Respective roles of migration and social deprivation for virological non-suppression in HIV-infected adults on antiretroviral therapy in France

Interventions to ensure access to and continuity of HIV care for international migrants: an evidence synthesis

International migrants, especially those belonging to key populations, face a considerable HIV burden. However, continuity of HIV care for this group is often challenged along the migration route. We assess the available evidence on the existing interventions that aim to strengthen community and health systems to ensure the continuity of HIV care for international migrants. We did a systematic search of PubMed for publications from 1989 until 2023 focused on different stages of the HIV care continuum regardless of the geographical region. The literature was reviewed with a thematic approach. Globally, legal regulations can restrict access to HIV care and fuel fear of deportation among undocumented migrants. The intersection of HIV-related and migration-related stigma creates further challenges for uninterrupted access to HIV care along the migration route, with negative clinical and public health consequences. Different potential interventions were identified including: provision of HIV care regardless of migration status; utilisation of mobile health, mobile units, and community-led initiatives to bring HIV care to migrants; and utilisation of participatory and co-creation methods to develop tailored and sustainable HIV-related interventions with migrant communities. Improving access to the continuity of care for migrants requires a shift towards intersectional policies rooted in co-creation approaches to address the underlying multiple and mutually reinforcing inequalities.

First-ever acute ischemic strokes in HIV-infected persons: A case-control study from stroke units

OBJECTIVE

The stroke risk for persons living with human immunodeficiency virus (PLHIVs) doubled compared to uninfected individuals. Stroke-unit (SU)-access, acute reperfusion therapy-use and outcome data on PLHIVs admitted for acute ischemic stroke (AIS) are scarce.

METHODS

AIS patients admitted (01 January 2017 to 31 January 2021) to 10 representative Paris-area SUs were screened retrospectively from the National Hospitalization Database. PLHIVs were compared to age-, initial NIHSS- and sex-matched HIV-uninfected controls (HUCs). Outcome was the 90-day modified Rankin Scale score.

RESULTS

Among 126 PLHIVs with confirmed first-ever AIS, ~80% were admitted outside the thrombolysis-administration window. Despite antiretrovirals, uncontrolled plasma HIV loads exceeded 50 copies/mL (26% of all PLHIVs; 38% of those ≤55 years). PLHIVs' stroke causes by decreasing frequency were large artery atherosclerosis (LAA), undetermined, other cause, cerebral small-vessel disease (CSVD) or cardioembolism. No stroke etiology was associated with HIV duration or detectable HIVemia. MRI revealed previously unknown AIS in one in three PLHIVs, twice the HUC rate (p = 0.006). Neither group had optimally controlled modifiable cardiovascular risk factors (CVRFs): 20%-30% without specific hypertension, diabetes, and/or dyslipidemia treatments. Their stroke outcomes were comparable. Multivariable analyses retained good prognosis associated solely with initial NIHSS or reperfusion therapy. Older age and hypertension were associated with CSVD/LAA for all PLHIVs. Standard neurovascular care and reperfusion therapy were well-tolerated.

INTERPRETATION

The high uncontrolled HIV-infection rate and suboptimal CVRF treatment support heightened vigilance to counter suboptimal HIV suppression and antiretroviral adherence, and improve CVRF prevention, mainly for younger PLHIVs. Those preventive, routine measures could lower PLHIVs' AIS risk.

Immune profiles of pre-frail people living with HIV-1: a prospective longitudinal study

BACKGROUND

People living with HIV (PLWH) are at risk of frailty, which is predictive for death. As an overactivity of the immune system is thought to fuel frailty, we characterized the immune activation profiles linked to frailty.

METHODS

We quantified twenty-seven activation markers in forty-six virological responders (four females and forty-two males; median age, 74 years; median duration of infection, 24 years; median duration of undetectability, 13 years), whose frailty was determined according to the Fried criteria. T cell and NK cell activation was evaluated by flow cytometry, using a panel of cell surface markers. Soluble markers of inflammation, and monocyte activation and endothelial activation were measured by ELISA. The participants' immune activation was profiled by an unsupervised double hierarchical clustering analysis. We used ANOVA p-values to rank immunomarkers most related to Fried score. A Linear Discriminant Analysis (LDA) was performed to link immune activation markers to frailty.

RESULTS

41% of the participants were pre-frail, including 24% with a Fried score of 1, and 17% with a Fried score of 2. ANOVA identified the 14 markers of T cell, monocyte, NK cell, endothelial activation, and inflammation the most linked to Fried 3 classes. The LDA performed with these 14 markers was capable of discriminating volunteers according to their Fried score. Two out of the 5 immune activation profiles revealed by the hierarchical clustering were linked to and predictive of pre-frailty. These two profiles were characterized by a low percentage of CD4 T cells and a high percentage of CD8 T cells, activated CD4 T cells, CD8 T cells, and NK cells, and inflammation.

CONCLUSIONS

We identified a particular immune activation profile associated with pre-frailty in PLWH. Profiling participants at risk of developing frailty might help to tailor the screening and prevention of medical complications fueled by loss of robustness. Further studies will indicate whether this frailty signature is specific or not of HIV infection, and whether it also precedes frailty in the general population.

Social deprivation and exclusion in Parkinson's disease: a cross-sectional and longitudinal study

OBJECTIVE

To describe prevalence and associated factors of social deprivation in people with Parkinson's disease (PwPD).

DESIGN

Cross-sectional and longitudinal cohort study.

SETTING

Data were taken from the Survey of Health, Ageing and Retirement in Europe (SHARE), a multidisciplinary, cross-national and longitudinal research project.

PARTICIPANTS

Community-dwelling adults from waves 5 (2013, n=66 188) and 6 (2015, n=68 186) of the SHARE dataset. After longitudinal analyses, participants in wave 5 can be retrospectively divided into the following three subgroups: PwPD at wave 5 (n=559), people newly reported PD from wave 5 to wave 6 (prodromal PD; n=215) and people without PD (n=46 737).

OUTCOME MEASURES

The prevalence and associated factors of social deprivation in PD, its impact on quality of life (QoL) and its onset within the course of PD.

RESULTS

PwPD had higher indices for material and social deprivation than non-PD participants, and 20% of PwPD were at risk of social exclusion. Social deprivation alone accounted for 35% and material deprivation for 21% of QoL variance and remained significant predictors of QoL after adjustment for cofactors. Social deprivation and risk of social exclusion were already increased in people with prodromal PD, and accordingly preceded PD diagnosis in wave 6.

CONCLUSIONS

For the treatment of PD, we should consider the impact of social deprivation and exclusion on QoL and their association with mental and physical functioning. However, the relevance of social deprivation as a prodromal phenomenon requires further investigation.

Respective roles of social deprivation, health literacy, and clinical factors for COVID-19: a case-control study in hospitalized patients

Introduction

To investigate the association between social deprivation and COVID-19 among hospitalized patients in an underprivileged department of the greater Paris area.

Methods

Individuals hospitalized for COVID-19 between March 1st and October 31, 2020, were included, matched on age and sex, and compared with patients hospitalized for any other reason with negative RT-PCR for SARS-CoV-2, through a case-control study. Clinical, socio-demographic characteristics, health literacy, and social deprivation, assessed by the EPICES score, were collected. Factors associated with COVID-19 in hospitalized patients were assessed using univariate and multivariate logistic regression models.

Results

69 cases and 180 controls were included. Participants were mostly men (N = 148: 59.4%) aged 65 or older (N = 109: 44.1%). Median EPICES score was 43.2 (IQR 29.4-62.9). EPICES score > 30.17 (precariousness threshold) was not significantly associated with COVID-19 in hospitalized patients (adjusted odds ratio (aOR) = 0.46; 95% Confidence Interval (CI) [0.21-1.01]). Advanced age, higher BMI, professional activity, home area of less than 25 m2 per person, and low health literacy, were significantly associated with COVID-19 in hospitalized patients.

Discussion

This study highlights probable risk factors for specific exposition in disadvantaged area: maintenance of professional activity, smaller home area, and low health literacy.

Frailty and prefrailty phenotypes increase the odds of abnormal cognitive impairment screens in people with HIV

OBJECTIVE

Evaluate whether prefrail and frail people with HIV (PWH) have a higher risk of cognitive impairment on screens.

METHODS

Analysis of PWH aged 70 or older included in the ANRS EP66 SEPTAVIH cohort, on antiretroviral therapy for at least 12 months and with a MoCA test at enrolment. Adjusted risk of a Montreal Cognitive Assessment (MoCA) less than 26 was compared in frail/prefrail versus robust PWH.

RESULTS

A total of 503 PWH were enrolled with a median age of 73 years, IQR [71-77], 81.5% were male, 73.8% were French natives, 32.9% had low socio-economic status (EPICES score >30.2), and 41.3% were college graduates; 27.3% had a history of clinical AIDS. A total of 294 (58.5%) PWH had a MoCA score less than 26; 182 (36%) a MoCA score 23 or less. Frailty, prefrailty and robustness were found in 13.1, 63.6 and 23.3% participants, respectively. PWH with a MoCA less than 26 had a significantly higher risk of being frail/prefrail, this before [odds ratio (OR) = 2.31; 95% confidence interval (CI) 1.50-3.57], and after adjustment for confounders (OR = 1.80; 95% CI 1.07-3.01). The risk of being frail/prefrail in patients with a MoCA 23 or less was higher (adjusted OR = 2.75; 95% CI 1.46-5.16). Other factors independently associated with a MoCA less than 26 were older age, birth outside of France and a lower education level and being diabetic.

CONCLUSION

Abnormal MoCA screens were frequent in our cohort of PWH aged 70 or older with controlled HIV disease. Cognitive impairment should be systematically screened in frail/prefrail PWH. Frailty/prefrailty, diabetes and social factors, but not HIV-related factors, are important determinants of cognitive function in PWH with controlled disease.

Prevalence and risk factors of frailty among adults living with HIV aged 70 years or older

OBJECTIVES AND DESIGN

Frailty is a phenotype associated with adverse health outcomes in older persons. It has been evaluated mainly in middle-aged persons with HIV (PWH). The French multicenter prospective ANRS EP66 SEPTAVIH study aimed to assess frailty prevalence and risk factors in PWH aged 70 years or older on antiretroviral treatment (ART) for at least 12 months.

METHODS

At baseline, Fried frailty phenotype criteria, sociodemographic data, medical/HIV history, functional status, comorbidities, including impaired cognitive function, depression, history of falls, and co-medications were collected. We measured the prevalence of frailty and compared the characteristics of frail versus prefrail and robust participants using univariate (Kruskal-Wallis tests for continuous variables and Chi 2 tests for categorical variables) and multivariate analyses.

RESULTS

Five hundred and ten PWH, mostly male (81.4%), were included with a median age of 73 years. The median HIV and ART durations were 22.7 years and 15.7 years, respectively. The prevalence of frailty was 13.5%, and of prefrailty 63.3%. In the multivariate analysis, increasing age [odds ratio (OR) 1.79 for each 5-year increment; 95% confidence interval (CI) 1.32-2.41], deprived socioeconomic status (OR 3.17; 95% CI 1.76-5.70), and multimorbidities (three or more) (OR 2.03; 95% CI 1.06-3.90) were associated with frailty.

CONCLUSION

A low prevalence of frailty was reported (13.5%) in PWH aged 70 years or older, whereas two-thirds of them were prefrail. Age, low socioeconomic status, and multimorbidities, but no HIV-related factors, were associated with frailty, suggesting the need to target these factors to help promoting successful aging in this population.

Spatiotemporal Variation and Predictors of Unsuppressed Viral Load among HIV-Positive Men and Women in Rural and Peri-Urban KwaZulu-Natal, South Africa

Unsuppressed HIV viral load is an important marker of sustained HIV transmission. We investigated the prevalence, predictors, and high-risk areas of unsuppressed HIV viral load among HIV-positive men and women. Unsuppressed HIV viral load was defined as viral load of ≥400 copies/mL. Data from the HIV Incidence District Surveillance System (HIPSS), a longitudinal study undertaken between June 2014 to June 2016 among men and women aged 15−49 years in rural and peri-urban KwaZulu-Natal, South Africa, were analysed. A Bayesian geoadditive regression model which includes a spatial effect for a small enumeration area was applied using an integrated nested Laplace approximation (INLA) function while accounting for unobserved factors, non-linear effects of selected continuous variables, and spatial autocorrelation. The prevalence of unsuppressed HIV viral load was 46.1% [95% CI: 44.3−47.8]. Predictors of unsuppressed HIV viral load were incomplete high school education, being away from home for more than a month, alcohol consumption, no prior knowledge of HIV status, not ever tested for HIV, not on antiretroviral therapy (ART), on tuberculosis (TB) medication, having two or more sexual partners in the last 12 months, and having a CD4 cell count of <350 cells/μL. A positive non-linear effect of age, household size, and the number of lifetime HIV tests was identified. The higher-risk pattern of unsuppressed HIV viral load occurred in the northwest and northeast of the study area. Identifying predictors of unsuppressed viral load in a localized geographic area and information from spatial risk maps are important for targeted prevention and treatment programs to reduce the transmission of HIV.

Measles seroprevalence in human immunodeficiency virus-infected adults born in the era of measles vaccination

OBJECTIVE

Widespread use of the measles vaccine should lead to the elimination of this disease. Here, we study the seroprevalence of measles in a cohort of adults living with HIV born after the introduction of measles vaccine in France and attempt to identify risk factors for the absence of serum measles antibody.

DESIGN

In this multi-centre cross-sectional study, adult outpatients born after 1980 were screened for the presence of measles IgG antibody. Demographic and clinical data were obtained from the standardized electronic medical record system. Univariate and multivariate logistic regressions were performed to identify factors associated with the absence of measles antibodies.

RESULTS

Between April 2019 and April 2020, 648 participants were enrolled. The median age was 33 years, 53.6% were born outside of France, and 74% were considered as socially deprived. Plasma HIV RNA was undetectable in 86% of patients. Among 603 evaluable patients, measles serology was positive in 87.2%. Only 81.8% of the patients with documented vaccination tested positive for measles IgG. Younger age was significantly associated with the absence of measles serum antibodies ( P  = 0.004 for each 10-year lower), as was birth in France ( P  < 0.001) and absence of social vulnerability ( P  = 0.04).

CONCLUSION

The current study revealed a low seroprevalence of measles compared with that previously reported in France 6 years earlier and to the expected rate to achieve herd immunity. Checking vaccination record should be systematically carried out in patients living with HIV to fill the immunity gaps.

Influence of Material Deprivation on Clinical Outcomes Among People Living with HIV in High-Income Countries: A Systematic Review and Meta-analysis

Despite developments in HIV treatment and care, disparities persist with some not fully benefiting from improvements in the HIV care continuum. We conducted a systematic review to explore associations between social determinants and HIV treatment outcomes (viral suppression and treatment adherence) in high-income countries. A random effects meta-analysis was performed where there were consistent measurements of exposures. We identified 83 observational studies eligible for inclusion. Social determinants linked to material deprivation were identified as education, employment, food security, housing, income, poverty/deprivation, socioeconomic status/position, and social class; however, their measurement and definition varied across studies. Our review suggests a social gradient of health persists in the HIV care continuum; people living with HIV who reported material deprivation were less likely to be virologically suppressed or adherent to antiretrovirals. Future research should use an ecosocial approach to explore these interactions across the lifecourse to help propose a causal pathway.

Living conditions, HIV and gender affirmation care pathways of transgender people living with HIV in France: a nationwide, comprehensive, cross-sectional, community-based research protocol (ANRS Trans&HIV)

INTRODUCTION

Transgender identity is poorly accepted in France, and data on living conditions and the daily difficulties transgender people encounter are scarce. This lack of data reinforces their invisibility in social life, contributes to their stigmatisation and probably increases the burden of HIV infection, especially for HIV-positive transgender people (TRHIV). The main objective of the community-based research study ANRS Trans&HIV is to identify personal and social situations of vulnerability in TRHIV, the obstacles they encounter in terms of access to and retention in medical care, and their gender affirmation and HIV care needs.

METHODS AND ANALYSIS

ANRS Trans&HIV is a national, comprehensive, cross-sectional survey of all TRHIV currently being followed in HIV care units in France. TRHIV women are exclusively included in the quantitative component, and TRHIV men in the qualitative component. Data are collected by community-based interviewers and will be analysed to explore patient care pathways and living conditions in the TRHIV population with regard to gender affirmation and HIV. Data collection began in October 2020 and should be completed in December 2021. The statistical analyses techniques used will be adapted to each of the study's objectives and to the type of data collected (cross-sectional (questionnaires) and retrospective (biographical trajectory)). The study's results will provide a greater understanding of TRHIV health needs in order to suggest possible national recommendations for comprehensive HIV and gender affirmation medical care.

ETHICS AND DISSEMINATION

ANRS Trans&HIV was approved by Inserm's Ethical Evaluation Committee (no 20-694 on 12 May 2020) and is registered with the National Commission on Informatics and Liberty under number 2518030720. Potential participants are informed about the study through an information note provided by their attending HIV physician. All results published in peer-reviewed journals will be disseminated to the HIV transgender community, institutional stakeholders and healthcare providers.

TRIAL REGISTRATION NUMBER

NCT04849767.

Socio-economic condition and lack of virological suppression among adults and adolescents receiving antiretroviral therapy in Ethiopia

Introduction

The potential impact of socio-economic condition on virological suppression during antiretroviral treatment (ART) in sub-Saharan Africa is largely unknown. In this case-control study, we compared socio-economic factors among Ethiopian ART recipients with lack of virological suppression to those with undetectable viral load (VL).

Methods

Cases (VL>1000 copies/ml) and controls (VL<150 copies/ml) aged ≥15years, with ART for >6 months and with available VL results within the last 3 months, were identified from registries at public ART clinics in Central Ethiopia. Questionnaire-based interviews on socio-economic characteristics, health condition and transmission risk behavior were conducted. Univariate variables associated with VL>1000 copies/ml (p<0.25) were added to a multivariable logistic regression model.

Results

Among 307 participants (155 cases, 152 controls), 61.2% were female, and the median age was 38 years (IQR 32–46). Median HIV-RNA load among cases was 6,904 copies/ml (IQR 2,843–26,789). Compared to controls, cases were younger (median 36 vs. 39 years; p = 0.004), more likely to be male (46.5% vs. 30.9%; p = 0.005) and had lower pre-ART CD4 cell counts (170 vs. 220 cells/μl; p = 0.009). In multivariable analysis of urban residents (94.8%), VL>1000 copies/ml was associated with lower relative wealth (adjusted odds ratio [aOR] 2.98; 95% CI 1.49–5.94; p = 0.016), geographic work mobility (aOR 6.27, 95% CI 1.82–21.6; p = 0.016), younger age (aOR 0.94 [year], 95% CI 0.91–0.98; p = 0.011), longer duration of ART (aOR 1.19 [year], 95% CI 1.07–1.33; p = 0.020), and suboptimal (aOR 3.83, 95% CI 1.33–10.2; p = 0.048) or poor self-perceived wellbeing (aOR 9.75, 95% CI 2.85–33.4; p = 0.012), after correction for multiple comparisons. High-risk sexual behavior and substance use was not associated with lack of virological suppression.

Conclusion

Geographic work mobility and lower relative wealth were associated with lack of virological suppression among Ethiopian ART recipients in this predominantly urban population. These characteristics indicate increased risk of treatment failure and the need for targeted interventions for persons with these risk factors.

Low-level HIV viremia is associated with low antiretroviral prescription refill rates and social deprivation

Optimal management of patients experiencing persistent low-level viremia (LLV) remains challenging and poorly understood. This study aimed to assess the association between poor antiretroviral treatment (ARV) adherence and persistent LLV. ADHELOW is a sub-study of the ECHEC cohort comprising HIV-infected adults with virological failure (viral load>50 copies/mL). Patients were recruited in 2013-2015 from 4 French university hospitals. Those with LLV (i.e., ≥2 viral load measurements between 50 and 500 copies/mL) were selected and matched on age and sex to 3 controls with virological suppression. The adherence rate was estimated using pharmacy-delivered prescription refills over one year. Overall, 60 patients were included (15 LLV and 45 controls). Mean age was 50.20 years, M/F sex ratio was 14 and mean EPICES (social deprivation) score was 42.90. In univariable analyses, LLV patients had significantly lower adherence (<80%: 53.30% vs. 6.67%, p < 0.01) and were more likely to have an EPICES score >40.2 (60.00% vs. 24.44%, p < 0.01). In multivariable analysis, these two variables remained significantly associated with LLV (OR 31.49, CI 95% [4.54-218.70]) and OR 11.00 (CI 95% [1.87-218.70], respectively). Poor long-term treatment adherence, estimated by prescription refills, was strongly associated with LLV. This reinforces the message that adherence counseling should be the primary intervention to overcome LLV.