Estimating HIV transmissions in a large U.S. clinic-based sample: effects of time and syndemic conditions

Introduction: Little is known about onward HIV transmissions from people living with HIV (PLWH) in care. Antiretroviral therapy (ART) has increased in potency, and treatment as prevention (TasP) is an important component of ending the epidemic. Syndemic theory has informed modelling of HIV risk but has yet to inform modelling of HIV transmissions. Methods: Data were from 61,198 primary HIV care visits for 14,261 PLWH receiving care through the Centers for AIDS Research (CFAR) Network of Integrated Clinical Systems (CNICS) at seven United States (U.S.) sites from 2007 to 2017. Patient-reported outcomes and measures (PROs) of syndemic conditions – depressive symptoms, anxiety symptoms, drug use (opiates, amphetamines, crack/cocaine) and alcohol use – were collected approximately four to six months apart along with sexual behaviours (mean = 4.3 observations). Counts of syndemic conditions, HIV sexual risk group and time in care were modelled to predict estimated HIV transmissions resulting from sexual behaviour and viral suppression status (HIV RNA \u3c 400/mL) using hierarchical linear modelling. Results: Patients averaged 0.38 estimated HIV transmissions/100 patients/year for all visits with syndemic conditions measured (down from 0.83, first visit). The final multivariate model showed that per 100 patients, each care visit predicted 0.05 fewer estimated transmissions annually (95% confidence interval (CI): 0.03 to 0.06; p \u3c 0.0005). Cisgender women, cisgender heterosexual men and cisgender men of undisclosed sexual orientation had, respectively, 0.47 (95% CI: 0.35 to 0.59; p \u3c 0.0005), 0.34 (95% CI: 0.20 to 0.49; p \u3c 0.0005) and 0.22 (95% CI: 0.09 to 0.35; p \u3c 0.005) fewer estimated HIV transmissions/100 patients/year than cisgender men who have sex with men (MSM). Each within-patient syndemic condition predicted 0.18 estimated transmissions/100 patients/year (95% CI: 0.12 to 0.24; p \u3c 0.0005). Each between-syndemic condition predicted 0.23 estimated HIV transmissions/100 patients/year (95% CI: 0.17 to 0.28; p \u3c 0.0005). Conclusions: Estimated HIV transmissions among PLWH receiving care in well-resourced U.S. clinical settings varied by HIV sexual risk group and decreased with time in care, highlighting the importance of TasP efforts. Syndemic conditions remained a significant predictor of estimated HIV transmissions notwithstanding the effects of HIV sexual risk group and time in care

Effects of Reforming HIV-Specific Criminal Laws on Internalized Stigma, ART Adherence, and Viral Suppression Among People Living with HIV

Background: Few if any studies have examined how the repeal or reform of criminal laws punishing people living with HIV (PLWH) for nondisclosure of serostatus to their sexual partners has affected individual-level health and mental health outcomes among PLWH. In the U.S., men who have sex with men (MSM) make up the majority of those living with HIV. California repealed and North Carolina reformed their HIV-specific criminal laws on January 1, 2018.Method: Data were from 2,986 men who have sex with men living with HIV (MSMLWH) receiving care through the Center for AIDS Research Network of Integrated Clinical Systems (CNICS) at three sites &ndash; UCSD, UCSF, and UNC Chapel Hill &ndash; between January 1, 2016 and March 1, 2020. Patient-reported outcomes and measures (antiretroviral therapy (ART) adherence, internalized HIV stigma, intimate partner violence (IPV) exposure) provided at clinic visits were combined with insurance and viral suppression data. Using interrupted time-series analyses, a series of multilevel models&nbsp;were run to examine the associations of the 2018 legal reforms with internalized HIV stigma, ART adherence, viral suppression, and overall HIV health, as well as whether any of these associations varied by race, Hispanic ethnicity, economic marginalization, or IPV exposure.Results: Each month following the 2018 legal reforms was associated with 9% greater odds of being ART adherent. No significant associations of the 2018 legal reforms emerged with respect to internalized HIV stigma, viremia, or overall HIV health. Differences in internalized HIV stigma and ART adherence emerged with respect to race and IPV exposure, as did differences in overall HIV health with respect to economic marginalization.Conclusion: Repeal or reform of HIV criminal statutes may improve ART adherence among PLWH.</p

Predicting HIV Transmissions From Syndemic Factors In a Large Clinic-Based Sample

Background: The theory of syndemics—whereby synergism between co-occurring psychosocial epidemics exacerbates health outcomes—has informed efforts to quantify the risk of contracting HIV, but it has rarely been used to quantify HIV transmission risk among people living with HIV (PLWH). To improve treatment as prevention (TasP) efforts, greater insight is needed about how syndemic factors influence viral suppression and biobehavioral transmission risk behavior among PLWH. Method: Data were from 14,261 PLWH receiving care through the Centers for AIDS Research Network of Integrated Clinical Systems at seven sites from 2007 to 2017. Syndemic factors (depressive symptoms, anxiety symptoms, drug use, and alcohol use) and sexual behaviors were collected through patient-reported outcomes and measures (PROs) at least 4–6 months apart. Using estimates of per-sex-act HIV transmission rates, estimated HIV transmissions were computed for each observation period. Hierarchical linear modeling was used to model the number of syndemic factors, sexual risk group (cisgender heterosexual men, cisgender men who have sex with men (MSM), cisgender men of unknown sexual orientation, cisgender women, and transgender women), and time in care as predictors of estimated HIV transmissions. Results: When comparing patients to one another based on their average number of syndemic factors, each additional syndemic factor in patients’ averages was associated with 0.527 estimated HIV transmissions per 100 patients annually. When comparing patients to themselves across the available time period, each increase in patients’ individual number of syndemic factors for a particular observation period was associated with 0.342 estimated transmissions per 100 patients annually. Cisgender women were estimated to contribute to 0.865 fewer transmissions per 100 patients annually than the referent group (cisgender MSM). Conclusion: Syndemic factors among PLWH appear to be predictive of biobehavioral HIV transmission risk as measured by estimates of infections accounting for sexual behavior and HIV RNA viral load suppression. Psychosocial interventions to address these syndemic factors in clinical settings may be an effective means of secondary HIV prevention.</p

Quantifying Sexual Orientation Among Homeless and Unstably Housed Women in a Longitudinal Study: Identity, Behavior, and Fluctuations Over a Three-Year Period.

Sexual orientation has been linked to certain health conditions, and yet quantifying sexual orientation in longitudinal studies is challenging. This study examined different methods of accounting for sexual orientation in a cohort study of 300 homeless and unstably housed women followed every 6&nbsp;months over 3&nbsp;years. Altogether, 39.7% (n&nbsp;=&nbsp;119) could be considered sexual minority at one or more time points based on identity and/or behavior; 16.3% (n&nbsp;=&nbsp;49) reported shifts in sexual identity. Only 24.0% (n&nbsp;=&nbsp;72) were identified as sexual minority through a single measure of sexual identity, 27.0% (n&nbsp;=&nbsp;81) were identified with a single measure of identity and behavior, 33.0% (n&nbsp;=&nbsp;99) were identified through annual measures of identity and behavior, and 22.0%-22.3% (n&nbsp;=&nbsp;66-67) were identified through latent class analysis including all identity/behavior measures. This study found that sexual fluidity is common in unstably housed women, and many sexual minority women would be missed in longitudinal studies with different methods of accounting for sexual orientation

Individual, Interpersonal, and Structural Factors That Influence Intentions to Use Pre-exposure Prophylaxis Among Sexual Minority Men in Miami

Pre-exposure prophylaxis for HIV or "PrEP" holds great promise for reducing HIV incidence. However, in certain geographic settings, like Miami, a US HIV epicenter, uptake of PrEP has been paradoxically very low compared to other areas of the country. The goal of the current study was to examine factors associated with low uptake of PrEP in young sexual minority men in Miami. Qualitative data were extracted from conversations during voluntary HIV/STI counseling and testing sessions with 24 young sexual minority men, most of whom identified as racial/ethnic minorities. These sessions were completed as part of a baseline visit for a combined mental and sexual health intervention trial. Thematic analysis of transcripts revealed barriers and facilitators associated with PrEP uptake at multiple levels (individual, interpersonal, and economic and healthcare systems barriers). Individual-level themes included concerns about the safety of PrEP, risk compensation, and taking daily oral medication; and potential benefits of PrEP as a backup plan to condom use to reassure and reduce worry about HIV. Interpersonal-level themes included lack of knowledgeable and affirming medical providers, changing norms within the community around "safe sex," and PrEP use in serodiscordant partnerships. Economic and healthcare systems barriers included challenges to accessing PrEP because of a lack of insurance and high out-of-pocket cost. These data can be used to inform the development of interventions aligned with Ending the HIV Epidemic priorities to increase PrEP use among young sexual minority men living in an HIV epicenter

Scaling Up and Out HIV Prevention and Behavioral Health Services to Latino Sexual Minority Men in South Florida: Multi-Level Implementation Barriers, Facilitators, and Strategies

Latino sexual minority men (LSMM) are disproportionately affected by HIV in the United States. Concurrently, behavioral health disparities, including mental health and substance use concerns, worsen HIV disparities affecting LSMM. Yet, evidence-based HIV prevention and behavioral health services are insufficiently scaled up and out to this population, perpetuating health disparities, thwarting efforts to control the HIV epidemic, and highlighting the need for culturally relevant evidence-based implementation strategies that address these disparities. Participants included 28 LSMM with varying degrees of engagement in HIV prevention and behavioral health services, and 10 stakeholders with experience delivering HIV prevention and behavioral health services to LSMM in South Florida, an HIV epicenter in general and in particular for LSMM. Participants completed semistructured interviews (English/Spanish) regarding LSMM's barriers and facilitators to engaging in HIV prevention and behavioral health services. Interviews were audio recorded and analyzed using thematic analysis. The 16 themes that emerged from the qualitative analysis were consistent with the consolidated framework for implementation research, an implementation research framework that articulates barriers and facilitators to implementing clinical interventions. Findings suggested the need for implementation strategies that simplify and reduce costs of HIV prevention and behavioral health services, address syndemic challenges impacting service use among LSMM, reduce stigma about service utilization, leverage peer networks, increase provider and community knowledge about services, and build LSMM's readiness and motivation to engage in services. Such strategies may ultimately address HIV and behavioral health disparities among LSMM and facilitate achievement of goals in this disproportionally affected population

Estimating HIV transmissions in a large U.S. clinic-based sample: effects of time and syndemic conditions.

IntroductionLittle is known about onward HIV transmissions from people living with HIV (PLWH) in care. Antiretroviral therapy (ART) has increased in potency, and treatment as prevention (TasP) is an important component of ending the epidemic. Syndemic theory has informed modelling of HIV risk but has yet to inform modelling of HIV transmissions.MethodsData were from 61,198 primary HIV care visits for 14,261 PLWH receiving care through the Centers for AIDS Research (CFAR) Network of Integrated Clinical Systems (CNICS) at seven United States (U.S.) sites from 2007 to 2017. Patient-reported outcomes and measures (PROs) of syndemic conditions - depressive symptoms, anxiety symptoms, drug use (opiates, amphetamines, crack/cocaine) and alcohol use - were collected approximately four to six months apart along with sexual behaviours (mean&nbsp;=&nbsp;4.3 observations). Counts of syndemic conditions, HIV sexual risk group and time in care were modelled to predict estimated HIV transmissions resulting from sexual behaviour and viral suppression status (HIV RNA&nbsp;&lt;&nbsp;400/mL) using hierarchical linear modelling.ResultsPatients averaged 0.38 estimated HIV transmissions/100 patients/year for all visits with syndemic conditions measured (down from 0.83, first visit). The final multivariate model showed that per 100 patients, each care visit predicted 0.05 fewer estimated transmissions annually (95% confidence interval (CI): 0.03 to 0.06; p&nbsp;&lt;&nbsp;0.0005). Cisgender women, cisgender heterosexual men and cisgender men of undisclosed sexual orientation had, respectively, 0.47 (95% CI: 0.35 to 0.59; p&nbsp;&lt;&nbsp;0.0005), 0.34 (95% CI: 0.20 to 0.49; p&nbsp;&lt;&nbsp;0.0005) and 0.22 (95% CI: 0.09 to 0.35; p&nbsp;&lt;&nbsp;0.005) fewer estimated HIV transmissions/100 patients/year than cisgender men who have sex with men (MSM). Each within-patient syndemic condition predicted 0.18 estimated transmissions/100 patients/year (95% CI: 0.12 to 0.24; p&nbsp;&lt;&nbsp;0.0005). Each between-syndemic condition predicted 0.23 estimated HIV transmissions/100 patients/year (95% CI: 0.17 to 0.28; p&nbsp;&lt;&nbsp;0.0005).ConclusionsEstimated HIV transmissions among PLWH receiving care in well-resourced U.S. clinical settings varied by HIV sexual risk group and decreased with time in care, highlighting the importance of TasP efforts. Syndemic conditions remained a significant predictor of estimated HIV transmissions notwithstanding the effects of HIV sexual risk group and time in care