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BackgroundSubstance use (SU) contributes to poor health outcomes, yet limited data exist to inform strategies to optimize SU treatment among persons with human immunodeficiency virus (HIV). We describe SU and SU treatment utilization among women with and without HIV in the Women's Interagency HIV Study (WIHS).MethodsWe included data from women enrolled in WIHS from 2013 to 2020. Current SU was self-reported, nonmedical use of drugs in the past year, excluding use of only marijuana. SU treatment utilization was self-reported use of a drug treatment program in the past year. Multivariable regression models were used to investigate associations between participant characteristics and SU treatment.ResultsAmong 2559 women (1802 women living with HIV [WWH], 757 women without HIV), 14% reported current SU. Among those with current SU (n = 367), 71% reported crack/cocaine followed by 40% reporting opioids, and 42% reported any treatment in the past year. The most common treatments were methadone (64%), Narcotics Anonymous (29%), inpatient programs (28%), and outpatient programs (16%). Among women using opioids (n = 147), 67% reported methadone use in the past year compared to 5% using buprenorphine/naloxone. Multivariable analysis showed lower odds of treatment utilization among WWH with concurrent alcohol or marijuana use. Visiting a psychiatrist/counselor was associated with higher odds of treatment. Among WWH, SU treatment was not associated with HIV-related clinical outcomes.ConclusionsTreatment utilization was high, especially for methadone use. Our results highlight opportunities for accessing SU treatment for WWH, such as the need to prioritize buprenorphine and comprehensive, wraparound services in HIV care settings.

ObjectiveTo test whether substance use mediates the associations between gender-based violence (GBV) and suboptimal adherence to antiretroviral therapy (ART), and GBV and poor engagement in care, among women living with HIV (WLHIV) in the United States (US).DesignWe analyzed longitudinal data collected among 1717 WLHIV in the Women's Interagency HIV Study (WIHS).MethodsFrom 2013 to 2017, WLHIV completed semi-annual assessments on GBV, substance use, and HIV treatment and care. Adjusted multilevel logistic regression models were built to estimate the impact of GBV on; suboptimal (

Neuropsychiatric complications are common among women with HIV (WWH). The pathophysiological mechanisms underlying these complications are not fully known but likely driven in part by immune modulation. We examined associations between T-cell activation states which are required to mount an effective immune response (activation, co-stimulation/normal function, exhaustion, senescence) and neuropsychiatric complications in WWH. 369 WWH (78% HIV RNA undetectable/

BackgroundFood insecurity is associated with increased morbidity and mortality in people with human immunodeficiency virus (HIV) on antiretroviral therapy, but its relationship with immune dysregulation, a hallmark of HIV infection and comorbidity, is unknown.MethodsIn 241 women participating in the Women's Interagency HIV Study, peripheral blood mononuclear cells were characterized by flow cytometry to identify cell subsets, comprising surface markers of activation (%CD38+HLADR+), senescence (%CD57+CD28-), exhaustion (%PD-1+), and co-stimulation (%CD57- CD28+) on CD4+ and CD8+ T cells. Mixed-effects linear regression models were used to assess the relationships of food insecurity with immune outcomes, accounting for repeated measures at ≤3 study visits and adjusting for sociodemographic and clinical factors.ResultsAt the baseline study visit, 71% of participants identified as non-Hispanic Black, 75% were virally suppressed, and 43% experienced food insecurity. Food insecurity was associated with increased activation of CD4+ and CD8+ T cells, increased senescence of CD8+ T cells, and decreased co-stimulation of CD4+ and CD8+ T cells (all P 40 copies/mL and CD4

Food insecurity (FI) contributes to HIV-related morbidity and mortality, but the mechanisms whereby FI negatively impacts HIV health are untested. We tested the hypothesis that FI leads to poor HIV clinical outcomes through nutritional, mental health, and behavioral paths. We analyzed data from Women's Interagency HIV Study (WIHS) among 1803 women living with HIV (WLWH) (8225 person-visits) collected from 2013 to 2015 biannually from nine sites across the United States participating in the WIHS. FI was measured with the US Household Food Security Survey Module. Outcomes included HIV viral nonsuppression, CD4 cell counts, and physical health status (PHS). We used longitudinal logistic and linear regression models with random effects to examine associations adjusting for covariates and path analysis to test nutritional, mental health, and behavioral paths. Increasing severity of FI was associated with unsuppressed viral load, lower CD4 counts, and worse PHS (all p

BackgroundFood insecurity is a well-established determinant of suboptimal, self-reported antiretroviral therapy (ART) adherence, but few studies have investigated this association using objective adherence measures. We examined the association of food insecurity with levels of ART concentrations in hair among women living with human immunodeficiency virus (WLHIV) in the United States.MethodsWe analyzed longitudinal data collected semiannually from 2013 through 2015 from the Women's Interagency HIV Study, a multisite, prospective, cohort study of WLHIV and controls not living with HIV. Our sample comprised 1944 person-visits from 677 WLHIV. Food insecurity was measured using the US Household Food Security Survey Module. ART concentrations in hair, an objective and validated measure of drug adherence and exposure, were measured using high-performance liquid chromatography with mass spectrometry detection for regimens that included darunavir, atazanavir, raltegravir, or dolutegravir. We conducted multiple 3-level linear regressions that accounted for repeated measures and the ART medication(s) taken at each visit, adjusting for sociodemographic and clinical characteristics.ResultsAt baseline, 67% of participants were virally suppressed and 35% reported food insecurity. In the base multivariable model, each 3-point increase in food insecurity was associated with 0.94-fold lower ART concentration in hair (95% confidence interval, 0.89 to 0.99). This effect remained unchanged after adjusting for self-reported adherence.ConclusionsFood insecurity was associated with lower ART concentrations in hair, suggesting that food insecurity may be associated with suboptimal ART adherence and/or drug absorption. Interventions seeking to improve ART adherence among WLHIV should consider and address the role of food insecurity.

BackgroundMen who have sex with men (MSM) have a high prevalence of anal and penile human papillomavirus (HPV) infections with MSM living with HIV (MSMLH) bearing the highest rates. Data on anogenital high-risk HPV (hrHPV) among MSM in Rwanda and the associated risk factors are scant.MethodsWe recruited 350 self-identified MSM aged 18 years living in Kigali, Rwanda, with 300 recruited from the community and 50 from partner clinics. Anal and penile specimens from all participants were analyzed for hrHPV using the AmpFire platform. Logistic regression was used to calculate crude odds ratios (ORs) and adjusted ORs (aORs) with 95% confidence intervals (95% CIs) as a measure of association between various factors and anal and penile hrHPV infection prevalence.ResultsAnal hrHPV prevalence was 20.1%, was positively associated with having receptive anal sex with more partners (aOR: 9.21, 95% CI: 3.66 to 23.14), and was negatively associated with having insertive anal sex with more partners (aOR: 0.28, 95% CI: 0.12 to 0.66). Penile hrHPV prevalence was 35.0%, was negatively associated with having receptive anal sex with more partners (aOR: 0.29, 95% CI: 0.13 to 0.66), and differed significantly by HIV status, with 55.2% and 29.7% for MSMLH and HIV-negative MSM, respectively (P < 0.01).ConclusionPenile hrHPV prevalence was higher than that of anal hrHPV and it was significantly higher in Rwandan MSMLH than in HIV-negative MSM. The prevalence of anal and penile HPV infections is likely variable at different locations in Africa, according to a number of factors including HIV status and sexual practices.

BackgroundFood insecurity, which disproportionately affects marginalized women in the United States, is associated with depressive symptoms. Few studies have examined relations of food insecurity with other mental health outcomes.ObjectiveThe aim of this study was to investigate the associations of food insecurity with symptoms of generalized anxiety disorder (GAD), stress, and posttraumatic stress disorder (PTSD) in the Women's Interagency HIV Study (WIHS), a prospective cohort study of women with or at risk of HIV in the United States.MethodsParticipants were 2553 women with or at risk of HIV, predominantly African American/black (71.6%). Structured questionnaires were conducted during April 2013-March 2016 every 6 mo. Food security (FS) was the primary predictor, measured using the Household Food Security Survey Module. We measured longitudinal outcomes for GAD (GAD-7 score and a binary GAD-7 screener for moderate-to-severe GAD). Only cross-sectional data were available for outcomes measuring perceived stress (PSS-10 score) and PTSD (PCL-C score and a binary PCL-C screener for PTSD). We examined associations of FS with the outcomes through use of multivariable linear and logistic regression, including lagged associations with GAD outcomes.ResultsAfter adjusting for sociodemographic and health-related factors including HIV serostatus, current marginal, low, and very low FS were associated with increasingly higher GAD-7 scores, and with 1.41 (95% CI: 1.10, 1.80; P

BackgroundFood insecurity and mental health negatively affect the lives of women in the United States. Participants in the Women's Interagency HIV Study (WIHS) provided the opportunity to understand the association of food insecurity with depression and mental well-being over time.ObjectiveWe investigated the association between current and persistent food insecurity and depression among women at risk of or living with HIV in the United States.MethodsWe used longitudinal data from the WIHS, a prospective cohort study in women at risk of or living with HIV from multiple sites in the United States. Participants completed 6 semiannual assessments from 2013 to 2016 on food security (FS; high, marginal, low, and very low) and mental health (i.e., depressive symptoms and mental well-being). We used multiple regression analysis to estimate the association between these variables.ResultsAmong 2551 participants, 44% were food insecure and 35% reported depressive symptoms indicative of probable depression. Current marginal, low, and very low FS were associated with 2.1-, 3.5-, and 5.5-point (all P

BackgroundChronic inflammation is associated with AIDS-defining and non-AIDS-defining conditions. Limited research has considered how food insecurity influences chronic inflammation among people living with human immunodeficiency virus (HIV). We examined whether food insecurity was associated with higher levels of inflammation among women living with HIV (WWH) in the United States.MethodsWe analyzed cross-sectional data collected in 2015 from 421 participants on antiretroviral therapy from the Women's Interagency HIV Study. The exposure was any food insecurity. The outcome was inflammation, measured by proinflammatory cytokine interleukin-6 (IL-6) and tumor necroses factor receptor 1 (TNFR1) levels. We conducted multivariable linear regressions, adjusting for sociodemographic, clinical, and nutritional factors.ResultsNearly one-third of participants (31%) were food insecure and 79% were virally suppressed (

Background and aimsFew longitudinal studies have examined the relationship between food insecurity and substance use. We aimed to investigate this relationship using longitudinal data among women with or at risk for HIV in the United States.DesignWomen's Interagency HIV Study (WIHS), a prospective cohort study.SettingNine sites across the United States.ParticipantsA total of 2553 women with or at risk for HIV.MeasurementsSemi-annual structured interviews were conducted during April 2013-March 2016. Food security (FS) was the primary predictor, measured using the Household Food Security Survey Module. Outcomes were: any illicit substance use except cannabis; licit or illicit cannabis use; stimulant use (crack, cocaine, or methamphetamine); opioid use (heroin or methadone in a non-prescribed way); and prescription drug misuse (prescription narcotics, amphetamines, or tranquilizers in a non-prescribed way) since the last visit. We used multivariable logistic regression with random effects to examine longitudinal associations of current and previous FS with the outcomes simultaneously, adjusting for socio-demographic factors, HIV serostatus, physical health and health insurance.FindingsAverage number of visits was 4.6. At baseline, 71% of participants were HIV-seropositive, 44% reported marginal, low, or very low FS, and 13% were using illicit substances. In adjusted analyses, current low and very low FS were significantly associated with 1.59 [95% confidence interval (CI) = 1.02, 2.46; P = 0.039] and 2.48 (95% CI = 1.52, 4.04; P

Food insecurity, internalized HIV stigma, and depressive symptoms are independently associated with poor HIV outcomes. Food insecurity, stigma, and depression may be interrelated among women living with HIV (WLHIV). We hypothesized that food insecurity would be independently associated with internalized stigma and depressive symptoms among WLHIV in the United States (US), and would partially account for associations between stigma and depressive symptoms. We tested hypotheses using regression models and partial correlation analysis with cross-sectional data among 1317 WLHIV from the Women's Interagency HIV Study. In adjusted models, greater food insecurity was associated with internalized HIV stigma and depressive symptoms (all p

Background Little is known about penile high-risk human papillomavirus (hrHPV) among men who have sex with men (MSM) in low- and middle-income countries. We aimed to determine the incidence, clearance, and persistence of penile hrHPV among Rwandan MSM. Methods We enrolled 350 MSM (345 with valid human papillomavirus [HPV] results) aged ≥18 years. At each visit (6–12 months apart), we collected penile PreservCyt specimens and blood for HPV and HIV testing, as well as sociodemographic and behavioral variables. HPV testing was performed with the Ampfire assay. Penile hrHPV incidence and clearance per 1000 person-months of follow-up, as well as prevalent and incident persistence, were computed and compared by HIV status. Results The mean (SD) age was 27.7 (6.7) years and 19.4% were living with HIV. Penile hrHPV incidence was 34.8 (95% CI, 29.1–41.8) per 1000 person-months of follow-up. HPV-16 (11.7; 95% CI, 9.26–14.9) and HPV-59 (6.1; 95% CI, 4.52–8.39) had the highest incidence rates. Prevalent and incident persistence was 47.5% and 46.6%, respectively. HPV-66 (33.3%), HPV-52 (30.8%), and HPV-16 (29.2%) had the highest prevalent persistence and HPV-33 (53.8%), HPV-31 (46.7%), and HPV-16 (42.6%) the highest incident persistence. No differences were found by HIV status except for HPV-45 (higher in MSM with HIV). Conclusions We found high incidence and prevalent/incident persistence of penile hrHPV among Rwandan MSM. This highlights the importance of preventive strategies for HPV-associated anogenital cancers. [ABSTRACT FROM AUTHOR]

Background: The syndemic of HIV, substance use (SU), and mental illness has serious implications for HIV disease progression among women. We described co-utilization of HIV care, SU treatment, and mental health treatment among women with or at risk for HIV. Methods: We included data from women with or at risk for HIV (n = 2559) enrolled in all 10 sites of the Women's Interagency HIV Study (WIHS) from 2013 to 2020. Current SU was defined as self-reported, non-medical use of drugs in the past year, excluding use of only marijuana. Tobacco and alcohol were assessed separately. We described co-utilization of SU treatment, tobacco and alcohol use treatment, HIV care, and mental health care in the past year among women who were eligible for each service. We compared service utilization by those who did/did not utilize SU treatment using Wald Chi-square tests. Results: Among women with current SU (n = 358), 42% reported utilizing SU treatment. Among those with current SU+HIV (n = 224), 84% saw their HIV provider, and 34% saw a mental health provider. Among women with current SU+heavy alcohol use (n = 95), 18% utilized alcohol use treatment; among current SU+tobacco use (n = 276), 8% utilized tobacco use treatment. Women who utilized SU treatment had higher utilization of alcohol use treatment (59% vs. 5%; P <.001) and tobacco use treatment (12% vs. 5%; P =.028). HIV care engagement was high regardless of SU treatment. Conclusions: We found high engagement in SU and HIV care, but low engagement in alcohol and tobacco use treatment. Integrated SU treatment services for women, including tobacco/alcohol treatment and harm reduction, are needed to optimize treatment engagement and HIV care continuum outcomes. [ABSTRACT FROM AUTHOR]

There is insufficient research on the impact of perceived discrimination in healthcare settings on adherence to antiretroviral therapy (ART), particularly among women living with HIV, and even less is known about psychosocial mechanisms that may mediate this association. Cross-sectional analyses were conducted in a sample of 1356 diverse women living with HIV enrolled in the Women's Interagency HIV Study (WIHS), a multi-center cohort study. Indirect effects analysis with bootstrapping was used to examine the potential mediating roles of internalized stigma and depressive symptoms in the association between perceived discrimination in healthcare settings and ART adherence. Perceived discrimination in healthcare settings was negatively associated with optimal (95% or better) ART adherence (adjusted odds ratio (AOR) = 0.81, p = 0.02, 95% confidence interval (CI) [0.68, 0.97]). Furthermore, internalization of stigma and depressive symptoms mediated the perceived discrimination-adherence association: Serial mediation analyses revealed a significant indirect effect of perceived discrimination in healthcare settings on ART adherence, first through internalized HIV stigma, and then through depressive symptoms (B = - 0.08, SE = 0.02, 95% CI [- 0.12, - 0.04]). Perceiving discrimination in healthcare settings may contribute to internalization of HIV-related stigma, which in turn may lead to depressive symptoms, with downstream adverse effects on ART adherence among women. These findings can guide the design of interventions to reduce discrimination in healthcare settings, as well as interventions targeting psychosocial mechanisms that may impact the ability of women living with HIV to adhere to ART regimens.

BackgroundAmong low-income women with and without HIV, it is a priority to reduce age-related comorbidities, including hypertension and its sequelae. Because consistent health insurance access has been identified as an important factor in controlling many chronic diseases, we estimated the effects of coverage interruption on loss of hypertension control in a cohort of women in the United States.MethodsWe analyzed prospective, longitudinal data from the Women's Interagency HIV Study. HIV-infected and HIV-uninfected women were included between 2005 and 2014 when they reported health insurance at consecutive biannual visits and had controlled hypertension, and were followed for any insurance break and loss of hypertension control. We estimated hazard ratios (HRs) by Cox proportional hazards regression with inverse-probability-of-treatment-and censoring weights (marginal structural models), and plotted the cumulative incidence of hypertension control loss.ResultsAmong 890 HIV-infected women, the weighted HR for hypertension control loss comparing health insurance interruption to uninterrupted coverage was 1.37 (95% confidence interval [CI], 0.99-1.91). Inclusion of AIDS Drug Assistance Program (ADAP) participation with health insurance modestly increased the HR (1.47; 95% CI, 1.04-2.07). Analysis of 272 HIV-uninfected women yielded a similar HR (1.39; 95% CI, 0.88-2.21). Additionally, there were indications of uninterrupted coverage having a protective effect on hypertension when compared with the natural course in HIV-infected (HR, 0.82; 95% CI, 0.61-1.11) and HIV-uninfected (HR, 0.78; 95% CI, 0.52-1.19) women.ConclusionsThis study provides evidence that health insurance continuity promotes hypertension control in key populations. Interventions that ensure coverage stability and ADAP access should be a policy priority.

Women in the general population experience more food insecurity than men. Few studies have examined food insecurity's impact on HIV treatment outcomes among women. We examined the association between food insecurity and HIV outcomes in a multi-site sample of HIV-infected women in the United States (n = 1154). Two-fifths (40%) of participants reported food insecurity. In an adjusted multivariable Tobit regression model, food insecurity was associated with 2.08 times higher viral load (95% confidence interval (CI): 1.04, 4.15) and lower CD4+ counts (- 42.10, CI: - 81.16, - 3.03). Integration of food insecurity alleviation into HIV programs may improve HIV outcomes in women.

There is limited research examining the sexual health and well-being of older women living with HIV (OWLH). Most studies focus on sexual dysfunction, leaving aside the richer context of sexuality and sexual health, including the effect of age-related psychosocial and interpersonal changes on sexual health behaviors. Guided by the integrative biopsychosocial model and the sexual health model, this study explored the importance of sex and sexuality among OWLH to identify their sexual health and HIV prevention needs for program planning. A purposive sample (n = 50) of OWLH was selected from a parent study (n = 2052). We conducted 8 focus groups and 41 in-depth interviews with 50 African American and Latina OWLH aged 50-69 years old in three U.S. cities. The triangulation approach was used to synthesize the data. Six salient themes emerged: sexual pleasure changes due to age, sexual freedom as women age, the role of relationships in sexual pleasure, changes in sexual ability and sexual health needs, sexual risk behaviors, and ageist assumptions about older women's sexuality. We found that sexual pleasure and the need for intimacy continue to be important for OWLH, but that changing sexual abilities and sexual health needs, such as the reduction of sexual desire, as well as increased painful intercourse due to menopause-associated vaginal drying, were persistent barriers to sexual fulfillment and satisfaction. Particular interpersonal dynamics, including low perceptions of the risk of HIV transmission as related to gender, viral suppression, and habitual condomless sex with long-term partners without HIV transmission have resulted in abandoning safer sex practices with serodiscordant partners. These findings suggest that HIV prevention for OWLH should focus on how sexual function and satisfaction intersect with sexual risk. HIV prevention for OWLH should promote ways to maintain satisfying and safe sex lives among aging women.

Introduction: High levels of HIV stigma as well as stigma directed towards sexual and/or gender minorities (SGMs) are well documented in the African setting. These intersecting stigmas impede psychosocial wellbeing and HIV prevention and care. Yet, there are few if any evidence‐based interventions that focus on reducing internalized stigma and promoting mental health and HIV wellness for SGMs in Africa. We developed and evaluated a group‐based intervention drawing on cognitive behavioural therapy (CBT) strategies for men who have sex with men (MSM) and transgender women (TGW) at risk for or living with HIV in Lagos, Nigeria. Methods: The intervention comprised four weekly in‐person group sessions facilitated by community health workers. We conducted a delayed intervention group randomized controlled trial (April−September 2022), with pre‐post surveys plus 3‐month follow‐up (immediate group only), as well as qualitative research with participants and programme staff. Outcomes included internalized stigma related to SGM and HIV status, depression, resiliency/coping and pre‐exposure prophylaxis (PrEP)/HIV treatment use. Results: Mean age of the 240 participants was 26 years (range 18−42). Seventy‐seven percent self‐identified as MSM and 23% TGW; 27% were people with HIV. Most (88%) participants attended all four sessions, and 98% expressed high intervention satisfaction. There was significant pre‐post improvement in each psychosocial outcome, in both the immediate and delayed arms. There were further positive changes for the immediate intervention group by 3‐month follow‐up (e.g. in intersectional internalized stigma, depression). While baseline levels of ever‐PrEP use were the same, 75% of immediate‐group participants reported currently using PrEP at 3 months post‐intervention versus 53% of delayed‐group participants right after the intervention (p<0.01). Participants post‐intervention described (in qualitative interviews) less self‐blame, and enhanced social support and resilience when facing stigma, as well as motivation to use PrEP, and indicated that positive pre‐intervention changes in psychosocial factors found in the delayed group mainly reflected perceived support from the study interviewers. Conclusions: This study demonstrated the feasibility and acceptability of a group‐based CBT model for MSM and TGW in Nigeria. There were also some indications of positive shifts related to stigma, mental health and PrEP, despite issues with maintaining the randomized design in this challenging environment. [ABSTRACT FROM AUTHOR]

Introduction: The COVID-19 pandemic has impacted population health around the globe, directly and indirectly. The objective of this study was to document changes in HIV care associated with the COVID-19 pandemic at selected clinics in Central Africa, along with clinic-level strategies for minimizing disruptions in HIV care and treatment for people with HIV (PWH). Methods: A 51-item questionnaire on COVID-19 pandemic-associated changes in HIV service delivery was completed by clinicians involved in HIV care at 21 clinics in five countries participating in Central Africa International epidemiology Databases to Evaluate AIDS (CA-IeDEA). The survey was completed at two timepoints: June-July 2020 and October 2020 to February 2021. Descriptive statistics were used to characterize changes in HIV care and related services. Results: While 81% of sites reported at least one negative consequence of COVID-19 for clinic operations during the first survey, none reported suspending antiretroviral therapy (ART) initiation services for new patients, and 24% reported adopting telemedicine. In the follow-up survey, fewer sites (48%) reported at least one disruption to clinic operations, and more sites reported mitigation strategies, including expanding rapid ART initiation services and providing extra supplies of ART medications to reduce visit frequency. In the follow-up survey, more sites, especially in Rwanda, reported stockouts of commodities, including HIV and viral load testing and HIV pre-exposure prophylaxis. More than one-fifth of sites reported stockouts of second- or third-line ART at each survey timepoint. Conclusions: While the initial wave of the COVID-19 pandemic resulted in concerning disruptions to HIV service delivery at CA-IeDEA sites, most of these disruptions attenuated over time, and many sites introduced measures to help PWH avoid frequent visits to the clinic for care and medications. The impact of HIV commodity stockouts and clinic mitigation strategies on treatment outcomes needs to be assessed. [ABSTRACT FROM AUTHOR]

Introduction: Transgender men and women in Nigeria experience many barriers in accessing HIV prevention and treatment services, particularly given the environment of transphobia (including harassment, violence and discrimination) and punitive laws in the country. HIV epidemic control in Nigeria requires improving access to and quality of HIV services for key populations at high risk, including transgender men and women. We assessed how stigma influences HIV services for transgender people in Lagos, Nigeria. Methods: In‐depth interviews (IDIs) and focus group discussions were conducted with transgender men (n = 13) and transgender women (n = 25); IDIs were conducted with community service organization (CSO) staff (n = 8) and healthcare providers from CSO clinics and public health facilities (n = 10) working with the transgender population in March 2021 in Lagos. Content analysis was used to identify how stigma influences transgender people's experiences with HIV services. Results and discussion: Three main findings emerged. First, gender identity disclosure is challenging due to anticipated stigma experienced by transgender persons and fear of legal repercussions. Fear of being turned in to authorities was a major barrier to disclose to providers in facilities not affiliated with a transgender‐inclusive clinic. Providers also reported difficulty in eliciting information about the client's gender identity. Second, respondents reported lack of sensitivity among providers about gender identity and conflation of transgender men with lesbian women and transgender women with being gay or men who have sex with men, the latter being more of a common occurrence. Transgender participants also reported feeling disrespected when providers were not sensitive to their pronoun of preference. Third, HIV services that are not transgender‐inclusive and gender‐affirming can reinforce stigma. Both transgender men and women spoke about experiencing stigma and being refused HIV services, especially in mainstream public health facilities, as opposed to transgender‐inclusive CSO clinics. Conclusions: This study highlights how stigma impedes access to appropriate HIV services for transgender men and women, which can have a negative impact along the HIV care continuum. There is a need for transgender‐inclusive HIV services and competency trainings for healthcare providers so that transgender clients can receive appropriate and gender‐affirming HIV services. [ABSTRACT FROM AUTHOR]

Introduction: Disclosure of one's HIV status may decrease depression and improve the quality of life among people living with HIV. However, there is mixed evidence on the impact of disclosure to partners for pregnant women living with HIV (WLHIV) in areas of intersecting social concerns over disclosure and high prevalence of intimate partner violence (IPV). We assessed the association between HIV disclosure and depressive symptoms among pregnant WLHIV in the Democratic Republic of Congo (DRC) and examined whether the knowledge of partner's status or recent IPV modified this association. Methods: We utilized data from participants enrolled in a trial to evaluate the effect of continuous quality interventions on long‐term therapy outcomes among HIV‐positive pregnant and breastfeeding women in DRC (NCT03048669). Only pregnant women (n = 1392) were included in this cross‐sectional analysis. Between November 2016 and June 2019, enrolled participants completed a survey that included the Patient Health Questionnaire‐9 (PHQ‐9) to screen recent depressive symptoms, questions about disclosure, knowledge of partner's status and IPV. We used linear models to calculate crude and adjusted mean differences (MDs) between disclosure and depressive symptoms. All analyses were stratified by timing of HIV diagnosis. Results: Disclosure was higher among participants diagnosed prior to current pregnancy (41% to their partners and 24% to family, friends or others) relative to those diagnosed during current pregnancy (21% to partners and 12% to family). About one‐quarter of women reported any type of IPV in the past 12 months. Disclosure to a partner was associated with lower depressive symptoms among women diagnosed prior to current pregnancy (MD −0.55; 95% CI: −1.06, −0.04) but the opposite was observed among those diagnosed during current pregnancy (MD 0.5; 95% CI: −0.4, 1.4). Adjustment for IPV, knowledge of partner's status, age, number of living children and primigravidae did not change MDs substantially. Conclusions: Women in our sample mostly disclosed to partners despite high IPV burden. The observed association between disclosure to partners and lower depressive symptoms among women diagnosed prior to current pregnancy is consistent with cross‐national evidence. A prospective study among pregnant WLHIV is needed to examine longitudinal effects of HIV status disclosure. [ABSTRACT FROM AUTHOR]

In 2019, the National Institutes of Health combined the Multicenter AIDS Cohort Study (MACS) and the Women's Interagency HIV Study (WIHS) into the MACS/WIHS Combined Cohort Study (MWCCS). In this paper, participants who made a study visit during October 2018–September 2019 (targeted for MWCCS enrollment) are described by human immunodeficiency virus (HIV) serostatus and compared with people living with HIV (PLWH) in the United States. Participants include 2,115 women and 1,901 men with a median age of 56 years (interquartile range, 48–63); 62% are PLWH. Study sites encompass the South (18%), the Mid-Atlantic/Northeast (45%), the West Coast (22%), and the Midwest (15%). Participant race/ethnicity approximates that of PLWH throughout the United States. Longitudinal data and specimens collected for 35 years (men) and 25 years (women) were combined. Differences in data collection and coding were reviewed, and key risk factor and comorbidity data were harmonized. For example, recent use of alcohol (62%) and tobacco (28%) are common, as are dyslipidemia (64%), hypertension (56%), obesity (42%), mildly or severely impaired daily activities (31%), depressive symptoms (28%), and diabetes (22%). The MWCCS repository includes serum, plasma, peripheral blood mononuclear cells, cell pellets, urine, cervicovaginal lavage samples, oral samples, B-cell lines, stool, and semen specimens. Demographic differences between the MACS and WIHS can confound analyses by sex. The merged MWCCS is both an ongoing observational cohort study and a valuable resource for harmonized longitudinal data and specimens for HIV-related research. [ABSTRACT FROM AUTHOR]

Clinical health record data are used for HIV surveillance, but the extent to which these data are population representative is not clear. We compared age, marital status, body mass index, and pregnancy distributions in the Central Africa International Databases to Evaluate AIDS (CA-IeDEA) cohorts in Burundi and Rwanda to all people living with HIV and the subpopulation reporting receiving a previous HIV test result in the Demographic and Health Survey (DHS) data, restricted to urban areas, where CA-IeDEA sites are located. DHS uses a probabilistic sample for population-level HIV prevalence estimates. In Rwanda, the CA-IeDEA cohort and DHS populations were similar with respect to age and marital status for men and women, which was also true in Burundi among women. In Burundi, the CA-IeDEA cohort had a greater proportion of younger and single men than the DHS data, which may be a result of outreach to sexual minority populations at CA-IeDEA sites and economic migration patterns. In both countries, the CA-IeDEA cohorts had a higher proportion of underweight individuals, suggesting that symptomatic individuals are more likely to access care in these settings. Multiple sources of data are needed for HIV surveillance to interpret potential biases in epidemiological data. [ABSTRACT FROM AUTHOR]

Background: Cervical cancer is a leading cause of death among Cameroon women. The burden of cervical cancer is in part traceable to the inadequate understanding of socio-contextual determinants of access to screening and prevention opportunities. We explored multilevel individual, community and structural factors that facilitate or inhibit cervical cancer prevention in women at risk in a low-income, high HIV prevalence context.Methods: We utilized an exploratory qualitative approach to obtain data through focus group discussions and in-depth interviews from May to August, 2018. A two-stage purposive sampling strategy was used to select 80 women and 20 men who participated in 8 focus group discussions and 8 in-depth interviews. The socio-ecological model guided data analyses to identify micro-, meso-, and macro-level determinants of cervical cancer screening.Results: Micro-level factors including lack of awareness and knowledge about cervical cancer, lack of access to information, excessive cost of cervical cancer screening, low risk perceptions, and poor health seeking behaviors were major barriers for women seeking cervical cancer screening. Meso-level factors, such as social networks, socio-cultural norms, perceptions of the role of men and HIV-related stigma when screening is integrated into HIV care, also engender negative attitudes and behaviors. Macro-level barriers to cervical cancer screening included poorly equipped health facilities and a lack of national cancer prevention policies and programs.Conclusion: In the context of the call for elimination of cervical cancer as a public health problem, our findings highlight challenges and opportunities that should be considered when implementing interventions to increase uptake of cervical cancer screening in low-middle income settings. [ABSTRACT FROM AUTHOR]

Background: Our objectives were to estimate the association of gender-based violence (GBV) experience with the risk of sexually transmitted infection (STI) acquisition in HIV-seropositive and HIV-seronegative women, to compare the STI risks associated with recent and lifetime GBV exposures, and to quantify whether these associations differ by HIV status. Methods: We conducted a multicenter, prospective cohort study in the Women's Interagency HIV Study, 1994–2018. Poisson models were fitted using generalized estimating equations to estimate the association of past 6-month GBV experience (physical, sexual, or intimate partner psychological violence) with subsequent self-reported STI diagnosis (gonorrhea, syphilis, chlamydia, pelvic inflammatory disease, or trichomoniasis). Results: Data from 2868 women who reported recent sexual activity comprised 12,069 person-years. Higher STI risk was observed among HIV-seropositive women (incidence rate [IR] 5.5 per 100 person-years) compared with HIV-seronegative women (IR 4.3 per 100 person-years). Recent GBV experience was associated with a 1.28-fold (95% confidence interval [CI] 0.99, 1.65) risk after adjustment for HIV status and relevant demographic, socioeconomic, and sexual risk variables. Other important risk factors for STI acquisition included unstable housing (adjusted incidence rate ratio [AIRR] 1.81, 95% CI 1.32–2.46), unemployment (AIRR 1.42, 95% CI 1.14–1.76), transactional sex (AIRR 2.06, 95% CI 1.52–2.80), and drug use (AIRR 1.44, 95% CI 1.19–1.75). Recent physical violence contributed the highest risk of STI acquisition among HIV-seronegative women (AIRR 2.27, 95% CI 1.18–4.35), whereas lifetime GBV experience contributed the highest risk among HIV-seropositive women (AIRR 1.59, 95% CI 1.20–2.10). Conclusions: GBV prevention remains an important public health goal with direct relevance to women's sexual health. [ABSTRACT FROM AUTHOR]

Background: In some time-to-event analyses, it is unclear whether loss to follow up should be treated as a censoring event or competing event. Such ambiguity is particularly common in HIV research that uses routinely collected clinical data to report the timing of key milestones along the HIV care continuum. In this setting, loss to follow up may be viewed as a censoring event, under the assumption that patients who are "lost" from a study clinic immediately enroll in care elsewhere, or a competing event, under the assumption that people "lost" are out of care all together.Methods: We illustrate an approach to address this ambiguity when estimating the 2-year risk of antiretroviral treatment initiation among 19,506 people living with HIV who enrolled in the IeDEA Central Africa cohort between 2006 and 2017, along with published estimates from tracing studies in Africa. We also assessed the finite sample properties of the proposed approach using simulation experiments.Results: The estimated 2-year risk of treatment initiation was 69% if patients were censored at loss to follow up or 59% if losses to follow up were treated as competing events. Using the proposed approach, we estimated that the 2-year risk of antiretroviral therapy initiation was 62% (95% confidence interval: 61, 62). The proposed approach had little bias and appropriate confidence interval coverage under scenarios examined in the simulation experiments.Conclusions: The proposed approach relaxes the assumptions inherent in treating loss to follow up as a censoring or competing event in clinical HIV cohort studies. [ABSTRACT FROM AUTHOR]

Introduction: Foreign‐born persons comprise ~13% of the US population. Immigrants, especially women, often face a complex set of social and structural factors that negatively impact health outcomes including greater risk of HIV infection. We described socio‐demographic, clinical and immunological characteristics and AIDs and non‐AIDS death among foreign‐born women living with HIV (FBWLWH) participating in the US Women's Interagency HIV Study (WIHS) in the US from 1994 to 2016. We hypothesized that FBW will experience higher AIDS‐related mortality compared to US‐born women (USBW). Methods: The WIHS is a multicenter prospective observational cohort study of mostly women living with HIV (WLWH). The primary exposure in this analysis, which focused on 3626 WLWH, was self‐reported country of birth collapsed into foreign‐born and US born. We assessed the association of birthplace with categorized demographic, clinical and immunological characteristics, and AIDS/non‐AIDS mortality of WLWH, using chi‐squared tests. Proportional hazard models examined the association of birthplace with time from enrolment to AIDS and non‐AIDS death. Results: Of the 628 FBW, 13% were born in Africa, 29% in the Caribbean and 49% in Latin America. We observed significant differences by HIV status in socio‐demographic, clinical and immunological characteristics and mortality. For both AIDS and non‐AIDS caused deaths FBW WLWH had lower rates of death. Adjusting for year of study enrolment and other demographic/clinical characteristics mitigated FBW's statistical survival advantage in AIDS deaths Relative Hazard (RH = 0.91 p = 0.53), but did not substantively change the survival advantage in non‐AIDS deaths RH = 0.33, p < 0.0001). Conclusion: Foreign‐born WLWH exhibited demographic, clinical and immunological characteristics that are significantly different compared with women born in the US or US territory. After adjusting for these characteristics, the FB WLWH had a significantly lower hazard of non‐AIDS but not AIDS mortality compared to women born in the US or a US territory. These findings of non‐increased mortality can help inform models of care to optimize treatment outcomes among FBWLWH in the United States. [ABSTRACT FROM AUTHOR]

Background Co-trimoxazole is recommended for all children with human immunodeficiency virus. In this analysis, we evaluate trends in pediatric co-trimoxazole use and survival on co-trimoxazole in children using antiretroviral therapy (ART). Methods We used data collected between January 1, 2006, and March 31, 2016, from the International Epidemiology Databases to Evaluate AIDS. Logistic regression was used to evaluate factors associated with using co-trimoxazole at ART initiation. Competing risk regression was used to assess factors associated with death. Results A total of 54113 children were included in this study. The prevalence of co-trimoxazole use at ART initiation increased from 66.5% in 2006 to a peak of 85.6% in 2010 and then declined to 48.5% in 2015–2016. A similar trend was observed among children who started ART with severe immunodeficiency. After adjusting for year of ART initiation, younger age (odds ratio [OR], 1.18 for <1 vs 1 to <5 years of age [95% confidence interval (CI), 1.09–1.28]), lower height-for-age z score (OR, 1.15 for less than −3 vs greater than −2 [95% CI, 1.08–1.22]), anemia (OR, 1.08 [95% CI, 1.02–1.15]), severe immunodeficiency (OR, 1.25 [95% CI, 1.18–1.32]), and receiving care in East Africa (OR, 8.97 vs Southern Africa [95% CI, 8.17–9.85]) were associated with a high prevalence of co-trimoxazole use. Survival did not differ according to co-trimoxazole use in children without severe immunodeficiency (hazard ratio, 1.01 for nonusers versus users [95% CI, 0.77–1.34]). Conclusions Recent declines in co-trimoxazole use may not be linked to the current shift toward early ART initiation. Randomized trial data might be needed to establish the survival benefit of co-trimoxazole in children without severe immunodeficiency. [ABSTRACT FROM AUTHOR]

Depression is common among women with HIV and untreated depression can result in poor quality of life and worsen HIV outcomes. Women with HIV who are dually enrolled in Medicaid and Medicare faced a potential disruption in medication access when Medicare Part D was implemented in 2006. The goal of this study was to estimate the effects of Medicare Part D implementation on antidepressant use, depressive symptoms, and hospitalization in Medicaid-Medicare dual eligible women with HIV. This study used 2003-2008 data from the Women's Interagency HIV Study. The effects of Medicare Part D were estimated using a difference-in-differences approach, adjusting for temporal trends using a matched control group of Medicaid-only enrollees. Before Medicare Part D implementation, dual eligibles differed from Medicaid-only enrollees in antidepressant use and hospitalization, despite having identical prescription drug coverage through Medicaid. For dual enrollees, the transition to Medicare Part D was not associated with changes in antidepressant use, depressive symptoms, or hospitalization. We did not find disruptive effects on antidepressant use and related outcomes among dual eligibles in this study. Stable antidepressant use may be due to better access to medical care for dual eligibles through Medicare both before and after Medicare Part D implementation, which may have eclipsed any effects of the transition. It may also signal that classification of antidepressants as a protected drug class under Medicare Part D was effective in preventing psychiatric medication disruption. [ABSTRACT FROM AUTHOR]

Background: Food insecurity and violence are two major public health issues facing U.S. women. The link between food insecurity and violence has received little attention, particularly regarding the temporal ordering of events. The present study used data from the Women’s Interagency Human Immunodeficiency Virus Study to investigate the longitudinal association of food insecurity and violence in a cohort of women at risk for or living with HIV. Methods: Study participants completed six assessments from 2013–16 on food insecurity (operationalized as marginal, low, and very low food security) and violence (sexual or physical, and psychological). We used multi-level logistic regression, controlling for visits (level 1) nested within individuals (level 2), to estimate the association of experiencing violence. Results: Among 2,343 women (8,528 visits), we found that victims of sexual or physical violence (odds ratio = 3.10; 95% confidence interval: 1.88, 5.19) and psychological violence (odds ratio = 3.00; 95% confidence interval: 1.67, 5.50) were more likely to report very low food security. The odds of experiencing violence were higher for women with very low food security at both the current and previous visit as compared to only the current visit. HIV status did not modify these associations. Conclusions: Food insecurity was strongly associated with violence, and women exposed to persistent food insecurity were even more likely to experience violence. Food programs and policy must consider persistent exposure to food insecurity, and interpersonal harms faced by food insecure women, such as violence. [ABSTRACT FROM AUTHOR]

Introduction: Men who have sex with men (MSM) are disproportionately impacted by HIV/AIDS resulting from risky sexual behaviors. Social and contextual factors are known to mediate risk behaviors, but there is limited information about the prevalence of risky sexual practices of Rwandan MSM and the concomitant socio-contextual determinants making it difficult to assess implications for preventing HIV/STI transmission in this key population. Methods: Using exploratory qualitative design, we obtained socio-contextual information regarding prevalence of risky sexual behavior and assessed implications for HIV/ STIs transmission and preventive measures taken by MSM to improve sexual health and wellbeing. Thirty MSM were recruited to participate in in-depth interviews using respondent-driven sampling from LGBT associations in Kigali. Data were analyzed using standard qualitative data analysis procedures. Results: Respondents’ were between 18–40 years old; all completed primary education and are mostly low-socioeconomic status. Risky sexual practices were common, but differed by peculiar individual and contextual factors. Older MSM often reported occasional sexual relations with women to avoid suspicion and social stigma. Younger MSM’s risky sexual practices are mostly transactional and mediated by the need for social acceptance and support. Knowledge of STIs was poor, but prevalence, especially of HPV was high. The options for improving sexual wellbeing are limited and mostly clandestine. Conclusion: Risky sexual behavior of Rwandan MSM has major implications for HIV/STI transmission. An environment of intense social stigma and social isolation makes it difficult to obtain information or services to improve sexual health. Effective interventions that address individual and contextual determinants of risk and access to health services are urgently needed to limit the consequence of MSM as a bridge for HIV transmission to the general population. [ABSTRACT FROM AUTHOR]

In the South, people living with HIV experience worse health outcomes than in other geographic regions, likely due to regional political, structural, and socioeconomic factors. We describe the neighborhoods of women (n = 1,800) living with and without HIV in the Women’s Interagency HIV Study (WIHS), a cohort with Southern sites in Chapel Hill, NC; Atlanta, GA; Birmingham, AL; Jackson, MS; and Miami, FL; and non-Southern sites in Brooklyn, NY; Bronx, NY; Washington, DC; San Francisco, CA; and Chicago, IL. In 2014, participants’ addresses were geocoded and matched to several administrative data sources. There were a number of differences between the neighborhood contexts of Southern and non-Southern WIHS participants. Southern states had the lowest income eligibility thresholds for family Medicaid, and consequently higher proportions of uninsured individuals. Modeled proportions of income devoted to transportation were much higher in Southern neighborhoods (Location Affordability Index of 28-39% compared to 16-23% in non-Southern sites), and fewer participants lived in counties where hospitals reported providing HIV care (55% of GA, 63% of NC, and 76% of AL participants lived in a county with a hospital that provided HIV care, compared to >90% at all other sites). Finally, the states with the highest adult incarceration rates were all in the South (per 100,000 residents: AL 820, MS 788, GA 686, FL 644). Many Southern states opted not to expand Medicaid, invest little in transportation infrastructure, and have staggering rates of incarceration. Resolution of racial and geographic disparities in HIV health outcomes will require addressing these structural barriers. [ABSTRACT FROM AUTHOR]

There is limited research examining the sexual health and well-being of older women living with HIV (OWLH). Most studies focus on sexual dysfunction, leaving aside the richer context of sexuality and sexual health, including the effect of age-related psychosocial and interpersonal changes on sexual health behaviors. Guided by the integrative biopsychosocial model and the sexual health model, this study explored the importance of sex and sexuality among OWLH to identify their sexual health and HIV prevention needs for program planning. A purposive sample (n = 50) of OWLH was selected from a parent study (n = 2052). We conducted 8 focus groups and 41 in-depth interviews with 50 African American and Latina OWLH aged 50-69 years old in three U.S. cities. The triangulation approach was used to synthesize the data. Six salient themes emerged: sexual pleasure changes due to age, sexual freedom as women age, the role of relationships in sexual pleasure, changes in sexual ability and sexual health needs, sexual risk behaviors, and ageist assumptions about older women's sexuality. We found that sexual pleasure and the need for intimacy continue to be important for OWLH, but that changing sexual abilities and sexual health needs, such as the reduction of sexual desire, as well as increased painful intercourse due to menopause-associated vaginal drying, were persistent barriers to sexual fulfillment and satisfaction. Particular interpersonal dynamics, including low perceptions of the risk of HIV transmission as related to gender, viral suppression, and habitual condomless sex with long-term partners without HIV transmission have resulted in abandoning safer sex practices with serodiscordant partners. These findings suggest that HIV prevention for OWLH should focus on how sexual function and satisfaction intersect with sexual risk. HIV prevention for OWLH should promote ways to maintain satisfying and safe sex lives among aging women. [ABSTRACT FROM AUTHOR]

Background: Despite the World Health Organization (WHO) regularly updating guidelines to recommend earlier initiation of antiretroviral therapy (ART) in children, timely enrollment into care and initiation of ART in sub-Saharan Africa in children lags behind that of adults. The impact of implementing increasingly less restrictive ART guidelines on ART initiation in Central Africa has not been described. Materials and Methods: Data are from the Central Africa International Epidemiologic Databases to Evaluate AIDS (IeDEA) pediatric cohort of 3,426 children (0–15 years) entering HIV care at 15 sites in Burundi, DRC, and Rwanda. Measures include CD4 count, WHO clinical stage, age, and weight-for-age Z score (WAZ), each at enrollment into HIV care and at ART initiation. Changes in the medians or proportions of each measure by year of enrollment and year of ART initiation were assessed to capture potential impacts of changing ART guidelines. Results: Median age at care enrollment decreased from 77.2 months in 2004–05 to 30.3 months in 2012–13. The median age at ART initiation (n = 2058) decreased from 83.0 months in 2004–05 to 66.9 months in 2012–13. The proportion of children ≤24 months of age at enrollment increased from 12.7% in 2004–05 to 46.7% in 2012–13, and from 9.6% in 2004–05 to 24.2% in 2012–13 for ART initiation. The median CD4 count at enrollment into care increased from 563 (IQR: 275, 901) in 2004–05 to 660 (IQR: 339, 1071) cells/μl in 2012–13, and the median CD4 count at ART initiation increased from 310 (IQR:167, 600) in 2004–05 to 589 (IQR: 315, 1113) cells/μl in 2012–13. From 2004–05 to 2012–13, median WAZ improved from -2 (IQR: -3.4, -1.1) to -1 (IQR: -2.5, -0.2) at enrollment in care and from -2 (IQR: -3.8, -1.6) to -1 (IQR: -2.6, -0.4) at ART initiation. Discussion and Conclusion: Although HIV-infected children ≤24 months of age accounted for half of all children enrolling in care in our cohort during 2012–13, they represented less than a quarter of all those who were initiated on ART during the same period. Further research is needed to identify barriers to timely diagnosis, linkage to care, and initiation of ART among children with HIV infection. [ABSTRACT FROM AUTHOR]

We describe the impact of an antiretroviral therapy program on human resource utilization and service delivery in a rural hospital in Monze, Zambia, using qualitative data. We assess project impact on staff capacity utilization, service delivery, and community perception of care. Increased workload resulted in fatigue, low staff morale, and exacerbated critical manpower shortages, but also an increase in users of antiretroviral therapy, improvement in hospital infrastructure and funding, and an overall community satisfaction with service delivery. Integrating HAART programs within existing hospital units and services may be a good alternative to increase overall efficiency. Commentary JPHP.2011.8, available at www.palgrave-journals.com/jphp/, relates to this article. [ABSTRACT FROM AUTHOR]

• There are limited data on cervical HPV prevalence in Cameroon and none from its Anglophone region. Study was conducted in Cameroon among a convenience sample 295 HIV negative women and 560 women living with HIV. • Crude HPV prevalence was 22 % for HIV[-] women and 47 % for WLWH (p < 0.001). Among WLWH, older age and higher CD4 counts were associated with lower HPV prevalence. There was a good-to-excellent agreement for HPV detection between specimens. • Self-collected were more likely than provider-collected specimens to test HPV positive, for all women and stratified by HIV status. • HIV-related immunosuppression was a risk factor for HPV prevalence in this population and HPV testing of self-collected specimens appeared to be less specific than HPV testing of provider-collected specimens. There are limited data on cervical HPV prevalence in Cameroon and none from its Anglophone region. We investigated cervical HPV prevalence in HIV-uninfected (HIV[-]) and HIV-infected (WLWH) women living in the region. A convenience sample of consecutively recruited HIV[-] women (n = 295) and women living with HIV (WLWH) (n = 560) attending the Limbé Regional Hospital were enrolled into a cervical screening study. Women underwent screening that included HPV testing of self-collected and provider-collected specimens. We calculated the HPV prevalence by HIV status, overall and stratified by age, and among WLWH, stratified by CD4 counts. We compared the concordance for the detection of HPV between self- and provider-collected specimens. Crude HPV prevalence was 21.69 % (95 % confidence interval [95 %CI] = 17.21–26.48 %) for HIV[-] women and 46.43 % (95 %CI = 42.24–50.66 %) for WLWH (p < 0.001). Among WLWH, older age (p trend = 0.01) and higher CD4 counts (p trend = 0.007) were associated with lower HPV prevalence. There was a good-to-excellent agreement for HPV detection between specimens, and self-collected were more likely than provider-collected specimens to test HPV positive, for all women and stratified by HIV status. HIV-related immunosuppression was a risk factor for HPV prevalence in this population. HPV testing of self-collected specimens appeared to be less specific than HPV testing of provider-collected specimens. [ABSTRACT FROM AUTHOR]

Introduction: We assessed mortality and losses to follow‐up (LTFU) during adolescence in routine care settings in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. Methods: Cohorts in the Asia‐Pacific, the Caribbean, Central, and South America, and sub‐Saharan Africa (Central, East, Southern, West) contributed data, and included adolescents living with HIV (ALHIV) enrolled from January 2003 and aged 10 to 19 years (period of adolescence) while under care up to database closure (June 2016). Follow‐up started at age 10 years or the first clinic visit, whichever was later. Entering care at <15 years was a proxy for perinatal infection, while entering care ≥15 years represented infection acquired during adolescence. Competing risk regression was used to assess associations with death and LTFU among those ever receiving triple‐drug antiretroviral therapy (triple‐ART). Results: Of the 61,242 ALHIV from 270 clinics in 34 countries included in the analysis, 69% (n = 42,138) entered care <15 years of age (53% female), and 31% (n = 19,104) entered care ≥15 years (81% female). During adolescence, 3.9% died, 30% were LTFU and 8.1% were transferred. For those with infection acquired perinatally versus during adolescence, the four‐year cumulative incidences of mortality were 3.9% versus 5.4% and of LTFU were 26% versus 69% respectively (both p < 0.001). Overall, there were higher hazards of death for females (adjusted sub‐hazard ratio (asHR) 1.19, 95% confidence interval (CI) 1.07 to 1.33), and those starting treatment at ≥5 years of age (highest asHR for age ≥15: 8.72, 95% CI 5.85 to 13.02), and in care in mostly urban (asHR 1.40, 95% CI 1.13 to 1.75) and mostly rural settings (asHR 1.39, 95% CI 1.03 to 1.87) compared to urban settings. Overall, higher hazards of LTFU were observed among females (asHR 1.12, 95% CI 1.07 to 1.17), and those starting treatment at age ≥5 years (highest asHR for age ≥15: 11.11, 95% CI 9.86 to 12.53), in care at district hospitals (asHR 1.27, 95% CI 1.18 to 1.37) or in rural settings (asHR 1.21, 95% CI 1.13 to 1.29), and starting triple‐ART after 2006 (highest asHR for 2011 to 2016 1.84, 95% CI 1.71 to 1.99). Conclusions: Both mortality and LTFU were worse among those entering care at ≥15 years. ALHIV should be evaluated apart from younger children and adults to identify population‐specific reasons for death and LTFU. [ABSTRACT FROM AUTHOR]

Introduction: retaining patients in antiretroviral treatment (ART) is essential for successful outcomes. Unfortunately, Cameroon continues to report suboptimal ART retention. This study focused on identifying determinants of ART retention in three HIV clinics in Cameroon within the HIV treat all context. Methods: a medical chart review of 423 subjects who initiated ART between July and September 2016 in the Limbe, Bamenda and Jamot Hospitals. Patients' sociodemographic and clinical characteristics and ART retention data were abstracted using structured paper forms. Chi square test was used to assess bivariate associations. Logistic regression was used to adjust for confounders. P-value was set at <0.05 at 95% confidence interval. Results: the mean age was 40±11 years, and 65.1% were females. Antiretroviral treatment retention after 24 months was 309/392 (78.83%) and 30/423 (7.1%) were transferred-out, 11/423 (2.6%) reported dead and 73/423 (17.3%) lost to follow-up. HIV status disclosure (AOR 0.16 95% CI: 0.05-0.51, p<0.01) and age group 31-50 years (AOR 3.63, 95% CI: 1.04- 12.59, P= 0.04) were associated with lower and higher ART retention respectively. Conclusion: about a quarter of the participants were not retained in ART after 24 months. Patient-level factors determined ART retention. These factors should be considered in designing strategies to improve ART retention. More research is needed to identify other determinants of ART retention under the HIV treat all strategy. [ABSTRACT FROM AUTHOR]

Overwhelming evidence highlights the negative impact of substance use on HIV care and treatment outcomes. Yet, the extent to which alcohol use disorder (AUD) and other substance use disorders (SUD) services have been integrated within HIV clinical settings is limited. We describe AUD/SUD screening and treatment availability in HIV clinical sites participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. In 2020, 223 IeDEA HIV clinical sites from 41 countries across seven geographic regions completed a survey on capacity and practices related to management of AUD/ SUD. Sites provided information on AUD and other SUD screening and treatment practices. Sites were from low-income countries (23%), lower-middle-income countries (38%), upper-middle income countries (17%) and high-income counties (23%). AUD and SUD screening using validated instruments were reported at 32% (n=71 located in 12 countries) and 12% (n=27 located in 6 countries) of the 223 sites from 41 countries, respectively. The North American region had the highest proportion of clinics that reported AUD screening (76%), followed by East Africa (46%); none of the sites in West or Central Africa reported AUD screening. 31% (n=69) reported both AUD screening and counseling, brief intervention, psychotherapy, or Screening, Brief Intervention, and Referral to Treatment; 8% (n=18) reported AUD screening and detox hospitalization; and 10% (n=24) reported both AUD screening and medication. While the proportion of clinics providing treatment for SUD was lower than those treating AUD, the prevalence estimates of treatment availability were similar. Availability of screening and treatment for AUD/SUD in HIV care settings is limited, leaving a substantial gap for integration into ongoing HIV care. A critical understanding is needed of the multilevel implementation factors or feasible implementation strategies for integrating screening and treatment of AUD/SUD into HIV care settings, particularly for resource-constrained regions. [ABSTRACT FROM AUTHOR]

Background: Data are limited on cumulative impacts of depression on engagement in care and HIV outcomes in women living with HIV (WLWH) during the era of universal antiretroviral therapy (ART). Understanding the relationship of accumulated depression with HIV disease management may help identify benefits of interventions to reduce severity and duration of depressive episodes. Setting: A cohort of WLWH (N = 1491) from the Women's Interagency HIV Study at 9 sites across the US. Methods: This longitudinal observational cohort study (2013-2017) followed WLWH for a maximum of 9 semiannual visits. Depression was quantified as a time-updated measure of percent of days depressed (PDD) created from repeated assessments using the Center for Epidemiologic Studies Depression scale. Marginal structural Poisson regression models were used to estimate the effects of PDD on the risks of missing an HIV care appointment, <95% ART adherence, and virological failure (≥200 copies/mL). Results: The risk of missing an HIV care appointment [risk ratio (RR) = 1.16, 95% confidence interval = 0.93 to 1.45; risk difference (RD) = 0.01, 20.01 to 0.03], being <95% ART adherent (RR = 1.27, 1.06-1.52; RD = 0.04, 20.01 to 0.07), and virological failure (RR = 1.09, 1.01-1.18; RD = 0.01, 20.01 to 0.03) increased monotonically with increasing PDD (comparing those with 25 to those with 0 PDD). The total effect of PDD on virological failure was fully (%100) mediated by being <95% ART adherent. Conclusions: Time spent depressed increases the risk of virological failure through ART adherence, even in the era of universal ART regimes forgiving of imperfect adherence. [ABSTRACT FROM AUTHOR]

Background: A low proportion of CD282CD8+ T cells that express CD57 is associated with increased mortality in HIV infection. The effect of increasing body mass index (BMI) changes in the proportion of CD57+CD282CD8+ T cells among HIV-infected individuals on antiretroviral therapy is unknown. Setting: In a US cohort of HIV-infected women, we evaluated associations of BMI and waist circumference with 3 distinct CD8+ T cell phenotypes: % CD282CD57+CD8+ T cells, % CD57+ of CD282CD8+ T cells, and % CD282 of all CD8+ T cells. Methods: Multivariable linear regression analysis was used to estimate beta coefficients for each of 3 T-cell phenotypes. Covariates included HIV parameters (current and nadir CD4, current viral load), demographics (age, race, income, and study site), and lifestyle (tobacco and alcohol use) factors. Results: Of 225 participants, the median age was 46 years and 50% were obese (BMI >30 m2/kg). Greater BMI and waist circumference were both associated with higher % CD282CD57+CD8+ T cells and % CD57+ of all CD282CD8+ T cells in multivariable analysis, including adjustment for HIV viral load (all P < 0.05). The association between greater BMI and the overall proportion of CD282 CD8+ cells in fully adjusted models (0.078, 95% confidence interval: 20.053 to 0.209) was not significant. Conclusions: In this analysis, greater BMI and waist circumference are associated with greater expression of CD57 on CD282CD8+ T cells and a greater proportion of CD57+CD282 CD8+ T cells. These findings may indicate that increasing BMI is immunologically protective in HIV-infected women. Future research is needed to understand the prognostic importance of these associations on clinical outcomes. [ABSTRACT FROM AUTHOR]