Objectives: To provide accurate forecasts of the age distribution of people with HIV (PWH) in Kenya from 2025 to 2040. Design: Development of a compartmental model of HIV in Kenya, calibrated to ...historical estimates of HIV epidemiology. Methods: We forecasted changes in population size and age distribution of new HIV infections and PWH under the status quo and under scale-up of HIV services. Results: Without scale-up, new HIV infections were forecasted to fall from 34 000 (28 000–41 000) in 2,025 to 29 000 (15 000–57 000) in 2,040; the percentage of new infections occurring among persons over 30 increased from 33% (20–50%) to 40% (24–62%). The median age of PWH increased from 39 years (38–40) in 2025 to 43 years (39–46) in 2040, and the percentage of PWH over age 50 increased from 26% (23–29%) to 34% (26–43%). Under the full intervention scenario, new infections were forecasted to fall to 6,000 (3,000–12 000) in 2,040. The percentage of new infections occurring in people over age 30 increased to 52% (34–71%) in 2,040, and there was an additional shift in the age structure of PWH forecasted median age of 46 (43–48) and 40% (33–47%) over age 50. Conclusion: PWH in Kenya are forecasted to age over the next 15 years; improvements to the HIV care continuum are expected to contribute to the growing proportion of older PWH.
This study sought to characterize changes in depressive symptom severity during the COVID-19 pandemic and the association of these changes with HIV viral nonsuppression among people with HIV (PWH).
A ...clinical cohort study.
We included PWH in the Johns Hopkins HIV Clinical Cohort who completed the Patient Health Questionnaire 8 (PHQ-8) prepandemic (1 March 2018 to 28 February 2020) and during the COVID-era (1 September 2020 to 28 February 2022). PWH were classified according to depression severity categories prepandemic and during the COVID-era as: consistently depressed (prepandemic PHQ-8 >4 and no change in severity category); consistently nondepressed (prepandemic PHQ-8 ≤4 and no change in severity category); worsened (changed to a higher severity category) and; improved (change to a lower severity category). The association between changes in depressive symptom severity and viral nonsuppression (HIV RNA >200 copies/ml on the earliest viral load measured 7 days before to 12 months after the COVID-era PHQ-8 survey) was assessed using multivariable logistic regression.
Of 793 PWH, mean age was 56 (SD 10) years, 60% were male individuals and 88% were Black. After the onset of the pandemic, 60% were consistently nondepressed, 9% were consistently depressed, 15% worsened and 16% improved. PWH who worsened had 2.47 times the odds of viral nonsuppression (95% CI: 1.09-5.55) compared with the nondepressed group. Associations among other groups were not statistically significant.
Worsening depression during the COVID-era was associated with HIV viral nonsuppression. Strategies to monitor and address depression among PWH may contribute to reduced risk of viral nonsuppression.
Abstract
Background
Opioid use is prevalent among people living with human immunodeficiency virus (HIV; PLWH) and adversely affects HIV outcomes. We assessed the effect of buprenorphine (BUP) ...initiation on subsequent HIV viral loads.
Methods
We identified PLWH from the Johns Hopkins HIV Clinical Cohort who initiated BUP between 2002 and 2017. Poisson regression with robust variance was used to estimate the prevalence of viral suppression (<200 copies/mL) before and after BUP initiation. We matched individuals who initiated BUP with controls based on viral load measurement dates and used prior event rate ratio (PERR) methods to estimate the effect of BUP initiation on viral suppression. PERR methods account for unmeasured confounders.
Results
We identified 279 PLWH who initiated BUP. After BUP initiation, PLWH were more likely to be virally suppressed (prevalence ratio PR, 1.19; 95% confidence interval CI, 1.03–1.37). After matching PLWH who initiated BUP to controls and accounting for measured and unmeasured confounders, BUP initiation increased viral suppression for both those on antiretroviral therapy (ART) at baseline (PERR PR, 1.08; 95% CI, 1.00–1.18) and those not on ART at baseline (PR, 1.31; 95% CI, 1.10–1.61).
Conclusions
Our results indicate that the initiation of BUP results in an increase in the probability of being virally suppressed after accounting for both measured and unmeasured confounders. Persons with opioid use disorder should initiate BUP to not only treat substance use but also to increase viral suppression allowing for treatment as prevention.
Buprenorphine initiation was found to increase viral suppression among people living with human immunodeficiency virus (HIV; PLWH) with an opioid use disorder (OUD). Therefore, initiation is important to improve individual HIV outcomes among PWH with OUD and to reduce the risk of HIV transmission.
Among persons with human immunodeficiency virus (HIV) infection, illegal drug use and hazardous alcohol use are hypothesized to be strong risk factors for failure to achieve or maintain a suppressed ...HIV viral load, but accurate quantification of this association is difficult because of challenges involved in measuring substance use as part of routine clinical care. We estimated the associations of recent cocaine use, opioid/heroin use, and hazardous alcohol use with unsuppressed viral load among 1,554 persons receiving care at the John G. Bartlett Specialty Practice (Baltimore, Maryland) between 2013 and 2017. We accounted for measurement error in substance use using Bayesian models and prior estimates of the sensitivity and specificity of 2 imperfect measures of substance use derived from a previous analysis in this cohort. The prevalence difference for unsuppressed viral load associated with recent cocaine use was 11.3% (95% credible interval (CrI): 6.4, 17.0); that associated with recent opioid/heroin use was 13.2% (95% CrI: 6.6, 20.7); and that associated with recent hazardous alcohol use was 8.5% (95% CrI: 3.2, 14.4). Failure to account for measurement error resulted in clinically meaningful underestimates of the prevalence difference. Time-varying substance use is prevalent and difficult to measure in routine care; here we demonstrate a method that improves the utility of imperfect data by accounting for measurement error.
Objective:
The aim of this study was to describe the risk of viral nonsuppression across the depression care cascade.
Design:
A clinical cohort study.
Methods:
We used depressive symptoms (PHQ-8 ≥ ...10) self-reported on computer-assisted surveys, clinical diagnoses of depression in the medical record in the prior year and pharmacologic (any prescription for an antidepressant) and psychologic treatments for depression (attendance at at least two mental health visits in the prior year) to classify patients into groups: no history of depression; prior depression diagnosis; current indication for depression treatment (symptoms or clinical diagnosis); and treated depression (stratified by presence of persistent symptoms). We associated position in the depression care cascade with viral nonsuppression (>200 copies/ml) 7 days before to 6 months after the index self-report of depressive symptoms.
Results:
History of depression adjusted risk difference (aRD) relative to no history = 5.9%, 95% confidence interval (95% CI): 1.5–10.3 and current depression (symptoms or diagnosis) in the absence of treatment (aRD relative to no current depression or depression treatment = 4.8%, 95% CI: 1.8–7.8) were associated with a higher risk of viral nonsuppression than no history of depression. Depression treatment mitigated this association (aRD = −0.4%, 95% CI: −2.5 to 1.7).
Conclusion:
The relationship between depression care cascade and viral suppression is complex. Untreated depression and clinically unrecognized depressive symptoms were both related to viral nonsuppression. Treated depression was not associated with viral nonsuppression; however, a high proportion of treated patients still had depressive symptoms. Depression treatment should be titrated if patients’ symptoms are not responsive and patients with a history of depression should be monitored for ART adherence.
Abstract
Accurate, routine measurement of recent illicit substance use is challenging. The Johns Hopkins Human Immunodeficiency Virus Clinical Cohort (Baltimore, Maryland) collects 2 imperfect but ...routine measurements of recent substance use: medical record review and self-interview. We used Bayesian latent class modeling to estimate sensitivity and specificity of each measurement as well as prevalence of substance use among 2,064 patients engaged in care during 2007–2015. Sensitivity of medical record review was higher than sensitivity of self-interview for cocaine and heroin use; posterior estimates ranged from 44% to 76% for cocaine use and from 39% to 67% for heroin use, depending on model assumptions and priors. In contrast, sensitivity of self-interview was higher than sensitivity of medical record review for any alcohol use, hazardous alcohol use, and cigarette smoking. Posterior estimates of sensitivity of self-interview were generally above 80%, 85%, and 87% for each substance, respectively. Specificity was high for all measurements. From one model, we estimated prevalence of substance use in the cohort to be 12.5% for cocaine, 9.3% for heroin, 48.5% for alcohol, 21.4% for hazardous alcohol, and 55.4% for cigarettes. Prevalence estimates from other models were generally comparable. Measurement error of substance use is nontrivial and should be accounted for in subsequent analyses.
Telemedicine became the primary mode of delivering care during the COVID-19 pandemic. We describe the impact of telemedicine on access to care for people with HIV (PWH) by comparing the proportion of ...PWH engaged in care prior to and during the COVID-19 pandemic.
We conducted an observational analysis of patients enrolled in the Johns Hopkins HIV Clinical Cohort, a single-center cohort of patients at an urban HIV subspecialty clinic affiliated with an academic center. Due to the COVID-19 pandemic, the clinic transitioned from in-person to mostly telemedicine visits. We compared patients receiving care in two time periods. The prepandemic period included 2010 people with at least one visit scheduled between 1 September 2019 and 15 March 2020. The pandemic period included 1929 people with at least one visit scheduled between 16 March 2020 and 30 September 2020. We determined the proportion of patients completing at least one of their scheduled visits during each period.
Visit completion increased significantly from 88% prepandemic to 91% during the pandemic (P = 0.008). Visit completion improved significantly for patients age 20-39 (82 to 92%, P < 0.001), women (86 to 93%, P < 0.001), Black patients (88 to 91%, P = 0.002) and patients with detectable viremia (77 to 85%, P = 0.06) during the pandemic. Only 29% of people who completed at least one telemedicine visit during the pandemic did so as a video (versus telephone) visit.
During the pandemic when care was widely delivered via telemedicine, visit completion improved among groups with lower prepandemic engagement but most were limited to telephone visits.
Abstract
Access to direct acting antivirals (DAAs) may be associated with reductions in hepatitis C virus (HCV) viremia prevalence among people with human immunodeficiency virus (PWH). Among 3755 ...PWH, estimated HCV viremia prevalence decreased by 94.0% from 36% (95% confidence interval CI, 27%–46%) in 2009 (pre-DAA era) to 2% (95% CI, 0%–4%) in 2021 (DAA era). Male sex, black race, and older age were associated with HCV viremia in 2009 but not in 2021. Injection drug use remained associated with HCV viremia in 2009 and 2021. Targeted interventions are needed to meet the HCV care needs of PWH who use drugs.
Among 3755 people with HIV, availability of direct acting antivirals (DAA) was associated with a reduction in HCV viremia prevalence from 36% in 2009 (pre-DAA era) to 2% in 2021 (DAA era) and changes in characteristics associated with HCV viremia.
In May, 2016, WHO endorsed a 9 month regimen for multidrug-resistant tuberculosis that is cheaper and potentially more effective than the conventional, longer (20–24 month) therapy. We aimed to ...investigate the population-level implications of scaling up this new regimen.
In this population modelling analysis, we developed a dynamic transmission model to simulate the introduction of this short-course regimen as an instantaneous switch in 2016. We projected the corresponding percentage reduction in the incidence of multidrug-resistant tuberculosis by 2024 compared with continued use of longer therapy. In the primary analysis in a representative southeast Asian setting, we assumed that the short-course regimen would double treatment access (through savings in resources or capacity) and achieve long-term efficacy at levels seen in preliminary cohort studies. We then did extensive sensitivity analyses to explore a range of alternative scenarios.
Under the optimistic assumptions in the primary analysis, the incidence of multidrug-resistant tuberculosis in 2024 would be 3·3 (95% uncertainty range 2·2–5·6) per 100 000 population with the short-course regimen and 4·3 (2·9–7·6) per 100 000 population with continued use of longer therapy—ie, the short-course regimen could reduce incidence by 23% (10–38). Incidence would be reduced by 14% (4–28) if the new regimen affected only treatment effectiveness and by 11% (3–24) if it affected only treatment availability. Under more pessimistic assumptions, the short-course regimen would have minimal effect and even potential for harm—eg, when 30% of patients are ineligible for the new regimen because of second-line drug resistance, we projected a change in incidence of −2% (−20 to +28). The new regimen's effect was greater in settings with more ongoing transmission of multidrug-resistant tuberculosis, but results were otherwise similar across settings with different levels of tuberculosis incidence and prevalence of multidrug resistance.
The short-course regimen has potential to substantially lessen the multidrug-resistant tuberculosis epidemic, but this effect depends on its long-term efficacy, its ability to expand treatment access, and the role of second-line drug resistance.
US National Institutes of Health and Bill & Melinda Gates Foundation.
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