Abstract
Background
Recent studies have reported weight gain in virologically suppressed persons living with human immunodeficiency virus (PLWH) switched from older antiretroviral therapy (ART) to ...newer integrase strand transfer inhibitor (INSTI)–based regimens. In this study, we investigated whether weight gain differs among treatment-naive PLWH starting INSTI-based regimens compared to other ART regimens.
Methods
Adult, treatment-naive PLWH in the Vanderbilt Comprehensive Care Clinic cohort initiating INSTI-, protease inhibitor (PI)–, and nonnucleoside reverse transcriptase inhibitor (NNRTI)–based ART between January 2007 and June 2016 were included. We used multivariable linear mixed-effects models to generate marginal predictions of weights over time, adjusting for baseline clinical and demographic characteristics. We used restricted cubic splines to relax linearity assumptions and bootstrapping to generate 95% confidence intervals.
Results
Among 1152 ART-naive PLWH, 351 initiated INSTI-based regimens (135 dolutegravir, 153 elvitegravir, and 63 raltegravir), 86% were male, and 49% were white. At ART initiation, median age was 35 years, body mass index was 25.1 kg/m2, and CD4+ T-cell count was 318 cells/μL. Virologic suppression at 18 months was similar between different ART classes. At all examined study time points, weight gain was highest among PLWH starting dolutegravir. At 18 months, PLWH on dolutegravir gained 6.0 kg, compared to 2.6 kg for NNRTIs (P < .05), and 0.5 kg for elvitegravir (P < .05). PLWH starting dolutegravir also gained more weight at 18 months compared to raltegravir (3.4 kg) and PIs (4.1 kg), though these differences were not statistically significant.
Conclusions
Treatment-naive PLWH starting dolutegravir-based regimens gained significantly more weight at 18 months than those starting NNRTI-based and elvitegravir-based regimens.
This report evaluates the differences in weight gain among treatment-naive persons living with HIV (PLWH) initiating antiretroviral therapy. The results highlight enhanced weight gain among PLWH starting dolutegravir-based therapy and lower weight gain with elvitegravir-based therapy.
OBJECTIVE:In virologically suppressed HIV-infected adults, noncommunicable diseases (NCDs) have been associated with immune senescence and low CD4/CD8 lymphocyte ratio. Age differences in the ...relationship between CD4/CD8 ratio and NCDs have not been described.
DESIGN:Observational cohort study.
METHODS:We assessed CD4/CD8 ratio and incident NCDs (cardiovascular, cancer, liver, and renal diseases) in HIV-infected adults started on antiretroviral therapy between 1998 and 2012. Study inclusion began once patients maintained virologic suppression for 12 months (defined as baseline). We examined age and baseline CD4/CD8 ratio and used Cox proportional hazard models to assess baseline CD4/CD8 ratio and NCDs.
RESULTS:This study included 2006 patients. Low baseline CD4/CD8 ratio was associated with older age, male sex, and low CD4 lymphocyte counts. In models adjusting for CD4 lymphocyte count, CD4/CD8 ratio was inversely associated with age (P < 0.01). Among all patients, 182 had incident NCDs, including 46 with coronary artery disease (CAD) events. CD4/CD8 ratio was inversely associated with risk of CAD events adjusted HR per 0.1 increase in CD4/CD8 ratio = 0.87, 95% confidence interval (CI)0.76–0.99, P = 0.03. This association was driven by those under age 50 years (adjusted HR 0.83 0.70–0.97, P = 0.02) vs. those over age 50 years (adjusted HR = 0.96 0.79–1.18, P = 0.71). CD4/CD8 ratio was not significantly associated with incident noncardiac NCDs.
CONCLUSIONS:Higher CD4/CD8 ratio after 1 year of HIV virologic suppression was independently predictive of decreased CAD risk, particularly among younger adults. Advanced immune senescence may contribute to CAD events in younger HIV patients on antiretroviral therapy.
A growing population of older adults with HIV will increase demands on HIV-related healthcare. Nearly a quarter of people receiving care for HIV in Latin America are currently 50 years or older, yet ...little is known about the frequency of comorbidities in this population. We estimated the prevalence and incidence of non-communicable diseases (NCDs) among people 50 years of age or older (greater than or equal to50yo) receiving HIV care during 2000-2015 in six centers affiliated with the Caribbean, Central and South American network for HIV epidemiology (CCASAnet). We estimated the annual prevalence, and overall prevalence and incidence of cardiovascular diseases, diabetes, hypertension, dyslipidemia, psychiatric disorders, chronic liver and renal diseases, and non-AIDS-defining cancers, and multimorbidity (more than one NCD) of people greater than or equal to50yo receiving care for HIV. Analyses were performed according to age at enrollment into HIV care (<50yo and greater than or equal to50yo). We included 3,415 patients greater than or equal to50yo, of whom 1,487(43%) were enrolled at age greater than or equal to50 years. The annual prevalence of NCDs increased from 32% to 68% and multimorbidity from 30% to 40% during 2000-2015. At the last registered visit, 53% of patients enrolled <50yo and 50% of those enrolled greater than or equal to50yo had at least one NCD. Most common NCDs at the last visit in each age-group at enrollment were dyslipidemia (36% in <50yo and 28% in greater than or equal to50yo), hypertension (17% and 18%), psychiatric disorders (15% and 10%), and diabetes (11% and 12%). The prevalence of NCDs and multimorbidity in people greater than or equal to50 years receiving care for HIV in CCASAnet centers in Latin America increased substantially in the last 15 years. Our results make evident the need of planning for provision of complex, primary care for aging adults living with HIV.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
To assess sex disparities in AIDS clinical and laboratory outcomes in the highly active antiretroviral therapy (HAART) era we conducted a systematic review of the published literature on mortality, ...disease progression, and laboratory outcomes among persons living with HIV and starting HAART. We performed systematic PubMed and targeted bibliographic searches of observational studies published between January, 1998, and November, 2013, that included persons starting HAART and reported analyses of mortality, progression to AIDS, or virologic or immunologic treatment outcomes by sex. Risk ratios (relative risks, odd ratios, and hazard ratios) and 95% confidence intervals were obtained. Sixty-five articles were included in this review. Thirty-nine studies were from North America and Europe and 26 were from Latin America, Asia, and Africa. Forty-four studies (68%) showed no statistically significant difference in risk of mortality, progression to AIDS, or virologic or immunologic treatment outcomes by sex. Decreased risk of death among females compared to males was observed in 24 of the 25 articles that included mortality analyses pooled risk ratio 0.72 (95% confidence interval=0.69-0.75), and decreased risk of death or AIDS was observed in 9 of the 13 articles that examined the composite outcome pooled risk ratio=0.91 (0.84-0.98). There was no significant effect of sex on the risk of progression to AIDS pooled risk ratio=1.15 (0.99-1.31). In this systematic review, females starting HAART appeared to have improved survival compared to males. However, this benefit was not associated with decreased progression to either AIDS or to differences in virologic or immunologic treatment outcomes.
Abstract
Background
Independent of CD4 cell count, a low CD4/CD8 ratio in people with HIV (PWH) is associated with deleterious immune senescence, activation, and inflammation, which may contribute to ...carcinogenesis and excess cancer risk. We examined whether low CD4/CD8 ratios predicted cancer among PWH in the United States and Canada.
Methods
We examined all cancer-free PWH with 1 or more CD4/CD8 values from North American AIDS Cohort Collaboration on Research and Design observational cohorts with validated cancer diagnoses between 1998 and 2016. We evaluated the association between time-lagged CD4/CD8 ratio and risk of specific cancers in multivariable, time-updated Cox proportional hazard models using restricted cubic spines. Models were adjusted for age, sex, race and ethnicity, hepatitis C virus, and time-updated CD4 cell count, HIV RNA, and history of AIDS-defining illness.
Results
Among 83 893 PWH, there were 5628 incident cancers, including lung cancer (n = 755), Kaposi sarcoma (n = 501), non-Hodgkin lymphoma (n = 497), and anal cancer (n = 439). The median age at cohort entry was 43 years. The overall median 6-month lagged CD4/CD8 ratio was 0.52 (interquartile range = 0.30-0.82). Compared with a 6-month lagged CD4/CD8 of 0.80, a CD4/CD8 of 0.30 was associated with increased risk of any incident cancer (adjusted hazard ratio = 1.24 95% confidence interval = 1.14 to 1.35). The CD4/CD8 ratio was also inversely associated with non-Hodgkin lymphoma, Kaposi sarcoma, lung cancer, anal cancer, and colorectal cancer in adjusted analyses (all 2-sided P < .05). Results were similar using 12-, 18-, and 24-month lagged CD4/CD8 values.
Conclusions
A low CD4/CD8 ratio up to 24 months before cancer diagnosis was independently associated with increased cancer risk in PWH and may serve as a clinical biomarker.
Abstract
Background
For reasons not fully explained to date, contraception usage among women with HIV remains low. The aim of our study was to understand attitudes toward and lifetime use of ...contraception among women with HIV.
Methods
We administered an anonymous, community-informed, voluntary survey to cisgender, English-speaking women with HIV (≥18 years of age) at a Southern urban HIV clinic. It included multiple choice and Likert-scale questions on reproductive health. Participants reported contraception use, recollection of provider conversations about contraception, and perceived empowerment and knowledge regarding reproductive health. We used chi-square and Fisher exact tests to compare attitudes and prior conversations about contraception by age (< vs ≥45 years), race (Black vs non-Black), and lifetime contraception use.
Results
The median age of the 114 participants was 52 years, and 62% of the women identified as Black and 31% as White. Women reported a median of 2 unique family planning methods used throughout life, with oral contraceptive pills being most the common (59%). Only 20% of women reported having ever used long-acting reversible contraception (LARC). Only 56% of women recalled talking with a provider about contraception. Women of non-Black race and those who had used LARC were more likely to remember (72 vs 52%; P = .035; 87 vs 56%; P = .022; respectively). When asked about preferences, 82% of women age <45 years wanted a nondaily method, and 60% felt uncomfortable with device insertion.
Conclusions
Throughout life, participants reported using a diversity of contraceptives. Only half of women remembered a provider conversation about contraception. Understanding women's preferences regarding contraception should guide counseling.
Women living with HIV use many different contraception methods throughout their life but many do not recall having a discussion of contraception options with their providers. Women living with HIV want contraception that is easily reversed and not taken daily.
We sought to investigate the association between insurance coverage history and cervical cancer screening among Davidson County, Tennessee, women diagnosed with incident cervical cancer.
We reviewed ...medical records of women diagnosed with invasive cervical cancer from 2008 through 2018 identified via the state's cancer registry and by active surveillance of diagnostic pathology reports for the HPV-IMPACT project. Per 2012 United States Preventive Services Task Force recommended cervical cancer screening guidelines, women were characterized into three screening history categories: "no screening", "no follow-up" and "test/screening failure". Multivariable logistic regression measured the association of prior inadequate insurance (underinsurance) and screening history ("no screening/no follow-up" compared to "test/screening failure").
Of 212 women, most (77%) had not undergone recommended cervical cancer screening or follow-up prior to cancer diagnosis. Overall, 28% of women had history of underinsurance in 5 years prior to diagnosis. In adjusted analyses, underinsured women were more likely to have a "no screening/no follow-up" prior to cancer diagnosis (aOR 4.26; 95% CI 1.15-15.80) compared to "test/screening failure" history. Non-white race (aOR 2.73; 95% CI 0.98-7.61), older age (aOR 1.03 per year; 95% CI 1.00-1.07), and history of smoking (aOR 4.07; 95% CI 1.54-10.74) were also associated with increased likelihood of "no screening/no follow-up".
Previous underinsurance was independently associated with non-adherence to cervical cancer screening and follow-up guidelines among women with incident cervical cancer. Further study of factors contributing to inadequate cervical cancer screening and interventions to increase cervical cancer screening in high-risk populations is needed.
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IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, UL, UM, UPUK, VSZLJ
Declines in cervical intraepithelial neoplasia grades 2 to 3 and adenocarcinoma in situ (CIN2+) observed among young women suggest impact from human papillomavirus (HPV) vaccination. To further ...evaluate vaccine impact including cross‐protection and type replacement, we described high‐risk (HR)‐HPV type‐specific cervical precancer incidence rates among women aged 20 to 39 years, 2008 to 2016. We analyzed cross‐sectional population‐based data on 18 344 cases of CIN2+ from a 5‐site surveillance system. Diagnostic specimens were tested for individual HPV types, including 14 HR‐HPV types (HPV16/18/31/33/35/39/45/51/52/56/58/59/66/68). We estimated age‐specific annual HR‐HPV type‐specific CIN2+ incidence per 100 000 screened women for individual types, vaccine HR‐HPV types (HPV16/18) and nonvaccine HR‐HPV types (non‐HPV16/18). We evaluated trends using average annual percent changes (AAPC) and 95% confidence intervals (CI), and estimated total declines by comparing 2015‐2016 to 2008‐2009 using incidence rate ratios. Among 20‐24‐year‐olds, HPV16/18‐CIN2+ declined from 2008 through 2016 (AAPC: −21.3%, 95% CI: −28.1%, −13.8%), whereas no trend was observed for non‐HPV16/18‐CIN2+ (AAPC: −1.8%, 95% CI: −8.1%, 4.9%). After 2010, CIN2+ among 20‐24‐year‐olds was more often caused by nonvaccine vs vaccine HR‐HPV types. No significant declining trends were observed in older age groups. In 2015‐2016 compared with 2008‐2009, HPV16‐CIN2+ declined 78%, HPV18‐CIN2+ 72% and HPV31‐CIN2+ 51% among 20‐24‐year‐olds; no increases were observed in type‐specific CIN2+ incidence. Among 25‐29‐year‐olds, HPV16‐CIN2+ declined 18%; CIN2+ attributed to seven nonvaccine types increased significantly. No significant declines were observed in older groups. Significant declines in HPV16/18‐CIN2+ in 20‐24‐year‐olds and HPV16‐CIN2+ in 25‐29‐year‐olds corroborate impact of HPV vaccination. A declining trend in HPV31‐CIN2+ is consistent with cross‐protection from vaccination.
What's new?
While vaccination against human papillomavirus (HPV) likely is responsible for recent declines in the incidence of cervical intraepithelial neoplasia grade 2 or higher (CIN2+) in young women, the true impact of vaccination on cervical precancer remains uncertain. Here, the authors examined trends in HPV‐type specific CIN2+ and CIN3+ in women in the United States. Analyses show that HPV vaccination had a strong and specific role in reducing cervical precancer incidence caused by high‐risk HPV types 16 and 18 among young women. A decline in HPV31 further suggests cross‐protection against a high‐risk HPV type not targeted by vaccination.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
We compared invasive cervical cancer (ICC) incidence rates in Europe, South Africa, Latin and North America among women living with HIV who initiated antiretroviral therapy (ART) between 1996 and ...2014. We analyzed cohort data from the International Epidemiology Databases to Evaluate AIDS (IeDEA) and the Collaboration of Observational HIV Epidemiological Research in Europe (COHERE) in EuroCoord. We used flexible parametric survival models to determine regional ICC rates and risk factors for incident ICC. We included 64,231 women from 45 countries. During 320,141 person‐years (pys), 356 incident ICC cases were diagnosed (Europe 164, South Africa 156, North America 19 and Latin America 17). Raw ICC incidence rates per 100,000 pys were 447 in South Africa (95% confidence interval CI: 382–523), 136 in Latin America (95% CI: 85–219), 76 in North America (95% CI: 48–119) and 66 in Europe (95% CI: 57–77). Compared to European women ICC rates at 5 years after ART initiation were more than double in Latin America (adjusted hazard ratio aHR: 2.43, 95% CI: 1.27–4.68) and 11 times higher in South Africa (aHR: 10.66, 95% CI: 6.73–16.88), but similar in North America (aHR: 0.79, 95% CI: 0.37–1.71). Overall, ICC rates increased with age (>50 years vs. 16–30 years, aHR: 1.57, 95% CI: 1.03–2.40) and lower CD4 cell counts at ART initiation (per 100 cell/μl decrease, aHR: 1.25, 95% CI: 1.15–1.36). Improving access to early ART initiation and effective cervical cancer screening in women living with HIV should be key parts of global efforts to reduce cancer‐related health inequities.
What's new?
Invasive cervical cancer (ICC) is a significant burden among women living with human immunodeficiency virus (HIV). Little is known, however, about geographical differences in ICC rates in women living with HIV. Here, ICC incidence rates in women who received antiretroviral therapy (ART) were compared across geographic regions. ICC incidence was notably high among women living with HIV in South Africa and Latin America. Five years after ART initiation, ICC incidence remained elevated for women in these two regions, compared with women in Europe and North America. Reduced CD4 cell count and older age at ART initiation were associated with increased ICC risk.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
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