Articles tagged as "United States of America"

Food insecurity among people living with HIV in the United States: time for structural level policy changes?

Food insecurity, chronic illness, and gentrification in the San Francisco Bay Area: an example of structural violence in United States public policy.

Whittle HJ, Palar K, Hufstedler LL, Seligman HK, Frongillo EA, Weiser SD. Soc Sci Med. 2015 Aug 20;143:154-161. doi: 10.1016/j.socscimed.2015.08.027. [Epub ahead of print]

Food insecurity continues to be a major challenge in the United States, affecting 49 million individuals. Quantitative studies show that food insecurity has serious negative health impacts among individuals suffering from chronic illnesses, including people living with HIV/AIDS (PLHIV). Formulating effective interventions and policies to combat these health effects requires an in-depth understanding of the lived experience and structural drivers of food insecurity. Few studies, however, have elucidated these phenomena among people living with chronic illnesses in resource-rich settings, including in the United States. Here we sought to explore the experiences and structural determinants of food insecurity among a group of low-income PLHIV in the San Francisco Bay Area. Thirty-four semi-structured in-depth interviews were conducted with low-income PLHIV receiving food assistance from a local non-profit in San Francisco and Alameda County, California, between April and June 2014. Interview transcripts were coded and analysed according to content analysis methods following an inductive-deductive approach. The lived experience of food insecurity among participants included periods of insufficient quantity of food and resultant hunger, as well as long-term struggles with quality of food that led to concerns about the poor health effects of a cheap diet. Participants also reported procuring food using personally and socially unacceptable strategies, including long-term dependence on friends, family, and charity; stealing food; exchanging sex for food; and selling controlled substances. Food insecurity often arose from the need to pay high rents exacerbated by gentrification while receiving limited disability income-a situation resulting in large part from the convergence of long-standing urban policies amenable to gentrification and an outdated disability policy that constrains financial viability. The experiences of food insecurity described by participants in this study can be understood as a form of structural violence, motivating the need for structural interventions at the policy level that extend beyond food-specific solutions.

Abstract access 

Editor’s notes: Studies in the United States of America have demonstrated a high prevalence of food insecurity among low-income people living with HIV. Despite this high prevalence, little is known about the precise structural mechanisms by which food insecurity is distributed across low and high income participants, particularly among people living with HIV. This paper begins to fill that knowledge gap.  Using in-depth interviews among a group of low-income people living with HIV residing in the San Francisco Bay area, this study sought to investigate questions around how food insecurity manifests among certain groups in the population. Three themes relevant to the lived experience of food insecurity emerged from the interviews. The first being periods of significant food shortage where hunger or the anticipation of hunger was a serious source of anxiety for participants. The second was around the perceived poor quality of food where participants were unable to afford a diet that they believed to be sufficiently healthy. They considered this to be detrimental to both their general and HIV-associated health. This led to a third theme: participants using a multitude of resourceful strategies in order to procure food. Some of the strategies they found personally uncomfortable or they perceived as socially unacceptable. A relevant theme around structural determinants of food security that also emerged was the disparity between rent payments and the disability income which participants received. In particular, rising rents due to an influx of people who benefited from the technology boom, alongside gentrification taking place in the San Francisco area made it particularly difficult for low income people living with HIV to afford to live in the city. In order to be able to purchase food which they considered as high priority they would have to ration their money and avoid buying items they considered as less of a necessity (for example, entertainment, travel or toiletries). This is particularly exacerbated by the issue of monthly disability payments being low relative to the cost of living. The findings presented in this paper suggest certain structural activities in order to prevent the adverse effects of food insecurity such as sexual risk, sub-optimal ART adherence and poor clinical outcomes for people living with HIV. There were two suggested measures. The first was protecting vulnerable populations from the market effects of urban regeneration through better state subsidies in housing. The second was helping state-dependent individuals afford an adequate and sufficiently healthy diet by reassessing the amount disbursed through the disability income.

In summary, the authors describe low-income people living with HIV participants who often found themselves pushed into situations of indignity, shame and poor health by large-scale economic forces beyond their control. Without funds to purchase food with adequate nutritional content, they often fell into absolute hunger or had poor diets that prompted concerns about their physical health. Despite the United States of America being a high income country with one of the highest GDP per capita, food insecurity continues to be a challenge. Only broad structural approaches with policy changes can help chronically ill and vulnerable individuals escape both indignities and negative health consequences of food insecurity in the 21st century. 

Northern America
United States of America
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Patient-provider encounters are a key factor in ART usage in the United States

Retained in HIV care but not on antiretroviral treatment: a qualitative patient-provider dyadic study.

Christopoulos KA, Olender S, Lopez AM, Lekas HM, Jaiswal J, Mellman W, Geng E, Koester KA. PLoS Med. 2015 Aug 11;12(8):e1001863. doi: 10.1371/journal.pmed.1001863. eCollection 2015.

Background: Patients retained in HIV care but not on antiretroviral therapy (ART) represent an important part of the HIV care cascade in the United States. Even in an era of more tolerable and efficacious ART, decision making in regards to ART offer and uptake remains complex and calls for exploration of both patient and provider perspectives. We sought to understand reasons for lack of ART usage in patients meeting the Health Resources Services Administration definition of retention as well as what motivated HIV primary care appointment attendance in the absence of ART.

Methods and findings: We conducted a qualitative study consisting of 70 in-depth interviews with ART-naive and ART-experienced patients off ART and their primary care providers in two urban safety-net HIV clinics in San Francisco and New York. Twenty patients and their providers were interviewed separately at baseline, and 15 dyads were interviewed again after at least 3 mo and another clinic visit in order to understand any ART use in the interim. We applied dyadic analysis to our data. Nearly all patients were willing to consider ART, and 40% of the sample went on ART, citing education on newer antiretroviral drugs, acceptance of HIV diagnosis, social support, and increased confidence in their ability to adhere as facilitators. However, the strength of the provider recommendation of ART played an important role. Many patients had internalized messages from providers that their health was too good to warrant ART. In addition, providers, while demonstrating patient-centered care through sensitivity to patients experiencing psychosocial instability, frequently muted the offer of ART, at times unintentionally. In the absence of ART, lab monitoring, provider relationships, access to social services, opiate pain medications, and acute symptoms motivated care. The main limitations of this study were that treatment as prevention was not explored in depth and that participants were recruited from academic HIV clinics in the US, making the findings most generalizable to this setting.

Conclusions: Provider communication with regard to ART is a key focus for further exploration and intervention in order to increase ART uptake for those retained in HIV care.

Abstract  Full-text [free] access

Editor’s notes: This paper draws on qualitative data from two clinics in the United States of America.  It examines the barriers to ART uptake in this new era of ART from the perspectives of people who are retained in clinic care and not currently on ART, and their primary care providers. It further explores factors that have promoted peoples’ regular primary care attendance even in the absence of ART. One of the strengths of this paper is the dyadic approach to the data collection which enabled the authors to compare and contrast the narratives of both care users and providers. The findings of this paper are useful as we reflect on the 90-90-90, an ambitious treatment target recently adopted by UNAIDS to help end the AIDS epidemic.

Recent studies including HPTN 052 and the Strategic Timing of AntirRetroviral Treatment (START) studies have highlighted the individual and public health benefits of early initiation of antiretroviral therapy (ART), regardless of CD4 count. The 90-90-90 target is that by 2020, 90% of all people living with HIV will know their status, 90% of people diagnosed with HIV infection will receive sustained antiretroviral therapy and 90% of people receiving antiretroviral therapy, will have viral suppression.

The findings of this article offer important challenges to sub-Saharan Africa and other resource-poor settings for meeting the 90-90-90 target.  First, although the DART trial illustrated that first-line ART can be delivered safely without routine tests, in this study, many people remained engaged in care because of laboratory monitoring of their health status. Second, many of the people valued strong connections to their healthcare providers which were developed through patient-centred medical care.  This contrasts with treatment contexts such as those in sub-Saharan Africa where people may be less likely to see the same provider continuously or even at consecutive visits. Third, access to additional social and acute care services also motivated some participants to maintain primary care visit attendance. In resource poor contexts, such services are rarely available. Understanding how to retain people on ART in resource-poor settings where economic, social and contextual factors differ, will be an important objective for both individual and public health approaches to managing the epidemic.

Northern America
United States of America
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HIV-associated stigma may impede HIV medication adherence among people living with HIV

The association of HIV-related stigma to HIV medication adherence: a systematic review and synthesis of the literature.

Sweeney SM, Vanable PA. AIDS Behav. 2015 Aug 25. [Epub ahead of print]

This paper provides a review of the quantitative literature on HIV-related stigma and medication adherence, including: (1) synthesis of the empirical evidence linking stigma to adherence, (2) examination of proposed causal mechanisms of the stigma and adherence relationship, and (3) methodological critique and guidance for future research. We reviewed 38 studies reporting either cross-sectional or prospective analyses of the association of HIV-related stigma to medication adherence since the introduction of antiretroviral therapies (ART). Although there is substantial empirical evidence linking stigma to adherence difficulties, few studies provided data on psychosocial mechanisms that may account for this relationship. Proposed mechanisms include: (a) enhanced vulnerability to mental health difficulties, (b) reduction in self-efficacy, and (c) concerns about inadvertent disclosure of HIV status. Future research should strive to assess the multiple domains of stigma, use standardized measures of adherence, and include prospective analyses to test mediating variables.

Abstract access 

Editor’s notes: People living with HIV often experience stigma and discrimination including social isolation and negative stereotyping. Recent evidence suggests that stigma may influence adherence to HIV medication among people living with HIV. This paper presents findings from a systematic review of the evidence on the impact of HIV-associated stigma on HIV medication adherence. The authors identified 38 studies which quantitatively assessed the association between stigma and medication adherence. All studies found evidence indicating that stigma contributed to adherence difficulties among people living with HIV. Included studies looked at diverse patient populations sampled from different countries and contexts. While stigma is heavily influenced by the socio-cultural context, the association between stigma and adherence across diverse contexts indicates that there may be commonalities in what causes stigma and how this relates to adherence.

The authors of this review suggest three possible causal mechanisms of HIV-associated stigma and medication adherence: (1) There may be links between stigma and depressive symptoms, and between depressive symptoms and adherence. Internalized stigma may enhance vulnerability to depressive symptoms, and this may influence adherence to HIV medication. (2) Stigma may cause reductions in self-efficacy – a person’s judgment of his or her ability to organize and execute behaviours - which may influence medication adherence. (3) People may fear HIV status disclosure by being seen taking HIV medication. Fear of status disclosure, and associated stigma, may cause people to avoid taking HIV medication.

The studies included in this review indicate a clear link between HIV-associated stigma and HIV medication adherence. There may be commonalities in what causes stigma across multiple populations. Future research should assess the influence of multiple forms of stigma on adherence, and on testing causal mechanisms between stigma and adherence. 

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START trial illustrates benefit of ART start with CD4>500

Initiation of antiretroviral therapy in early asymptomatic HIV infection.

Lundgren J, Babiker A,  Gordin F, Emery S, Grund B, Sharma S, Avihingsanon A, Cooper D, Fätkenheuer G, Llibre J, Molina J, Munderi P, Schechter M, Wood R, Klingman K, Collins S, Lane H, Phillips A,  Neaton J. INSIGHT START Study Group. N Engl J Med. 2015 Jul 20. [Epub ahead of print]

Background: Data from randomized trials are lacking on the benefits and risks of initiating antiretroviral therapy in patients with asymptomatic human immunodeficiency virus (HIV) infection who have a CD4+ count of more than 350 cells per cubic millimeter.

Methods: We randomly assigned HIV-positive adults who had a CD4+ count of more than 500 cells per cubic millimeter to start antiretroviral therapy immediately (immediate-initiation group) or to defer it until the CD4+ count decreased to 350 cells per cubic millimeter or until the development of the acquired immunodeficiency syndrome (AIDS) or another condition that dictated the use of antiretroviral therapy (deferred-initiation group). The primary composite end point was any serious AIDS-related event, serious non-AIDS-related event, or death from any cause.

Results: A total of 4685 patients were followed for a mean of 3.0 years. At study entry, the median HIV viral load was 12 759 copies per milliliter, and the median CD4+ count was 651 cells per cubic millimeter. On May 15, 2015, on the basis of an interim analysis, the data and safety monitoring board determined that the study question had been answered and recommended that patients in the deferred-initiation group be offered antiretroviral therapy. The primary end point occurred in 42 patients in the immediate-initiation group (1.8%; 0.60 events per 100 person-years), as compared with 96 patients in the deferred-initiation group (4.1%; 1.38 events per 100 person-years), for a hazard ratio of 0.43 (95% confidence interval [CI], 0.30 to 0.62; P<0.001). Hazard ratios for serious AIDS-related and serious non-AIDS-related events were 0.28 (95% CI, 0.15 to 0.50; P<0.001) and 0.61 (95% CI, 0.38 to 0.97; P=0.04), respectively. More than two thirds of the primary end points (68%) occurred in patients with a CD4+ count of more than 500 cells per cubic millimeter. The risks of a grade 4 event were similar in the two groups, as were the risks of unscheduled hospital admissions.

Conclusions: The initiation of antiretroviral therapy in HIV-positive adults with a CD4+ count of more than 500 cells per cubic millimeter provided net benefits over starting such therapy in patients after the CD4+ count had declined to 350 cells per cubic millimeter.

Abstract  Full-text [free] access

Editor’s notes: Guidelines on when to start antiretroviral therapy (ART) are rapidly evolving. The major point of uncertainty, and disagreement between guidelines, has been whether the benefits to individuals of starting ART outweigh the risks for people with high CD4 counts, where the absolute risk of morbidity and mortality is relatively low.

The START study addressed this question among people with CD4 counts greater than 500 cells per µl. Study participants were recruited across the global regions, with the largest number from Europe (33%) followed by Latin America (25%) and Africa (21%). Some 55% were gay men and other men who have sex with men. Retention in the study was very good, and virologic outcomes among people who started ART were excellent (98% and 97% had virologic suppression by 12 months in the immediate versus deferred study arms). There was a 57% reduction in the hazard of the primary outcome, a composite of serious AIDS-associated events, serious non-AIDS associated events or death from any cause. The most common AIDS-associated events were tuberculosis (mostly seen in African participants), malignant lymphoma and Kaposi’s sarcoma. Among the serious non-AIDS events, cancers unrelated to AIDS were reduced by 50%, but interestingly there was no change in cardiovascular events. There was no increase in risk of serious adverse events. Interestingly the magnitude of risk reduction for the primary outcome was similar in high- and low-income countries.

These results will be very important as ART guidelines are reviewed and are likely to lead to recommendations for ART initiation, regardless of CD4 count in most settings. The authors note that, with a relatively low absolute risk of serious events, some people with high CD4 counts may opt to defer treatment, and this trial has produced very useful data to inform this discussion. Benefits from earlier ART initiation are dependent on earlier testing.  With an estimated 50% of people with HIV globally unaware of their status, the uptake of testing by asymptomatic people will need to be increased. In addition, retention in care will need to be optimised if the potential benefits of ART demonstrated by this study are to be realised.

HIV Treatment
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TAF: a new, safer version of tenofovir?

Tenofovir alafenamide versus tenofovir disoproxil fumarate, coformulated with elvitegravir, cobicistat, and emtricitabine, for initial treatment of HIV-1 infection: two randomised, double-blind, phase 3, non-inferiority trials.

Sax PE, Wohl D, Yin MT, Post F, DeJesus E, Saag M, Pozniak A, Thompson M, Podzamczer D, Molina JM, Oka S, Koenig E, Trottier B, Andrade-Villanueva J, Crofoot G, Custodio JM, Plummer A, Zhong L, Cao H, Martin H, Callebaut C, Cheng AK, Fordyce MW, McCallister S, GS-US-292-0104/0111 Study Team. Lancet. 2015 Jun 27;385(9987):2606-15. doi: 10.1016/S0140-6736(15)60616-X. Epub 2015 Apr 15.

Background: Tenofovir disoproxil fumarate can cause renal and bone toxic effects related to high plasma tenofovir concentrations. Tenofovir alafenamide is a novel tenofovir prodrug with a 90% reduction in plasma tenofovir concentrations. Tenofovir alafenamide-containing regimens can have improved renal and bone safety compared with tenofovir disoproxil fumarate-containing regimens.

Methods: In these two controlled, double-blind phase 3 studies, we recruited treatment-naive HIV-infected patients with an estimated creatinine clearance of 50 mL per min or higher from 178 outpatient centres in 16 countries. Patients were randomly assigned (1:1) to receive once-daily oral tablets containing 150 mg elvitegravir, 150 mg cobicistat, 200 mg emtricitabine, and 10 mg tenofovir alafenamide (E/C/F/tenofovir alafenamide) or 300 mg tenofovir disoproxil fumarate (E/C/F/tenofovir disoproxil fumarate) with matching placebo. Randomisation was done by a computer-generated allocation sequence (block size 4) and was stratified by HIV-1 RNA, CD4 count, and region (USA or ex-USA). Investigators, patients, study staff, and those assessing outcomes were masked to treatment group. All participants who received one dose of study drug were included in the primary intention-to-treat efficacy and safety analyses. The main outcomes were the proportion of patients with plasma HIV-1 RNA less than 50 copies per mL at week 48 as defined by the US Food and Drug Administration (FDA) snapshot algorithm (pre-specified non-inferiority margin of 12%) and pre-specified renal and bone endpoints at 48 weeks. These studies are registered with ClinicalTrials.gov, numbers NCT01780506 and NCT01797445.

Findings: We recruited patients from Jan 22, 2013, to Nov 4, 2013 (2175 screened and 1744 randomly assigned), and gave treatment to 1733 patients (866 given E/C/F/tenofovir alafenamide and 867 given E/C/F/tenofovir disoproxil fumarate). E/C/F/tenofovir alafenamide was non-inferior to E/C/F/tenofovir disoproxil fumarate, with 800 (92%) of 866 patients in the tenofovir alafenamide group and 784 (90%) of 867 patients in the tenofovir disoproxil fumarate group having plasma HIV-1 RNA less than 50 copies per mL (adjusted difference 2.0%, 95% CI -0.7 to 4.7). Patients given E/C/F/tenofovir alafenamide had significantly smaller mean serum creatinine increases than those given E/C/F/tenofovir disoproxil fumarate (0.08 vs 0.12 mg/dL; p<0.0001), significantly less proteinuria (median % change -3 vs 20; p<0.0001), and a significantly smaller decrease in bone mineral density at spine (mean % change -1.30 vs -2.86; p<0.0001) and hip (-0.66 vs -2.95; p<0.0001) at 48 weeks.

Interpretation: Through 48 weeks, more than 90% of patients given E/C/F/tenofovir alafenamide or E/C/F/tenofovir disoproxil fumarate had virological success. Renal and bone effects were significantly reduced in patients given E/C/F/tenofovir alafenamide. Although these studies do not have the power to assess clinical safety events such as renal failure and fractures, our data suggest that E/C/F/tenofovir alafenamide will have a favourable long-term renal and bone safety profile.

Abstract access 

Editor’s notes: Tenofovir alafenamide fumarate (TAF) is a new antiretroviral agent developed by Gilead Sciences and is closely related to tenofovir disoproxil fumarate (TDF).  TDF is widely used, highly potent, and safe in the majority of people but long-term use has been associated with small risks of decreased kidney function, chronic kidney disease, and decreased bone mineral density.  Both TAF and TDF are prodrugs of tenofovir but TAF achieves highly potent concentrations of tenofovir inside HIV-relevant immune cells with much lower plasma concentrations than TDF.  The lower plasma concentration of tenofovir associated with TAF is hypothesised to reduce the toxic effects with regards to kidney and bone health. TAF is also effective at the lower dose of 10-25 mg, compared with the standard TDF dose of 300mg per day.  This may translate into lower drug costs if the lower dose required means lower manufacturing costs.

The authors report the combined results of two phase III, non-inferiority studies comparing the safety and effectiveness of TAF with TDF, funded by Gilead Sciences. In both studies, TAF was co-formulated into one, once-a-day tablet with elvitegravir, cobicistat and emtricitabine. There was a high rate of virologic suppression with the TAF-containing regimen, which was non-inferior to the TDF regimen. Compared to TDF, TAF had significantly more favourable effects on renal and bone parameters, with smaller decreases in creatinine clearance and bone mineral density and smaller increases in proteinuria. The real-world clinical significance of these findings remains to be seen but TAF-containing regimens may offer meaningful safety and cost benefits over TDF regimens in the long-term. The favourable characteristics of TAF have also led to the development of a sustained-release subcutaneous TAF implant, which has recently been evaluated in dogs. A long-acting TAF implant could have translational potential as a candidate for HIV prophylaxis in vulnerable populations.

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Tenofovir-based regimens improve outcomes in HIV-HBV co-infection

Comparison of HBV-active HAART regimens in an HIV-HBV multinational cohort: outcomes through 144 weeks.

Thio CL, Smeaton L, Hollabaugh K, Saulynas M, Hwang H, Saravanan S, Kulkarni S, Hakim J, Nyirenda M, Iqbal HS, Lalloo UG, Campbell TB, Lockman S, Currier JS. AIDS. 2015 Jun 19;29(10):1173-82. doi: 10.1097/QAD.0000000000000686.

Objectives: To explore factors associated with short and long-term hepatitis B virus (HBV) DNA suppression in a multinational cohort of HIV-HBV co-infected patients receiving HBV-active antiretrovirals.

Methods: One hundred and fifteen HIV-HBV co-infected patients participating in one of the two global randomized clinical trials conducted by the Adult AIDS Clinical Trials Group of different antiretroviral regimens received either HBV monotherapy with either lamivudine or emtricitabine (N = 56), or HBV dual therapy with tenofovir disoproxil fumarate (TDF) + lamivudine or emtricitabine (N = 59). Associations of pretreatment characteristics with the primary (HBV DNA <200 IU/ml at 24 weeks) and longitudinal outcomes through 144 weeks were explored using logistic regression. HBV drug-resistance mutations were determined by pol sequencing in those with viral rebound.

Results: The proportion with HBV DNA below 200 IU/ml was 60% (95% confidence interval 50-69%) at 24 weeks and 79% (95% confidence interval 69-88%) at 144 weeks. Pretreatment factors associated with the primary outcome were HBV DNA, CD4 T-cell count, and aspartate aminotransferase, but only pretreatment HBV DNA remained associated with long-term suppression (P < 0.0001). HBV therapy group was not significantly associated with the primary outcome at 24 weeks; however, longitudinally, a greater proportion in the dual-therapy group achieved HBV DNA below 200 IU/ml (P = 0.007). A higher proportion of hepatitis B e antigen-negative patients (n = 57) achieved HBV DNA below 200 IU/ml at any point, regardless of the therapy group. All 12 patients with emergence of lamivudine-resistant mutants were in the monotherapy group.

Conclusions: TDF-based dual HBV-active antiretroviral therapy is preferred to treat HIV-HBV co-infected patients. In resource-limited settings in which TDF may not be universally available, lamivudine or emtricitabine HBV monotherapy is a reasonable option in patients with low HBV replication.

Abstract access 

Editor’s notes: Hepatitis B virus infection remains a leading cause of preventable morbidity and mortality globally, through cirrhosis and liver cancer. In settings with a high prevalence of HIV-HBV coinfection, there is an opportunity to optimise clinical management within the public health approach to antiretroviral therapy. This study adds to the evidence base suggesting that antiretroviral regimens containing lamivudine/emtricitabine and tenofovir are associated with better virologic outcomes than regimens without tenofovir for people co-infected with HIV and HBV. In this study, a post hoc analysis of two multicentre randomised controlled trials, regimens with two HBV-active agents provided more durable virologic suppression and limited the emergence of lamivudine-resistant HBV strains. Although recommendations about the treatment of HIV-HBV coinfection are incorporated into WHO antiretroviral guidelines, testing for HBV infection within antiretroviral programmes is still uncommon and tenofovir is not universally employed in standard first-line antiretroviral regimens. With an increasing number of people switching to second-line antiretroviral regimens, there is the additional challenge of identifying HBV infection in order to maintain HBV-active agents within the second-line regimen. There is now a need for better evidence around how to operationalise these recommendations within national antiretroviral programmes.        

Comorbidity, HIV Treatment
Africa, Asia, Latin America
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Diminished immunity despite MMR immunisation in children with perinatally-acquired HIV

Immunity to measles, mumps and rubella in US children with perinatal HIV infection or perinatal HIV exposure without infection.

Siberry GK, Patel K, Bellini W, Karalius B, Purswani M, Burchett SK, Meyer WA, 3rd, Sowers SB, Ellis A, Van Dyke RB, Pediatric HIVACS, Pediatric  HIV AIDS Cohort Study PHACS. Clin Infect Dis. 2015 Jun 9. pii: civ440. [Epub ahead of print]

Background: Children with perinatal HIV infection (PHIV) may not be protected against measles, mumps and rubella because of impaired initial vaccine response or waning immunity. Our objectives were to estimate seroimmunity in PHIV and perinatally HIV-exposed but uninfected (HEU) children and identify predictors of immunity in the PHIV cohort.

Methods: PHIV and HEU were enrolled in the Pediatric HIV/AIDS Cohort Study (PHACS) at ages 7-15 years from 2007-2009. At annual visits, demographic, laboratory, immunization and clinical data were abstracted and serologic specimens were collected. Most recent serologic specimen was used to determine measles seroprotection by plaque-reduction neutralization assay and rubella seroprotection and mumps seropositivity by enzyme immunoassay. Sustained cART was defined as taking cART for at least 3 months.

Results: Among 428 PHIV and 221 HEU PHACS participants, the prevalence was significantly lower in PHIV children for measles seroprotection (57%[95% CI: 52-62%] vs. 99% [95% CI: 96-100%]), rubella seroprotection (65% [95% CI: 60-70%] vs. 98% [95% CI: 95-100%]), and mumps seropositivity (59% [95% CI: 55-64%] vs. 97% [95% CI: 94-99%]). On multivariable analysis, greater number of vaccine doses while receiving sustained cART and higher nadir CD4 percentage between last vaccine dose and serologic testing independently improved the cumulative prediction of measles seroprotection in PHIV. Predictors of rubella seroprotection and mumps seropositivity were similar.

Conclusions: High proportions of PHIV children, but not HEU children, lack serologic evidence of immunity to measles, mumps and rubella, despite documented immunization and current cART. Effective cART before immunization is a strong predictor of current seroimmunity.

Abstract access 

Editor’s notes: Administration of combination measles, mumps and rubella (MMR) vaccine has resulted in dramatic declines in these diseases. Children with HIV, however, may be susceptible to vaccine-preventable diseases despite immunisation, due to weaker or short-lived immunological responses following immunisation. Children living with HIV may be at higher risk of more severe disease. In addition, children who are susceptible to these diseases may contribute to community risk of outbreaks as control of measles, mumps and rubella depends upon a high proportion of the population being immune.

This study demonstrates that sero-protection to rubella and measles and sero-positivity to mumps was substantially lower among children with HIV aged seven to 15 years than among HIV-exposed but HIV-negative children. Notably, nearly all children with HIV in this study had received the full two-dose series of MMR vaccines, in contrast to previous studies where HIV infection has been a risk factor for failure to receive recommended immunisations. Also, despite concerns that HIV-exposed, but HIV-negative children may have subtle immunological abnormalities that could impair their responses to vaccines, the rates of sero-protection and sero-immunity in this group were high, and comparable to rates in the general population.

Previous studies have illustrated that immunosuppression, lack of antiretroviral therapy (ART) or incomplete HIV virologic suppression are associated with a poor response to vaccines. This study demonstrates that a high proportion of older children and youth (all infected perinatally) may not be protected against MMR despite achieving virologic suppression and good immune status with ART.  Timing of receipt of MMR immunisation in relation to ART, but not overall number of vaccine doses, was independently associated with seropositivity to MMR vaccine. Children who received MMR doses after being on sustained ART had significantly higher levels of sero-positivity and sero-protection than children who received MMR vaccine before ART was instituted.    

This study has important policy implications. ART coverage in children globally is still less than coverage in adults. Many children with HIV start ART only in older childhood. Early ART for children followed by the standard MMR schedule as well as repeating MMR vaccine dosing for older children, particularly children who received MMR vaccine prior to starting ART, will be important to avert the risk of these vaccine-preventable infections in this vulnerable population.     

Avoid TB deaths
Northern America
United States of America
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Men who have sex with men in sub-Saharan Africa: a review of the evidence

Emerging themes for sensitivity training modules of African healthcare workers attending to men who have sex with men: a systematic review.

Dijkstra M, van der Elst EM, Micheni M, Gichuru E, Musyoki H, Duby Z, Lange JM, Graham SM, Sanders EJ. Int Health. 2015 May;7(3):151-162. Epub 2015 Jan 16.

Sensitivity training of front-line African health care workers (HCWs) attending to men who have sex with men (MSM) is actively promoted through national HIV prevention programming in Kenya. Over 970 Kenyan-based HCWs have completed an eight-modular online training free of charge (http://www.marps-africa.org) since its creation in 2011. Before updating these modules, we performed a systematic review of published literature of MSM studies conducted in sub-Saharan Africa (sSA) in the period 2011-2014, to investigate if recent studies provided: important new knowledge currently not addressed in existing online modules; contested information of existing module topics; or added depth to topics covered already. We used learning objectives of the eight existing modules to categorise data from the literature. If data could not be categorised, new modules were suggested. Our review identified 142 MSM studies with data from sSA, including 34 studies requiring module updates, one study contesting current content, and 107 studies reinforcing existing module content. ART adherence and community engagement were identified as new modules. Recent MSM studies conducted in sSA provided new knowledge, contested existing information, and identified new areas of MSM service needs currently unaddressed in the online training.

Abstract  Full-text [free] access

Editor’s notes: Same sex practices remain criminalised in sub-Saharan Africa. Gay men and other men who have sex with men face stigma, discrimination, harassment and arrest. Health care workers frequently have no training on issues affecting gay men and other men who have sex with men and are ill-prepared to work sensitively with them. Together these can deter these men from accessing health care and HIV/STI services, increasing their risk of HIV and other poor health outcomes.

This study conducted a systematic review of gay men and other men who have sex with men in sub-Saharan Africa. The findings were used to update an on-line training programme for health care workers in Kenya. This previously comprised modules on i) men who have sex with men and HIV in Africa ii) homophobia: stigma and its effects; iii) sexual identity, coming out and disclosure; iv) anal sex and common sexual practices; v) HIV and STIs; vi) condom and lubricant use; vii) mental health: anxiety, depression and substance use; and viii) risk-reduction counselling. The review updated the training programme with new evidence and two new modules were introduced: ix) ART adherence; and x) community engagement.

Health care workers play a crucial role in reducing stigma and discrimination facing gay men and other men who have sex with men. This systematic review provided a valuable step in updating an important, accessible training programme. Reducing homoprejudice and ensuring health care workers have accurate and up-to-date knowledge are key to improving service uptake by gay men and other men who have sex with men.

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In or out of HIV-care? It depends who you ask

Sorting through the lost and found: are patient perceptions of engagement in care consistent with standard continuum of care measures?

Castel AD, Tang W, Peterson J, Mikre M, Parenti D, Elion R, Wood A, Kuo I, Willis S, Allen S, Kulie P, Ikwuemesi I, Dassie K, Dunning J, Saafir-Callaway B, Greenberg A. J Acquir Immune Defic Syndr. 2015 May 1;69 Suppl 1:S44-55. doi: 10.1097/QAI.0000000000000575.

Background: Indicators for determining one's status on the HIV care continuum are often measured using clinical and surveillance data but do not typically assess patient perspectives. We assessed patient-reported care status along the care continuum and whether it differed from medical records and surveillance data.

Methods: Between June 2013 and October 2014, a convenience sample of clinic-attending HIV-infected persons was surveyed regarding care-seeking behaviors and self-perceived status along the care continuum. Participant responses were matched to DC Department of Health surveillance data and clinic records. Participants' care patterns were classified using Health Resources Services Administration-defined care status: in care (IC), sporadic care (SC), or out of care (OOC). Semistructured qualitative interviews were analyzed using an open coding process to elucidate relevant themes regarding participants' perceptions of engagement in care.

Results: Of 169 participants, most were male participants (64%) and black (72%), with a mean age of 50.7 years. Using self-reported visit patterns, 115 participants (68%) were consistent with being IC, 33 (20%) SC, and 21 (12%) OOC. Among OOC participants, 52% perceived themselves to be fully engaged in HIV care. In the previous year, among OOC participants, 71% reported having a non-HIV-related medical visit and 90% reported current antiretroviral use. Qualitatively, most SC and OOC persons did not see their HIV providers regularly because they felt healthy.

Conclusions: Participants' perceptions of HIV care engagement differed from actual care receipt as measured by surveillance and clinical records. Measures of care engagement may need to be reconsidered as persons not receiving regular HIV care maybe accessing other health care and HIV medications elsewhere.

Abstract access 

Editor’s notes: This interesting mixed methods study examined engagement and retention in HIV care among people living with HIV in Washington DC. In addition to the convenience sample of clinic attendees listed in the abstract of the paper, data were also accessed on people who had not received clinical care in the previous 12 months, according to clinic records. These people were being focused on by a Department of Health initiative to re-engage them in care. As the clinic staff contacted people to re-engage with them they were offered the opportunity to be recruited into this study. A very helpful diagram on page S46 of this paper sets out this recruitment strategy. This sampling approach allowed the authors to compare data collected from an interviewer-administered structured survey (collecting self-reported data) with data abstracted from clinic records (with the participant’s consent)  and data from Department of Health surveillance records. In addition 62 of the participants took part in in-depth interviews. In keeping with other studies on linkage to care, the authors found that participants who were considered ‘out of care’ by the Department of Health and clinic records did not necessarily consider themselves to be out of care. These were often people who were doing well and saw no need to visit the clinic regularly, particularly if, for individuals on antiretroviral therapy, they were able to access drug supplies from other sources. 

The study also suggests the importance of understanding the limitations of different data sources.  While the limitations of self-reported data are well known, the authors also highlight the drawback of using clinic records. The Department of Health re-engagement initiative had found that 57% of the people thought to be out of care were actually receiving care elsewhere. The authors therefore stress the importance of using a combination of data sources in care surveillance. 

Many people considered to be ‘out of care’ by their clinic were surprised to have had this label applied to them. The authors suggest that this finding emphasises the need for better communication between provider and patient so that treatment goals and the importance of regular clinic visits are understood. However, they go on to say that this finding also supports the on-going process of rethinking definitions of ‘engagement in care’ to be more responsive to individual needs and perceptions. Indeed the change in the United States Department of Health and Human Services guidelines to recommend that patients who are virally suppressed can be monitored less-frequently, is in keeping with this suggestion.

Northern America
United States of America
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HIV and sexuality curricula programmes that address gender or power are five times more effective than those that do not

The case for addressing gender and power in sexuality and HIV education: a comprehensive review of evaluation studies.

Haberland NA. Int Perspect Sex Reprod Health. 2015 Mar;41(1):31-42. doi: 10.1363/4103115.

Context: Curriculum-based sexuality and HIV education is a mainstay of interventions to prevent STIs, HIV and unintended pregnancy among young people. Evidence links traditional gender norms, unequal power in sexual relationships and intimate partner violence with negative sexual and reproductive health outcomes. However, little attention has been paid to analyzing whether addressing gender and power in sexuality education curricula is associated with better outcomes.

Methods: To explore whether the inclusion of content on gender and power matters for program efficacy, electronic and hand searches were conducted to identify rigorous sexuality and HIV education evaluations from developed and developing countries published between 1990 and 2012. Intervention and study design characteristics of the included interventions were disaggregated by whether they addressed issues of gender and power.

Results: Of the 22 interventions that met the inclusion criteria, 10 addressed gender or power, and 12 did not. The programs that addressed gender or power were five times as likely to be effective as those that did not; fully 80% of them were associated with a significantly lower rate of STIs or unintended pregnancy. In contrast, among the programs that did not address gender or power, only 17% had such an association.

Conclusions: Addressing gender and power should be considered a key characteristic of effective sexuality and HIV education programs.

Abstract  Full-text [free] access

Editor’s notes: Curriculum-based sexuality and HIV education plays a central role in the prevention of sexually transmitted infections (STI), HIV and unintended pregnancy among young people. This paper synthesizes current evidence from 22 rigorous evaluation studies that assessed the impacts of different curricula based programmes on HIV, STI or pregnancy risk. The nearly opposite outcomes of programmes that address gender and power compared to those that do not, was striking, with programmes that addressed gender or power being five times as likely to be effective as those that did not.

Several common characteristics of effective programmes were identified. In addition to having interactive and learner-centered pedagogical approaches, effective programmes tended to give explicit attention to gender or power in relationships. Effective programmes fostered critical thinking about how gender norms or inequalities in power manifest and operate and influence life, sexual relationships or health. The programmes also support participants to value themselves and recognize their ability to effect change in their life, relationship or community.

The review findings are consistent with broader theory and evidence that links gender, power and intimate partner violence with sexual and reproductive health outcomes, including HIV. The findings illustrate the value of addressing gender in sexual health programming, illustrating that this is not a luxury for programmes, but rather a critical component of successful programming. 

Africa, Northern America
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