Pre-exposure prophylaxis service among men who have sex with men in Malaysia: findings from a discrete choice experiment.

Men who have sex with men (MSM) in Malaysia are disproportionately affected by HIV. As pre-exposure prophylaxis (PrEP) is being introduced, we assessed population-based PrEP delivery preferences among MSM in Malaysia. We conducted a discrete choice experiment through an online survey among 718 MSM. The survey included 14 choice tasks presenting experimentally varied combinations of five attributes related to PrEP delivery (i.e., cost, dosing strategy, clinician interaction strategy, dispensing venue, and burden of visits to start PrEP). We used latent class analysis and Hierarchical Bayesian modeling to generate the relative importance of each attribute and preference across six possible PrEP delivery programs. PrEP dosing, followed by cost, was the most important attribute. The participants were clustered into five preference groups. Two groups (n = 290) most commonly preferred on-demand, while the other three preferred injectable PrEP. One group (n = 188) almost exclusively considered cost in their decision-making, and the smallest group (n = 86) was substantially less interested in PrEP for reasons unrelated to access. In simulated scenarios, PrEP initiation rates varied by the type of program available to 55·0% of MSM. Successful PrEP uptake among Malaysian MSM requires expanding beyond daily oral PrEP to on-demand and long-acting injectable PrEP, especially at affordable cost

Drivers of HIV self-testing among female sex workers: Findings from a multi-state study in Malaysia

BackgroundAlthough research on HIV self-testing (HIVST) has rapidly increased, few studies have explored HIVST uptake in female sex workers (FSW), and none in Malaysia. Therefore, we endeavored to assess the willingness to use HIVST in this at-risk, vulnerable population.MethodsA cross-sectional survey study was conducted among 113 HIV-negative Malaysian FSW in 2017. Participants were recruited using advertisements on social media, flyers, and direct referrals from community-based organizations. Data were collected using self-administered surveys. Multivariable logistic regression was used to identify correlates of willingness to use HIVST.ResultsNearly a third of participants (30.1%) reported they would be willing to use HIVST. Multivariable analyses adjusting for Malay ethnicity, stable housing, living in Kuala Lumpur (KL), years in sex work, age of first sex work, childhood sexual assault, history of HIV testing, and previously in prison indicated that living in KL [adjusted odds ratio (aOR) = 5.214, p = 0.0137] was associated with a greater willingness to use HIVST. In contrast, having stable housing (aOR = 0.100, p = 0.0064) was negatively associated with willingness to use HIVST.ConclusionsOur results indicate that HIVST may potentially enhance the uptake of HIV testing among FSWs living in an urban environment and experiencing unstable housing, but an overall willingness to use HIVST is low. These findings highlight the need for efforts to increase awareness of HIVST among FSWs and additional research on the effective implementation of HIVST for FSW

Performance of a Novel Low-Cost, Instrument-Free Plasma Separation Device for HIV Viral Load Quantification and Determination of Treatment Failure in People Living with HIV in Malaysia: a Diagnostic Accuracy Study

HIV viral load (VL) testing is the recommended method for monitoring the response of people living with HIV and receiving antiretroviral therapy (ART). The availability of standard plasma VL testing in low- and middle-income countries (LMICs), and access to this testing, are limited by the need to use fresh plasma. Good specimen collection methods for HIV VL testing that are applicable to resource-constrained settings are needed. We assessed the diagnostic performance of the filtered dried plasma spot (FDPS), created using the newly developed, instrument-free VLPlasma device, in identifying treatment failure at a VL threshold of 1,000 copies/ml in fresh plasma. Performance was compared with that of the conventional dried blood spot (DBS). Venous blood samples from 201 people living with HIV and attending an infectious disease clinic in Malaysia were collected, and HIV VL was quantified using fresh plasma (the reference standard), FDPS, and DBS specimens. VL testing was done using the Roche Cobas AmpliPrep/Cobas TaqMan v2.0 assay. At a threshold of 1,000 copies/ml, the diagnostic performance of the FDPS was superior (sensitivity, 100% [95% confidence interval {CI}, 89.1 to 100%]; specificity, 100% [95% CI, 97.8 to 100%]) to that of the DBS (sensitivity, 100% [95% CI, 89.4 to 100%]; specificity, 36.8% [95% CI, 29.4 to 44.7%]) (P 0.001). A stronger correlation was observed between the FDPS VL and the plasma VL (r 0.94; P 0.001) than between the DBS VL and the plasma VL (r 0.85; P 0.001). The mean difference in VL measures between the FDPS and plasma (plasma VL minus FDPS VL) was 0.127 log10 copies/ml (standard deviation [SD], 0.32), in contrast to – 0.95 log10 copies/ml (SD, 0.84) between the DBS and plasma. HIV VL measurement using the FDPS outperformed that with the DBS in identifying treatment failure at a threshold of 1,000 copies/ml and compared well with the quantification of VL in plasma. The FDPS can be an attractive alternative to fresh plasma for improving access to HIV VL monitoring among people living with HIV on ART in LMICs

Kidney function in tenofovir disoproxil fumarate-based oral pre-exposure prophylaxis users: a systematic review and meta-analysis of published literature and a multi-country meta-analysis of individual participant data

BACKGROUND: Previous WHO guidance on tenofovir disoproxil fumarate-based oral pre-exposure prophylaxis (PrEP) suggests measuring creatinine levels at PrEP initiation and regularly afterwards, which might represent barriers to PrEP implementation and uptake. We aimed to systematically review published literature on kidney toxicity among tenofovir disoproxil fumarate-based oral PrEP users and conducted an individual participant data meta-analysis (IPDMA) on kidney function among PrEP users in a global implementation project dataset. METHODS: In this systematic review and meta-analysis we searched PubMed up to June 30, 2021, for randomised controlled trials (RCTs) or cohort studies that reported on graded kidney-related adverse events among oral PrEP users (tenofovir disoproxil fumarate-based PrEP alone or in combination with emtricitabine or lamivudine). We extracted summary data and conducted meta-analyses with random-effects models to estimate relative risks of grade 1 and higher and grade 2 and higher kidney-related adverse events, measured by elevated serum creatinine or decline in estimated creatinine clearance or estimated glomerular filtration rate. The IPDMA included (largely unpublished) individual participant data from 17 PrEP implementation projects and two RCTs. Estimated baseline creatinine clearance and creatinine clearance change after initiation were described by age, gender, and comorbidities. We used random-effects regressions to estimate the risk in decline of creatinine clearance to less than 60 mL/min. FINDINGS: We identified 62 unique records and included 17 articles reporting on 11 RCTs with 13 523 participants in meta-analyses. PrEP use was associated with increased risk of grade 1 and higher kidney adverse events (pooled odds ratio [OR] 1·49, 95% CI 1·22-1·81; I2=25%) and grade 2 and higher events (OR 1·75, 0·68-4·49; I2=0%), although the grade 2 and higher association was not statistically significant and events were rare (13 out of 6764 in the intervention group vs six out of 6782 in the control group). The IPDMA included 18 676 individuals from 15 countries (1453 [7·8%] from RCTs) and 79 (0·42%) had a baseline estimated creatinine clearance of less than 60 mL/min (increasing proportions with increasing age). Longitudinal analyses included 14 368 PrEP users and 349 (2·43%) individuals had a decline to less than 60 mL/min creatinine clearance, with higher risks associated with increasing age and baseline creatinine clearance of 60·00-89·99 mL/min (adjusted hazard ratio [aHR] 8·49, 95% CI 6·44-11·20) and less than 60 mL/min (aHR 20·83, 12·83-33·82). INTERPRETATION: RCTs suggest that risks of kidney-related adverse events among tenofovir disoproxil fumarate-based oral PrEP users are increased but generally mild and small. Our global PrEP user analysis found varying risks by age and baseline creatinine clearance. Kidney function screening and monitoring might focus on older individuals, those with baseline creatinine clearance of less than 90 mL/min, and those with kidney-related comorbidities. Less frequent or optional screening among younger individuals without kidney-related comorbidities may reduce barriers to PrEP implementation and use. FUNDING: Unitaid, Bill & Melinda Gates Foundation, WHO

Long-Term Benefits from Early Antiretroviral Therapy Initiation in HIV Infection

BACKGROUND: For people with HIV and CD4+ counts >500 cells/mm3, early initiation of antiretroviral therapy (ART) reduces serious AIDS and serious non-AIDS (SNA) risk compared with deferral of treatment until CD4+ counts are 500 cells/mm3, excess risk of AIDS and SNA associated with delaying treatment initiation was diminished after ART initiation, but persistent excess risk remained. (Funded by the National Institute of Allergy and Infectious Diseases and others.)

Human Immunodeficiency Virus (HIV) in Pregnancy: A Review of the Guidelines for Preventing Mother-to-Child Transmission in Malaysia

Mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) is a devastating consequence of HIV infection during pregnancy and is largely preventable. Evidence-based interventions such as universal antenatal screening, provision of antiretroviral therapy, delivery by elective caesarean section and avoidance of breastfeeding have ensured that the rates of MTCT remain low in Malaysia. This review discusses the most recent advances in the management of HIV infection in pregnancy with emphasis on antiretroviral treatment strategies and obstetric care in a middle income country. Key words: Antiretrovirals, HIV, Neonate, Pregnancy, Screening</jats:p

The prevalence of depression, anxiety and associated factors among adults with living human immunodeficiency virus in University Malaya Medical Centre

Background This study estimates prevalence of depression and anxiety among adults living with Human Immunodeficiency Virus (HIV) in University Malaya Medical Centre (UMMC) and determines its associated factors. Methods This cross-sectional study was conducted between August 2020 and January 2021, in the Infectious Disease clinic and ward. One hundred ninety-one patients were recruited via convenience sampling. Patients’ sociodemographic were obtained, followed by Depression, Anxiety, Stress Scale -21 (DASS-21), Multidimensional Scale of Perceived Social Support (MSPSS), and M.I.N.I. international neuropsychiatric interview (M.I.N.I.) The cut off DASS-21 point for depression is ≥5, for anxiety, ≥ 4. Mann-Whitney U and Chi square test were used to analyse the association between variables, and logistic regression to find predictability. Results Of the 191 participants, 89.5% outpatient, mean age 40 years (SD 0.742), 91.1% male, 65.4% single, 71.2% working, 46.1% Malaysian Chinese, 59.8% non- heterosexual, mean 6 years of being HIV positive; mean CD4 count 449/μL; mean viral load 116,690 (median = 20). 85.9% were taking antiretroviral therapy. The prevalence of depression was 35.1% ( n = 67); anxiety was 42.9% ( n = 82). Regression analysis revealed anxiety and stress increased odds of depression by 3.8 times ( p = .001) and 12 times ( p &lt; .001) respectively. Those 40 years old and younger had 2.3 times odds of anxiety ( p = .048). Increased social support from friends increased odds of anxiety by 1.7 times ( p = .018). Depression and stress increased odds of anxiety by 4.4 times ( p = .001) and 3.7 times ( p = .008) respectively. Conclusions Depression and anxiety among people with HIV is often under-recognised. Early identification and treatment of the mental illness is warranted. Screening with DASS-21 is useful to detect depression in patients with HIV. </jats:sec