At the end of 2012, 3 decades after the human immunodeficiency virus (HIV) was first identified, neither a cure nor a fully preventive vaccine was available. Despite multiple efforts, the epidemic remains an exceptional public health challenge. At the end of 2012, it was estimated that, globally, 35 million people were living with HIV, 2.3 million had become newly infected, and 1.6 million had died from AIDS-related causes. Despite substantial prevention efforts and increases in the number of individuals on highly active antiretroviral therapy (HAART), the epidemic burden continues to be high. Here, we provide a brief overview of the epidemiology of HIV transmission, the work that has been done to date regarding HIV modeling in different settings around the world, and how to finance the response to the HIV epidemic. In addition, we suggest discussion topics on how to move forward with the prevention agenda and highlight the role of treatment as prevention (TasP) in curbing the epidemic.

Background

Why some persons living with human immunodeficiency virus (HIV) (PLWH) progress quickly and others remain "healthy" for a decade or more without treatment remains a fundamental question of HIV pathology. We aimed to assess the epidemiological characteristics of HIV long-term nonprogressors (LTNPs) based on a cohort of PLWH in China observed between 1989 and 2016.

Methods

We conducted a nationwide, retrospective cohort study among Chinese PLWH with HIV diagnosed before 1 January 2008. Records were extracted from China's national HIV/AIDS database on 30 June 2016. LTNPs were defined as those with AIDS-free, antiretroviral therapy-naive survival, with CD4 cell counts consistently ≥500/μL for ≥8 years after diagnosis. Prevalence was calculated, characteristics were described, and determinants were assessed by means of logistic regression. Potential sources of bias were also investigated.

Results

Our cohort included 89 201 participants, of whom 1749 (2.0%) were categorized as LTNPs. The injection drug use (IDU) route of infection was reported by 70.7% of LTNPs, compared with only 37.1% of non-LTNPs. The odds of LTNP status were greater among those infected via IDU (adjusted odds ratio [95% confidence interval], 2.28 [1.94-2.68]) and with HIV diagnosed in settings with large populations of persons who inject drugs (1.75 [1.51-2.02] for detention centers, 1.61 [1.39-1.87] for Yunnan, 1.94 [1.62-2.31] for Guangdong, and 2.90 [2.09-4.02] for Xinjiang).

Conclusions

Overrepresentation of the IDU route of infection among LTNPs is a surprising finding worthy of further study, and this newly defined cohort may be particularly well suited to exploration of the molecular biological mechanisms underlying HIV long-term nonprogression.

In recent years, evidence has accumulated regarding the ability of HAART to prevent HIV transmission. Early supportive evidence was derived from observational, ecological and population-based studies. More recently, a randomized clinical trial showed that immediate use of HAART led to a 96% decrease in HIV transmission events within HIV serodiscordant heterosexual couples. However, the generalizability of the effect of HAART, and the population-level impact on HIV transmission continues to generate substantial debate. We, therefore, conducted a review of the evidence regarding the preventive effect of HAART on HIV transmission within the context of the Bradford Hill criteria for causality. Taken together, we find the accumulated evidence supporting HIV treatment as prevention meets each of the Bradford Hill criteria for causality. We conclude that the opportunity cost of inaction while waiting for additional evidence on the generalizability of effect in other risk groups is too high. Efforts should be redoubled to mobilize the financial capital and political will to optimize implementation of HIV Treatment as Prevention strategies on a wide scale.

Background

Why some persons living with human immunodeficiency virus (HIV) (PLWH) progress quickly and others remain "healthy" for a decade or more without treatment remains a fundamental question of HIV pathology. We aimed to assess the epidemiological characteristics of HIV long-term nonprogressors (LTNPs) based on a cohort of PLWH in China observed between 1989 and 2016.

Methods

We conducted a nationwide, retrospective cohort study among Chinese PLWH with HIV diagnosed before 1 January 2008. Records were extracted from China's national HIV/AIDS database on 30 June 2016. LTNPs were defined as those with AIDS-free, antiretroviral therapy-naive survival, with CD4 cell counts consistently ≥500/μL for ≥8 years after diagnosis. Prevalence was calculated, characteristics were described, and determinants were assessed by means of logistic regression. Potential sources of bias were also investigated.

Results

Our cohort included 89 201 participants, of whom 1749 (2.0%) were categorized as LTNPs. The injection drug use (IDU) route of infection was reported by 70.7% of LTNPs, compared with only 37.1% of non-LTNPs. The odds of LTNP status were greater among those infected via IDU (adjusted odds ratio [95% confidence interval], 2.28 [1.94-2.68]) and with HIV diagnosed in settings with large populations of persons who inject drugs (1.75 [1.51-2.02] for detention centers, 1.61 [1.39-1.87] for Yunnan, 1.94 [1.62-2.31] for Guangdong, and 2.90 [2.09-4.02] for Xinjiang).

Conclusions

Overrepresentation of the IDU route of infection among LTNPs is a surprising finding worthy of further study, and this newly defined cohort may be particularly well suited to exploration of the molecular biological mechanisms underlying HIV long-term nonprogression.

Background

Food insecurity and intimate partner violence (IPV) are associated with suboptimal HIV prevention and treatment outcomes, yet limited research has explored how food insecurity and IPV intersect to influence HIV-related behaviors. To fill this gap, we conducted a qualitative study with women living with or at risk for HIV in the United States.

Methods

We conducted 24 in-depth interviews with women enrolled in the San Francisco and Atlanta sites of the Women's Interagency HIV study (WIHS). Participants were purposively sampled so half were living with HIV and all reported food insecurity and IPV in the past year. Semi-structured interviews explored experiences with food insecurity and IPV, how these experiences might be related and influence HIV risk and treatment behaviors. Analysis was guided by an inductive-deductive approach.

Results

A predominant theme centered on how food insecurity and IPV co-occur with poor mental health and substance use to influence HIV-related behaviors. Women described how intersecting experiences of food insecurity and IPV negatively affected their mental health, with many indicating using substances to "feel no pain". Substance use, in turn, was described to perpetuate food insecurity, IPV, and poor mental health in a vicious cycle, ultimately facilitating HIV risk behaviors and preventing HIV treatment adherence.

Conclusions

Food insecurity, IPV, poor mental health and substance use intersect and negatively influence HIV prevention and treatment behaviors. Findings offer preliminary evidence of a syndemic that goes beyond the more widely studied "SAVA" (substance use, AIDS, and violence) syndemic, drawing attention to additional constructs of mental health and food insecurity. Quantitative research must further characterize the extent and size of this syndemic. Policies that address the social and structural drivers of this syndemic, including multi-level and trauma-informed approaches, should be implemented and evaluated to assess their impact on this syndemic and its negative health effects.

Background

Transgender women (TW) are disproportionately affected by both HIV and cardiovascular disease (CVD).

Objectives

We aim to quantify prevalence of elevated predicted CVD risk for TW compared to cisgender women (CW) and cisgender men (CM) in HIV care and describe the impact of multiple operationalizations of CVD risk score calculations for TW.

Design

We conducted a cross-sectional analysis of patients engaged in HIV care between October 2014 and February 2018.

Setting

The Centers for AIDS Research Network of Integrated Clinical Systems, a collaboration of 8 HIV clinical sites in the United States contributed data for this analysis.

Patients

221 TW, 2983 CW, and 13467 CM.

Measurements

The measure of interest is prevalence of elevated 10-year cardiovascular disease risk based on ACC/AHA Pooled Cohort Risk Assessment equations (PCE) and the Framingham Risk Score (FRS), calculated for TW by: birth-assigned sex (male); history of exogenous sex hormone use (female/male); and current gender (female).

Results

Using birth-assigned sex, the adjusted prevalence ratio (aPR) was 2.52 (95% CI: 1.08,5.86) and 2.58 (95% CI: 1.71,3.89) comparing TW to CW, by PCE and FRS, respectively. It was 1.25 (95% CI: 0.54,2.87) and 1.25 (95% CI: 0.84,1.86) comparing TW to CM, by PCE and FRS, respectively. If TW were classified according to current gender versus birth-assigned sex, their predicted CVD risk scores were lower.

Limitations

PCE and FRS have not been validated in TW with HIV. Few adjudicated CVD events in the data set precluded analyses based on clinical outcomes.

Conclusions

After adjustment for demographics and history of HIV care, prevalence of elevated CVD risk in TW was similar to CM and equal to or higher than in CW, depending operationalization of the sex variable. Future studies with CVD outcomes are needed to help clinicians accurately estimate CVD risk among TW with HIV.

Background

Antiretroviral therapy scale-up in Sub-Saharan Africa has created a growing, aging HIV-positive population at risk for non-communicable diseases such as hypertension. However, the prevalence and risk factors for hypertension in this population remain incompletely understood.

Methods

We measured blood pressure and collected demographic data on over 65,000 adults attending multi-disease community health campaigns in 20 rural Ugandan communities (SEARCH Study: NCT01864603). Our objectives were to determine (i) whether HIV is an independent risk factor for hypertension, and (ii) awareness and control of hypertension in HIV-positive adults and the overall population.

Results

Hypertension prevalence was 14% overall, and 11% among HIV-positive individuals. 79% of patients were previously undiagnosed, 85% were not taking medication, and 50% of patients on medication had uncontrolled blood pressure. Multivariate predictors of hypertension included older age, male gender, higher BMI, lack of education, alcohol use, and residence in Eastern Uganda. HIV-negative status was independently associated with higher odds of hypertension (OR 1.2, 95% CI: 1.1-1.4). Viral suppression of HIV did not significantly predict hypertension among HIV-positives.

Significance

The burden of hypertension is substantial and inadequately controlled, both in HIV-positive persons and overall. Universal HIV screening programs could provide counseling, testing, and treatment for hypertension in Sub-Saharan Africa.

Unlabelled

Substantial reductions in hepatitis C virus (HCV) prevalence among people who inject drugs (PWID) cannot be achieved by harm reduction interventions such as needle exchange and opiate substitution therapy (OST) alone. Current HCV treatment is arduous and uptake is low, but new highly effective and tolerable interferon-free direct-acting antiviral (DAA) treatments could facilitate increased uptake. We projected the potential impact of DAA treatments on PWID HCV prevalence in three settings. A dynamic HCV transmission model was parameterized to three chronic HCV prevalence settings: Edinburgh, UK (25%); Melbourne, Australia (50%); and Vancouver, Canada (65%). Using realistic scenarios of future DAAs (90% sustained viral response, 12 weeks duration, available 2015), we projected the treatment rates required to reduce chronic HCV prevalence by half or three-quarters within 15 years. Current HCV treatment rates may have a minimal impact on prevalence in Melbourne and Vancouver (<2% relative reductions) but could reduce prevalence by 26% in 15 years in Edinburgh. Prevalence could halve within 15 years with treatment scale-up to 15, 40, or 76 per 1,000 PWID annually in Edinburgh, Melbourne, or Vancouver, respectively (2-, 13-, and 15-fold increases, respectively). Scale-up to 22, 54, or 98 per 1,000 PWID annually could reduce prevalence by three-quarters within 15 years. Less impact occurs with delayed scale-up, higher baseline prevalence, or shorter average injecting duration. Results are insensitive to risk heterogeneity or restricting treatment to PWID on OST. At existing HCV drug costs, halving chronic prevalence would require annual treatment budgets of US $3.2 million in Edinburgh and approximately $50 million in Melbourne and Vancouver.

Conclusion

Interferon-free DAAs could enable increased HCV treatment uptake among PWID, which could have a major preventative impact. However, treatment costs may limit scale-up, and should be addressed.