Effectiveness of an intervention to improve ART adherence among men who have sex with men living with HIV: a randomized controlled trial in three public HIV clinics in Mexico

We conducted a parallel-group randomized controlled trial in three HIV clinics in Mexico to evaluate a user-centred habit-formation intervention to improve ART adherence among MSM living with HIV. We randomized 74 participants to the intervention group and 77 to the control group. We measured adherence at one, four, and ten months through medication possession ratio and self-reported adherence. Additionally, we measured viral load, CD4 cell count, major depression disorder symptoms, and alcohol and substance use disorder at baseline, fourth and tenth months. We found no statistically significant effect on adherence between groups. However, the intervention demonstrated positive results in major depression disorder symptoms (21% vs. 6%, p = 0.008) and substance use disorder (11% vs. 1%, p = 0.018) in the fourth month. The latter is relevant because, in addition to its direct benefit, it might also improve the chances of maintaining adequate adherence in the long term. This trial was retrospectively registered at ClinicalTrials.gov (trial number NCT03410680) on 8 January 2018.Trial registration: ClinicalTrials.gov identifier: NCT03410680.

Negative clinic experiences as a barrier to care for people with HIV and their impact on patient preferences for intervention support: a qualitative study in Cape Town, South Africa

We conducted qualitative research among people with HIV (PWH) and care providers in Cape Town, South Africa to understand the impact of negative clinic experiences on adherence and support preferences. In-depth interviews were conducted with 41 patients with an unsuppressed viral load or a treatment gap, and focus group discussions with physicians, nurses, counselors, and community health workers. Questions addressed treatment history and adherence barriers, then participants evaluated evidence-based adherence interventions for potential scale up. Inductive analysis examined care experiences and corresponding preference for intervention options. More than half of PWH described negative experiences during clinic visits, including mistreatment by staff and clinic administration issues, and these statements were corroborated by providers. Those with negative experiences in care stated that fear of mistreatment led to nonadherence. Most patients with negative experiences preferred peer support groups or check-in texts to clinic-based interventions. We found that PWH's negative clinic experiences were a primary reason behind nonadherence and influenced preferences for support mechanisms. These findings emphasize the importance of HIV treatment adherence interventions at multiple levels both in and outside of the clinic, and providing more comprehensive training to providers to better serve PWH in adherence counseling, especially those who are most vulnerable..

Long-Acting Injectable ART in Practice: A Mixed Methods Implementation Study Assessing the Feasibility of Using LAI ART in High Risk Populations and At Alternative Low Barrier Care Sites

Long-acting injectable (LAI) antiretroviral therapy (ART) has the potential to change the lives of people living with HIV (PLWH). To ensure equitable access to new treatment modalities, we examined the feasibility and acceptability of administering Cabotegravir Rilpivirine Long Acting (CAB/RPV LA) to individuals who experience challenging social determinants of health (SDoH) and struggle with adherence to traditional oral ART. Quantitative and qualitative data were used to assess feasibility of utilizing ART at alternative clinic. Data were collected on individuals eligible to receive CAB/RPV LA at an alternative street-based clinic and on individuals receiving CAB/RPV LA at a traditional HIV clinic. After 6 months, participants were interviewed about their experience. Providers involved in the implementation were also interviewed about their experiences. Only one participant (out of 5) who received CAB/RPV LA at the alternative clinic received consistent treatment, whereas 17 out of 18 participants receiving CAB/RPV LA at the traditional clinic site were adherent. Participants and providers believed that LAI had potential for making treatment adherence easier, but identified several barriers, including discrepancies between patients' desires and their lifestyles, impact of LAI on interactions with the medical system, risk of resistance accompanying sub-optimal adherence, and need for a very high level of resources. While LAI has major potential benefits for high-risk patients, these benefits must be balanced with the complexities of implementation. Despite challenges that impacted study outcomes, improving treatment outcomes for PLWH requires addressing SDoH and substance use.

Depression mediates the relationship between exposure to stigma and medication adherence among people living with HIV in low-resource setting: a structural equation modeling approach

This study hypothesizes that depression mediates the association between exposure to stigma and medication non-adherence in people living with HIV (PLHIV). We recruited 372 PLHIV from the Stigma, health-related Quality of life, antiretroviral Adherence, and Depression among people living with HIV (SQuAD-HIV) project, a multicenter cross-sectional study conducted between October 2021 and February 2022 among PLHIV attending six ART clinics in two geopolitical regions of northern Nigeria. A structural equation modeling (SEM) framework, utilizing the full information maximum likelihood estimator, was used to elucidate the pathways linking stigma, depression, and ART medication adherence, adjusting for sociodemographic characteristics. The total number of eligible participants analyzed (353) included 32.7% male PLHIV with a mean age (SD) of 39.42 (10.14). Being female was positively associated with adherence (β, 95% CI 0.335, 0.163-0.523, p-value < 0.001) but negatively associated with stigma (β, 95% CI - 0.334, - 0.561 to - 0.142, p-value = 0.001), while urban residence was negatively associated with stigma (β, 95% CI - 0.564, - 0.804 to - 0.340, p-value < 0.001). Our analysis also indicated that a higher level of experienced stigma was associated with decreased medication adherence. This association was partially mediated by depression (indirect effect = (0.256) (- 0.541) =  - 0.139; p-value < 0.01). The proportion of the association between stigma and medication adherence explained through mediation by depression was 35.6%. These findings underscore the need for targeted interventions aimed at lowering exposure to stigma among PLHIV to improve medication adherence.

The development of social capital in a peer-led mHealth cognitive behavioral antiretroviral therapy adherence intervention for HIV + adolescents and young adults

Adherence Connection for Counseling, Education, and Support (ACCESS)-I is a peer-led mHealth antiretroviral therapy adherence intervention for adolescents and young adults living with HIV who are in treatment but have detectable viral loads. Participants received five online sessions with peer health coaches who followed a structured intervention manual. Peers maintained intervention fidelity but also engaged in casual discussion that was not directly related to ART adherence or HIV. We conducted a qualitative analysis of the casual interactions that occurred during the ACCESS I intervention. Sessions were transcribed and coded, and these casual interactions were then coded into 10 subcodes to document their content, and also coded for three types of social capital - emotional, informational, and instrumental. Emotional and Informational social capital codes were the most common, while instrumental codes were rare. Activities was the most common topic overall, while encouragement was more common in emotional social capital narratives and personal experience was more common in informational social capital narratives. These casual interactions may strengthen peer-participant relationships, building social capital that could then be used to encourage positive behavior change. Although social capital was not directly measured, these analyses illustrate the value of attending to seemingly casual interactions in peer-led interventions.

Stigmatization of food insecurity helps explain the association between food insecurity and medication nonadherence among people living with HIV

Food insecurity is an established barrier to antiretroviral therapy (ART) adherence among people living with HIV (LWHIV). While insufficient access to food reliably impedes medication adherence, the link between food insecurity and ART nonadherence has not been fully explained. In addition, depression is reliably associated with both food insecurity and ART nonadherence, but again the link between food insecurity and depression is not understood. A potential explanatory mechanism in the associations among food insecurity, depression and ART nonadherence is the experience of food insecurity stigma (FI-stigma). The current study tested FI-stigma in relation to depression as explanatory mechanisms in the association between food insecurity and ART nonadherence. Men and women (n = 495) LWHIV in the southeastern United States completed confidential surveys that included measures of food insecurity, FI-stigma, depression, and ART adherence. Results from the serial mediation model indicated significant direct effects of food insecurity and depression on ART adherence. In addition, food insecurity was indirectly associated with ART adherence through FI-stigma and depression symptoms. Results suggest that the stigmatization of food insecurity predicts increased depression which in turn predicts ART nonadherence, with both FI-stigma and depression symptoms partially mediating the relationship between food insecurity and ART nonadherence. Interventions aimed to reduce food insecurity should include it's associated stigma to improve treatment adherence among people LWHIV.

The salience of structural barriers and behavioral health problems to ART adherence in people receiving HIV primary care in South Africa

Multilevel factors (individual and structural) influence adherence to antiretroviral therapy, particularly in high HIV prevalence areas such as South Africa. The present study examined the relative importance of structural barriers to HIV care and behavioral health factors, depression and alcohol use, in Khayelitsha, Cape Town, South Africa. People receiving HIV care in six primary care clinics in Khayelitsha (N = 194) completed the Center for Epidemiologic Studies Depression Scale, the Alcohol Use Disorders Identification Test, the Structural Barriers to Medication Taking questionnaire, and a qualitative rating of past-two-week adherence. Correlations were employed to examine associations among these variables, and hierarchical regression analysis was used to examine the unique effects of structural barriers over and above depression and alcohol use as predictors of adherence. Participants were primarily Black South African (99%) women (83%), and 41 years old on average. All four variables were significantly correlated. The hierarchical regression analysis showed that among behavioral health predictors, alcohol use alone significantly predicted ART adherence (b = -.032, p = .002). When structural barriers was added to the model, it was the only significant unique predictor of ART adherence (b = -1.58, p < .001). Findings highlight the need to consider structural vulnerabilities in HIV care in South Africa when developing behavioral health interventions.

Police Violence Experienced by Black Gay and Bisexual Men: The Effects on HIV Care Engagement and Medication Adherence

Black men face high rates of police violence, including direct victimization and indirect exposure to or knowledge of harmful policing. This violence can result in death and physical harm, as well as in numerous poor mental health outcomes. There has been little research examining experiences of police violence experienced by Black gay and bisexual men or the effects of police brutality on HIV continuum of care outcomes. To address this important gap, in this exploratory study, we examined the effects of police brutality on engagement in HIV care and adherence to antiretroviral medications. Cross-sectional survey data were collected from 107 Black gay and bisexual men living with HIV. The path analysis showed that men with greater exposure to police violence had increased symptoms of post-traumatic stress disorder and were more likely to have missed HIV care appointments in the past year. Additionally, there was a significant indirect effect of exposure to police violence on missed medication doses via PTSD symptoms.

Heavy Alcohol Use and HIV Outcomes: The Moderating Role of Pain

Pain and heavy alcohol consumption are prevalent among people living with HIV/AIDS (PLWH), each contributing to impaired functioning and diminished quality of life. Each of these conditions may have negative effects on the HIV care continuum, but less is known about their combined influences. The current study examined how heavy drinking and pain were associated with HIV viral suppression and CD4 cell count among participants receiving antiretroviral therapy (ART). The study sample consisted of 220 PLWH with past 12-month substance dependence or ever injection drug use enrolled in a large HIV cohort study. Logistic regression analyses showed an interaction between pain level (no/mild pain vs moderate/severe) and heavy drinking on viral suppression such that heavy drinking was a significant predictor of poorer viral suppression only for those who experienced moderate/severe pain. We also examined whether ART adherence differentially mediated the association between heavy drinking and HIV viral suppression by level of pain. Although there was a significant indirect effect of heavy drinking on viral suppression among those with moderate/severe pain, moderated mediational analyses did not indicate that the indirect effect of heavy drinking on viral suppression through ART adherence differed significantly by level of pain. Pain level did not significantly moderate the association between heavy drinking and CD4 cell count. We conclude that heavy drinking may be particularly likely to be associated with poorer HIV viral suppression among PLWH with moderate or severe pain. Providers should routinely address comorbid heavy drinking and pain to improve HIV outcomes.

The Inherent Violence of Anti-Black Racism and its Effects on HIV Care for Black Sexually Minoritized Men

The goal of this study was to examine the effects of racial discrimination, depression, and Black LGBTQ community support on HIV care outcomes among a sample of Black sexually minoritized men living with HIV. We conducted a cross-sectional survey with 107 Black sexually minoritized men living with HIV in Chicago. A path model was used to test associations between racial discrimination, Black LGBTQ community support, depressive symptoms, and missed antiretroviral medication doses and HIV care appointments. Results of the path model showed that men who had experienced more racism had more depressive symptoms and subsequently, missed more doses of HIV antiretroviral medication and had missed more HIV care appointments. Greater Black LGBTQ community support was associated with fewer missed HIV care appointments in the past year. This research shows that anti-Black racism may be a pervasive and harmful determinant of HIV inequities and a critical driver of racial disparities in ART adherence and HIV care engagement experienced by Black SMM. Black LGBTQ community support may buffer against the effects of racial discrimination on HIV care outcomes by providing safe, inclusive, supportive spaces for Black SMM.

Childhood sexual abuse and antiretroviral therapy adherence among older adults living with HIV: a mixed methods study

Findings on the association between childhood sexual abuse (CSA) and antiretroviral therapy (ART) adherence have been varied, with some studies showing a relationship, or a lack thereof. However, to our knowledge, no study has examined this association among older adults living with HIV (OALH). Therefore, the purpose of this study was to examine the association between CSA and ART adherence among OALH using a mixed methods approach. This study, which involved a concurrent design, had two phases. The first phase comprised in-depth, semi-structured interviews of 24 adults aged 50 and older living with HIV in South Carolina. The second phase included data from 91 OALH. Thematic analysis and multivariable regression models, adjusting for age, gender, race, and income, were used to determine the association between CSA and ART adherence. The main theme emerging from the qualitative data was that CSA was not linked with ART adherence. However, contrastingly, quantitative analyses revealed a negative statistically significant association between CSA and ART adherence (adjusted β: -3.35; 95% CI: -5.37, -1.34). This difference in findings could be due to the hidden impact of trauma and/or the use of different study populations. Future research should assess mediating pathways between CSA and ART adherence.

Over forty percent of women living with HIV report interruption in antiretroviral therapy during intrapartum and early postpartum inpatient stay: findings from five hospitals in Ghana

Antiretroviral therapy (ART) adherence during and after pregnancy is essential to reduce perinatal transmission of HIV. However, little is known about adherence during the intrapartum and early postpartum inpatient hospital stay. Using secondary data from a hospital-based cohort study focused on the relationship between birthweight and engagement in HIV care, we examined the magnitude of, reasons for, and factors associated with incomplete intrapartum and early postpartum ART adherence among adult women (18 years or older) living with HIV who delivered within the previous two weeks at one of five hospitals in Accra, Ghana. Of the 142 enrolled participants who had complete adherence data and reported being on ART at the time of hospital admission, 43% (61/142) reported missing at least one ART dose during labor, delivery, and postpartum, including almost 20% (28/142) missing 2 or more consecutive doses. Women who reported frequently missing ART doses during pregnancy had higher odds of reporting missed doses during their intrapartum and postpartum hospital stays. Among those with inpatient ART interruption, the most frequently cited reasons were: forgetting medication at home (42%) and challenges of being in or recovering from labor (29%). Maternal perception of infant health at birth, hospital level of care, and frequency of missing HIV medications during pregnancy were associated with incomplete ART adherence during the intrapartum and early postpartum inpatient stay. An enabling clinical environment to facilitate access to ART during inpatient stays may have positive implications for ART adherence.

HIV Testing Disruptions and Service Adaptations During the COVID-19 Pandemic: A Systematic Literature Review

Access to treatment and care in safe clinical settings improves people's lives with HIV. The COVID-19 pandemic disrupted vital HIV programs and services, increasing the risk of adverse health outcomes for people with HIV and HIV transmission rates in the community. This systematic literature review provides a meta-analysis of HIV testing disruptions and a synthesis of HIV/AIDS services adapted during COVID-19. We searched scholarly databases from 01 January 2020 to 30 June 2022 using key terms on HIV testing rates and services during the COVID-19 pandemic. The process of how the included articles were identified, selected, appraised, and synthesised was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We included 17 articles that reported changes in HIV testing during the COVID-19 pandemic and 22 that reported adaptations in HIV/AIDS services. We found that HIV testing decreased by 37% during the search period because of the COVID-19 pandemic. Service providers adopted novel strategies to support remote service delivery by expanding community antiretroviral therapy dispensing, setting up primary care outreach points, and instituting multi-month dispensing services to sustain client care. Therefore, service providers and policymakers should explore alternative strategies to increase HIV testing rates impacted by COVID-19 and leverage funding to continue providing the identified adapted services.

Dyadic typology of illness perceptions in human immunodeficiency virus (HIV) Serodiscordant couples

OBJECTIVE

Illness perceptions direct coping resources in the illness adaptation process. Previous studies regarding illness perception profiles have been conducted at the individual level, without considering the couple as a unit. This study aimed to investigate the dyadic topologies of illness perceptions in HIV-serodiscordant couples and the association between the identified profiles and individual- and couple-level outcomes.

METHODS

A comprehensive examination was undertaken, encompassing 231 Chinese HIV-serodiscordant couples, who voluntarily participated in this cross-sectional study during the period spanning June to October 2022. To discern various patterns of illness perception, dyadic latent profile analyses were performed, followed by the implementation of one-way analyses of variance to investigate outcome differences at both the individual and couple levels across the identified profiles.

RESULTS

We identified three distinct profiles of illness perception, namely the incongruent-but-low, congruent-but-high, and incongruent-and-high profiles. Except for the partner's sex (p < .01, Cramer' v = 0.214) and the education levels of persons living with HIV and their partners (both p < .01, Cramer' v = 0.236 for persons living with HIV and 0.198 for partners), no significant demographic differences across the various profiles were found. Furthermore, we observed significant differences in all outcomes among the different couple profiles (all p < .001). These differences were of medium-to-large magnitudes (partial η2 values ranging from 0.07 to 0.22).

CONCLUSION

A couple-centered typological approach provides a useful way of identifying the couple's configuration of illness perceptions, which will inform the provision of tailor-made treatment for couples with different profiles.

"It Soothes Your Heart": A Multimethod Study Exploring Acceptability of Point-of-Care Viral Load Testing among Ugandan Pregnant and Postpartum Women Living with HIV

BACKGROUND

High adherence to antiretroviral therapy (ART) is critical for achieving viral suppression and preventing onward HIV transmission. ART continuation can be challenging for pregnant women living with HIV (PWLHIV), which has critical implications for risk of vertical HIV transmission. Point-of-care viral load (POC VL) testing has been associated with improved treatment and retention outcomes. We sought to explore acceptability of POC VL testing among Ugandan PWLHIV during pregnancy and postpartum.

METHODS

This multimethod analysis drew on quantitative and qualitative data collected between February and December 2021. Quantitatively, we used an intent-to-treat analysis to assess whether randomization to clinic-based POC VL testing during pregnancy and infant testing at delivery was associated with improved viral suppression (≤50 copies/mL) by 3 months postpartum compared to standard-of-care (SOC) VL testing through a central laboratory, adjusting for factorial randomization for the male partner testing strategy. Additionally, a subset of 22 PWLHIV in the POC VL arm participated in in-depth qualitative interviews. We inductively analyzed transcripts to develop categories representing concepts that characterized women's perceptions of POC VL testing during pregnancy and at delivery and ways that POC VL testing may have impacted their ART adherence and viral suppression. Key themes around women's perceptions of POC VL testing were then organized into main categories.

RESULTS

Overall, 151 PWLHIV were enrolled into the study, 77 (51%) of whom were randomized to receive POC VL testing during pregnancy and at delivery. Women reported in qualitative interviews that POC VL testing had (1) motivated their ART adherence during pregnancy and postpartum and that they felt this testing method had (2) helped them protect their infants from acquiring HIV and (3) improved their emotional wellbeing.

CONCLUSIONS

POC VL testing was highly acceptable among Ugandan PWLHIV and was viewed as an important tool that women believed improved their ART adherence, gave them information necessary to protect their infants from vertical HIV acquisition, and improved their emotional wellbeing. These findings support the global scale-up of POC VL testing in settings with high HIV burden, especially for PWLHIV who may be at risk of treatment disruptions or loss to follow-up.

Effects of intimate partner violence and homophobic bullying on ART adherence among young Thai men who have sex with men: a causal mediation analysis

Background

Adherence to antiretroviral therapy is crucial in determining health outcomes and secondary HIV transmission for people living with HIV/AIDS. Young men who have sex with men (YMSM) living with HIV are often challenged by the prevailing experiences of psychosocial stressors, such as intimate partner violence and homophobic bullying, which may negatively affect their HIV care engagement.

Methods

This study is the first to utilize a prospective cohort design (N= 185) involving YMSM living with HIV in Thailand. We examined the effects of intimate partner violence and homophobic bullying on ART adherence. We also tested the mediating effect of depression on the relationship between intimate partner violence and homophobic bullying on ART adherence.

Results

We found that intimate partner violence (AOR: 2.58, 95% CI: 1.13, 5.42) and homophobic bullying (AOR: 2.40, 95% CI: 1.26, 4.48) were associated with subsequent ART nonadherence. Moreover, depression partially mediated 17.4% (95% CI: 0.75%, 56%) of the effect of homophobic bullying on ART nonadherence.

Conclusions

The results suggest that tailored interventions to optimize ART adherence should address the impacts of intimate partner violence and homophobic bullying for HIV+ YMSM. The screening and subsequent treatment of depression alone may not be sufficient to address the effects of intimate partner violence, homophobic bullying, and possibly other MSM-specific psychosocial stressors on ART adherence.

Time-to-completion of COVID-19 vaccination primary series varies by HIV viral load status among people who inject drugs in Baltimore, Maryland

People who inject drugs (PWID) may have diminished access to essential preventive services like COVID-19 vaccination given structural and substance use barriers. We aimed to assess the role of HIV on COVID-19 vaccination uptake among adult PWID participating in the ALIVE cohort study in Baltimore, Maryland who were alive as of April 2021. We abstracted COVID-19 vaccination data from electronic medical records via the regional health information exchange. We used Kaplan-Meier method to estimate time from universal vaccine eligibility (April 6, 2021) to completion of the COVID-19 vaccination primary series (1 dose J&J or 2 doses mRNA) by HIV viral load status (uninfected, PWH [HIV-RNA < 400 copies/mL], PWH [HIV-RNA ≥ 400 copies/mL]) and Cox Proportional Hazards regression to adjust for potential confounders. Our sample (N = 960) was primarily black (77%) and male (65%) with 31% reporting recent injection drug use. Among 265 (27%) people living with HIV (PWH) in our sample, 84% were virally suppressed. As of February 22, 2022, 539 (56%) completed the primary series, 131 (14%) received a single dose of mRNA vaccine and 290 (30%) remained unvaccinated. Compared to PWID without HIV, virally suppressed PWH were more likely to complete the primary series (Adjusted Hazard Ratio [aHR]:1.23,95% Confidence Interval [95 %CI]:1.07,1.50), while PWH who were not virally suppressed were less likely (aHR:0.72,95 %CI:0.45,1.16), although this was not statistically significant. We conclude that among PWID, HIV infection and viral suppression is associated with quicker vaccination uptake, likely due to HIV care engagement. Targeted improvements along the HIV care continuum may bolster vaccine uptake.

Depression and HIV Care-seeking Behaviors in a Population-based Sample in North West Province, South Africa

Depression is associated with key HIV-related prevention and treatment behaviors in sub-Saharan Africa. We aimed to identify the association of depressive symptoms with HIV testing, linkage to care, and ART adherence among a representative sample of 18-49 year-olds in a high prevalence, rural area of South Africa. Utilizing logistic regression models (N = 1044), depressive symptoms were inversely associated with reported ever HIV testing (AOR 0.92, 95% CI 0.85-0.99; p = 0.04) and ART adherence (AOR 0.82, 95% CI: 0.73-0.91; p < 0.01) among women. For men, depressive symptoms were positively associated with linkage to care (AOR: 1.21, 95% CI: 1.09-1.34; p < 0.01). Depression may adversely impact ART adherence for HIV-positive women and reduce the likelihood of HIV testing for women not aware of their HIV status which, in settings with high HIV prevalence, carries severe consequences. For HIV-positive men, findings suggest that depression may encourage help-seeking behavior, thereby impacting their health system interactions. These findings underscore the need for health-care settings to factor mental health, such as depression, into their programs to address health-related outcomes, particularly for women.

Promoting HIV care continuum outcomes among people who use drugs and alcohol: a systematic review of randomized trials evaluating behavioral HIV care interventions published from 2011 to 2023

BACKGROUND

Substance use remains a robust predictor of HIV infection and a serious impediment to HIV care continuum progression for people living with HIV. The primary research question of this systematic review is focused on understanding the extent to which behavioral HIV care interventions have been efficacious in helping people who live with HIV and who use substances along the HIV care continuum.

METHODS

Using PubMed and ProQuest databases, we performed a systematic review of randomized trials of behavioral HIV care continuum interventions among people who use substances published from 2011 to August 2023, since the beginning of the treatment-as-prevention era.

RESULTS

We identified 11 studies (total participants: N = 5635), ten intentionally targeting substance-using populations. Four studies involved samples using ≥ 1 substance (e.g., alcohol, opioids, stimulants, marijuana); four involved injection drug use; one involved methamphetamine use; and one involved alcohol use. One study targeted a population with incidental substance use (i.e., alcohol, injection drug use, non-injection drug use reported in most participants). Each study defined one or more HIV care outcomes of interest. Viral suppression was an outcome targeted in 9/11 studies, followed by uptake of antiretroviral therapy (ART; 7/11), ART adherence (6/11), retention in care (5/11), and linkage to care (3/11). While most (nine) of the studies found significant effects on at least one HIV care outcome, findings were mostly mixed. Mediated (2/11) and moderated (2/11) effects were minimally examined.

CONCLUSIONS

The results from this systematic review demonstrate mixed findings concerning the efficacy of previous HIV care interventions to improve HIV care continuum outcomes among people who use substances. However, heterogeneity of study components (e.g., diversity of substances used/assessed, self-report vs. objective measures, attrition) prevent broad deductions or conclusions about the amenability of specific substance-using populations to HIV care intervention. More coordinated, comprehensive, and targeted efforts are needed to promote and disentangle intervention effects on HIV care continuum outcomes among substance-using populations.

Factors Associated with Antiretroviral Therapy Adherence Among a Community-Based Sample of Sexual Minority Older Adults with HIV

Older sexual minorities (e.g., gay, bisexual) living with HIV are at risk for poor HIV outcomes due to their frequent experience with both psychosocial challenges and structural barriers to care. This study utilized a stochastic search variable selection (SVSS) approach to explore potential psychosocial and structural factors associated with HIV-related health outcomes among a community-based sample of older sexual minorities (N = 150) in South Florida, an U.S. HIV-epidemic epicenter. After SVSS, a forward entry regression approach suggested unstable housing, illicit substance use, current nicotine use, and depression were all associated with poorer ART adherence among older sexual minority adults living with HIV. No associations between potential correlates and biological measures of HIV disease severity were observed. Findings highlight a need to focus on multiple levels of intervention that target a combination of psychosocial and structural factors to improve HIV-care outcomes among older sexual minorities and achieve Ending the HIV Epidemic goals.

Amphetamine use and its associations with antiretroviral adherence and viral load among sexual minority men and transgender women living with HIV

Substance use has complex associations to HIV disease progression. The current study tested the associations between several substances and HIV viral load while accounting for confounders relevant to HIV disease progression and substance use. Young sexual minority men and transgender women living with HIV (LWH) in Georgia (N = 385) completed measures and biological tests for HIV viral load and substance use. Multivariable regression models tested the role of specific drugs (i.e., alcohol, cannabis/THC, cocaine, and combined amphetamine and methamphetamine) directly on viral load and indirectly through antiretroviral (ART) adherence. ART adherence and HIV care self-efficacy were consistently associated with greater HIV suppression. Alcohol and cocaine were not associated with ART adherence or viral load. Cannabis was negatively associated with ART adherence (B = -.053, p = .037) but not viral load. Amphetamine/methamphetamine demonstrated significant direct effects on higher viral load (B = .708, p = .010) while indirectly influencing viral load through a negative association with ART adherence. Our findings support previous research demonstrating amphetamine/methamphetamine use impacts viral load both directly and indirectly through ART adherence. Interventions addressing amphetamine/methamphetamine use by young sexual minority men and transgender women LWH are urgently needed, and future research should focus on determining the mechanisms by which formulations of amphetamine impact HIV replication.Trial registration: ClinicalTrials.gov identifier: NCT03665532.

Understanding the role of religious beliefs in adherence to antiretroviral therapy among Pentecostal Christians living with HIV in sub-Saharan Africa: a scoping review

BACKGROUND

Optimum adherence to antiretroviral therapy (ART) is crucial in managing HIV. However, some people's religious beliefs can influence how they deal with HIV and the psychosocial factors influencing their adherence to ART, such as disclosure, acceptance of HIV status, belief in ART, and depression. In sub-Saharan Africa (SSA), the role of religious beliefs in ART adherence is underexplored. We aimed to identify and conceptualize the literature on religious beliefs concerning ART adherence among Pentecostal Christians living with HIV in SSA.

METHODS

We conducted a scoping review of the literature on religious beliefs and ART adherence. We searched papers from PubMed, Web of Science, Medline, Sabinet, Academic Search Complete, CINAHL Plus, Health Source/Nursing Academic, Scopus, and Google Scholar and published papers from conference proceedings and dissertations. Data were extracted according to a predetermined population, concept, context framework, and eligibility criteria for selecting or rejecting studies. We used a narrative synthesis to summarize the data on evidence and the impact of religious beliefs on ART adherence.

RESULTS

Seven papers published between January 2010 and February 2022 met the inclusion criteria. Nineteen aspects of religious beliefs were identified as negatively influencing ART adherence, while eight aspects facilitated optimal adherence. "Being saved" or "born again" enhanced coping strategies for optimal adherence through actions such as less alcohol use, fidelity to a sexual partner(s), disclosure, acceptance of HIV status, reduced depression, and facilitated PLHIV to access social support from church members or other institutions.

CONCLUSION

Religious beliefs are integral to Pentecostal Christians living with HIV and affect their adherence to ART. While some Pentecostal Christians living with HIV on ART use their religious beliefs and practices to access psychosocial support from other church members or organizations and achieve good clinical outcomes, others apply their religious beliefs and practices differently and compromise their commitments to taking ART as prescribed, thus experiencing poor viral suppression and clinical outcomes. However, more research is required to understand and theorize how religious beliefs impact ART adherence among Pentecostals living with HIV to inform guidelines for practitioners.

The effect of a customised digital adherence tool on HIV treatment outcomes in young people living with HIV (YPLHIV) in Blantyre, Malawi: a protocol for a randomised controlled trial

BACKGROUND

People living with HIV (PLHIV) have to take lifelong antiretroviral treatment, which is often challenging. Young people living with HIV (YPLHIV) have the lowest viral load suppression rates in Malawi and globally, mostly due to poor treatment adherence. This is a result of complex interactions of multiple factors unique to this demographic group. The use of digital health interventions, such as real-time medication monitor (RTMM)-based digital adherence tools (DATs), could improve ART adherence in YPLHIV and subsequently improve viral load suppression which in turn could lead to reduced HIV-associated morbidity and mortality.

AIM

To provide the evidence base for a digital adherence intervention to improve treatment outcomes in YPLHIV on ART.

OBJECTIVES

1. The primary objective is to determine the efficacy of a customised DAT compared to the standard of care in improving ART adherence in YPLHIV. 2. The secondary objective is to determine the efficacy of the customised DAT compared to the standard of care in improving viral load suppression in YPLHIV.

METHODOLOGY

This will be a parallel open-label randomised control controlled two-arm trial in which non-adherent YPLHIV in selected ART facilities in Blantyre will be randomised in a 1:1 ratio to a customised DAT and standard care arms and followed up for 9 months. The primary outcome is the proportion adherent at 9 months (> = 95% by pill count), and the secondary outcome is the proportion with viral load suppressed at 9 months (< 200 copies/ml).

DISCUSSION

There is a paucity of good quality evidence on effective digital health interventions to improve ART adherence and viral load suppression in YPLHIV globally and particularly in HIV high-burden settings like Malawi. This study will provide good-quality evidence on the effectiveness of a customised DAT in improving ART adherence and viral load suppression in this important demographic.

TRIAL REGISTRATION

The trial has been registered in the Pan African Clinical Trials Registry number: PACTR202303867267716 on 23 March 2023 and can be accessed through the following URL: https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=25424 . All items from the WHO Trial Registration Data Set are described in this manuscript.

The impact of same-day antiretroviral therapy initiation on retention in care and clinical outcomes at four eThekwini clinics, KwaZulu-Natal, South Africa

BACKGROUND

Same-day initiation (SDI) of antiretroviral therapy (ART) increases ART uptake, however retention in care after ART initiation remains a challenge. Public health behaviours, such as retention in HIV care and adherence to antiretroviral therapy (ART) pose major challenges to reducing new Human Immunodeficiency Virus (HIV) transmission and improving health outcomes among HIV patients.

METHODS

We evaluated 6-month retention in care, and clinical outcomes of an ART cohort comprising of SDI and delayed ART initiators. We conducted a 6 months' observational prospective cohort study of 403 patients who had been initiated on ART. A structured questionnaire was used to abstract data from patient record review which comprised the medical charts, laboratory databases, and Three Interlinked Electronic Registers.Net (TIER.Net). Treatment adherence was ascertained by patient visit constancy for the clinic scheduled visit dates. Retention in care was determined by status at 6 months after ART initiation.

RESULTS

Among the 403 participants enrolled in the study and followed up, 286 (70.97%) and 267 (66.25%) complied with scheduled clinics visits at 3 months and 6 months, respectively. One hundred and thirteen (28.04%) had been loss to follow-up. 17/403 (4.22%) had died and had been out of care after 6 months. 6 (1.49%) had been transferred to other health facilities and 113 (28.04%) had been loss to follow-up. Among those that had been lost to follow-up, 30 (33.63%) deferred SDI while 75 (66.37%) initiated ART under SDI. One hundred and eighty-nine (70.79%) participants who had remained in care were SDI patients while 78 (29.21%) were SDI deferred patients. In the bivariate analysis; gender (OR: 1.672; 95% CI: 1.002-2.791), number of sexual partners (OR: 2.092; 95% CI: 1.07-4.061), age (OR: 0.941; 95% CI: 0.734-2.791), ART start date (OR: 0.078; 95% CI: 0.042-0.141), partner HIV status (OR: 0.621; 95% CI: 0.387-0.995) and the number of hospitalizations after HIV diagnosis (OR: 0.173; 95% CI: 0.092-0.326). were significantly associated with viral load detection. Furthermore, SDI patients who defaulted treatment were 2.4 (95% CI: 1.165-4.928) times more likely to have increased viral load than those who had been returned in care.

CONCLUSION

Viral suppression under SDI proved higher but with poor retention in care. However, the results also emphasise a vital need, to not only streamline processes to increase immediate ART uptake further, but also to ensure retention in care.

Managing household income and antiretroviral therapy adherence among people living with HIV in a low-income setting: a qualitative data from the HPTN 071 (PopART) trial in South Africa

BACKGROUND

South Africa is reported to have the highest burden of HIV with an estimated 8.2 million people living with HIV (PLHIV) in 2021- despite adopting the World Health Organisation (WHO) universal HIV test and treat (UTT) recommendations in 2016. As of 2021, only an estimated 67% (5.5 million) of all PLHIV were accessing antiretroviral therapy (ART), as per recorded clinic appointments attendance. Studies in sub-Saharan Africa show that people living in low-income households experience multiple livelihood-related barriers to either accessing or adhering to HIV treatment including lack of resources to attend to facilities and food insecurity. We describe the interactions between managing household income and ART adherence for PLHIV in low-income urban and semi-urban settings in the Western Cape, South Africa.

METHODS

We draw on qualitative data collected as part of the HPTN 071 (PopART) HIV prevention trial (2016 - 2018) to provide a detailed description of the interactions between household income and self-reported ART adherence (including accessing ART and the ability to consistently take ART as prescribed) for PLHIV in the Western Cape, South Africa. We included data from 21 PLHIV (10 men and 11 women aged between 18 and 70 years old) from 13 households. As part of the qualitative component, we submitted an amendment to the ethics to recruit and interview community members across age ranges. We purposefully sampled for diversity in terms of age, gender, and household composition.

RESULTS

We found that the management of household income interacted with people's experiences of accessing and adhering to ART in diverse ways. Participants reported that ART adherence was not a linear process as it was influenced by income stability, changing household composition, and other financial considerations. Participants reported that they did not have a fixed way of managing income and that subsequently caused inconsistency in their ART adherence. Participants reported that they experienced disruptions in ART access and adherence due to competing household priorities. These included difficulties balancing between accessing care and/or going to work, as well as struggling to cover HIV care-related costs above other basic needs.

CONCLUSION

Our analysis explored links between managing household income and ART adherence practices. We showed that these are complex and change over the course of treatment duration. We argued that mitigating negative impacts of income fluctuation and managing complex trade-offs in households be included in ART adherence support programmes.

The relationship between life satisfaction, personal health, quality of life, and medication adherence among adolescents living with HIV in southwestern Uganda

Purpose

Adolescents living with HIV (ALHIV) are at high risk for adherence to antiretroviral (ART) treatment and poor health-seeking behaviors, both of which potentially compromise their quality of and satisfaction with life. This study, therefore, seeks to examine the relationship between physical health, pediatric quality of life, life satisfaction, and medication adherence among ALHIV in southwestern Uganda.

Methods

Baseline data from the Suubi+Adherence study, 2012-2018, that recruited 702 adolescents, aged 10-16 years, living with HIV in Uganda were analyzed. To account for overdispersion, negative binomial regression analyses were used to examine the impact of physical health, pediatric quality of life, and life satisfaction on self-reported medication adherence. We controlled for participants' socio-demographic factors.

Results

Results indicated that after adjusting for socio-demographic characteristics, adolescents' reported satisfaction with life was associated with a decrease in the reported number of days missed taking medication by 41.2% (IRR (incidence risk ratio)=0.588; p (p-value)=0.014). On the other hand, the low level of pediatric quality of life was associated with a 5% increase in the reported number of days missed taking medication (IRR=1.055, p=0.044). Personal health was not statistically significant in the model.

Conclusion

Our study findings indicated that quality of life and life satisfaction are significantly associated with antiretroviral (ART) medication among ALHIV. Hence, strengthening existing support systems and creating additional support for optimal ART adherence and treatment outcomes for ALHIV in low-resource communities might be beneficial. Moreover, with the increasing HIV prevalence rates among adolescents, effective and comprehensive efforts that are responsive to the special needs of ALHIV must be developed to ensure optimal adherence to ART medication as it leads to low vertical infection and superinfection rates.

Substance Use and Depression Impede ART Adherence Among Female Sex Workers Living with HIV in the Dominican Republic

Female sex workers (FSW) have worse HIV outcomes in part due to lower anti-retroviral therapy (ART) adherence. Substance use and depression are important barriers to ART adherence, yet few studies have assessed these relationships among FSW in longitudinal studies. Cross-Lagged Panel Models and autoregressive mediation analyses assessed substance use (illicit drug use and alcohol use disorders) in relation to ART non-adherence and the mediation role of depressive symptoms among 240 FSW living with HIV in the Dominican Republic. In annual visits (T1, T2, T3), the majority (70%, 66%, and 53%) reported at-risk drinking and 15%, 13% and 9% used illicit drug during the past 6 months. Most FSW (70%, 62% and 46%) had mild-to-severe depression. Illicit drug use predicted later ART non-adherence. This relationship was not mediated via depressive symptoms. Integrated substance use and HIV care interventions are needed to promote ART adherence and viral suppression among FSW.

Mental health and adherence to antiretroviral therapy among Mexican people living with HIV during the COVID-19 pandemic

BACKGROUND

The mental health and medical follow-up of people living with HIV (PLWH) have been disrupted by the COVID-19 pandemic. The objectives of this study were to assess anxiety, depression and substance use in Mexican PLWH during the pandemic; to explore the association of these symptoms with adherence to antiretroviral therapy (ART), and to compare patients with and without vulnerability factors (low socioeconomic level, previous psychological and/or psychiatric treatment).

METHODS

We studied 1259 participants in a cross-sectional study, PLWH receiving care at the HIV clinic in Mexico City were contacted by telephone and invited to participate in the study. We included PLWH were receiving ART; answered a structured interview on sociodemographic data and adherence to ART; and completed the psychological instruments to assess depressive and anxiety symptoms and substance use risk. Data collection was performed from June 2020 to October 2021.

RESULTS

84.7% were men, 8% had inadequate ART adherence, 11% had moderate-severe symptoms of depression, and 13% had moderate-severe symptoms of anxiety. Adherence was related to psychological symptoms (p < 0.001). Vulnerable patients were more likely to be women, with low educational level and unemployed (p < 0.001).

CONCLUSIONS

It is important to address mental health of PLWH during the COVID-19 pandemic, with special attention to the most vulnerable individuals. Future studies are needed to understand the relationship between mental health and ART adherence.

Sexual violence and antiretroviral adherence among women of reproductive age in African population-based surveys: the moderating role of the perinatal phase

INTRODUCTION

Women face challenges in antiretroviral therapy (ART) adherence and achieving viral suppression despite progress in the expansion of HIV treatment. Evidence suggests that violence against women (VAW) is an important determinant of poor ART adherence in women living with HIV (WLH). In our study, we examine the association of sexual VAW and ART adherence among WLH and assess whether this association varies by whether women are pregnant/breastfeeding or not.

METHODS

A pooled analysis was conducted among WLH from Population-Based HIV Impact Assessment cross-sectional surveys (2015-2018) from nine sub-Saharan African countries. Logistic regression was used to examine the association between lifetime sexual violence and suboptimal ART adherence (≥1 missed day in the past 30 days) among reproductive age WLH on ART, and to assess whether there was any evidence for interaction by pregnancy/breastfeeding status, after adjusting for key confounders.

RESULTS

A total of 5038 WLH on ART were included. Among all included women, the prevalence of sexual violence was 15.2% (95% confidence interval [CI]: 13.3%-17.1%) and the prevalence of suboptimal ART adherence was 19.8% (95% CI: 18.1%-21.5%). Among only pregnant and breastfeeding women, the prevalence of sexual violence was 13.1% (95% CI: 9.5%-16.8%) and the prevalence of suboptimal ART adherence was 20.1% (95% CI: 15.7%-24.5%). Among all included women, there was evidence for an association between sexual violence and suboptimal ART adherence (adjusted odds ratio [aOR]: 1.69, 95% CI: 1.25-2.28). There was evidence that the association between sexual violence and ART adherence varied by pregnant/breastfeeding status (p = 0.004). Pregnant and breastfeeding women with a history of sexual violence had higher odds of suboptimal ART adherence (aOR: 4.11, 95% CI: 2.13-7.92) compared to pregnant and breastfeeding women without a history of sexual violence, while among non-pregnant and non-breastfeeding women, this association was attenuated (aOR: 1.39, 95% CI: 1.00-1.93).

CONCLUSIONS

Sexual violence is associated with women's suboptimal ART adherence in sub-Saharan Africa, with a greater effect among pregnant and breastfeeding WLH. To improve women's HIV outcomes and to achieve the elimination of vertical transmission of HIV, violence prevention efforts within maternity services and HIV care and treatment should be a policy priority.

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.

A Structural Equation Model of the Impact of a Family-Based Economic Intervention on Antiretroviral Therapy Adherence Among Adolescents Living With HIV in Uganda

PURPOSE

Antiretroviral therapy (ART) adherence among adolescents living with HIV (ALWHIV) is low, with poverty remaining a significant contributor. We examined the mediation pathways between an economic empowerment intervention and ART adherence among ALWHIV.

METHODS

This cluster-randomized controlled trial (2012-2018) recruited 702 ALWHIV aged 10-16 in Uganda between January 2014 and December 2015. We randomized 39 clinics into the control (n = 344) or intervention group (n = 358). The intervention comprised a child development account, four microenterprise workshops, and 12 mentorship sessions. We used six self-reported items to measure adherence at 24 months, 36 months, and 48 months. We used structural equation modeling to assess the mediation effects through mental health and adherence self-efficacy, on adherence. We ran models corresponding to the 24, 36, and 48 months of follow-up.

RESULTS

The mean age of the participants was 12 years, and 56% were female. At 36 (model 2) and 48 months (model 3), the intervention had a significant indirect effect on ART adherence [B = 0.069, β = 0.039 (95% confidence interval [CI]: 0.005-0.074)], and [B = 0.068, β = 0.040 (95% CI: 0.010-0.116)], respectively. In both models, there was a specific mediation effect through mental health [B = 0.070, β = 0.040 (95% CI: 0.007-0.063)], and [B = 0.039, β = 0.040 (95% CI: 0.020-0.117)]. Overall, 49.1%, 90.7%, and 36.8% of the total effects were mediated in models, 1, 2, and 3, respectively.

DISCUSSION

EE interventions improve adherence, by improving mental health functioning. These findings warrant the need to incorporate components that address mental health challenges in programs targeting poverty to improve ART adherence in low-income settings.

Association between mental disorders and adherence to antiretroviral treatment in health facilities in two Mozambican provinces in 2018: a cross-sectional study

INTRODUCTION

Lower adherence to antiretroviral treatment (ART) has been found among people with HIV (PWH) who have comorbid mental disorders like depression and alcohol use in Sub-Saharan African. However, there has been less exploration with regards to other mental disorders.

METHODS

This study assessed the association of multiple mental disorders and adherence to ART based on the data from primary/tertiary health care facilities in Maputo and Nampula, Mozambique. We administered a sociodemographic questionnaire, Mini International Neuropsychiatric Interview (MINI) Plus 4.0.0 adapted for use in Mozambique to assess mental conditions, and a 3-item self-report to measure ART adherence.

RESULTS

395 HIV-positive (self-report) participants on ART, with an average age of 36.7 years (SD = 9.8), and 30.4% were male. The most common mental disorders were major depressive disorder (27.34%) followed by psychosis (22.03%), suicidal ideation/behavior (15.44%), and alcohol-use disorder (8.35%). Higher odds of missing at least one dose in the last 30 days (OR = 1.45, 95% CI: 1.01, 2.10) were found in participants with any mental disorder compared to those without a mental disorder. The highest levels of non-adherence were observed among those with drug use disorders and panic disorder.

CONCLUSIONS

In Mozambique, PWH with any co-occurring mental conditions had a lower probability of ART adherence. Integrating comprehensive mental health assessment and treatment and ART adherence interventions tailored to PWH with co-occurring mental disorders is necessary to attain optimal ART adherence and reach the UNAIDS ART target.

Efficacy of an mHealth self-management intervention for persons living with HIV: the WiseApp randomized clinical trial

IMPORTANCE

Progression of HIV disease, the transmission of the disease, and premature deaths among persons living with HIV (PLWH) have been attributed foremost to poor adherence to HIV medications. mHealth tools can be used to improve antiretroviral therapy (ART) adherence in PLWH and have the potential to improve therapeutic success.

OBJECTIVE

To determine the efficacy of WiseApp, a user-centered design mHealth intervention to improve ART adherence and viral suppression in PLWH.

DESIGN, SETTING, AND PARTICIPANTS

A randomized (1:1) controlled efficacy trial of the WiseApp intervention arm (n = 99) versus an attention control intervention arm (n = 101) among persons living with HIV who reported poor adherence to their treatment regimen and living in New York City.

INTERVENTIONS

The WiseApp intervention includes the following components: testimonials of lived experiences, push-notification reminders, medication trackers, health surveys, chat rooms, and a "To-Do" list outlining tasks for the day. Both study arms also received the CleverCap pill bottle, with only the intervention group linking the pill bottle to WiseApp.

RESULTS

We found a significant improvement in ART adherence in the intervention arm compared to the attention control arm from day 1 (69.7% vs 48.3%, OR = 2.5, 95% CI 1.4-3.5, P = .002) to day 59 (51.2% vs 37.2%, OR = 1.77, 95% CI 1.0-1.6, P = .05) of the study period. From day 60 to 120, the intervention arm had higher adherence rates, but the difference was not significant. In the secondary analyses, no difference in change from baseline to 3 or 6 months between the 2 arms was observed for all secondary outcomes.

CONCLUSIONS

The WiseApp intervention initially improved ART adherence but did not have a sustained effect on outcomes.

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.

Mental health and ART adherence among adolescents living with HIV in Mozambique

Little is known about the mental health needs of adolescents living with HIV (ALWH) in Mozambique, including the potential relationship between mental health challenges and poor antiretroviral treatment (ART) adherence. We examined mental health problems (anxiety, depression, post-traumatic stress disorder [PTSD] symptoms and impairment) and their association with self-reported ART adherence among ALWH ages 15-19 in Nampula, Mozambique. The associations between each mental health problem area and sub-optimal adherence were estimated using logistic regression, controlling for age, education, and social support, with interaction by gender. Males had significantly higher anxiety (5.6 vs 4.3, p = 0.01), depression (5.8 vs 4.1, p = 0.005), and PTSD (13.3 vs 9.8, p = 0.02) symptoms and impairment (1.8 vs 0.56, p<0.0001) scores than females. Proportion reporting sub-optimal adherence (65%) did not differ by gender. Higher anxiety, depression, and PTSD symptom and impairment scores were significantly associated with higher odds of sub-optimal ART adherence in males but not females. Among Mozambican ALWH, mental health problems were prevalent and two-thirds had ART adherence less than 90%. Worse mental health was associated with increased odds of sub-optimal ART adherence in males but not females. Interventions are needed to address mental health problems and improve ART adherence in Mozambican ALWH, particularly among males.

Between empathy and anger: healthcare workers' perspectives on patient disengagement from antiretroviral treatment in Khayelitsha, South Africa - a qualitative study

BACKGROUND & OBJECTIVES

The benefits of long-term adherence to antiretroviral therapy (ART) are countered by interruptions in care or disengagement from care. Healthcare workers (HCWs) play an important role in patient engagement and negative or authoritarian attitudes can drive patients to disengage. However, little is known about HCWs' perspectives on disengagement. We explored HCWs' perspectives on ART disengagement in Khayelitsha, a peri-urban area in South Africa with a high HIV burden.

METHOD

Semi-structured interviews were conducted with 30 HCWs in a primary care HIV clinic to explore their perspectives of patients who disengage from ART. HCWs interviewed included clinical (doctors and nurses) and support staff (counsellors, social workers, data clerks, security guards, and occupational therapists). The interview guide asked HCWs about their experience working with patients who interrupt treatment and return to care. Transcripts were audio-recorded, transcribed, and analysed using an inductive thematic analysis approach.

RESULTS

Most participants were knowledgeable about the complexities of disengagement and barriers to sustaining engagement with ART, raising their concerns that disengagement poses a significant public health problem. Participants expressed empathy for patients who interrupted treatment, particularly when the challenges that led to their disengagement were considered reasonable by the HCWs. However, many also expressed feelings of anger and frustration towards these patients, partly because they reported an increase in workload as a result. Some staff, mainly those taking chronic medication themselves, perceived patients who disengage from ART as not taking adequate responsibility for their own health.

CONCLUSION

Lifelong engagement with HIV care is influenced by many factors including disclosure, family support, and HCW interactions. Findings from this study show that HCWs had contradictory feelings towards disengaged patients, experiencing both empathy and anger. Understanding this could contribute to the development of more nuanced interventions to support staff and encourage true person-centred care, to improve patient outcomes.

HIV Stigma, HIV status disclosure, and ART adherence in the context of an integrated opioid use disorder and HIV treatment setting in Dar es Salaam, Tanzania

Little is known about social factors, including stigma, that affect antiretroviral therapy (ART) adherence among people enrolled in opioid use disorder treatment (OUDT) in the context of integrated OUDT and HIV treatment models. We qualitatively examined the relationship between HIV stigma, HIV status disclosure, and ART adherence among clients living with HIV at an OUDT clinic with integrated HIV services in Tanzania. We conducted in-depth interviews with 25 clients receiving HIV care at an OUDT clinic in Dar es Salaam, Tanzania between January and April 2020. HIV stigma, particularly anticipated stigma, and HIV status disclosure were key factors that affected ART adherence. Participants feared non-voluntary HIV status disclosure to and HIV stigma from their peers enrolled in OUDT. Most participants reported concealing their HIV status from peers at the OUDT clinic and not associating with other clients living with HIV at the clinic. Reducing HIV stigma and enhancing clinic structures and procedures to maintain privacy and confidentiality are essential to mitigating the effects of stigma on ART adherence.

Virtual voices: examining social support exchanged through participant-generated and unmoderated content in a mobile intervention to improve HIV antiretroviral therapy adherence among GBMSM

Antiretroviral therapy (ART) adherence is suboptimal among gay, bisexual, and other men who have sex with men (GBMSM). Online interventions that incorporate social support represent new opportunities to improve adherence. This study focused on how social support was provided and sought within a technology-based ART adherence intervention. We coded and analyzed 1,751 messages. Within the social support messages, half of the time participants sought social support and half of the time they provided social support. Emotional and informational support were the most frequently exchanged forms. The most frequent topic that participants sought support around was interpersonal relationships (29%), followed by HIV care and treatment (28%). Similarly, 31% and 27% of messages in which participants provided support was related to HIV treatment and care and interpersonal relationships, respectively. HIV treatment and care issues most salient were ART adherence, lab results and upcoming tests, ART side effects, changes in ART regimens, and relationships with healthcare providers. Participants used the messaging feature in this intervention to spontaneously discuss and exchange support around HIV treatment and care. This analysis provided an opportunity to understand how participants informally interact with one another, how they seek and provide social support online, and their salient personal issues.

Factors associated with HIV testing and treatment among young Black MSM and trans women in three jail systems

Black men who have sex with men (BMSM) and transgender women (BTW) are disproportionately affected by incarceration and HIV. We assessed factors associated with HIV testing and viral suppression among 176 incarcerated BMSM and BTW in Chicago, IL; Los Angeles, CA; and Houston, TX. In multivariable logistic regression, having a sexual orientation of bisexual, heterosexual, or other vs. gay or same-gender loving was associated with higher odds of testing in custody (aOR 8.97; 95% CI 1.95 - 41.24). Binge drinking (aOR 0.19; 95% CI 0.04 - 0.92) and being unemployed prior to incarceration (aOR 0.03; 95% CI 0.00 - 0.23) were associated with lower odds of testing; participants in Los Angeles were also more likely to be tested than those in Chicago. Being housed in protective custody (aOR 3.12; 95% CI 1.09-9.59) and having a prescription for ART prior to incarceration (aOR 2.58; 95% CI 1.01-6.73) were associated with higher odds of viral suppression when adjusted for site and duration of incarceration, though the associations were not statistically significant in the full multivariable model. Future research should examine structural and process level factors that impact engagement in HIV testing and treatment among detained BMSM and BTW.

Development of a Psychological Intervention to Improve Depressive Symptoms and Enhance Adherence to Antiretroviral Therapy among Adolescents and Young People Living with HIV in Dar es Salaam Tanzania

Background: Interventions that simultaneously target depression and antiretroviral therapy (ART) medication adherence are recommended for improving HIV treatment outcomes and quality of life for adolescents living with HIV. However, evidence is scarce on culturally feasible and acceptable interventions that can be implemented for HIV-positive adolescents in Tanzania. We, therefore, developed a manualized brief psychological intervention that utilizes evidence-based strategies to address depression and ART adherence in adolescents living with HIV in Tanzania. Methods: We used the Theory of Change Enhanced Medical Research Council framework (TOCMRC) for developing complex interventions in health care to develop the intervention in five phases. First, the literature was reviewed to identify potential intervention components. Second, we conducted a situational analysis using qualitative interviews with adolescents living with HIV, health care providers, and caregivers. Third, we conducted a mental health expert workshop; and fourth, theory of change workshops with representatives from the Ministry of Health, mental health professionals, HIV implementing partners, adolescents, and healthcare providers. Lastly, we synthesized results to finalize the intervention and a theory of change map showing the causal pathway for how we expect the developed intervention to achieve its impact. Results: Adolescents living with HIV in Tanzania experience several unmet mental health needs ranging from overwhelming depressive symptoms to not feeling understood by healthcare providers who lack mental health knowledge. Participants perceived psychological intervention that utilizes a task-shifting approach to be acceptable and beneficial to addressing those problems. The novel components of the NITUE intervention included incorporating evidence-based intervention components, namely, cognitive-behavioral therapy, motivational interviewing, and problem solving. In addition, caregiver inclusion in the treatment was essential to ensure access to care, compliance, and improved outcomes. Conclusions: A culturally appropriate brief psychological intervention that utilizes a task-shifting approach to address depression and medication adherence for adolescents living with HIV in Dar es Salaam, Tanzania, was developed. The intervention will be piloted for appropriateness, feasibility, and acceptability and will provide material for a future trial to determine its effectiveness.

"When you have an immune disease like HIV and there is a pandemic, you still have to pay your bills": COVID-19-related challenges among people living with HIV and lessons for care delivery

COVID-19 has disrupted routine medical care and increased psychosocial and economic stressors on a global scale, yet the full impact on people living with HIV (PLWH) and the HIV continuum of care remains unknown. As the pandemic continues to pose a significant threat to PLWH and their care, this research qualitatively aimed to elicit COVID-19-related challenges and perspectives of PLWH during the early phase of the pandemic and to identify lessons learned and impactful strategies for facilitating HIV care. We recruited 32 PLWH who receive care at a large academic medical center for semi-structured remote interviews to assess psychological/structural stressors experienced during the pandemic and to discern strategies for improving care. Most participants identified as Black (91%) and heterosexual (56%). Overall, PLWH reported exacerbated mental health stressors (e.g., anxiety, depression, substance use). Most participants cited no issues with antiretroviral therapy (ART) adherence or retention in care, yet five participants reported appointment cancellations or physician inaccessibility. Participants provided specific feedback for facilitating continued engagement in care during the pandemic, including telemedicine and education/patient empowerment. By seeking participant-provided solutions, this study centered on PLWH's experiences and emphasized proactive HIV care strategies for prioritizing patient empowerment and healthcare adaptability during a rapidly evolving pandemic.

Internalized HIV-related stigma in women of color obtaining care at an HIV specialty center in Los Angeles County, California

The current study examined the role of internalized HIV-related stigma in antiretroviral therapy adherence, viral load, and retention in care among women of color living with HIV in Los Angeles County, California. African American and Hispanic/Latino women 18 years of age and older completed a one-time brief survey between September 2017 and February 2018. Descriptive statistics, and univariable and multivariable logistic regressions were used to analyze the data. Seventy-six participants enrolled in the study and 74 completed the entire survey. Seventy-six percent of respondents were Hispanic/Latino, 24% were African American, 71% were unemployed, and 54% had less than a high school education. Thirty-five percent were defined as having "high" stigma with a score in the upper quartile of the scale. Being unemployed, having a high school education or less, and not meeting the Health Resources and Services Administration's annual retention in care measure were associated with "high" stigma. When controlling for education and employment status, those reporting "high" stigma vs. "low" stigma were 18.8 times more likely to not meet the criteria for annual retention in care (OR = 18.8, 95% CI = 1.9-189.2, p = 0.013). Stigma-reduction interventions targeting healthcare settings may be necessary to improve patient retention and engagement in care.

Supporting Treatment for Anti-Retroviral Therapy (START) Together: Protocol for a pilot, randomized, couple-based intervention to promote women's ART adherence and men's engagement in HIV care in KwaZulu-Natal, South Africa

Background

South Africa currently has the greatest number of people with HIV globally. The country has not yet met its 95-95-95 goals, with different gaps in the HIV care cascade for women and men. This paper reports on a protocol to pilot test a couple-based intervention designed to improve women's antiretroviral therapy (ART) adherence and men's engagement in care in heterosexual couples living in the Vulindlela area of KwaZulu-Natal, South Africa. Study goals are two-fold: (1) assess the acceptability, feasibility, and fidelity of the experimental intervention, START Together, and (2) collect efficacy data on START Together for women's ART adherence, men's engagement in HIV care, and the couple's relationship functioning.

Methods

Women (N = 20) who were not engaged with ART adherence (defined via self-reported ART difficulties, record of missed clinic visits, or viral non-suppression) are the target patients; male partners are not required to know or disclose their HIV status to be part of the study. Couples are randomized 1:1 to the experimental treatment (START Together) or treatment as usual (referrals to the local clinic to support ART adherence or any other HIV-related care). START Together is a 5-session intervention based in cognitive-behavioral couple therapy, which is a skill-based intervention focusing on communication and problem-solving skills, and Life Steps, a problem-solving intervention identifying barriers and solutions to medication adherence. Couples are assessed at baseline, post-treatment (8 weeks post-randomization), and follow-up (12 weeks post-randomization).

Conclusion

This study will provide preliminary implementation and efficacy data on whether this novel approach has potential to improve women and men's HIV and healthcare-related needs.

Lessons from +LOVE, Improving HIV Care for Black Men Who Have Sex with Men in New Orleans Using an Integrated Behavioral Health Crisis Support Model of Care

Black men who have sex with men (BMSM) experience higher rates of HIV infection than other groups. They also face disparities in linkage and retention to HIV care, as well as in viral suppression. To address the needs of the BMSM population living with HIV, we developed a novel intervention program (+LOVE), which integrated case management with behavioral health/crisis support. The intervention consisted of (1) a dedicated therapist; (2) an SMS (text message)-based engagement program, CareSignal that provided medication reminders and administered routine ecological momentary assessments (EMAs); (3) a triage crisis coordinator to respond to alerts generated by the EMA responses; and (4) a case manager. This study assessed the additional impact of the first three components of the intervention (a dedicated therapist, text messaging application, along with a triage crisis coordinator), compared with the fourth component alone, the current standard of care (a case manager) on access to HIV care, antiretroviral therapy (ART) adherence, and viral suppression. Analyzing electronic medical record data, survey data, and EMA response data extracted from CareSignal, we found that those who engaged in the behavioral health therapy had higher odds of remaining in HIV care than those who only engaged with the case manager. We also found that increased engagement with CareSignal led to an increased probability of achieving positive HIV-related health outcomes. Our results suggest that an integrated behavioral health/crisis support model of intervention integrated with case managementincreased positive outcomes over case management alone.

Social Support for Improved ART Adherence and Retention in Care among Older People Living with HIV in Urban South Africa: A Complex Balance between Disclosure and Stigma

The number of older people living with HIV (OPLWH) (aged 50-plus) in South Africa is increasing as people age with HIV or are newly infected. OPLWH are potentially vulnerable because of the intersection of age-related and HIV stigmas, co-morbidities, and lack of social support. Evidence from younger populations suggests that social support can improve ART adherence and retention in care. Further, HIV status disclosure plays a role in mediating social support and may reduce stigma by facilitating access to social support. This paper draws on qualitative research with OPLWH to explore the complex associations between disclosure, social support, and HIV stigma among OPLWH in urban Western Cape. The findings demonstrate that OPLWH receive most of their support from their family and this support can facilitate adherence to ART and retention in care. However, social support is facilitated by participants' disclosure, thus, when perceived stigma limits disclosure, social support is less accessible. Gender, age, and pre-existing vulnerability also affect disclosure to and support from kin and community. Given that social support, particularly from family members, amplifies HIV care access and ART adherence, encouraging disclosure stimulating household HIV competency is likely to both address anticipated stigma and support improved OPLWH's health outcomes.

Racial disparity in ART adherence is closed in states with high social trust: Results from the Medical Monitoring Project (MMP), 2015

Racial/ethnic disparities persist in antiretroviral therapy (ART) adherence and viral suppression. We examined associations between state-level social trust and individual-level ART adherence and viral suppression and assessed whether these relationships varied by race/ethnicity. The Medical Monitoring Project (MMP) annually reports nationally representative estimates of the behavioral and clinical characteristics of HIV-positive adults in primary care. A total of 3298 adults diagnosed with HIV between 2015 and 2016 from 16 US states were included. We used weighted logistic regression to model the association between state-level social trust, race/ethnicity (Non-Hispanic Black, White, and Hispanic/Latino), and cross-product interactions with ART adherence (a binary measure derived from three self-reported questions), and viral suppression (a binary measure corresponding to plasma HIV RNA < 200 copies/ml). Social trust was the percentage of people in each state who agreed that most people in their neighborhood could be trusted. A high level of social trust was associated with a higher likelihood of ART adherence (PR [prevalence ratio] = 1.17; 95% confidence interval [CI]: 1.05-1.30). In covariate-adjusted analyses, the association between state-level social trust and individual-level ART adherence significantly varied by race/ethnicity (Wald χ2  F = 9.8 [df = 4], p = 0.044). Social trust was positively associated with ART, but the effect was smaller for Blacks than for Whites (PR = 0.66; 95% CI: 0.57-0.82) in states with the lowest social trust. Black-White differences were closed and no longer significant above mean social trust (PP [predicted probability] = 0.50 vs. 0.53, at two standard deviations). Racial/ethnic disparities in ART adherence were closed among individuals living in states with high social trust. Understanding the mechanisms that promote social trust among neighbors may have downstream impacts on reducing disparities in ART adherence among people with HIV (PWH).

Monitoring adherence to antiretroviral therapy among adolescents in Southern Uganda: comparing Wisepill to Self-report in predicting viral suppression in a cluster-randomized trial

INTRODUCTION

Optimal antiretroviral therapy (ART) adherence is crucial for improved patient outcomes; however, ART adherence among adolescents living with HIV (ALHIV) is low. Also, the performance of various adherence measures among ALHIV is under contention. We monitored ART adherence and compared Self-report (SR) and Wisepill electronic monitoring (EM) performance in measuring ART adherence and predicting HIV viral suppression among ALHIV.

METHODS

Between January 2014 and December 2015, we recruited 702 ALHIV aged 10-16 years into our cluster-randomized controlled trial (2012-2018) in 39 clinics in Uganda. The intervention included a long-term savings child development account, four micro-enterprise workshops and 12 mentorship sessions. Using the entire sample, we performed multilevel logistic regression to predict monthly ART adherence trends for the first year of follow-up. Since it is possible that the intervention had different effects on SR and EM adherence, we used participants in the control arm only to compare adherence using SR and EM and to calculate their sensitivity and specificity in predicting viral suppression.

RESULTS

There was a significant decline in adherence for each month throughout the entire follow-up period regardless of the group assigned. Good ART adherence was measured at 79.2% (75.2-82.6%) and 97.0% (95.4-98.1%) using EM and SR, respectively. Overall, 64.3% (60.6-67.9%) had suppressed viral loads. The specificities for EM and SR in predicting viral non-suppression were 80.4% (73.6-85.7%) and 96.7% (93.3-98.4%), while the sensitivities were 22.9% (15.0-33.3%) and 1.8% (0.4-6.9%), respectively. The area under the curve was low for both EM and SR, at 53.6% (45.7-61.5%) and 56.2% (53.2-59.3%), respectively. There was high agreement (78%) between SR and EM in monitoring adherence.

CONCLUSIONS

Our findings highlighted the need for strategies for sustained optimal adherence. SR and EM measure adherence with a considerable agreement; however, neither is an accurate predictor of virological outcome. There is still a need for an acceptable, feasible and affordable method that predicts viral suppression among ALHIV.

Exercise and antiretroviral adherence in adults living with HIV: A systematic review

This systematic review assessed the relationship between exercise and ART adherence in adults living with HIV. A comprehensive search through June 2020 for relevant studies was conducted, and PRISMA guidelines were followed. To be included, studies had to meet the following criteria: (a) published in a peer-reviewed journal; and (b) examined the relationship between exercise and ART adherence. A total of 4310 studies were identified, and nine were included. The majority (five out of nine) of studies found a significant and positive relationship between exercise and ART adherence. Strengths, limitations, and future directions are discussed.

Health-related needs reported by adolescents living with HIV and receiving antiretroviral therapy in sub-Saharan Africa: a systematic literature review

Introduction

Adolescents living with HIV (ALHIV) on antiretroviral therapy (ART) have specific health needs that can be challenging to deliver. Sub‐Saharan Africa (SSA) is home to 84% of the global population of ALHIV, of whom about 59% receive ART. Several studies in SSA have demonstrated health service gaps due to lack of synchronized healthcare for ALHIV receiving ART. We conducted a systematic review of health‐related needs among ALHIV on ART in SSA to inform decisions and policies on care.

Methods

We searched MEDLINE, Web of Science, EMBASE, PsycINFO, Cochrane library and grey literature for studies reporting health‐related needs among ALHIV receiving ART in SSA, between January 2003 and May 2020.

Results and discussion

Of the 2333 potentially eligible articles identified, 32 were eligible. Eligible studies were published between 2008 and 2019, in 11 countries: Zambia (7), Uganda (6), Tanzania (4), South Africa (4), Kenya (3), Ghana (2), Zimbabwe (2), Rwanda (1), Malawi (1), Botswana (1) and Democratic Republic of Congo (1). Seven categories of health needs among ALHIV were identified. In descending order of occurrence, these were: psychosocial needs (stigma reduction, disclosure and privacy support, and difficulty accepting diagnosis); dependency of care (need for family and provider support, and desire for autonomy); self‐management needs (desire for better coping strategies, medication adherence support and reduced ART side effects); non‐responsive health services (non‐adolescent friendly facility services and non‐compatible school system); need for food, financial and material support; inadequate information about HIV (desire for more knowledge to fight misinformation and misconception); and developmental and growth needs (desire to experience sex, parenthood and love). Ecological analysis identified different priority needs between ALHIV, their caregivers and healthcare providers, including psychosocial needs, financial challenges and non‐responsive health services, respectively.

Conclusions

To respond effectively to the health needs of ALHIV and improve ART adherence, interventions should focus on stigma reduction, disclosure challenges and innovative coping mechanisms for ART. Interventions that address the health needs of ALHIV from the perspective of carers and providers, such as financial support schemes and adolescent‐friendly healthcare strategies, should supplement efforts to improve adolescent ART adherence outcomes.

Gender Moderates Results of a Randomized Clinical Trial for the Khanya Intervention for Substance Use and ART Adherence in HIV Care in South Africa

Little is known about gender effects of alcohol and drug use (AOD) among people living with HIV (PLWH) in resource-limited settings. Using multilevel models, we tested whether gender moderated the effect of Khanya, a cognitive-behavioral therapy-based intervention addressing antiretroviral (ART) adherence and AOD reduction. We enrolled 61 participants from HIV care and examined outcomes at 3- and 6-months compared to enhanced treatment as usual (ETAU). Gender significantly moderated the effect of Khanya on ART adherence (measured using electronically-monitored and biomarker-confirmed adherence), such that women in Khanya had significantly lower ART adherence compared to men in Khanya; no gender differences were found for AOD outcomes. Exploratory trajectory analyses showed men in Khanya and both genders in ETAU had significant reductions in at least one AOD outcome; women in Khanya did not. More research is needed to understand whether a gender lens can support behavioral interventions for PLWH with AOD.

Trial registry ClinicalTrials.gov identifier: NCT03529409. Trial registered on May 18, 2018.