Centers for AIDS Research (CFAR) Diversity, Equity, and Inclusion Pathway Initiative (CDEIPI): Developing Career Pathways for Early-Stage Scholars From Racial and Ethnic Groups Underrepresented in HIV Science and Medicine

BACKGROUND

There is an urgent need to increase diversity among scientific investigators in the HIV research field to be more reflective of communities highly affected by the HIV epidemic. Thus, it is critical to promote the inclusion and advancement of early-stage scholars from racial and ethnic groups underrepresented in HIV science and medicine.

METHODS

To widen the HIV research career pathway for early-stage scholars from underrepresented minority groups, the National Institutes of Health supported the development of the Centers for AIDS Research (CFAR) Diversity, Equity, and Inclusion Pathway Initiative (CDEIPI). This program was created through partnerships between CFARs and Historically Black Colleges and Universities and other Minority Serving Institutions throughout the United States.

RESULTS

Seventeen CFARs and more than 20 Historically Black Colleges and Universities and Minority Serving Institutions have participated in this initiative to date. Programs were designed for the high school (8), undergraduate (13), post baccalaureate (2), graduate (12), and postdoctoral (4) levels. Various pedagogical approaches were used including didactic seminar series, intensive multiday workshops, summer residential programs, and mentored research internship opportunities. During the first 18 months of the initiative, 257 student scholars participated in CDEIPI programs including 150 high school, 73 undergraduate, 3 post baccalaureate, 27 graduate, and 4 postdoctoral students.

CONCLUSION

Numerous student scholars from a wide range of educational levels, geographic backgrounds, and racial and ethnic minority groups have engaged in CDEIPI programs. Timely and comprehensive program evaluation data will be critical to support a long-term commitment to this unique training initiative.

Police abuse and care engagement of people with HIV who inject drugs in Ukraine

Police abuse affects people who inject drugs (PWID), including those with HIV, and negatively impacts care engagement. This cross-sectional study evaluated police abuse among PWID receiving MOUD (medication for opioid use disorder) living with HIV and associations with HIV treatment adherence and receipt of NGO services. We assessed lifetime and past six-month rates of police abuse among a cohort of Ukrainian PWID with HIV receiving MOUD (n = 190) from August to September 2017. Logistic regression models evaluated associations between past six-month police abuse and past 30-day antiretroviral therapy (ART) adherence, and past six-month NGO service receipt. Almost all (90%) participants reported lifetime police abuse: 77% reported physical violence and 75% reported paying the police to avoid arrest. One in four females (25%) reported police-perpetrated sexual violence. Recent police abuse was reported by 16% of males and 2% of females and was not associated with ART adherence (aOR: 1.1; 95% CI:0.3-5.0) or NGO service receipt (aOR: 3.4; 95% CI:0.6-18.3). While lifetime police abuse rates were high, few participants reported recent police abuse, which was not linked to care engagement. These trends should encourage the Ukrainian government for public health-public safety partnerships and legal interventions to eliminate human rights violations against PWID living with HIV.

Exploratory qualitative study examining acceptability of strategies to improve access to substance use treatment and HIV prevention services for young adults on probation in Ukraine

OBJECTIVE

Adults <30 years' of age experience elevated HIV-rates in Ukraine. Young adults (YA) involved in the criminal justice system (CJS) are at an increased HIV-risk given elevated rates of substance use, engagement in high-risk sexual behaviour and insufficient healthcare access. The objective of this exploratory study was to investigate the acceptability of strategies to refer and link CJS-involved YA to HIV-prevention and substance use treatment services from CJS settings.

DESIGN

We conducted qualitative individual interviews with CJS-involved YA (18-24 years), and CJS stakeholders. Interviews were guided by the Social Ecological Model. Interviews with YA explored substance use and sexual behaviour, and acceptability of strategies to link YA to HIV-prevention and substance use treatment services from CJS. Stakeholder interviews explored system practices addressing HIV-prevention and substance use and addiction. Data were analysed using Inductive Thematic Analysis.

SETTING

Data were collected in three locales, prior to the 2022 Russian-Ukrainian conflict.

PARTICIPANTS

Thirty YA and 20 stakeholders.

RESULTS

Most YA were men, reported recent injection drug use and were M age=23 years. YA were receptive to linkage to HIV-prevention services from CJS; this was shaped by self-perceived HIV-risk and lack of access to HIV-prevention services. YA were less receptive to being referred to substance use treatment services, citing a lack of self-perceived need and mistrust in treatment efficacy. Stakeholders identified multilevel contextual factors shaping acceptability of HIV-prevention and substance use treatment from CJS (eg, stigma).

CONCLUSIONS

Findings should be reviewed as a historical record of the pre-conflict context. In that context, we identified strategies that may have been used to help curtail the transmission of HIV in a population most-at-risk, including CJS-involved YA. This study demonstrates that improving access to substance use treatment and HIV-prevention services via CJS linkage were acceptable if provided in the right conditions (eg, low or no-cost, confidential).

Development of benchmark datasets for text mining and sentiment analysis to accelerate regulatory literature review

In the field of regulatory science, reviewing literature is an essential and important step, which most of the time is conducted by manually reading hundreds of articles. Although this process is highly time-consuming and labor-intensive, most output of this process is not well transformed into machine-readable format. The limited availability of data has largely constrained the artificial intelligence (AI) system development to facilitate this literature reviewing in the regulatory process. In the past decade, AI has revolutionized the area of text mining as many deep learning approaches have been developed to search, annotate, and classify relevant documents. After the great advancement of AI algorithms, a lack of high-quality data instead of the algorithms has recently become the bottleneck of AI system development. Herein, we constructed two large benchmark datasets, Chlorine Efficacy dataset (CHE) and Chlorine Safety dataset (CHS), under a regulatory scenario that sought to assess the antiseptic efficacy and toxicity of chlorine. For each dataset, ∼10,000 scientific articles were initially collected, manually reviewed, and their relevance to the review task were labeled. To ensure high data quality, each paper was labeled by a consensus among multiple experienced reviewers. The overall relevance rate was 27.21% (2,663 of 9,788) for CHE and 7.50% (761 of 10,153) for CHS, respectively. Furthermore, the relevant articles were categorized into five subgroups based on the focus of their content. Next, we developed an attention-based classification language model using these two datasets. The proposed classification model yielded 0.857 and 0.908 of Area Under the Curve (AUC) for CHE and CHS dataset, respectively. This performance was significantly better than permutation test (p < 10E-9), demonstrating that the labeling processes were valid. To conclude, our datasets can be used as benchmark to develop AI systems, which can further facilitate the literature review process in regulatory science.

Characterizing Post-treatment Lyme Disease Syndrome: A Mixed Methods Study of Patients at a Lyme Disease Clinic in Rhode Island

BACKGROUND

Mixed quantitative and qualitative research methods may be useful for characterizing the experiences of patients with post-treatment Lyme disease syndrome.

METHODS

15 participants completed demographic and screening questions, surveys assessing quality of life, fatigue, pain, cognitive functioning, and other patient- reported outcomes, a semi-structured in-depth interview, and consented to a Lyme-related medical chart review.

RESULTS

Participants reported mild to moderate symptoms and functional impairments on patient-reported outcome surveys and in-depth interviews. Participants reported on a number of management strategies that they found more or less effective in managing their symptoms. Participants endorsed the need for better clinical assessment of symptom patterns over time, greater Lyme-related education for providers, more holistic approaches to diagnosis and care, and the desire to participate in Lyme-focused support groups.

CONCLUSIONS

Overall, participants desired a more holistic approach to diagnosis, symptom assessment, and symptom management. Recommendations for future research and clinical considerations are discussed.

Measuring Adolescent Participation: Results from a Qualitative Pretest in Cote D’Ivoire and Indonesia

Adolescence, or the period of transition between childhood and adulthood, is a significant stage in human development. Not only is it a time of physical growth and neurological development, but it is also a time when many young people begin to expand their networks beyond their family, form close ties with their peers, develop and express their views, and have a greater desire to be involved in decisions that affect them. This act of forming and expressing their views and influencing matters that concern them is sometimes referred to as adolescent participation. When viewed through an international human rights lens, adolescent participation is considered a fundamental right, and consequently, there is a need for reliable and valid measures that accurately assess adolescent participation and allow for internationally comparable data. The purpose of this study was to qualitatively test a draft questionnaire designed to measure adolescent participation. The goal was to gain insight into both how the items would perform cross-culturally and how adolescents’ comprehension and interpretation of different constructs related to adolescent participation. Cognitive interviews were conducted with 123 adolescents aged 10 to 19 in Côte d’Ivoire and Indonesia. This paper describes the development of the draft questionnaire, presents the methods used to pretest the questionnaire, and summarizes the findings. This study reveals important considerations for researchers and practitioners interested in qualitatively pretesting questionnaires with adolescents and in measuring and understanding adolescent participation across a range of international contexts.

Violence, HIV Risks, and Polysubstance Use Among HIV-Positive People Who Inject Drugs in Ukraine

Violence experience has been consistently associated with HIV risks and substance use behaviors. Although many studies have focused on intimate partner violence (IPV), the role of violence at a structural level (i.e., police abuse) remains relevant for people who inject drugs. This study evaluated the association of IPV and police-perpetrated violence experiences with HIV risk behaviors and substance use in a cohort of HIV-positive people who inject drugs in Ukraine. We also evaluated possible moderation effects of gender and socioeconomic status in the links between violence exposure and HIV risk and polysubstance use behaviors. Data came from the Providence/Boston-CFAR-Ukraine Study involving 191 HIV-positive people who inject drugs conducted at seven addiction treatment facilities in Ukraine. Results from logistic regressions suggest that people who inject drugs and experienced IPV had higher odds of polysubstance use than those who did not experience IPV. Verbal violence and sexual violence perpetrated by police were associated with increased odds of inconsistent condom use. The odds of engaging in polysubstance use were lower for women in relation to police physical abuse. We found no evidence supporting socioeconomic status moderations. Violence experiences were associated with substance use and sexual HIV risk behaviors in this cohort of HIV-positive people who inject drugs in Ukraine. Trauma-informed prevention approaches that consider both individual and structural violence could improve this population's HIV risks.

Characterizing the Symptoms of Patients with Persistent Post-Treatment Lyme Symptoms: A Survey of Patients at a Lyme Disease Clinic in Rhode Island

BACKGROUND

10-20% of individuals diagnosed with Lyme disease develop chronic symptoms after antibiotic treatment.

METHODS

A convenience sample of adults with self- reported, persistent post-Lyme treatment symptoms seeking treatment at the Lifespan Lyme Disease Center in Rhode Island completed a demographic and medical survey, the Patient Reported Outcomes Measurement Information System (PROMIS)-29 v2.0, and other short-form PROMIS measures of cognitive function, sleep disturbance, and fatigue.

RESULTS

Compared to average standardized scale scores (T=50; SD=10), participants had mild impairments in physical (T=41) and social (T=42) functioning, mild symptoms of depression (T=56), anxiety (T=60), and sleep disturbance (T=57), and moderate pain interference (T=62), and fatigue (T=65). Participants reported greater symptoms than some other clinical samples including those with cancer and chronic pain. Post-hoc analyses revealed that women reported higher levels of fatigue than men.

CONCLUSIONS

People with persistent post-Lyme treatment symptoms report debilitating symptoms and functional impairments which must be considered in clinical care.

Predictors of COVID-19 severity: A literature review

The coronavirus disease 2019 (COVID-19) pandemic is a rapidly evolving global emergency that continues to strain healthcare systems. Emerging research describes a plethora of patient factors-including demographic, clinical, immunologic, hematological, biochemical, and radiographic findings-that may be of utility to clinicians to predict COVID-19 severity and mortality. We present a synthesis of the current literature pertaining to factors predictive of COVID-19 clinical course and outcomes. Findings associated with increased disease severity and/or mortality include age > 55 years, multiple pre-existing comorbidities, hypoxia, specific computed tomography findings indicative of extensive lung involvement, diverse laboratory test abnormalities, and biomarkers of end-organ dysfunction. Hypothesis-driven research is critical to identify the key evidence-based prognostic factors that will inform the design of intervention studies to improve the outcomes of patients with COVID-19 and to appropriately allocate scarce resources.

Lessons Learned from a Rhode Island Academic Out-Patient Lyme and Tick-Borne Disease Clinic

Although the prevalence of Lyme and tick-borne diseases (TBDs) continues to rise, there is conflicting information regarding the best approach to management. The Lifespan Lyme Disease Clinic (LDC) is an academic out- patient clinic for Lyme and other TBDs. A chart review of 218 new patients between March and November 2018 was conducted. Symptoms most commonly reported included fatigue (66.5%), joint pain (58.2%), cognitive difficulty (32.1%), and headaches (27.9%). Most (87.1%) patients had received TBD-directed antibiotic treatment prior to their first appointment. Of the 136 patients who had experienced more than 6 months of symptoms attributed to Lyme, 55.1% had positive two-tiered serologies. Many patients characterized themselves as having "chronic Lyme" or had a diagnosis of "post-treatment Lyme disease syndrome," a condition for which there is no clear consensus on pathophysiology or treatment. Outlined here are some lessons learned and practical approaches used by LDC physicians in caring for this patient population.

Modified Antiretroviral Treatment Access Study (MARTAS): A Randomized Controlled Trial of the Efficacy of a Linkage-to-Care Intervention Among HIV-Positive Patients in Ukraine

Between October 2015 and March 2018, we conducted the Modified Antiretroviral Treatment Access Study (MARTAS), a nurse-delivered case management intervention to improve linkage-to-care for persons recently tested HIV positive. Adult participants from nine urban clinics in three regions of Ukraine were randomized to either MARTAS or standard of care (SOC) using individual, parallel, two-arm design. The main study outcome was linkage-to-care (defined as registration at an HIV clinic) within a 3-month period from enrollment in the study. Intention-to-treat analysis of MARTAS (n = 135) versus SOC (n = 139) showed intervention efficacy in linkage to HIV care (84.4% vs. 33.8%; adjusted RR 2.45; 95% CI 1.72, 3.47; p < 0.001). MARTAS is recommended for implementation in Ukraine and may be helpful in other countries with similar gaps in linkage-to-care. Clinicaltrials.gov registration number: NCT02338024.

SARS-CoV-2 and HIV coinfection: clinical experience from Rhode Island, United States

INTRODUCTION

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has infected >6 million people worldwide since December 2019. Global reports of HIV/SARS-CoV-2 coinfection are limited. To better understand the impact of the coronavirus disease 2019 (COVID-19) pandemic on persons with HIV and improve their care, we present an outpatient and inpatient clinical experience of HIV/SARS-CoV-2 coinfection from Rhode Island, US.

METHODS

We describe outpatient and inpatient preparedness for the COVID-19 pandemic, and present a case series of all known patients with HIV/SARS-CoV-2 coinfection at The Miriam Hospital and Rhode Island Hospital, and The Miriam Hospital Infectious Diseases and Immunology Center, in Providence, Rhode Island, US.

RESULTS AND DISCUSSION

The Infectious Diseases and Immunology Center rapidly prepared for outpatient and inpatient care of persons with HIV and SARS-CoV-2. Between 30 March and 20 May 2020, 27 patients with HIV were diagnosed with SARS-CoV-2. Twenty were male, six female and one transgender female; average age was 49 years; 13/27 were Hispanic and 6/27 were African American. All had HIV viral load <200 copies/mL and were on antiretroviral therapy with CD4 count range 87 to 1441 cells/µL. Twenty-six of the 27 had common COVID-19 symptoms for one to twenty-eight days and most had other co-morbidities and/or risk factors. Nine of the 27 were hospitalized for one to thirteen days; of those, three lived in a nursing home, six received remdesivir through a clinical trial or emergency use authorization and tolerated it well; eight recovered and one died. Overall, 17% of known Center people had HIV/SARS-CoV-2 coinfection, whereas the comparable state-wide prevalence was 9%.

CONCLUSIONS

We highlight challenges of outpatient and inpatient HIV care in the setting of the COVID-19 pandemic and present the largest detailed case series to date from the United States on HIV/SARS-CoV-2 coinfection, adding to limited global reports. The aggregated clinical findings suggest that the clinical presentation and outcomes of COVID-19 appear consistent with those without HIV. Whether SARS-CoV-2 infection is more frequent among persons with HIV remains to be determined. More data are needed as we develop our understanding of how HIV and antiretroviral therapy are affected by or have an impact on this pandemic.

Compassionate Use of Remdesivir for Patients with Severe Covid-19

BACKGROUND

Remdesivir, a nucleotide analogue prodrug that inhibits viral RNA polymerases, has shown in vitro activity against SARS-CoV-2.

METHODS

We provided remdesivir on a compassionate-use basis to patients hospitalized with Covid-19, the illness caused by infection with SARS-CoV-2. Patients were those with confirmed SARS-CoV-2 infection who had an oxygen saturation of 94% or less while they were breathing ambient air or who were receiving oxygen support. Patients received a 10-day course of remdesivir, consisting of 200 mg administered intravenously on day 1, followed by 100 mg daily for the remaining 9 days of treatment. This report is based on data from patients who received remdesivir during the period from January 25, 2020, through March 7, 2020, and have clinical data for at least 1 subsequent day.

RESULTS

Of the 61 patients who received at least one dose of remdesivir, data from 8 could not be analyzed (including 7 patients with no post-treatment data and 1 with a dosing error). Of the 53 patients whose data were analyzed, 22 were in the United States, 22 in Europe or Canada, and 9 in Japan. At baseline, 30 patients (57%) were receiving mechanical ventilation and 4 (8%) were receiving extracorporeal membrane oxygenation. During a median follow-up of 18 days, 36 patients (68%) had an improvement in oxygen-support class, including 17 of 30 patients (57%) receiving mechanical ventilation who were extubated. A total of 25 patients (47%) were discharged, and 7 patients (13%) died; mortality was 18% (6 of 34) among patients receiving invasive ventilation and 5% (1 of 19) among those not receiving invasive ventilation.

CONCLUSIONS

In this cohort of patients hospitalized for severe Covid-19 who were treated with compassionate-use remdesivir, clinical improvement was observed in 36 of 53 patients (68%). Measurement of efficacy will require ongoing randomized, placebo-controlled trials of remdesivir therapy. (Funded by Gilead Sciences.).

Stigma and quality of co-located care for HIV-positive people in addiction treatment in Ukraine: a cross-sectional study

INTRODUCTION

Co-located treatment for HIV and opioid use disorder has been shown to improve care outcomes for HIV-positive people who inject drugs (PWID) in Ukraine. However, patients continue to be stigmatized for both HIV and substance use. This study aimed to assess whether co-located care for HIV-positive PWID receiving opioid agonist treatment (OAT) services in Ukraine is associated with less stigma and better perceived quality of HIV services.

METHODS

This cross-sectional study enrolled 191 HIV-positive PWID who received OAT services at three healthcare facilities providing substance use treatment (OAT only) and at four facilities that provided co-located care (both OAT and HIV treatment) in six regions in Ukraine during July-September, 2017. Primary outcomes were HIV stigma (Berger scale), substance use stigma (Substance Abuse Stigma Scale) and intersectional stigma (both stigma forms above 75th percentile). Secondary outcome was quality of HIV care, a composite score based on a package of received services. Linear and ordinal regressions were used to assess the predictors of selected outcomes.

RESULTS

Study participants were 75% male, mean age 40 ± 7 years; 47% received co-located care, and 10.5% had both high HIV and substance use stigma. Co-located care was neither associated with HIV nor substance use stigma but it was linked to better quality of HIV care (adjusted odds ratio: 4.13; 95% CI: 2.31, 7.54). HIV stigma was associated with suicide attempts (adjusted beta (aβ): 5.90; 95% CI: 2.05, 9.75), and substance use stigma was linked to poor mental health (aβ: -0.26; 95% CI: -0.44, -0.08) and lower likelihood of receipt of services from non-governmental organization (NGO; aβ: -6.40; 95% CI: -10.23, -2.57).

CONCLUSION

One in ten people with HIV in this cohort who received OAT services experienced high levels of both HIV and substance use stigma, which was associated with poorer mental health and less NGO support. Co-located HIV and OAT services were linked to better perceived quality of HIV care, but did not seem to reduce stigma for this key population. Stigma interventions for PWID, possibly delivered involving NGOs, may be an approach to mitigate this challenge.

Feasibility and Acceptability of the Modified Antiretroviral Treatment Access Study (MARTAS) Intervention Based on a Pilot Study in Ukraine

We conducted a pilot of the Modified Antiretroviral Treatment Access Study (MARTAS), a linkage to HIV treatment intervention, prior to implementing a multisite randomized controlled trial (RCT) in Ukraine. The objectives of the pilot were to assess the feasibility and acceptability of the MARTAS intervention among a small sample of adults recently diagnosed with HIV at specialty clinics in the Mykolaiv region of Ukraine in 2015. The adapted intervention consisted of up to 6 individual-level sessions with a linkage coordinator (nurse) over a 90-day period. Overall, 22 persons participated in the pilot. On average, participants received 4.2 sessions and 14 participants linked to HIV care within 3 months of study enrollment. All 18 participants who completed the acceptability survey expressed high satisfaction with their interaction with their linkage coordinator. The results of the pilot demonstrated feasibility and acceptability of the MARTAS intervention in advance of a larger scale RCT in Ukraine.

Insurance Coverage, Employment Status, and Financial Well-Being of Young Women Diagnosed with Breast Cancer

BACKGROUND

The economic cost of breast cancer is a major personal and public health problem in the United States. This study aims to evaluate the insurance, employment, and financial experiences of young female breast cancer survivors and to assess factors associated with financial decline.

METHODS

We recruited 830 women under 40 years of age diagnosed with breast cancer between January 2013 and December 2014. The study population was identified through California, Florida, Georgia, and North Carolina population-based cancer registries. The cross-sectional survey was fielded in 2017 and included questions on demographics, insurance, employment, out-of-pocket costs, and financial well-being. We present descriptive statistics and multivariate analysis to assess factors associated with financial decline.

RESULTS

Although 92.5% of the respondents were continuously insured over the past 12 months, 9.5% paid a "higher price than expected" for coverage. Common concerns among the 73.4% of respondents who were employed at diagnosis included increased paid (55.1%) or unpaid (47.3%) time off, suffering job performance (23.2%), and staying at (30.2%) or avoiding changing (23.5%) jobs for health insurance purposes. Overall, 47.0% experienced financial decline due to treatment-related costs. Patients with some college education, multiple comorbidities, late stage diagnoses, and self-funded insurance were most vulnerable.

CONCLUSIONS

The breast cancer diagnosis created financial hardship for half the respondents and led to myriad challenges in maintaining employment. Employment decisions were heavily influenced by the need to maintain health insurance coverage.

IMPACT

This study finds that a breast cancer diagnosis in young women can result in employment disruption and financial decline.

A qualitative analysis of interprofessional students' perceptions toward patients with opioid use disorder after a patient panel experience

Background: Students from health professional schools participated in a half-day interprofessional education workshop centered on substance use disorder training. One component was a patient panel featuring individuals with a history of opioid use disorder who described the impact of addiction on their lives and their road to recovery using varied treatment options. We hypothesized that interacting with individuals with opioid use disorder early in training would elicit more humanistic perspectives and decrease bias and stigma in future health care professionals. Methods: After participating in the panel experience, health professional students (N = 580) from medicine, nursing, pharmacy, physical therapy, and social work were asked to complete short, 5-minute, rapid reflections. Prompts asked students whether the panel changed their perception of individuals with substance use disorder, to reflect on their attitudinal changes or lack thereof, and how working in interprofessional teams could impact the management and treatment of these patients. Conventional content analysis was performed. Results: Eighty-nine percent of students who attended the session completed the rapid reflections (n = 514). Overall, approximately 70% (n = 369) of students indicated that their perceptions of individuals with substance use disorder had changed as a result of the patient panel, with students from pharmacy more likely to indicate a change in attitudes. Themes across all professions included a change toward a more humanistic perspective, value of hearing real patient stories, and learning about treatment and recovery options. Student responses described how interprofessional health care teams can provide more holistic care with a broader range of therapeutic options that may improve long-term outcomes. Conclusions: A patient panel experience is influential on interprofessional students' attitudes toward patients who suffer from opioid use disorder. Students identified an interprofessional approach as being a valuable component of management and treatment of these patients.

Patient and provider perspectives inform an intervention to improve linkage to care for HIV patients in Ukraine

BACKGROUND

Engagement with HIV medical care is critical to successful HIV treatment and prevention efforts. However, in Ukraine, delays in the timely initiation of HIV treatment hamper viral suppression. By January 01, 2016, only 126,604 (57.5%) of the estimated 220,000 people living with HIV (PLWH) had registered for HIV care, and most (55.1%) of those who registered for HIV care in 2015 did that at a late stage of infection. In the US, Anti-Retroviral Treatment and Access to Services (ARTAS) intervention successfully linked newly diagnosed PLWH to HIV services using strengths-based case management with a linkage coordinator. To tailor the ARTAS intervention for Ukraine, we conducted a qualitative study with patients and providers to understand barriers and facilitators that influence linkage to HIV care.

METHODS

During September-October 2014, we conducted 20 in-depth interviews with HIV-positive patients and two focus groups with physicians in infectious disease, sexually transmitted infection (STI), and addiction clinics in Dnipropetrovsk Region of Ukraine. Interviews and focus groups were audio-recorded and transcribed verbatim. We translated illustrative quotes into English. We used thematic analysis for the data analysis.

RESULTS

Participants (20 patients and 14 physicians) identified multiple, mostly individual-level factors influencing HIV care initiation. Key barriers included lack of HIV knowledge, non-acceptance of HIV diagnosis, fear of HIV disclosure, lack of psychological support from health providers, and HIV stigma in community. Responsibility for one's health, health deterioration, and supportive provider communication were reported as facilitators to linkage to care. Expected benefits from the case management intervention included psychological support, HIV education, and help with navigating the segmented health system.

CONCLUSIONS

The findings from the study will be used to optimize the ARTAS for the Ukrainian context. Our findings can also support future linkage-to-care strategies in other countries of Eastern Europe and Central Asia.

The changing face of women living with HIV in western Ukraine

Ukraine has the second largest HIV epidemic in Eastern Europe/Central Asia. This study characterizes the demographics of HIV-infected women in the Lviv region of western Ukraine, patterns in their clinical presentation, and factors associated with delays in seeking care. A retrospective chart review was conducted of 622 HIV-infected women who registered for HIV treatment at the Lviv AIDS Center between 2008 and 2013. A total of 81.6% of women were infected through heterosexual transmission and the remaining 18.4% through intravenous drug use. Slightly less than half (45.4%) was between 26 and 35 years old. Slightly more than half (56.7%) listed their residence in a city, 22.6% in villages. One-third (30.0%) of all women presented with AIDS, and 37.7% presented with symptomatic conditions. Women diagnosed with HIV during antenatal care experienced a median delay of 34 days between diagnosis and registration, compared to 87.5 days for nonpregnant women tested in the context of intravenous drug use. Overall, HIV-infected women in western Ukraine experience time delays in care, and often present with advanced HIV disease and secondary complications. Linkage to care in a timely manner is a high priority and substantial challenge for women, particularly for intravenous drug users who may face stigma and other additional barriers.

Physician's advice on quitting smoking in HIV and TB patients in south India: a randomised clinical trial

Setting: National Institute for Research in Tuberculosis, Madurai, India. Objective: To determine the efficacy of physician's advice on quitting smoking compared with standard counselling in patients with tuberculosis (TB) and patients with human immunodeficiency virus (HIV) infection. Design/Methods: This was a clinical trial conducted in Madurai, south India, among 160 male patients (80 with TB and 80 with HIV), randomised and stratified by nicotine dependence (low/high according to the Fagerström scale), who received physician's advice with standard counselling or standard counselling alone for smoking cessation. Abstinence at 1 month was assessed by self-report and carbon monoxide breath analysis. Results: The patients' mean age was 39.4 years (SD 8.5). Overall, 35% of the patients had high nicotine dependence. Most patients (41%) smoked both cigarettes and bidis. In a combined analysis including both the HIV and the TB groups, quit rates were 41% of the 68 patients in the physician group and 35% of the 68 patients in the standard counselling arm. Conclusions: Physician's advice to quit smoking delivered to patients with TB or HIV is feasible and acceptable. Smoking cessation could easily be initiated in TB patients in programme settings. Future studies should assess long-term abstinence rates with a larger sample size to demonstrate the efficacy of physician's advice.

Proportion and factors associated with Hepatitis B viremia in antiretroviral treatment naïve and experienced HIV co-infected Ghanaian patients

BACKGROUND

The global burden of Hepatitis B virus (HBV) and HIV co-infection is enormous. The risk of developing cirrhosis and hepatocellular cancer is associated with HBV DNA levels. The main objective of the study was to determine proportion of Hepatitis B viremia in ART-naïve and ART-experienced co-infected Ghanaian patients and factors associated with HBV viremia after at least 36 weeks of lamivudine with or without tenofovir containing ART.

METHODS

Hepatitis B and HIV co-infected patients who were ART-naïve or had received at least 9 months of lamivudine-containing ART were enrolled in a cross-sectional study at Korle-Bu Teaching Hospital. Demographic and clinical data were collected and samples obtained for Hepatitis B serology, liver function tests and HBV DNA. Factors associated with viremia were determined using univariate and multivariate logistic regression analysis.

RESULTS

Of 3108 HIV-infected patients screened, 257 (8.3%) were HBsAg-positive, of which 235 enrolled. Overall, 152 (64.7%) were ART-experienced and 83 (35.3%) were ART-naïve. Eighty-nine-percent of ART-naïve and 42.1% of ART-experienced patients had HBV DNA > 20 IU/mL. In multivariate analysis of all patients, being ART-naïve (OR 10.1, 95% CI 4.6-21.9) and elevated ALT (OR 3.7, 95% CI 1.8-7.9) were associated with Hepatitis B viremia. In treatment experienced patients, elevated ALT (OR 4.8 CI 2.0-12.1) and male sex (OR 2.1, 95% CI 1.0-4.2) were associated with Hepatitis B viremia.

CONCLUSIONS

Majority of ART-naïve (89%) and 42% of ART-experienced patients had detectable hepatitis B viremia > 20 IU/mL. An abnormal serum ALT was significantly associated with hepatitis B viremia in HBV and HIV co-infected patients irrespective of treatment status. Baseline and on-treatment ALT may be a useful non-invasive predictor of Hepatitis B viremia in resource-constrained countries in sub-Saharan Africa where infection is endemic and viral load tests are not widely available.

Evaluation of a Nurse-Initiated Routine HIV Testing Pilot on a Medical-Surgical Unit

National guidelines recommending a shift from risk-based to routine HIV testing for persons ages 13-64 are described. The role of nurses, particularly medical-surgical nurses, in increasing the number of people screened is discussed.

Delayed entry to care by men with HIV infection in Kumasi, Ghana

INTRODUCTION

In resource-limited settings, men may face considerable barriers to accessing HIV care as early interventions tend to focus on antenatal care settings.

METHODS

We performed a retrospective chart review of all adult patients referred to Komfo Anokye Teaching Hospital HIV clinic in Kumasi, Ghana in 2011 to identify the differences in clinical and demographic variables by gender at presentation to care using two-sample t tests with adjusted variance and Wilcox rank sum tests for continuous variables and Pearson chi-squared tests for categorical variables. We also compared differences in clinical and demographic variables among men stratified by CD4 count at initiation of care in order to identify variables associated with later entry to care.

RESULTS

Demographically, men were more likely to be older (men age 42 vs. 37, p<0.01), have a greater number of dependent children (1.8 v. 1.5, p = 0.04), to be living with or married to their partner (65.4% vs. 49.0%, p<0.01), and to have a higher level of education (tertiary education, 45.8% vs. 25.4%, p<0.01) than women. Clinically, men were more likely to have a lower CD4 count at entry to care (260 v. 311 cells/µL, p<0.01), to report clinical symptoms to the nurse during intake (p<0.01), and to have any history of alcohol use (p<0.01).

CONCLUSION

Men in Ghana are accessing treatment at a later stage of their disease than women. Efforts to test and link men to care early should be intensified.

Retention in Care of HIV-Positive Postpartum Females in Kumasi, Ghana

BACKGROUND

Despite the success of prevention of mother-to-child transmission programs, transition to care in the postpartum period is vulnerable to being lost to care.

METHODS

The authors performed a 2-year retrospective study of postpartum HIV-infected patients at Komfo Anokye Teaching Hospital in Kumasi, Ghana. The outcome was classified as optimal follow-up, suboptimal follow-up, and loss to follow-up (LTFU). Univariate and multivariate analyses were used to identify factors associated with optimal retention.

RESULTS

Follow-up was optimal in 66%, suboptimal in 16%, and LTFU in 18% of patients. The rate of LTFU was 22% among women diagnosed at pregnancy and 13% among those with known HIV diagnosis (P = .078). Adherence counseling (odds ratio [OR] 5.0, confidence interval [CI] 1.6-15.7; P = .006) and family planning (FP; OR 2.3, CI 1.0-5.3; P = .041) were predictive of optimal follow-up.

CONCLUSION

At 1 year, only two-thirds of postpartum women remained in care. Investigating barriers to adherence counseling and FP may impact engagement in care among HIV-infected women.

Pretreatment HIV Drug Resistance and HIV-1 Subtype C Are Independently Associated With Virologic Failure: Results From the Multinational PEARLS (ACTG A5175) Clinical Trial

BACKGROUND

Evaluation of pretreatment HIV genotyping is needed globally to guide treatment programs. We examined the association of pretreatment (baseline) drug resistance and subtype with virologic failure in a multinational, randomized clinical trial that evaluated 3 antiretroviral treatment (ART) regimens and included resource-limited setting sites.

METHODS

Pol genotyping was performed in a nested case-cohort study including 270 randomly sampled participants (subcohort), and 218 additional participants failing ART (case group). Failure was defined as confirmed viral load (VL) >1000 copies/mL. Cox proportional hazards models estimated resistance-failure association.

RESULTS

In the representative subcohort (261/270 participants with genotypes; 44% women; median age, 35 years; median CD4 cell count, 151 cells/µL; median VL, 5.0 log10 copies/mL; 58% non-B subtypes), baseline resistance occurred in 4.2%, evenly distributed among treatment arms and subtypes. In the subcohort and case groups combined (466/488 participants with genotypes), used to examine the association between resistance and treatment failure, baseline resistance occurred in 7.1% (9.4% with failure, 4.3% without). Baseline resistance was significantly associated with shorter time to virologic failure (hazard ratio [HR], 2.03; P = .035), and after adjusting for sex, treatment arm, sex-treatment arm interaction, pretreatment CD4 cell count, baseline VL, and subtype, was still independently associated (HR, 2.1; P = .05). Compared with subtype B, subtype C infection was associated with higher failure risk (HR, 1.57; 95% confidence interval [CI], 1.04-2.35), whereas non-B/C subtype infection was associated with longer time to failure (HR, 0.47; 95% CI, .22-.98).

CONCLUSIONS

In this global clinical trial, pretreatment resistance and HIV-1 subtype were independently associated with virologic failure. Pretreatment genotyping should be considered whenever feasible.

CLINICAL TRIALS REGISTRATION

NCT00084136.

Evaluating HIV prevention strategies for populations in key affected groups: the example of Cabo Verde

OBJECTIVES

We used an individual-based model to evaluate the effects of hypothetical prevention interventions on HIV incidence trajectories in a concentrated, mixed epidemic setting from 2011 to 2021, and using Cabo Verde as an example.

METHODS

Simulations were conducted to evaluate the extent to which early HIV treatment and optimization of care, HIV testing, condom distribution, and substance abuse treatment could eliminate new infections (i.e., reduce incidence to less than 10 cases per 10,000 person-years) among non-drug users, female sex workers (FSW), and people who use drugs (PWUD).

RESULTS

Scaling up all four interventions resulted in the largest decreases in HIV, with estimates ranging from 1.4 (95 % CI 1.36-1.44) per 10,000 person-years among non-drug users to 8.2 (95 % CI 7.8-8.6) per 10,000 person-years among PWUD in 2021. Intervention scenarios prioritizing FWS and PWUD also resulted in HIV incidence estimates at or below 10 per 10,000 person-years by 2021 for all population sub-groups.

CONCLUSIONS

Our results suggest that scaling up multiple interventions among entire population is necessary to achieve elimination. However, prioritizing key populations with this combination prevention strategy may also result in a substantial decrease in total incidence.

Geographic variability in HIV and injection drug use in Ukraine: implications for integration and expansion of drug treatment and HIV care

BACKGROUND

Ukraine has the highest HIV burden of any European country with much of the current HIV epidemic concentrated among people who inject drugs (PWIDs) and their sexual partners. Opiate substitution therapy (OST) is limited in Ukraine and expansion of OST is urgently needed to help stem the tide of the HIV epidemic.

METHODS

We accessed publicly available data in Ukraine in order to explore geographic variability with respect to prevalence of HIV, PWIDs and OST programmes.

RESULTS

The regions of Ukraine with the largest number of opioid dependent persons (the south and eastern portions of the country) correspond to the regions with the highest HIV prevalence and HIV incidence. The number of opioid PWIDs per 100,000 population as well as the number of all OST treatment slots per 100,000 varied significantly across the three HIV prevalence categories. Overall, the proportion of individuals receiving either methadone maintenance therapy (MMT) or buprenorphine maintenance therapy (BMT) was quite low: average across categories: 7.3% and 0.4%, respectively. Additionally, less than half of OST patients receiving MMT or BMT were HIV positive patients.

CONCLUSION

There is significant geographic variability in both numbers of HIV positive individuals and numbers of PWIDs across Ukraine, however, there may be a more concentrated epidemic among PWIDs in many regions of the country. Scale up of addiction treatment for PWID, especially OST, can have a significant impact on preventing injection related morbidity, such as HIV and HCV infection. Ukraine can learn from the mistakes other nations have made in denying critical treatment opportunities to PWID.

Sex differences in perceived risk and testing experience of HIV in an urban fishing setting in Ghana

Introduction

Understanding sex differences in willingness to test and testing experience could aid the design of focus interventions to enhance uptake and engagement with care, treatment and support services. This study determined differences in perceived risk of acquiring HIV, willingness to test and HIV testing experience in an urban fishing community.

Methods

A cross-sectional community survey was conducted in 2013 among men and women in two fishing communities (Chorkor and James Town) in Accra. In all, 554 subjects (≥18 years) were involved, 264 in Chorkor and 290 in James Town. Data on demographic characteristics, perceived risk for HIV and willingness to test for HIV and testing experience were collected with a structured questionnaire. Descriptive statistics and Chi square test were used for the analysis at 95% significant level, using SPSS version 21.

Results

Of 554 subjects, 329 (59.4%) were females, and median age was 32 years. Overall, only 91(40.4%) men and 118(35.9%) women perceived themselves to be at risk of acquiring HIV. A significant proportion of women were willing to test for HIV compared to men (86.3% vs. 80.0%, P = 0.048). Women were more likely to have ever tested for HIV compared to men (42.2% vs. 28.6%, P = 0.001) and more women had tested within 12 months prior to survey than men (49.6% vs. 40.6%, P = 0.230). Of the number who had tested for HIV infection, a higher proportion of men tested voluntarily 42(65.6%), while a higher proportion of women tested as part of healthcare service received 96(69.1%); (P = 0.001; indicating women vs. men).

Conclusion

Sex differences in risk perception and willingness to test need more focused public education and behaviour change communication strategies to achieve high coverage. Community-based strategies could improve HIV testing among men whilst more access to testing in health settings should be available to women in these communities.

The feasibility of implementing the HIV seek, test, and treat strategy in jails

To successfully implement the Seek, Test, and Treat (STT) strategy to curb the HIV epidemic, the criminal justice system must be a key partner. Increasing HIV testing and treatment among incarcerated persons has the potential to decrease HIV transmission in the broader community, but whether it is feasible to consider the implementation of the STT within jail facilities is not known. We conducted a retrospective review of Rhode Island Department of Corrections (RIDOC) medical records to assess whether persons newly diagnosed in the jail were able to start ART and be linked to community HIV care after release. From 2001 to 2007, 64 RIDOC detainees were newly diagnosed with HIV. During their index incarcerations, 64% were informed of positive confirmatory HIV test results, 50% completed baseline evaluations, and 9% began ART. Linkage to community care was confirmed for 58% of subjects. Subjects incarcerated for >14 days were significantly more likely to receive HIV test results and complete baseline evaluation (p<0.001). A similar association was not observed for ART initiation until incarceration length reached 60 days (p<0.001). There was no association between incarceration length and linkage to care. This comprehensive analysis demonstrates that length of incarceration impacts HIV test result delivery, baseline evaluation, and ART initiation in the RIDOC. Jails are an important venue to "Seek" and "Test"; however, completing the "Treat" part of the STT strategy is hindered by the transient nature of this criminal justice population and may require new strategies to improve linkage to care.

Missed opportunities for HIV screening in pharmacies and retail clinics

In the wake of new recommendations to offer HIV screening to everyone aged 13-64 years and to start all people living with HIV/AIDS on highly active antiretroviral therapy (HAART) regardless of CD4 count, the need to generate widespread, scalable HIV screening programs is greater than ever. Nearly 50,000 new HIV infections occur in the United States each year, and the Centers for Disease Control and Prevention estimates that approximately half of these new infections are transmitted by individuals who are unaware of their HIV serostatus. Numerous barriers to screening exist, including the lack of primary care for many at-risk patients, expense of screening in traditional settings, and need for repeat testing in high-risk populations. With their relative accessibility and affordability, community pharmacies and retail clinics within those pharmacies are practical and appealing venues for expanded HIV screening. For widespread pharmacy-based testing to become a reality, policymakers and corporate pharmacy leadership would need to develop innovative solutions to the existing time pressures of pharmacists' behind-the-counter functions and absence of reimbursement for direct patient care services. Pharmacists nationwide should also receive training to assist with risk reduction counseling and linkage to care for customers purchasing the new over-the-counter HIV test.

Care at the Crossroads: Navigating the HIV, HCV, and Substance Abuse Syndemic

For patients with both HIV/HCV coinfection and substance addiction, multidisciplinary teams can facilitate coordination of care and improve clinical outcomes. Such teams should include HIV/HCV treatment providers, mental health specialists, case managers, social workers, and substance abuse counselors.

Love, lust and the emotional context of multiple and concurrent sexual partnerships among young Swazi adults

Men and women in Swaziland who are engaged in multiple or concurrent sexual partnerships, or who have sexual partners with concurrent partners, face a very high risk of HIV infection. Ninety-four in-depth interviews were conducted with 28 Swazi men and women (14 of each sex) between the ages of 20 and 39 to explore participants' sexual partnership histories, including motivations for sexual relationships which carried high HIV risk. Concurrency was normative, with most men and women having had at least one concurrent sexual partnership, and all women reporting having had at least one partner who had a concurrent partner. Men distinguished sexual partnerships that were just for sex from those that were considered to be 'real relationships', while women represented most of their relationships, even those which included significant financial support, as being based on love. Besides being motivated by love, concurrent sexual partnerships were described as motivated by a lack of sexual satisfaction, a desire for emotional support and/or as a means to exact revenge against a cheating partner. Social and structural factors were also found to play a role in creating an enabling environment for high-risk sexual partnerships. These factors included social pressure and norms; a lack of social trust; poverty and a desire for material goods; and geographical separation of partners.

Outcomes among HIV-1 infected individuals first starting antiretroviral therapy with concurrent active TB or other AIDS-defining disease

Background

Tuberculosis (TB) is common among HIV-infected individuals in many resource-limited countries and has been associated with poor survival. We evaluated morbidity and mortality among individuals first starting antiretroviral therapy (ART) with concurrent active TB or other AIDS-defining disease using data from the “Prospective Evaluation of Antiretrovirals in Resource-Limited Settings” (PEARLS) study.

Methods

Participants were categorized retrospectively into three groups according to presence of active confirmed or presumptive disease at ART initiation: those with pulmonary and/or extrapulmonary TB (“TB” group), those with other non-TB AIDS-defining disease (“other disease”), or those without concurrent TB or other AIDS-defining disease (“no disease”). Primary outcome was time to the first of virologic failure, HIV disease progression or death. Since the groups differed in characteristics, proportional hazard models were used to compare the hazard of the primary outcome among study groups, adjusting for age, sex, country, screening CD4 count, baseline viral load and ART regimen.

Results

31 of 102 participants (30%) in the “TB” group, 11 of 56 (20%) in the “other disease” group, and 287 of 1413 (20%) in the “no disease” group experienced a primary outcome event (p = 0.042). This difference reflected higher mortality in the TB group: 15 (15%), 0 (0%) and 41 (3%) participants died, respectively (p<0.001). The adjusted hazard ratio comparing the “TB” and “no disease” groups was 1.39 (95% confidence interval: 0.93–2.10; p = 0.11) for the primary outcome and 3.41 (1.72–6.75; p<0.001) for death.

Conclusions

Active TB at ART initiation was associated with increased risk of mortality in HIV-1 infected patients.

The future of generic HIV drugs in Rhode Island

The number of HIV-infected persons in the United States continues to increase and most patients with HIV will be on antiretroviral therapy (ART) for many decades. The introduction of generic antiretroviral medications has the potential for significant cost savings which may then be accompanied by improved access. State AIDS Drug Assistance Programs will be made more effective by the switch to generic ARTs. Cost savings and barriers to the introduction of generic ART are discussed.

Changes in HIV-1 subtypes B and C genital tract RNA in women and men after initiation of antiretroviral therapy

BACKGROUND

Combination antiretroviral therapy (cART) reduces genital tract human immunodeficiency virus type 1 (HIV-1) load and reduces the risk of sexual transmission, but little is known about the efficacy of cART for decreasing genital tract viral load (GTVL) and differences in sex or HIV-1 subtype.

METHODS

HIV-1 RNA from blood plasma, seminal plasma, or cervical wicks was quantified at baseline and at weeks 48 and 96 after entry in a randomized clinical trial of 3 cART regimens.

RESULTS

One hundred fifty-eight men and 170 women from 7 countries were studied (men: 55% subtype B and 45% subtype C; women: 24% subtype B and 76% subtype C). Despite similar baseline CD4(+) cell counts and blood plasma viral loads, women with subtype C had the highest GTVL (median, 5.1 log10 copies/mL) compared to women with subtype B and men with subtype C or B (4.0, 4.0, and 3.8 log10 copies/mL, respectively; P < .001). The proportion of participants with a GTVL below the lower limit of quantification (LLQ) at week 48 (90%) and week 96 (90%) was increased compared to baseline (16%; P < .001 at both times). Women were significantly less likely to have GTVL below the LLQ compared to men (84% vs 94% at week 48, P = .006; 84% vs 97% at week 96, P = .002), despite a more sensitive assay for seminal plasma than for cervical wicks. No difference in GTVL response across the 3 cART regimens was detected.

CONCLUSIONS

The female genital tract may serve as a reservoir of persistent HIV-1 replication during cART and affect the use of cART to prevent sexual and perinatal transmission of HIV-1.

Building international collaborations from the ground up: Brown University partnerships in Haiti and Ukraine

The world is becoming more interconnected with a need for a global approach to healthcare. Brown University has remained a leader in global health through clinical service, education, cutting edge research and dedication to the development of sustainable global partnerships. We describe two programs from the ground up in Haiti and Ukraine, and the important lessons learned in their development. The path towards the development of global health programs in Ukraine and Haiti both illustrate that although circumstances may vary between global health programs, the recipe for successful collaboration is the same: identifying specific needs, developing strong and sustained partnerships, and addressing barriers by crafting effective solutions to ongoing challenges.

What's God got to do with it? Engaging African-American faith-based institutions in HIV prevention

African-Americans are disproportionately infected and affected by HIV/AIDS. Although faith-based institutions play critical leadership roles in the African-American community, the faith-based response to HIV/AIDS has historically been lacking. We explore recent successful strategies of a citywide HIV/AIDS awareness and testing campaign developed in partnership with 40 African-American faith-based institutions in Philadelphia, Pennsylvania, a city with some of the USA's highest HIV infection rates. Drawing on important lessons from the campaign and subsequent efforts to sustain the campaign's momentum with a citywide HIV testing, treatment and awareness programme, we provide a road map for engaging African-American faith communities in HIV prevention that includes partnering with faith leaders, engaging the media to raise awareness, destigmatising HIV/AIDS and encouraging HIV testing, and conducting educational and HIV testing events at houses of worship. African-American faith-based institutions have a critical role to play in raising awareness about the HIV/AIDS epidemic and reducing racial disparities in HIV infection.

Efficacy and safety of three antiretroviral regimens for initial treatment of HIV-1: a randomized clinical trial in diverse multinational settings

BACKGROUND

Antiretroviral regimens with simplified dosing and better safety are needed to maximize the efficiency of antiretroviral delivery in resource-limited settings. We investigated the efficacy and safety of antiretroviral regimens with once-daily compared to twice-daily dosing in diverse areas of the world.

METHODS AND FINDINGS

1,571 HIV-1-infected persons (47% women) from nine countries in four continents were assigned with equal probability to open-label antiretroviral therapy with efavirenz plus lamivudine-zidovudine (EFV+3TC-ZDV), atazanavir plus didanosine-EC plus emtricitabine (ATV+DDI+FTC), or efavirenz plus emtricitabine-tenofovir-disoproxil fumarate (DF) (EFV+FTC-TDF). ATV+DDI+FTC and EFV+FTC-TDF were hypothesized to be non-inferior to EFV+3TC-ZDV if the upper one-sided 95% confidence bound for the hazard ratio (HR) was ≤1.35 when 30% of participants had treatment failure. An independent monitoring board recommended stopping study follow-up prior to accumulation of 472 treatment failures. Comparing EFV+FTC-TDF to EFV+3TC-ZDV, during a median 184 wk of follow-up there were 95 treatment failures (18%) among 526 participants versus 98 failures among 519 participants (19%; HR 0.95, 95% CI 0.72-1.27; p = 0.74). Safety endpoints occurred in 243 (46%) participants assigned to EFV+FTC-TDF versus 313 (60%) assigned to EFV+3TC-ZDV (HR 0.64, CI 0.54-0.76; p<0.001) and there was a significant interaction between sex and regimen safety (HR 0.50, CI 0.39-0.64 for women; HR 0.79, CI 0.62-1.00 for men; p = 0.01). Comparing ATV+DDI+FTC to EFV+3TC-ZDV, during a median follow-up of 81 wk there were 108 failures (21%) among 526 participants assigned to ATV+DDI+FTC and 76 (15%) among 519 participants assigned to EFV+3TC-ZDV (HR 1.51, CI 1.12-2.04; p = 0.007).

CONCLUSION

EFV+FTC-TDF had similar high efficacy compared to EFV+3TC-ZDV in this trial population, recruited in diverse multinational settings. Superior safety, especially in HIV-1-infected women, and once-daily dosing of EFV+FTC-TDF are advantageous for use of this regimen for initial treatment of HIV-1 infection in resource-limited countries. ATV+DDI+FTC had inferior efficacy and is not recommended as an initial antiretroviral regimen.

TRIAL REGISTRATION

www.ClinicalTrials.gov NCT00084136. Please see later in the article for the Editors' Summary.

African American patient experiences with a rapid HIV testing program in an urban public clinic

BACKGROUND

Of 1174 new human immunodeficiency virus (HIV) cases diagnosed in Philadelphia, Pennsylvania, in 2008, a total of 771 (66%) were among African Americans. Philadelphia recently introduced a citywide rapid HIV testing program in public clinics.

METHODS

We conducted a qualitative study among 60 African Americans undergoing rapid HIV testing in one of Philadelphia's public clinics located in a zip code with high HIV incidence. Employing grounded theory, we used semistructured interviews to assess patients' motivations, perceptions, and clinical experiences with rapid HIV testing. Interviews were transcribed and coded; 20% were double coded to enhance reliability.

RESULTS

Primary motivations for undergoing rapid HIV testing included: testing during routine clinical care, presenting for care with symptomatic sexually transmitted infections or opportunistic infections, knowing someone living with HIV/ AIDS, and perceiving oneself at risk for HIV. Most patients reported positive experiences with rapid testing and preferred it to conventional testing because it eliminated the need for return visits and decreased anxiety; however, many expressed concerns about accuracy of rapid HIV testing. Barriers to HIV testing among this population included low self-perceived risk, HIV stigma, and reported homophobia in respondents' communities.

CONCLUSION

This rapid testing program was acceptable, convenient, and preferred over conventional HIV testing. Providing educational information about rapid and confirmatory HIV testing may further enhance acceptability of rapid HIV testing in this population. Nationwide expansion of rapid HIV testing in public health centers is an important and acceptable means of achieving President Obama's National AIDS Strategy goals of reducing racial disparities in HIV infection and improving linkage to HIV/AIDS treatment and care services.

Acceptance of HIV Antibody Testing Among Women in Domestic Violence Shelters

The purpose of this study was to examine which factors derived from an adapted version of the Health Belief Model are associated with HIV testing among women at domestic violence shelters in the rural south (N = 112). Participants were administered self-report questionnaires to assess for test acceptance and were offered private and free HIV rapid testing. A logistic regression analysis was performed. Results indicated that higher perceived susceptibility and higher PTSD symptoms predicted a greater likelihood of HIV test acceptance. The most common reason given for not testing was a lack of time. Implications are discussed.

Quality of life among individuals with HIV starting antiretroviral therapy in diverse resource-limited areas of the world

As Antiretroviral Therapy (ART) is scaled up in low- and middle-income countries, it is important to understand Quality of Life (QOL) correlates including disease severity and person characteristics and to determine the extent of between-country differences among those with HIV. QOL and medical data were collected from 1,563 of the 1,571 participants at entry into a randomized clinical trial of ART conducted in the U.S. (n = 203) and 8 resource-limited countries (n = 1,360) in the Caribbean, South America, Asia, and Africa. Participants were interviewed prior to initiation of ART using a modified version of the ACTG SF-21, a health-related QOL measure including 8 subscales: general health perception, physical functioning, role functioning, social functioning, cognitive functioning, pain, mental health, and energy/fatigue. Other measures included demographics, CD4+ lymphocyte count, plasma HIV-1 RNA viral load. Higher quality of life in each of the 8 QOL subscales was associated with higher CD4+ lymphocyte category. General health perception, physical functioning, role functioning, and energy/fatigue varied by plasma HIV-1 RNA viral load categories. Each QOL subscale included significant variation by country. Only the social functioning subscale varied by sex, with men having greater impairments than women, and only the physical functioning subscale varied by age category. This was the first large-scale international ART trial to conduct a standardized assessment of QOL in diverse international settings, thus demonstrating that implementation of the behavioral assessment was feasible. QOL indicators at study entry varied with disease severity, demographics, and country. The relationship of these measures to treatment outcomes can and should be examined in clinical trials of ART in resource-limited settings using similar methodologies.

Recent clinical history and cognitive dysfunction for attention and executive function among human immunodeficiency virus-infected patients

This study examined the association between recent trends in CD4 and viral loads and cognitive test performance with the expectation that recent history could predict cognitive performance. Eighty-three human immunodeficiency virus (HIV)-infected patients with a mean CD4 count of 428 copies/ml were examined in this study (62% with undetectable plasma viral load [PVL]). We investigated the relationships between nadir CD4 cell count, 1-year trends in immunologic function/PVLs, and cognitive performance across several domains using linear regression models. Nadir CD4 cell count was predictive of current executive function (p = .004). One year clinical history for CD4 cell counts and/or PVLs were predictive of executive function, attention/working memory, and learning/memory measures (p < .05). Models that combined recent clinical history trends and nadir CD4 cell counts suggested that recent clinical trends were more important in predicting current cognitive performance for all domains except executive function. This research suggests that recent CD4 and viral load history is an important predictor of current cognitive function across several cognitive domains. If validated, clinical variables and cognitive dysfunction models may improve our understanding of the dynamic relationships between disease evolution and progression and CNS involvement.

High Frequency of First-Line Anti-Tuberculosis Drug Resistance among Persons with Chronic Pulmonary Tuberculosis at a Teaching Hospital Chest Clinic

INTRODUCTION

The burden of MDR-TB is unknown in areas that do not have drug susceptibility testing (DST), but its frequency is expected to be higher in previously treated cases. Where DST is not available the WHO recommended standardized retreatment (Category II) regimen is given to previously treated TB patients

OBJECTIVE

To evaluate the frequency and pattern of drug resistance of Mycobacterium tuberculosis isolated from patients with chronic smear positive pulmonary tuberculosis.

METHOD

We conducted a retrospective review of mycobacterial cultures and drug susceptibility testing (DST) performed on sputum samples collected, between January 2005 and September 2006, from 40 patients with pulmonary TB who had failed at least one standard retreatment regimen. Clinical data was extracted from patients' case notes.

RESULTS

M. tuberculosis was recovered from 28 (70%) of the 40 patients. Of the 28 culture positive cases, 10 (36%) had resistance to at least rifampicin and isoniazid (multi-drug resistant TB), 22 (79%) isolates had resistance to streptomycin and 13 (46%) to ethambutol. Of the patients with a positive culture, only one (3.6%) had a fully susceptible organism. Of the 10 patients with MDR TB, 7 had received two or more retreatment courses.

CONCLUSION

The frequency of drug resistant TB was high among patients who failed at least one course of category II therapy. Effective combination regimens based on DST is necessary in patients who remain smear positive on the standardized retreatment regimen.

Sex-associated differences in pre-antiretroviral therapy plasma HIV-1 RNA in diverse areas of the world vary by CD4(+) T-cell count

BACKGROUND

Sex differences in the natural history of HIV infection may vary between resource-rich and resource-limited settings.

METHODS

Baseline characteristics from a randomized clinical trial of treatment-naive subjects conducted at sites in Africa, Asia, the Caribbean, and North and South America were analysed to determine if there were significant differences by sex.

RESULTS

Of the 1,571 participants, 740 (47.1%) were women. Women had higher mean screening CD4(+) T-cell counts (mean 15 cells higher; P<0.001), lower mean haemoglobin and creatinine clearance, a lower mean baseline HIV-1 viral load (4.85 log(10) versus 5.05 log₁₀ copies/ml; P<0.001) and were less likely to have a prior AIDS diagnosis than men. The sex difference in viral load was related to CD4(+) T-cell count; however, it was independent of country and persisted within the strata with CD4(+) T-cell count <200 cells/mm³.

CONCLUSIONS

Women in resource-limited settings have lower levels of plasma HIV-1 RNA and appear to present for enrolment into clinical trials at an earlier stage of disease than men. The biological basis for lower viral load in women compared to men remains unexplained. It will be important to determine if the sex differences observed at baseline impact clinical outcomes once the PEARLS clinical trial is completed.

Comparisons of anemia, thrombocytopenia, and neutropenia at initiation of HIV antiretroviral therapy in Africa, Asia, and the Americas

BACKGROUND

Hematological abnormalities are common manifestations of advanced HIV-1 infection that could affect the outcomes of highly-active antiretroviral therapy (HAART). Although most HIV-1-infected individuals live in resource-constrained countries, there is little information about the frequency of hematological abnormalities such as anemia, neutropenia, and thrombocytopenia among individuals with advanced HIV-1 disease.

METHODS

This study compared the prevalence of pre-antiretroviral therapy hematological abnormalities among 1571 participants in a randomized trial of antiretroviral efficacy in Africa, Asia, South America, the Caribbean, and the USA. Potential covariates for anemia, neutropenia, and thrombocytopenia were identified in univariate analyses and evaluated in separate multivariable models for each hematological condition.

RESULTS

The frequencies of neutropenia (absolute neutrophil count ≤1.3×10⁹/l), anemia (hemoglobin ≤10g/dl), and thrombocytopenia (platelets ≤125×10⁹/l) at initiation of antiretroviral therapy were 14%, 12%, and 7%, respectively, and varied by country (p<0.0001 for each). In multivariable models, anemia was associated with gender, platelet count, and country; neutropenia was associated with CD4+ lymphocyte and platelet counts; and thrombocytopenia was associated with country, gender, and chronic hepatitis B infection.

CONCLUSIONS

Differences in the frequency of pretreatment hematological abnormalities could have important implications for the choice of antiretroviral regimen in resource-constrained settings.

Heavy injection drug use is associated with lower percent body fat in a multi-ethnic cohort of HIV-positive and HIV-negative drug users from three U.S. cities

BACKGROUND

The clinical implications of lower body weight in drug using populations are uncertain given that lower mean weights may still fall within the healthy range.

OBJECTIVES

To determine the effect of type, mode and frequency of drug use on underlying body composition after accounting for differences in body shape and size.

METHODS

We conducted a cross-sectional analysis of 511 participants from the Tufts Nutrition Collaborative (TNC) Study. Data included measures of body composition, a 24-hour dietary recall, and a detailed health history and lifestyle questionnaire. Multivariate regression analysis was used to determine the independent effect of drug use on percent body fat (BF) after adjusting for BMI and waist circumference.

RESULTS

Heavy injection drug users (IDUs) had a 2.6% lower percent BF than non-users after adjusting for BMI, waist circumference, and other confounders. (p = 0.0006). Differences in percent BF were predominantly due to higher lean mass, rather than lower fat mass. Cocaine and heroin had similar effects on body composition.

CONCLUSIONS

In the U.S., where the general population is prone to over-nutrition, the average percent BF for heavy injectors does not fall into a range low enough to suggest harmful effects. However, in populations with substantial levels of under-nutrition, small differences in percent BF among drug users will have a greater impact on health status.

SCIENTIFIC SIGNIFICANCE

Differences in BMI, weight and body composition are not always straightforward. Accounting for underlying nutritional status and relative differences in fat and FFM is critical when interpreting results. diagnosed patients and prevent them from returning to prison.

Cost-effectiveness of tenofovir as first-line antiretroviral therapy in India

BACKGROUND

World Health Organization guidelines for antiretroviral treatment (ART) in resource-limited settings recommend either stavudine or tenofovir as part of initial therapy. We evaluated the clinical outcomes and cost-effectiveness of first-line ART using tenofovir in India, compared with current practice using stavudine or zidovudine.

METHODS

We used a state-transition model of human immunodeficiency virus (HIV) disease to examine strategies using different nucleoside reverse-transcriptase inhibitors, combined with lamivudine and nevirapine, compared with no ART: (1) stavudine, (2) stavudine with substitution by zidovudine after 6 months, (3) zidovudine, and (4) tenofovir. Data were from the Y. R. Gaitonde Centre for AIDS Research and Education in Chennai, India, and published studies. Results. Discounted mean per person survival was 36.9 months (40.2 months undiscounted) with no ART, 115.5 months (145.3) with stavudine-containing ART, 115.7 months (145.6) with stavudine and 6-month zidovudine substitution, 115.8 months (145.6) with zidovudine-containing ART, and 125.8 months (162.0) with initial tenofovir. Discounted lifetime medical costs were $610 with no ART and ranged from $5580 with stavudine-containing ART to $5720 with zidovudine-containing ART. Initial tenofovir had an incremental cost-effectiveness ratio of $670 per year of life saved, compared with no ART, and was more economically efficient than the other regimens.

RESULTS

were most sensitive to variations in the costs of first-line tenofovir, access to additional ART after treatment failure, and quality of life adjustment.

CONCLUSIONS

Using tenofovir as part of first-line ART in India will improve survival, is cost-effective by international standards, and should be considered for initial therapy for HIV-infected patients in India.