survey

This study examined the HIV patients' attitudes towards the practice of organ transplant between HIV patients using a cross-sectional survey design. In total, 206 patients participated with a mean age of 42 (±8.8) years. The majority (70%) were black African and women (54%), and 83% described themselves as heterosexual. Most participants (n = 171, 83%) were on treatment, and 159 (93%) had viral load less than 40 copies/ml. Mean duration of illness and mean duration of treatment were 77 (±42.7) and 68 (±41) months, respectively. Of all participants, 128 (62%) reported that they would consider donating either any organ or a specific organ/s to an HIV patient, 33 (16%) would not consider it and 45 (22%) were unsure about donating their organs. Furthermore, 113 (55%) participants would consider receiving an organ from an HIV patient, 37 (18%) would not consider it, and 56 (27%) were unsure. Ninety-eight participants (42%) reported that they would consider both donating and receiving an organ. Multinomial logistic regression analysis found that significantly more Black African than Caucasian participants were unsure about organ donation (p = 0.011, OR = 3.887). Participants with longer duration of infection were significantly less likely to consider receiving an organ from an HIV patient (p = 0.036, OR = 1.297). Overall, the study findings indicated that the majority of participants were in favour of organ transplant between HIV patients. Use of HIV-infected donors could potentially reduce current organ waiting list among HIV patients.

Contraceptive methods and risk of HIV acquisition or female-to-male transmission

Effective family planning with modern contraception is an important intervention to prevent unintended pregnancies which also provides personal, familial, and societal benefits. Contraception is also the most cost-effective strategy to reduce the burden of mother-to-child HIV transmission for women living with HIV who wish to prevent pregnancy. There are concerns, however, that certain contraceptive methods, in particular the injectable contraceptive depot medroxyprogesterone acetate (DMPA), may increase a woman's risk of acquiring HIV or transmitting it to uninfected males. These concerns, if confirmed, could potentially have large public health implications. This paper briefly reviews the literature on use of contraception among women living with HIV or at high risk of HIV infection. The Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) recommendations place no restrictions on the use of hormonal contraceptive methods by women with or at high risk of HIV infection, although a clarification recommends that, given uncertainty in the current literature, women at high risk of HIV who choose progestogen-only injectable contraceptives should be informed that it may or may not increase their risk of HIV acquisition and should also be informed about and have access to HIV preventive measures, including male or female condoms.

HIV-1 superinfection with a triple-class drug-resistant strain in a patient successfully controlled with antiretroviral treatment

We report a case of HIV-1 superinfection (HSI) with a clade B, triple-class resistant virus in a patient successfully controlling viremia with continuous combination antiretroviral therapy started 8 years earlier during primary HIV infection. The course of HIV infection prior to HSI was monitored in both the source partner and recipient (8 and 11 years, respectively) and 4 years following HSI. This case report demonstrates re-infection with HIV-1 despite effective combination antiretroviral therapy.

Alcohol use and sexual risk behaviors among individuals infected with HIV: a systematic review and meta-analysis 2012 to early 2013

The purpose of this meta-analytic study is to summarize the current science concerning the (a) prevalence of alcohol use, (b) prevalence of sexual risk behaviors, and (c) association between alcohol use and sexual risk behaviors among people livingwithHIV/AIDS (PLWHA). Studies were included if they sampled PLWHA, evaluated both alcohol use and sexual risk behavior (e.g., condom use, multiple partners), and were published between January 1, 2012, and April 1, 2013. Comprehensive electronic database searches located 728 published studies with relevant keywords; 17 studies (k =19 reports) were included. Findings indicate that a substantial proportion of PLWHA use alcohol and engage in sexual risk behaviors. Among PLWHA, alcohol use was significantly associated with unprotected sex (d +=0.23, 95 % CI=0.05, 0.40; k =5). Secondary prevention programs for PLWHA that address alcohol use in the context of sexual behavior are needed.

Analysis of HIV-1 protease gene reveals frequent multiple infections followed by recombination among drug treated individuals living in São Paulo and Santos, Brazil

The present study investigated the prevalence of HIV-1 multiple infections in a population composed by 47 patients under HAART failure and enrolled at the National DST/AIDS, Program, Ministry of Health, Brazil.Detection of multiple infections was done using a previously published RFLP assay for the HIV-1 protease gene, which is able of distinguishing between infections caused by a single or multiple HIV-1 subtypes. Samples with multiple infections were cloned, and sequence data submitted to phylogenetic analysis. We were able to identify 17 HIV-1 multiple infections out of 47 samples. Multiple infections were mostly composed by a mixture of recombinant viruses (94%), with only one case in which protease gene pure subtypes B and F were recovered. This is the first study that reports the prevalence of multiple infections and intersubtype recombinants in a population undergoing HAART in Brazil. Based on the data there was a steep increase of multiple infections after the introduction of the combined antiretroviral therapy in Brazil. Cases of multiple infections may be associated with HIV-1 genetic diversity through recombination allowing for the generation of viruses showing a combination of resistance mutations.

Superinfection with drug-resistant HIV is rare and does not contribute substantially to therapy failure in a large European cohort

Background

Superinfection with drug resistant HIV strains could potentially contribute to compromised therapy in patients initially infected with drug-sensitive virus and receiving antiretroviral therapy. To investigate the importance of this potential route to drug resistance, we developed a bioinformatics pipeline to detect superinfection from routinely collected genotyping data, and assessed whether superinfection contributed to increased drug resistance in a large European cohort of viremic, drug treated patients.

Methods

We used sequence data from routine genotypic tests spanning the protease and partial reverse transcriptase regions in the Virolab and EuResist databases that collated data from five European countries. Superinfection was indicated when sequences of a patient failed to cluster together in phylogenetic trees constructed with selected sets of control sequences. A subset of the indicated cases was validated by re-sequencing pol and env regions from the original samples.

Results

4425 patients had at least two sequences in the database, with a total of 13816 distinct sequence entries (of which 86% belonged to subtype B). We identified 107 patients with phylogenetic evidence for superinfection. In 14 of these cases, we analyzed newly amplified sequences from the original samples for validation purposes: only 2 cases were verified as superinfections in the repeated analyses, the other 12 cases turned out to involve sample or sequence misidentification. Resistance to drugs used at the time of strain replacement did not change in these two patients. A third case could not be validated by re-sequencing, but was supported as superinfection by an intermediate sequence with high degenerate base pair count within the time frame of strain switching. Drug resistance increased in this single patient.

Conclusions

Routine genotyping data are informative for the detection of HIV superinfection; however, most cases of non-monophyletic clustering in patient phylogenies arise from sample or sequence mix-up rather than from superinfection, which emphasizes the importance of validation. Non-transient superinfection was rare in our mainly treatment experienced cohort, and we found a single case of possible transmitted drug resistance by this route. We therefore conclude that in our large cohort, superinfection with drug resistant HIV did not compromise the efficiency of antiretroviral treatment.

Frequency and implications of HIV superinfection

HIV superinfection occurs when an individual with HIV is infected with a new distinct HIV viral strain. Superinfection has been reported throughout the world, and studies have recorded incidence rates of 0-7·7% per year. Use of next-generation sequencing has improved detection of superinfection, which can be transmitted by injecting drug use and sexual intercourse. Superinfection might have incidence rates comparable to those of initial HIV infection. Clinicians should encourage safe sexual and injecting drug use practices for HIV-infected patients because superinfection has detrimental effects on clinical outcomes and could pose a concern for large-scale antiretroviral treatment plans. The occurrence of superinfection has implications for vaccine research, since it seems initial HIV infection is not fully protective against a subsequent infection. Additional collaborative research could benefit care of patients and inform future vaccine design.

Gendered constructions of the impact of HIV and AIDS in the context of the HIV-positive seroconcordant heterosexual relationship

Introduction

This article explores the complex, dynamic and contextual frameworks within which men working in a mining community and their live-in long-term partners or spouses (termed “couples” in this study) respond to the introduction of HIV into their heterosexual relationships; the way in which partners adopt gendered positions in enabling them to make sense of their illness; how they negotiate their respective masculine and feminine roles in response to the need for HIV-related lifestyle changes; as well as the gendered nature of partner support in relation to antiretroviral therapy (ARV) adherence.

Methods

We conducted an in-depth qualitative study with a sample of 12 HIV-positive seroconcordant heterosexual couples in a South African mining organization. Transcripts based on semi-structured couple's interviews were analyzed using an inductive emergent thematic analytical method.

Results

The findings present compelling evidence that the impact of HIV and AIDS is mitigated, in the main, by the nature of the dyadic relationship. Where power and agency were skewed in accordance with traditional gender scripts, the impact of HIV and AIDS was deleterious in terms of negotiating disclosure, meeting expectations of care and support, and promoting treatment adherence. As a corollary, the study also revealed that where the relational dynamic evidenced a more equitable distribution of power, the challenge of negotiating illness was embraced in a way that strengthened the couples’ affiliation in profound ways, manifested not simply in a reduction in risk behaviours, but in both partner's courage to re-visit sensitive issues related to managing their relationship in the context of a debilitating illness.

Conclusions

Gendered positioning (by self and others) was found to play a crucial role in the way couples experienced HIV and ARV treatment, and underscored the positive role of a couples-counselling approach in the negotiation of the illness experience. However, as part of a broader social project, the findings highlight the need to address the shortcomings of a public health discourse on illness normalization that reifies and reinforces skewed gender relations. In essence, the findings make a compelling case for targeting couples as the primary unit of analysis and intervention in HIV and AIDS praxis, not only to enhance treatment and prevention outcomes, but to impact on and potentially transform the lived identity of such relationships, in AIDS-affected communities. We recommend early intervention with couples in terms of couples HIV testing, risk-reduction counselling and gender-based interventions giving couples opportunities to revisit and challenge their prevailing gendered identities. We note, however, that these efforts will be undermined in the long term, if the structural drivers of HIV risk and vulnerability, contained within macro-level social, economic and cultural practices, are not simultaneously addressed.

A gp41-based heteroduplex mobility assay provides rapid and accurate assessment of intrasubtype epidemiological linkage in HIV type 1 heterosexual transmission Pairs

A critical step in HIV-1 transmission studies is the rapid and accurate identification of epidemiologically linked transmission pairs. To date, this has been accomplished by comparison of polymerase chain reaction (PCR)-amplified nucleotide sequences from potential transmission pairs, which can be cost-prohibitive for use in resource-limited settings. Here we describe a rapid, cost-effective approach to determine transmission linkage based on the heteroduplex mobility assay (HMA), and validate this approach by comparison to nucleotide sequencing. A total of 102 HIV-1-infected Zambian and Rwandan couples, with known linkage, were analyzed by gp41-HMA. A 400-base pair fragment within the envelope gp41 region of the HIV proviral genome was PCR amplified and HMA was applied to both partners' amplicons separately (autologous) and as a mixture (heterologous). If the diversity between gp41 sequences was low (<5%), a homoduplex was observed upon gel electrophoresis and the transmission was characterized as having occurred between partners (linked). If a new heteroduplex formed, within the heterologous migration, the transmission was determined to be unlinked. Initial blind validation of gp-41 HMA demonstrated 90% concordance between HMA and sequencing with 100% concordance in the case of linked transmissions. Following validation, 25 newly infected partners in Kigali and 12 in Lusaka were evaluated prospectively using both HMA and nucleotide sequences. Concordant results were obtained in all but one case (97.3%). The gp41-HMA technique is a reliable and feasible tool to detect linked transmissions in the field. All identified unlinked results should be confirmed by sequence analyses.

A time lag insensitive approach for estimating HIV-1 transmission direction

OBJECTIVES

Identifying the direction of transmission in transmission pairs is important both for forensic investigations and for the monitoring of HIV epidemics, however, reliable methods are not yet available due to the long time lag between infection and sampling in most real cases.

DESIGNS

Based on bottleneck effect and coreceptor switching, we aimed at identifying an estimator from sequences of viral gp120 proteins to determine transmission direction between transmission pairs. The estimator should be changed with HIV transmission but was independent of disease progression in an individual.

METHODS

Here, we present a novel and reliable approach for identifying transmission direction. We derived a set of conserved patterns, called common patterns, from the sequences of viruses, which differed in their coreceptor usage. The number of unique common patterns in viral sequences decreased with transmission but remained almost constant with the progress of disease in an individual. We used this number as an estimator to determine transmission direction in 73 transmission pairs for which the transmission direction was already known.

RESULTS

Our method predicted transmission direction with an accuracy of up to 94.5%. Of greater importance, our approach was not influenced by time lags between infection and sampling, and even transmission direction for transmission pairs with long time lags ranging from 2 years to more than 18 years were correctly determined.

CONCLUSION

Our approach for accurately determining transmission direction between transmission pairs is irrespective of the time lag between infection and sampling, which means a promising applications prospect.

What HIV-positive MSM want from sexual risk reduction interventions: findings from a qualitative study

To facilitate the development of a tailored intervention that meets the needs of HIV-positive men who have sex with men (HIV-positive MSM), we conducted formative research with 52 HIV-positive MSM. We sought to (a) identify major barriers to consistent condom use, (b) characterize their interest in sexual risk reduction interventions, and (c) elicit feedback regarding optimal intervention format. Men identified several key barriers to consistent condom use, including treatment optimism, lessened support for safer sex in the broader gay community, challenges communicating with partners, and concerns about stigmatization following serostatus disclosure. Many men expressed an interest in health promotion programming, but did not want to participate in an intervention focusing exclusively on safer sex. Instead, they preferred a supportive group intervention that addresses other coping challenges as well as sexual risk reduction. Study results reveal important considerations for the development of appealing and efficacious risk reduction interventions for HIV-positive MSM.

Stampidine as a promising antiretroviral drug candidate for pre-exposure prophylaxis against sexually transmitted HIV/AIDS

INTRODUCTION

Pre-exposure prophylaxis (PrEP) is an evolving new approach to prevention of sexually transmitted HIV-1 that employs antiretroviral (ARV) agents prior to potential HIV-1 exposure in an attempt to reduce the likelihood of HIV-1 infection postexposure. The identification of new ARV agents with potent activity against multidrug-resistant HIV remains an unmet and urgent challenge in the field of PrEP.

AREAS COVERED

This article reviews the preclinical and early clinical activity and safety profile of stampidine, a novel antiretroviral (ARV) drug candidate that exhibits remarkable subnanomolar to low nanomolar in vitro antiretroviral potency against genotypically and phenotypically nucleoside reverse transcriptase inhibitor (NRTI)-resistant primary clinical HIV isolates, non-nucleoside RT-resistant HIV-1 isolates. Stampidine has a favorable pharmacokinetic profile in mice, rats, dogs and cats with 25 or 50 mg/kg tolerable dose levels yielding micromolar plasma concentrations that are 1000-fold higher than its in vitro IC(50) value against HIV. Stampidine has a favorable, safety profile in mice, rats, dogs and cats and it showed significant in vivo ARV activity in HIV-infected Hu-PBL-SCID mice as well as FIV-infected domestic cats. Furthermore, it did not cause any maternal toxicity, developmental toxicity or teratogenicity in rabbits treated at 10 - 40 mg/kg/day dose levels. In a recently completed first-in-human Phase I clinical trial, stampidine did not cause dose-limiting toxicity at single dose levels ranging from 5 to 25 mg/kg.

EXPERT OPINION

The favorable safety and activity profile of stampidine warrants its further development as a promising next-generation PrEP candidate to prevent the sexual transmission of HIV-1. The discovery of stampidine as a potent antiretroviral agent represents a significant step forward in the development of effective therapeutic as well as preventive strategies against HIV/AIDS.

Secondary HIV prevention: novel intervention approaches to impact populations most at risk

This paper reviews recent secondary prevention interventions designed to reduce sexual risk behaviors among people living with HIV/AIDS (PLWHA). A summary of findings from previous meta-analyses and narrative reviews of interventions is provided. Next, novel HIV prevention approaches for PLWHA are reviewed. The review reports on the efficacy of interventions delivered in primary care settings or by technology-formats, interventions that also address mental health difficulties, and programs to address particular at-risk populations (eg, men who have sex with men). A critique of recent interventions for people living with HIV/AIDS is provided as well as suggestions for future research.

Sexual behaviour and HIV sero-discordance among HIV patients receiving HAART in rural Uganda

Globally, HIV sero-discordance is a major public health problem, due to increased risk of HIV transmission to HIV-negative partners. From January to August 2009, we assessed the sexual behaviour of HIV-infected patients attending an HIV treatment centre in Uganda and analysed characteristics associated with HIV sero-discordance. Of the 278 respondents, 256 (92.1%) were female, 218 (78.1%) were on antiretroviral drugs and 107 (38.7%) belonged to a sero-discordant couple. In the prior 3 months, 238 (88.5%) had more than one sexual partner and 98 (35.8%) had acquired new sexual partners. Only 171 (61.5%) had ever disclosed sero-status to main sexual partners. Participants who had changed sexual partners in the previous 3 months were more likely to be sero-discordant (OR 1.87, 95% CI 1.13, 3.11). Respondents who used condoms during their last sexual intercourse and those currently on ARVs were significantly less likely to be sero-discordant (OR 0.52 95% CI 0.28, 0.96 and OR 0.52 95% CI 0.30, 0.94, respectively). Only disclosure of sero-status was independently though inversely associated with discordance (adjusted OR 0.41, 95% CI 0.20, 0.64). Our findings indicate that HIV patients continue exhibiting high risk behaviour characterised by changing sexual partners, having multiple sexual partners and non-use of condoms.

Perceptions of superinfection risk among gay men with diagnosed HIV who have unprotected anal intercourse

This paper explores how men who have sex with men (MSM) with diagnosed HIV who engage in unprotected anal intercourse (UAI) perceive the potential risk of superinfection and how they respond to it. Semistructured interviews were carried out with 42 MSM recruited via community-based agencies throughout England and Wales. The interviews examined sexual risk taking and the ways in which men sought to manage the risks they perceived. All participants had heard of superinfection and one-third considered it a personal risk when they had UAI with men with the same sero-status. The risk of being superinfected with HIV was often situated among a number of other concerns that men felt they needed to manage when having sex. There was significant uncertainty about the likelihood of acquiring an additional strain of HIV, which was exacerbated by competing, and often conflicting, advice from a variety of expert sources. Men frequently drew upon lay and expert understandings of viral load and infectiousness to rationalize engagement in UAI with other diagnosed positive men. HIV health-care providers should seek to find consensus on how to discuss superinfection with MSM, taking account of the array of other physical and social risks associated with sex.

Estimating the potential pool of HIV-infected deceased organ donors in the United States

Human immunodeficiency virus (HIV) is no longer a contraindication to transplantation. For HIV-infected patients, HIV-infected deceased donors (HIVDD) could attenuate the organ shortage and waitlist mortality. However, this practice would violate United States federal law. The goal of this study was to estimate the potential impact of legalizing transplantation of HIV-infected organs by quantifying the potential pool of HIVDD. Using Nationwide Inpatient Sample (NIS) data, HIV-infected deaths compatible with donation were enumerated. Using HIV Research Network (HIVRN) data, CD4 count, plasma HIV-1 RNA level, AIDS-defining illnesses and causes of death were examined in potential HIVDD. Using UNOS data, evaluated donors who later demonstrated unanticipated HIV infections were studied. From NIS, a yearly average of 534 (range: 481-652) potential HIVDD were identified, with 63 (range: 39-90) kidney-only, 221 (range: 182-255) liver-only and 250 (range: 182-342) multiorgan donors. From HIVRN, a yearly average of 494 (range: 441-533) potential HIVDD were identified. Additionally, a yearly average of 20 (range: 11-34) donors with unanticipated HIV infection were identified from UNOS. Deceased HIV-infected patients represent a potential of approximately 500-600 donors per year for HIV-infected transplant candidates. In the current era of HIV management, a legal ban on the use of these organs seems unwarranted and likely harmful.

HIV super-infection beliefs and sexual practices of people living with HIV/AIDS

BACKGROUND

People living with HIV can be reinfected with a new viral strain resulting in potential treatment-resistant recombinant virus known as HIV super-infection. Individual's beliefs about the risks for HIV super-infection may have significant effects on the sexual behaviours of people living with HIV/AIDS. HIV super-infection beliefs and sexual behaviours among people living with HIV/AIDS were examined in the present study.

METHODS

Three hundred and twenty men, 137 women, and 33 transgender persons completed confidential surveys in a community research setting.

RESULTS

A majority of participants were aware of HIV super-infection and most believed it was harmful to their health. Hierarchical multiple regressions predicting protected anal/vaginal intercourse with same HIV status (seroconcordant) partners showed that older age and less alcohol use were associated with greater protected sex. In addition, HIV super-infection beliefs predicted protected sexual behaviour over and above participant age and alcohol use.

CONCLUSIONS

Beliefs about HIV super-infection exert significant influence on sexual behaviours of people living with HIV/AIDS and should be targeted in HIV prevention messages for HIV infected persons.

Previous reproductive history and post-natal family planning among HIV-infected women in Ukraine

BACKGROUND

Ukraine has the highest antenatal HIV prevalence in Europe. The national prevention of mother-to-child transmission (MTCT) programme has reduced the MTCT rate, but less attention has been given to the prevention of unintended pregnancy among HIV-positive women. Our objectives were to describe the reproductive health, condom use and family planning (FP) practices of HIV-positive childbearing Ukrainian women and to identify factors associated with different methods of post-natal contraception.

METHODS

HIV-infected childbearing women, diagnosed before or during pregnancy, were enrolled prospectively in a post-natal cohort study in four regional HIV/AIDS centres in Ukraine from December 2007. Logistic regression models were used to identify factors associated with post-natal FP practices.

RESULTS

Data were available for 371 women enrolled by March 2009; 82% (n = 303) were married or cohabiting, 27% (97 of 363) reported a current HIV-negative sexual partner and 69% were diagnosed with HIV during their most recent pregnancy. Overall, 21% (75 of 349) of women were not using contraception post-natally (of whom 80% reported no current sexual activity), 50% (174 of 349) used condoms, 20% (74 of 349) relied solely/partially on coitus interruptus and 4% used hormonal methods or intrauterine device. Among married/cohabiting women, consistent use of condoms in the previous pregnancy [AOR 1.96 (95%CI 1.06-3.62)], having an HIV-positive partner [AOR 0.42 (0.20-0.87)], current sexual activity [AOR 4.53 (1.19-17.3)] and study site were significantly associated with post-natal condom use; 16% of those with HIV-negative partners did not use condoms. Risk factors for non-use of FP were lack of affordability [AOR 6.34 (1.73-23.2)] and inconsistent use of condoms in the previous pregnancy [AOR 7.25 (1.41-37.2)].

CONCLUSIONS

More than 40% of HIV-positive women in this population are at risk of unintended pregnancy and the one in six women in HIV-discordant couples not using barrier methods risk transmitting HIV to their partners. Our study results are limited by the observational nature of the data and the potential for both measured and unmeasured confounding.

Sexual risk behaviour for transmission of HIV in men who have sex with men: recent findings and potential interventions

PURPOSE OF REVIEW

Men who have sex with men (MSM) remain one of the groups most at risk of HIV, particularly in countries with concentrated epidemics. Here, we review findings from behavioural research with MSM and discuss the potential of behavioural interventions.

RECENT FINDINGS

Increasing sexual risk behaviour and HIV transmission among MSM is apparent. Although risk reduction strategies, including serosorting and strategic positioning, are being widely reported, these appear to offer limited protection to HIV-negative MSM. There are emerging HIV epidemics among MSM in low-income and middle-income countries, with reported high levels of HIV and sexual risk behaviour. Studies of African MSM report higher HIV prevalence than that in the adult male general population. Evidence of effective behavioural interventions is growing. However, further trials, incorporating biological endpoints, are required.

SUMMARY

Reducing HIV transmission among MSM remains a significant challenge. Risk reduction strategies, other than condom use, could reduce the risk, but their efficacy is questionable, particularly when knowledge of HIV status may be inaccurate. Behaviour change alone is unlikely to produce the sustained reductions in HIV transmission necessary to change the course of the epidemic. 'Combination prevention', which incorporates biomedical, behavioural, social and structural interventions, should be explored further.

DIVEIN: a web server to analyze phylogenies, sequence divergence, diversity, and informative sites

DIVEIN is a web interface that performs automated phylogenetic and other analyses of nucleotide and amino acid sequences. Starting with a set of aligned sequences, DIVEIN estimates evolutionary parameters and phylogenetic trees while allowing the user to choose from a variety of evolutionary models; it then reconstructs the consensus (CON), most recent common ancestor (MRCA), and center of tree (COT) sequences. DIVEIN also provides tools for further analyses, including condensing sequence alignments to show only informative sites or private mutations; computing phylogenetic or pairwise divergence from any user-specified sequence (CON, MRCA, COT, or existing sequence from the alignment); computing and outputting all genetic distances in column format; calculating summary statistics of diversity and divergence from pairwise distances; and graphically representing the inferred tree and plots of divergence, diversity, and distance distribution histograms. DIVEIN is available at http://indra.mullins.microbiol.washington.edu/DIVEIN.