JAIDS Journal of Acquired Immune Deficiency Syndromes

HIV Positivity and Referral to Treatment Following Testing of Partners and Children of PLHIV Index Patients in Public Sector Facilities in South Africa Background: There is an imperative need for innovative interventions to identify people living with HIV and initiate them on antiretroviral therapy. The objective of this study was to determine the feasibility of providing index partner/child testing of people living with HIV. Methods: We trained 86 nurses and counsellors in 56 public health facilities in 6 high HIV burden Districts in South Africa 2017 to provide index partner/child testing (tracing and testing of partners/children of people living with HIV). We collected programmatic data including index partner/child HIV positivity by age, gender, and location of testing. In subanalyses, we evaluated factors associated with identifying HIV-positive partners and children in separate models using multivariable logistic regression. Results: We tested 16,033 partners and children of index patients between October 2017 and June 2018. Most of those tested were women (61%) and 20–39 years old (39%). Overall, 6.4% were 10–14 years old, 9.5% were 15–19 years, and 8% were ≥50 years. HIV positivity was 38% [95% confidence interval (CI) = 36% to 40%]. In children ages 10–14 years, 13% were HIV-infected (95% CI = 11% to 14%). In subanalyses, HIV positivity in partners was associated with their increased age [adjusted odds ratio (aOR) for increase in 5-year age category = 1.21; 95% CI = 1.04 to 1.42], female gender (aOR = 1.38; 95% CI = 1.04 to 1.82), and index partner bringing the partner in for HIV testing vs. referring the partner through the provider or recommending testing to the partner (aOR = 1.94, 95% CI = 1.43 to 2.63), adjusting for location of testing. Almost all patients diagnosed (97%) were referred to antiretroviral therapy. Conclusions: Providing index partner/child testing was feasible and we identified a very high yield when testing partners and children of index patients. Index partner and children testing should be offered to all patients living with HIV to improve case finding.

Pregnancy and Neonatal Outcomes Following Prenatal Exposure to Dolutegravir Background: Birth outcome data with dolutegravir exposure during pregnancy, particularly in the first trimester, are needed. Setting: Data were prospectively collected from the Antiretroviral Pregnancy Registry and European Pregnancy and Paediatric HIV Cohort Collaboration. Methods: We reviewed 2 large, independent antiretroviral pregnancy registries to assess birth outcomes associated with maternal dolutegravir treatment during pregnancy. Results: Of 265 pregnancies reported to the Antiretroviral Pregnancy Registry, initial exposure to dolutegravir occurred at conception or first trimester in 173 pregnancies and during the second or third trimester in 92 pregnancies. There were 246 (92.8%) live births resulting in 255 neonates (9 twins), 6 (2.3%) induced abortions, 11 (4.2%) spontaneous abortions, and 2 (0.8%) stillbirths. Birth defects occurred in 7 (2.7%) of 255 live-born neonates, 5 (3.1%) of 162 (includes 6 twins) with conception/first-trimester exposure. Of 101 pregnancies reported to the European Pregnancy and Paediatric HIV Cohort Collaboration, outcomes were available for 84 pregnancies (16 continuing to term and 1 lost to follow-up). There were 81 live births (80 with known initial dolutegravir exposure at conception or first, second, and third trimesters in 42, 21, and 17 live births, respectively), 1 stillbirth (second-trimester exposure), 1 induced abortion (first-trimester exposure), and 1 spontaneous abortion (first-trimester exposure), respectively. Birth defects occurred in 4 live births (4.9%; 95% confidence interval: 1.4 to 12.2), 3 of 42 (7.1%) with exposure at conception or first trimester. Conclusions: Our findings are reassuring regarding dolutegravir treatment of HIV infection during pregnancy but remain inconclusive because of small sample sizes.

Impact of HIV-Status Disclosure on HIV Viral Load in Pregnant and Postpartum Women on Antiretroviral Therapy Background: HIV-status disclosure is widely encouraged by counseling services, in part because it is thought to improve antiretroviral therapy (ART) adherence and thus HIV viral suppression. However, few longitudinal studies have examined the impact of disclosure on HIV viral load (VL) during pregnancy and postpartum. Methods: We explored these associations among 1187 women living with HIV, enrolled between March 2013 and June 2014 in Cape Town, South Africa. Results: Among women who tested HIV-positive before pregnancy, we observed no association between disclosure and VL at entry into antenatal care among those already on ART, nor at delivery and 12 months postpartum among those initiating ART. Among women who tested HIV-positive during pregnancy and initiated ART subsequently, disclosure to a male partner was associated with a reduced risk of VL ≥50 copies/mL at delivery (adjusted risk ratio: 0.56; 95% confidence interval: 0.31 to 1.01). After stratification by relationship status, this association was only observed among women who were married and/or cohabiting. In addition, disclosure to ≥1 family/community member was associated with a reduced risk of VL ≥50 copies/mL at 12 months postpartum (adjusted risk ratio: 0.69; 95% confidence interval: 0.48 to 0.97) among newly-diagnosed women. Conclusions: These findings suggest that the impact of disclosure on VL is modified by 3 factors: (1) timing of HIV diagnosis (before vs. during the pregnancy); (2) relationship to the person(s) to whom women disclose; and (3) in the case of disclosure to a male partner, relationship status. Counseling about disclosure may be most effective if tailored to individual women's circumstances.

Incidence of AIDS-Related Kaposi Sarcoma in All 50 United States From 2000 to 2014 Background: Although declining rates of incident AIDS-related Kaposi sarcoma (KS) have been reported, KS incidence rates have noted race/ethnic, age, and geographic diversity. We performed a comprehensive assessment of recent secular trends in AIDS-related KS incidence in the United States. Methods: We identified incident KS diagnosed in men aged 20–54 years (who comprise most AIDS-related KS in the United States) using the US Cancer Statistics registry data. Joinpoint analysis assessed for trends in age-adjusted incidence rates between 2000 and 2014 calculating average annual percentage changes (AAPCs) with 95% confidence intervals. Heat maps were generated to compare age-adjusted HIV incidence rates with KS incidence rates. Results: Age-adjusted KS incidence rates nationwide decreased from 1.44/100,000 to 0.95/100,000 between 2000 and 2014. Observed rate changes varied across subgroups; eg, there were significant decreases in 30–44 years (AAPC = −5.4%), particularly in Whites and Blacks, significant increases among 20–29 years (AAPC = 2.7), primarily in Blacks, and stable rates among 45–54 years (AAPC = −0.03). In Southern United States, the incidence rates among Blacks did not significantly change. The states with highest average age-adjusted rates over the study period were Georgia (2.71/100,000), New York (2.16/100,000), California (2.02/100,000), Florida (1.90/100,000), and Texas (1.39/100,000), with significantly decreasing trends over time, except Georgia where rates increased (AAPC = 1.8). Conclusions: Although KS incidence rates have decreased nationally, age, racial, and geographic disparities persist, including increasing risk among younger Black men and particularly elevated rates in some southern states and urban areas. Further research is needed to address racial and geographic AIDS-related KS disparities.

Sharing of Injection Drug Preparation Equipment Is Associated With HIV Infection: A Cross-sectional Study Background: Sharing needles/syringes and sexual transmission are widely appreciated as means of HIV transmission among persons who inject drugs (PWIDs). London, Canada, is experiencing an outbreak of HIV among PWIDs, despite a large needle/syringe distribution program and low rates of needle/syringe sharing. Objective: To determine whether sharing of injection drug preparation equipment (IDPE) is associated with HIV infection. Methods: Between August 2016 and June 2017, individuals with a history of injection drug use and residence in London were recruited to complete a comprehensive questionnaire and HIV testing. Results: A total of 127 participants were recruited; 8 were excluded because of failure to complete HIV testing. The remaining 35 HIV-infected (cases) and 84 HIV-uninfected (controls) participants were assessed. Regression analysis found that sharing IDPE, without sharing needles/syringes, was strongly associated with HIV infection (adjusted odds ratio: 22.1, 95% confidence interval: 4.51 to 108.6, P < 0.001). Conclusions: Sharing of IDPE is a risk factor for HIV infection among PWIDs, even in the absence of needle/syringe sharing. Harm reduction interventions to reduce HIV transmission associated with this practice are urgently needed.

Current US Guidelines for Prescribing HIV Pre-exposure Prophylaxis (PrEP) Disqualify Many Women Who Are at Risk and Motivated to Use PrEP Background: US Centers for Disease Control and Prevention clinical guidelines for HIV pre-exposure prophylaxis (PrEP) are widely used to assess patients' PrEP eligibility. The guidelines include 2 versions of criteria—guidance summary criteria and recommended indications criteria—that diverge in a potentially critical way for heterosexually active women: Both require women's knowledge of their own risk behavior, but the recommended indications also require women's knowledge of their partners' HIV risk or recognition of a potentially asymptomatic sexually transmitted infection. This study examined women's PrEP eligibility according to these 2 different versions of criteria across risk and motivation categories. Setting/Methods: HIV-negative women (n = 679) recently engaged in care at Connecticut Planned Parenthood centers were surveyed online in 2017. The survey assessed PrEP eligibility by both versions of Centers for Disease Control and Prevention criteria, HIV risk indicators, PrEP motivation indicators, and sociodemographic characteristics. Results: Participants were mostly non-Hispanic white (33.9%) or black (35.8%) and had low income (<$30,000/year; 58.3%). Overall, 82.3% were eligible for PrEP by guidance summary criteria vs. 1.5% by recommended indications criteria. Women disqualified by recommended indications criteria included those reporting condomless sex with HIV-positive or serostatus-unknown male partners (n = 27, 11.1% eligible); 1 or more recent sexually transmitted infection(s) (n = 53, 3.8% eligible); multiple sex partners (n = 168, 3.0% eligible); intended PrEP use (n = 211, 2.8% eligible); and high self-perceived risk (n = 5, 0.0% eligible). Conclusion: Current guidelines disqualify many women who could benefit from PrEP and may lead to discrepant assessments of eligibility. Guideline reform is needed to improve clarity and increase women's PrEP access and consequent HIV protection.

Adherence to PrEP Among Young Men Who Have Sex With Men Participating in a Sexual Health Services Demonstration Project in Alameda County, California Background: Young men of color who have sex with men face a continual increase in rates of HIV infection. Pre-exposure prophylaxis (PrEP) is an important prevention method for these young men. Setting: The Connecting Resources for Urban Sexual Health (CRUSH) demonstration project provided sexual health services, including PrEP, to young men who have sex with men aged 18–29 years. We report on adherence and factors influencing it. Methods: Participants were offered HIV and sexually transmitted infection testing, prevention counseling, PrEP, and when appropriate, sexually transmitted infection treatment and postexposure prophylaxis. Participants taking PrEP had erythrocyte tenofovir diphosphate and emtricitabine levels measured through dried blood spot testing at 4, 12, and 24 weeks to estimate medication adherence. Participants also completed surveys to assess demographic and psychosocial measures. Results: From February 2014 to November 2015, CRUSH enrolled 257 participants. Ninety-three percent started PrEP, 81% of whom initiated it at their first visit. Twelve percent required postexposure prophylaxis before starting PrEP. Adherence at protective levels was initially high with 87% demonstrating levels consistent with at least 4 doses per week at week 4, compared with 77% at the 48-week follow-up. African American race, exposure to violence, and having survival needs were associated with significantly lower levels of adherence [odds ratio (OR): 0.33; confidence interval (CI): 0.11 to 0.97, P < 0.04; OR: 0.79; CI: 0.59 to 1.04, P < 0.10; OR: 0.51; CI: 0.24 to 1.05, P < 0.07]. Conclusions: Most young men who initiate PrEP adhere at levels that confer protection against HIV infection. Interventions should account for differences in life experiences, particularly addressing the structural challenges facing young African American men.

Brief Report: Impact of PrEP Training for Family Planning Providers on HIV Prevention Counseling and Patient Interest in PrEP in Atlanta, Georgia Background: Safety net family planning (FP) clinics provide vital care for women in high HIV-burden areas and may be ideal pre-exposure prophylaxis (PrEP) delivery sites. Yet, many FP providers lack knowledge about PrEP. Setting: Four safety net FP clinics in Atlanta, Georgia. Methods: We provided a 1.5-hour PrEP informational training for 28 providers working in these sites. To assess the training's impact on PrEP counseling, we enrolled 500 female patients after training (47% ≤ 28 years; 69% black; 12% Hispanic) and determined their PrEP indication based on CDC guidelines. We conducted a postvisit survey to assess provider counseling and patients' interest in PrEP and acceptance of off-site PrEP referral. Results: From pre-training to post-training, provider PrEP knowledge and confidence to identify women who may benefit from PrEP significantly increased. Only 19% of women knew about PrEP before the visit. Among 376 sexually active women, 29% had risk consistent with PrEP indication. Among PrEP-indicated women, 66% reported the provider discussed PrEP, 29% were interested in taking PrEP, but only 18% accepted off-site PrEP referral. Most (76%) were more willing to take PrEP if provided by the FP clinic. Conclusions: After a brief PrEP training, most women with HIV-risk indicators received PrEP counseling during their visits. Once counseled, women expressed interest if it were offered at the FP clinic rather than through off-site referral. Findings highlight the potential impact that PrEP capacity building within safety net FP clinics in high HIV-burden areas may have on PrEP scale-up for women.

Differences Between Groups of Pre-exposure Prophylaxis (PrEP) Using Couples in HIV-Negative/Unknown Relationships Background: Epidemiology research is limited on the characteristics of HIV pre-exposure prophylaxis (PrEP) using couples. Setting: US nationwide sample recruited online in 2017. Methods: HIV negative/unknown gay, bisexual, and other men who have sex with men with HIV negative/unknown partners (n = 3140) were asked about individual and main partner PrEP uptake. Men were coded into the following 5 groups: (1) neither participant nor partner on PrEP, (2) partner only on PrEP, (3) participant only on PrEP, (4) both on PrEP, and (5) unknown partner PrEP use. We examined associations of demographics, relationship factors, condomless anal sex (CAS) with main and causal partners, bacterial sexually transmitted infection diagnoses, and sexual positioning with reported dyadic PrEP use using fully adjusted multinomial logistic regressions. Results: PrEP use was 3.2% for the partner only, 5.7% for the participant only, and 4.9% for both the participant and partner; 5.6% reported not knowing their partner's PrEP use status. Men who reported any CAS with their main partner or any CAS with male casual partners were both more likely to be classified in the dyadic PrEP use group compared with the neither on PrEP group. Compared with monogamous, men in open arrangements were more likely to be classified in each of the 3 PrEP groups compared with the neither on PrEP group. Six-month bacterial sexually transmitted infection prevalence was 2.8%, 8.1%, 8.3%, 15.6%, and 4.0% for the 5 groups, respectively. Conclusions: PrEP use occurred during times of higher risk behavior engagement, but further efforts are needed to expand PrEP use to more partnered gay, bisexual, and other men who have sex with men.

Predictors of Disengagement in Care for Individuals Receiving Pre-exposure Prophylaxis (PrEP) Background: HIV pre-exposure prophylaxis (PrEP) reduces incident HIV infections, but efficacy depends on adherence and retention, among other factors. Substance use disorders, unmet mental health needs, and demographic factors are associated with nonadherence in HIV-infected patients; we studied whether these affect PrEP retention in care. Methods: To investigate potential risk factors disengagement in a comprehensive HIV prevention program, we conducted a retrospective cohort analysis of individuals starting tenofovir–emtricitabine between January 1, 2015, and November 30, 2017. The primary outcome was adherence to the initial 3-visit schedule after PrEP initiation. Results: The cohort was predominantly African American (23%) and Hispanic (46%). Race, ethnicity, substance use, patient health questionnaire 9 score, insurance, and housing status were not associated with retention at the third follow-up visit. Age <30, PrEP initiation in 2017, PrEP initiation in the sexual health clinic, and PrEP same-day start were associated with lower retention; male gender at birth, transition from post‐exposure prophylaxis (PEP) to PrEP, feeling that they could benefit from, or participating in mental health services were associated with increased retention. Overall, retention in HIV preventative care at the first follow-up visit (68%) and third follow-up visit (35%) after PrEP initiation was low. Conclusion: Clinic services and ancillary services (such as mental health) may facilitate retention in care. In this study, select social and behavioral determinants of health were not found to be linked to retention. Focused investigation of reasons for dropout may elucidate the challenges to maintaining individuals in PrEP care and direct resource allocation to those in greatest need.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com