Social determinants of health and long-term conditions in people of Black African and Black Caribbean ethnicity living with HIV in London: A qualitative study.

BACKGROUND: People living with human immunodeficiency virus (HIV) are disproportionately impacted by socioeconomic deprivation and are at increased risk of developing other long-term conditions (LTCs). These illnesses require transformative action to tackle the adverse effects on their health. Data on lived experiences of LTCs among people living with HIV of Black African and Black Caribbean ethnicities are sparse, and how people with LTCs are impacted by social determinants of health (SDoH). METHODS: Through a phenomenological study design this qualitative study, conducted in 2022, comprised four focus group discussions (FGDs) with 20 people of Black ethnicities living with HIV were purposively invited from a community organisation (CO) in London, including four semistructured interviews with CO staff. Following transcription, qualitative data were analysed thematically and measures to validate the findings were implemented. RESULTS: The findings are presented in terms of the following four levels of SDoH: (1) individual determinants (such as the impact of SDoH on lifestyle modification and self-management); (2) interpersonal determinants (such as positive experiences of accessing healthcare for LTCs); (3) clinical determinants (such as care pathway barriers) and (4) systemic determinants (such as systemic barriers related to race/ethnicity). CONCLUSIONS: It is necessary to provide ongoing and interactive education to community members who live with HIV, focusing on risks and management of LTCs. Additionally, individuals would benefit from support to navigate increasingly complex and fragmented health services. Health Service staff require cultural competence when caring for patients of Black African and Black Caribbean ethnicities with complex health and psychosocial needs. PATIENT OR PUBLIC CONTRIBUTION: The research team collaborated with an HIV CO in South London from the very start of the project to agree the study design and learn about the realities of their daily lived experiences. Community collaborators helped to develop the semistructured interview and FGD topic guides, and were directly involved in the data gathering, analysis and validation.

HIV outcomes during the COVID-19 pandemic in people of Black ethnicities living with HIV in England.

OBJECTIVES: To describe HIV care outcomes in people of Black ethnicities living in England during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; coronavirus disease 2019 [COVID-19]) pandemic. METHODS: This was an observational cohort study of people of self-reported Black ethnicities attending for HIV care at nine HIV clinics across England. The primary outcome was a composite of antiretroviral therapy (ART) interruption and HIV viraemia (HIV RNA ≥200 copies/mL) ascertained via self-completed questionnaires and review of medical records. We used multivariable logistic regression to explore associations between ART interruption/HIV viraemia and demographic factors, pre-pandemic HIV immunovirological control, comorbidity status, and COVID-19 disease and vaccination status. RESULTS: We included 2290 people (median age 49.3 years; 56% female; median CD4 cell count 555 cells/mm3; 92% pre-pandemic HIV RNA <200 copies/mL), of whom 302 (13%) reported one or more ART interruption, 312 (14%) had documented HIV viraemia ≥200 copies/mL, and 401 (18%) experienced the composite endpoint of ART interruption/HIV viraemia. In multivariable analysis, a pre-pandemic HIV RNA <200 copies/mL (odds ratio [OR] 0.21; 95% confidence interval [CI] 0.15-0.30) and being vaccinated against SARS-CoV-2 (OR 0.41; 95% CI 0.30-0.55) were associated with reduced odds of ART interruption/HIV viraemia; pandemic-related disruptions to HIV care were common self-reported additional factors. CONCLUSIONS: During the COVID-19 pandemic, one in six people of Black ethnicities in this HIV cohort experienced an ART interruption/HIV viraemia. Some of these episodes resulted from pandemic-related healthcare disruptions. Associations with suboptimal engagement in HIV care pre-pandemic and not being vaccinated against SARS-CoV-2 suggest that wider health beliefs and/or poor healthcare access may have been contributory factors.

"We decided together": a qualitative study about women with HIV navigating infant-feeding decisions with the father of their children.

BACKGROUND: The World Health Organization (WHO) recommends that women with HIV breastfeed for a minimum of one year. In contrast, United Kingdom (UK) guidelines encourage formula feeding, but breastfeeding can be supported under certain circumstances. Infant-feeding decisions often involve personal and social networks. Currently, little research addresses how individuals with HIV in high-income countries navigate infant-feeding decisions with the father of their children. METHODS: Semi-structured remote interviews were conducted with UK-based individuals with a confirmed HIV positive diagnosis who were pregnant or one-year postpartum, and two partners. Using purposive sampling, pregnant and postpartum participants were recruited through HIV NHS clinics and community-based organisations, and where possible, fathers were recruited via them. Data were analysed using thematic analysis and organised using NVivo 12. RESULTS: Of the 36 women interviewed, 28 were postpartum. The majority were of Black African descent (n = 22) and born outside the UK. The key factors in women navigating HIV and infant-feeding discussions with respect to their baby's father were the latter's: (1) awareness of woman's HIV status; (2) relationship with the woman; (3) confidence in infant-feeding decision; (4) support and opinion about woman's infant-feeding intentions. Most women made a joint decision with biological fathers when in a long-term (> one year) relationship with them. Single women tended not to discuss their infant-feeding decision with the father of their child, often for safety reasons. CONCLUSION: Women in ongoing relationships with the father of their child valued their support and opinions regarding infant-feeding. In contrast, single women chose not to involve the father for reasons of privacy and safety. Clinical teams and community-based organisations should support mothers in discussing infant-feeding decisions regardless of relationship status. When appropriate, they should also support discussions with their partners, but remain sensitive to circumstances where this may put women at risk.

Associations between social determinants of health and comorbidity and multimorbidity in people of black ethnicities with HIV.

OBJECTIVE: Social determinants of health (SDH) are important determinants of long-term conditions and multimorbidity in the general population. The intersecting relationship between SDH and multimorbidity in people with HIV remains poorly studied. DESIGN: A cross-sectional study investigating the relationships between eight socio-economic parameters and prevalent comorbidities of clinical significance and multimorbidity in adults of African ancestry with HIV aged 18-65 years in South London, UK. METHODS: Multivariable logistic regression analysis was used to evaluate associations between SDH and comorbidities and multimorbidity. RESULTS: Between September 2020 and January 2022, 398 participants (median age 52 years, 55% women) were enrolled; 85% reported at least one SDH and 72% had at least one comorbidity. There were no associations between SDH and diabetes mellitus or kidney disease, few associations between SDH (job and food insecurity) and cardiovascular or lung disease, and multiple associations between SDH (financial, food, housing and job insecurity, low educational level, social isolation, and discrimination) and poor mental health or chronic pain. Associations between SDH and multimorbidity mirrored those for constituent comorbidities. CONCLUSION: We demonstrate strong associations between SDH and poor mental health, chronic pain and multimorbidity in people of black ethnicities living with HIV in the UK. These findings highlight the likely impact of enduring socioeconomic hardship in these communities and underlines the importance of holistic health and social care for people with HIV to address these adverse psychosocial conditions.

Clinical epidemiology of COVID-19 in people of black ethnicity living with HIV in the UK.

OBJECTIVES: To describe the clinical epidemiology of COVID-19 in people of black ethnicity living with HIV in the UK. METHODS: We investigated the incidence and factors associated with COVID-19 in a previously established and well-characterized cohort of black people with HIV. Primary outcomes were COVID-19 acquisition and severe COVID-19 disease (requiring hospitalization and/or resulting in death). Cumulative incidence was analysed using Nelson-Aalen methods, and associations between demographic, pre-pandemic immune-virological parameters, comorbidity status and (severe) COVID-19 were identified using Cox regression analysis. RESULTS: COVID-19 status was available for 1847 (74%) of 2495 COVID-AFRICA participants (median age 49.6 years; 56% female; median CD4 cell count = 555 cells/µL; 93% HIV RNA <200 copies/mL), 573 (31%) of whom reported at least one episode of COVID-19. The cumulative incidence rates of COVID-19 and severe COVID-19 were 31.0% and 3.4%, respectively. Region of ancestry (East/Southern/Central vs. West Africa), nadir CD4 count and kidney disease were associated with COVID-19 acquisition. Diabetes mellitus [adjusted hazard ratio (aHR) = 2.39, 95% confidence interval (CI): 1.26-4.53] and kidney disease (aHR = 2.53, 95% CI: 1.26-4.53) were associated with an increased risk, and recent CD4 count >500 cells/µL (aHR = 0.49, 95% CI: 0.25-0.93) with a lower risk of severe COVID-19. CONCLUSIONS: Region of ancestry was associated with COVID-19 acquisition, and immune and comorbidity statuses were associated with COVID-19 disease severity in people of black ethnicity living with HIV in the UK.

Comorbidities and menopause assessment in women living with HIV: a survey of healthcare providers across the WHO European region.

ABSTRACTWomen living with HIV are reaching older age and experiencing menopause and age-related comorbidities. Data suggest that women living with HIV experience earlier menopause and more menopausal symptoms and age-related comorbidities compared to women without HIV. However, there are no guidelines on the screening for and management of age-related comorbidities and events in women living with HIV. Moreover, little is known about provision of care to this population across Europe. We surveyed 121 HIV healthcare providers in 25 World Health Organization European countries to ascertain screening practices for, and management of, menopause, psychosocial and sexual well-being and age-related comorbidities in women with HIV. Most respondents screened for diabetes, cardiovascular disease (CVD) risk factors and poor mental health at least annually. Low bone mineral density (BMD) was regularly checked but less than once a year. Fewer regularly screened for sexual well-being and intimate partner violence. Menstrual pattern and menopausal symptoms in women aged 45-54 were assessed by 67% and 59% of respondents. 44% stated that they were not confident assessing menopausal status and/or symptoms. CVD, diabetes, low BMD and poor mental health were managed mainly within HIV clinics, whereas menopause care was mainly provided by gynaecology or primary care. Most respondents stated a need for HIV and menopause guidelines. In conclusion, we found that whilst metabolic risk factors and poor mental health are regularly screened for, psychosocial and sexual well-being and menopausal symptoms could be improved. This highlights the need for international recommendations and clinician training to ensure the health of this population.

Setting the research agenda: involving parents in research on children who are HIV-free.

INTRODUCTION: There is growing interest in health, developmental and survival outcomes of children who are born HIV-free to women living with HIV (children born HIV-free). To date, the research agenda has been largely determined by researchers, funders and policy makers, with limited involvement of parents, who are key stakeholders. Researchers at UCL Great Ormond Street Institute of Child Health in partnership with community-based organisation 4M Network of Mentor Mothers conducted two workshops with parents in March 2022 to establish research priorities for children born HIV-free, and key considerations for methodological approaches both to research and engagement with the affected communities. DISCUSSION: When exploring research on children born HIV-free, we consider the following: what aspects of current research are aligned with women and parents' priorities, what is missing and what approaches would be preferred. A holistic approach to research on children born HIV-free should be prioritised, focussing on a breadth of outcomes and how they intersect. Secondary use of existing data sources should be maximised to facilitate this, with a view of monitoring the long-term effects of fetal antiretroviral drug exposure alongside other key health and developmental outcomes. Involving and engaging with parents, and children where possible, must be at the heart of research design to maximise relevance and impact of findings for the affected communities. Potential barriers to engaging with individuals who were children born HIV-free include parental disclosure and individuals not identifying as a child born HIV-free to a mother living with HIV. Stigma-free language must be incorporated into the vocabulary of researchers and other stakeholders, avoiding reference to exposure; we propose the term "children born HIV-free." CONCLUSIONS: Mothers and parents living with HIV should be involved in research about their children born HIV-free and are key in identifying research priorities so that findings may translate into an impact on their children's health and wellbeing. Meaningful involvement of women living with HIV through trusted community partners is an effective mechanism by which to elicit views on research about their children.

Hospital admissions for physical health and psychosocial adversity among people experiencing homelessness in England: a population-based retrospective cross-sectional study.

BACKGROUND: Homeless health care is often characterised by physical health, mental health, and substance use problems, resulting in high use of emergency care, poor outcomes, and extreme social inequities. We assessed health needs as prevention opportunities for hospitalised people experiencing homelessness (PEH) in England. METHODS: This population-based retrospective cross-sectional study used anonymised national Hospital Episodes Statistics Admitted Patient Care data. PEH were identified as having at least one homeless code ("no fixed abode", "registered with a homeless-exclusive GP practice", "clinical diagnosis of homelessness") from April 1, 2017, to March 31, 2018. We analysed admissions for PEH and for housed people. We estimated the prevalence of demographic and admission characteristics and diagnoses by 10th International Classification of Disease (ICD-10) chapter. We developed novel diagnostic phenotypes for physical health (internal disease processes) and psychosocial adversity (mental health, substance use, violence, and social factors). We compared admissions between PEH and housed people using sex-stratified logistic regression adjusted for age and ethnicity. FINDINGS: There were 15 566 010 admissions (51 643 PEH and 15 514 367 housed people). Compared with housed people, proportionately more PEH were younger (PEH aged 26-45 years, n=24 224 [46·9%], housed people n=3 323 951 [21·4%]), male (PEH n=37 662 [72·9%], housed people n=6 819 157 [44·0%]), and not White British (PEH n=14 605 [28·3%], housed people n=3 447 183 [22·2%]). Emergency admissions were more common among PEH (PEH male n=30 958 [82·2%], housed people male n=5 321 428 [34·3%], adjusted odds ratio [aOR] 8·76, 95% CI 8·53-9·00). The most common primary diagnoses by ICD-10 chapter for PEH were mental and behavioural conditions (PEH male n=7118 admissions [18·9%], housed people male n=155 144 [1·0%], 12·97, 12·61-13·34). Admissions for the psychosocial adversity phenotype were higher in PEH, particularly for women (PEH female n=3922 [28·1%], housed people female n=155 644 [1·79%], 18·18, 17·50-18·88). Physical health phenotype admissions were less common in PEH (PEH male n=7510 [19·9%], housed people male n=1 821 397 [26·7%], 0·91, 0·89-0·94), but specific infections, cancers, respiratory, and cardiovascular diseases were more common among PEH for both men and women. INTERPRETATION: These results support targeting of preventative interventions for PEH before, during and after admission to hospital, highlighting psychosocial needs. Future research should aim to produce reliable estimates of the size of the national homeless population to enable calculation of admission rates for psychosocial and physical health diagnoses. FUNDING: National Institute for Health and Care Research (NIHR).

A systematic review of qualitative research on recently acquired HIV.

OBJECTIVES: Recently acquired HIV is a critical time when people may experience debilitating symptoms and is when they are most likely to pass HIV on. Qualitative research offers insights into lived experiences and a deeper understanding of the contextual factors underlying HIV acquisition. We aimed to synthesize qualitative literature on recently acquired HIV. DESIGN: Systematic review and textual narrative synthesis. METHODS: We searched MEDLINE, CINAHL Plus, PsycINFO and Sociology Database. Articles were screened, and two authors completed full text review and data extraction. Quality appraisal was conducted (Critical Appraisal Skills Programme Qualitative Studies Checklist) and certainty of findings graded (GRADE-CERQual). RESULTS: We reviewed 1890 articles (1554 following de-duplication), excluding 1539. Fifteen articles were included and an additional article was included after updating the search. We identified 15 themes, three of which we have high confidence in: recent acquisition of HIV facilitates understanding of circumstances of HIV acquisition; indeterminate HIV tests generate uncertainty and anxiety; and people with recently acquired HIV are motivated to reduce risk of onward transmission. CONCLUSIONS: Our findings highlight the importance of continued research into recently acquired HIV, as well as the need for support to manage the emotional impact of indeterminate test results and negotiate risk reduction. We found no studies exploring sexual risk in the context of recently acquired HIV, or use of pre-exposure prophylaxis or treatment as prevention. The literature is primarily focused on HIV acquisition from an individual and behavioural perspective, neglecting important aspects of lived experience such as immediate ART, stigma, and health and wellbeing.

Psychosocial support interventions to improve treatment outcomes for people living with tuberculosis: a mixed methods systematic review and meta-analysis.

Background: People with tuberculosis (TB) face multi-dimensional barriers when accessing and engaging with care. There is evidence that providing psychosocial support within people-centered models of care can improve TB outcomes, however, there is limited consensus on what works. It remains important for such interventions to be rigorously assessed, and mixed methods systematic reviews are one way of synthesising data for policy makers to be able to access such evidence. Mixed methods reviews take a complexity perspective, with qualitative data being used to contextualise the quantitative findings and giving an insight into how interventions are contingent on variations in design and context. Methods: Five electronic databases were searched from January 1 2015 to 14 January 2023 for randomised controlled trials, quasi-experimental trials, cohort studies and qualitative studies of interventions providing psychosocial support (material and/or psychological-based support) to adults with any clinical form of active TB. Studies with inpatient treatment as the standard of care were excluded. Quantitative studies reporting pre-specified standard TB outcomes were eligible. In line with established mixed methods review methodology, a convergent parallel-results synthesis design was followed: quantitative and qualitative syntheses were distinct and carried out using appropriate methods. A convergent coding matrix was then used to integrate the results. The protocol was registered on PROSPERO (CRD42021235211). Findings: Twenty-three studies of interventions were included (12 quantitative, 10 qualitative, and 1 mixed methods study) were included. Most studies were conducted in low-and middle-income countries with a high-burden of TB. Three explanatory and contextual middle-range theories from the integration of qualitative and quantitative data were developed: effective interventions provide multi-dimensional support; psychological-based support is transformative but there is insufficient evidence that it improves treatment outcomes on its own; intervention delivery shapes a logic of care. Interpretation: This review takes a complexity perspective to provide actionable and timely insight to inform the design and implementation of locally-appropriate and people-centered psychosocial support interventions within national TB programmes. Funding: There was no funding source for this study.

CASCADE protocol: exploring current viral and host characteristics, measuring clinical and patient-reported outcomes, and understanding the lived experiences and needs of individuals with recently acquired HIV infection through a multicentre mixed-methods observational study in Europe and Canada.

INTRODUCTION: Despite the availability of pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART), 21 793 people were newly diagnosed with HIV in Europe in 2019. The Concerted action on seroconversion to AIDS and death in Europe study aims to understand current drivers of the HIV epidemic; factors associated with access to, and uptake of prevention methods and ART initiation; and the experiences, needs and outcomes of people with recently acquired HIV. METHODS AND ANALYSIS: This longitudinal observational study is recruiting participants aged ≥16 years with documented laboratory evidence of HIV seroconversion from clinics in Canada and six European countries. We will analyse data from medical records, self-administered questionnaires, semistructured interviews and participatory photography. We will assess temporal trends in transmitted drug resistance and viral subtype and examine outcomes following early ART initiation. We will investigate patient-reported outcomes, well-being, and experiences of, knowledge of, and attitudes to HIV preventions, including PrEP. We will analyse qualitative data thematically and triangulate quantitative and qualitative findings. As patient public involvement is central to this work, we have convened a community advisory board (CAB) comprising people living with HIV. ETHICS AND DISSEMINATION: All respective research ethics committees have approval for data to contribute to international collaborations. Written informed consent is required to take part. A dissemination strategy will be developed in collaboration with CAB and the scientific committee. It will include peer-reviewed publications, conference presentations and accessible summaries of findings on the study's website, social media and via community organisations.

Prevalence of pain in women living with HIV aged 45-60: associated factors and impact on patient-reported outcomes.

As the population of women with HIV ages, an increasing proportion are experiencing the menopause, with potential associated pain. Among 844 participants in the Positive Transitions Through the Menopause (PRIME) study (72.3% black African; median age 49 (interquartile-range 47-53) years; 20.9%, 44.0% and 35.1% pre-, peri- and post-menopausal), 376 (44.6%) and 73 (8.7%) reported moderate or extreme pain. Women had been diagnosed with HIV for 14 (9-18) years, 97.7% were receiving antiretroviral therapy and 88.4% had a suppressed viral load. In adjusted ordinal logistic regression, peri-menopausal status (adjusted odds ratio (1.80) [95% confidence interval 1.22-2.67]), current smoking (1.85 [1.11-3.09]), number of comorbid conditions (1.95 [1.64-2.33] /condition) and longer duration of HIV (1.12 [1.00-1.24]/5 years) were independently associated with increased reported pain, whereas being in full-time work (0.61 [0.45-0.83]) and having enough money for basic needs (0.47 [0.34-0.64]) were associated with decreased pain reporting. Increasing pain was independently related to insomnia symptoms (moderate: 2.76 [1.96-3.90]; extreme: 8.09 [4.03-16.24]) and severe depressive symptoms (PHQ4 ≥ 6; moderate: 3.96 [2.50-6.28]; extreme: 9.13 [4.45-18.72]). Whilst our analyses cannot determine the direction of any associations, our findings point to the importance of eliciting a history of pain and addressing symptoms in order to improve wellbeing.

Hospital-based preventative interventions for people experiencing homelessness in high-income countries: A systematic review.

Background: People experiencing homelessness have significant unmet needs and high rates of unplanned care. We aimed to describe preventative interventions, defined in their broadest sense, for people experiencing homelessness in a hospital context. Secondary aims included mapping outcomes and assessing intervention effectiveness. Methods: We searched online databases (MEDLINE, Embase, PsycINFO, HMIC, CINAHL, Web of Science, Cochrane Library) from 1999-2019 and conducted backward and forward citation searches to 31 December 2020 (PROSPERO CRD42019154036). We included quantitative studies in emergency and inpatient settings measuring health or social outcomes for adults experiencing homelessness in high income countries. We assessed rigour using the "Quality Assessment Tool for Quantitative Studies" and summarised findings using descriptive quantitative methods, a binomial test, a Harvest Plot, and narrative synthesis. We used PRISMA and SWiM reporting guidelines. Findings: Twenty-eight studies identified eight intervention types: care coordination (n=18); advocacy, support, and outreach (n=13); social welfare assistance (n=13); discharge planning (n=12); homelessness identification (n=6); psychological therapy and treatment (n=6); infectious disease prevention (n=5); and screening, treatment, and referrals (n=5). The evidence strength was weak (n=16) to moderate (n=10), with two high quality randomised controlled trials. We identified six outcome categories with potential benefits observed for psychosocial outcomes, including housing (11/13 studies, 95%CI=54.6-98.1%, p=0.023), healthcare use (14/17, 56.6-96.2%, p=0.013), and healthcare costs (8/8, 63.1-100%, p=0.008). Benefits were less likely for health outcomes (4/5, 28.3-99.5%, p=0.375), integration with onward care (2/4, 6.8-93.2%, p=1.000), and feasibility/acceptability (5/6, 35.9-99.6%, p=0.219), but confidence intervals were very wide. We observed no harms. Most studies showing potential benefits were multi-component interventions. Interpretation: Hospital-based preventative interventions for people experiencing homelessness are potentially beneficial, but more rigorous research is needed. In the context of high needs and extreme inequities, policymakers and healthcare providers may consider implementing multi-component preventative interventions. Funding: SL is supported by an NIHR Clinical Doctoral Research Fellowship (ICA-CDRF-2016-02-042). JD is supported by an NIHR School of Public Health Research Pre-doctoral Fellowship (NU-004252). RWA is supported by a Wellcome Clinical Research Career Development Fellowship (206602).

Understanding the attitudes and experiences of people living with potentially stigmatised long-term health conditions with respect to collecting and sharing health and lifestyle data.

Background: The emerging landscape of patient-generated data (PGData) provides an opportunity to collect large quantities of information that can be used to develop our understanding of different health conditions and potentially improve the quality of life for those living with long-term health condition (LTHCs). If the potential benefits of PGData are to be realised, we need a better understanding of the psychological barriers and facilitators to the collection and beneficial sharing of health and lifestyle data. Due to the understudied role that stigma plays in sharing PGData, we explore the attitudes and experiences of those living with potentially stigmatised LTHCs with respect to collecting and sharing health and lifestyle data. Methods: This study used semi-structured interviews and a card sorting task to explore the attitudes and experiences of people living with potentially stigmatised LTHCs. Fourteen adult participants who reported having a range of conditions were recruited in England. Template analysis was used to analyse interview transcripts and descriptive statistics were used for the card sorting task. Results: The findings present four overarching themes: Preferences for collecting health and lifestyle data, Importance of anonymity, Expected use of data, and Sources of emotional support. Participants illustrated a general willingness to share health and lifestyle data; however, there were some notable differences in sharing experiences, varying both by information type and recipient group. Overall, participants did not identify health-related stigma as a barrier to collecting or sharing their personal health and lifestyle data. Conclusions: We outline a number of preferences that participants feel would encourage them to collect and share data more readily, which may be considered when developing data sharing tools for the future.

Patterns of mental health symptoms among women living with HIV ages 45-60 in England: associations with demographic and clinical factors.

OBJECTIVE: We aimed to describe the prevalence of various mental health symptoms according to menopausal status (pre, peri, post) among women living with HIV ages 45-60 in England, and to identify groups of women with similar general and menopause-related mental health symptoms. We then investigated demographic predictors of group-membership and group differences in HIV-related care outcomes (antiretroviral therapy adherence, HIV clinic attendance, CD4-count, and last HIV viral load). METHODS: An analysis of cross-sectional data from the Positive Transitions through Menopause study, an observational study of the health and well-being impacts of menopause on 869 women with HIV aged 45-60 years. Self-reported data on eight mental health indicators were collected from women in pre-, peri- and post-menopausal state using validated measures. Groups (termed "classes") of women with similar mental health symptoms were derived via latent class analysis. Class membership was linked to demographic factors using nominal logistic regression, and to clinical outcomes using Wald tests. RESULTS: We identified five classes: 1) few mental health symptoms (n = 501, 57.8%); 2) high current anxiety/depression (n = 120, 13.8%); 3) history of depression, with elevated current substance use (n = 40, 4.6%); 4) history of depression with current psychological menopause symptoms (n = 81, 9.3%); and 5) high previous and concurrent mental health problems (n = 125, 14.4%). University attendance, ethnicity, and longer time since HIV diagnosis predicted class membership. Antiretroviral therapy adherence was lower in classes 3 (11%), 4 (19%) and 5 (24%) compared to class 1 (4%; all P<0.001). Members of class 5 were more likely to have missed ≥1 HIV clinic appointment in the past year than those in class 1 (34% vs 17%, P = 0.005). CONCLUSIONS: Women with a history of depression, current anxiety/depression, and current menopause-related mental health symptoms were more likely to have poorer clinical outcomes. Although we cannot comment on causality, our findings highlight the importance of assessing and managing menopausal symptoms and mental health to improve well-being and engagement in HIV care.

Obesity in women living with HIV aged 45-60 in England: An analysis of the PRIME study.

OBJECTIVES: Menopause contributes to weight gain in women. We explored factors associated with obesity in women with HIV aged 45-60 years. METHODS: The present study is an analysis of cross-sectional questionnaire and clinic data from the Positive Transitions Through the Menopause (PRIME) Study. We categorized body mass index (BMI) as normal/underweight (< 25 kg/m2 ), overweight (25-29.9 kg/m2 ) and obese (> 30 kg/m2 ). We used logistic regression to explore demographic, social, lifestyle and clinical factors associated with BMI. RESULTS: We included 396 women in this analysis. Median age was 49 years [interquartile range (IQR): 47-52]. Most (83.6%) were not UK-born; the majority (69.4%) were black African (BA). Median (IQR) BMI was 28.6 (24.6-32.6) kg/m2 ; and 110 (27.8%), 127 (32.1%) and 159 (40.1%) of the women were normal/underweight, overweight and obese, respectively. Median (IQR) BMI did not differ in pre-, peri- and post-menopausal women (p = 0.90). In univariable analysis, being non-UK-born was associated with BMI > 30 kg/m2 [odds ratio (OR) = 1.94, 95% confidence interval (CI): 1.07-3.53]. Compared with BA women, women of other black ethnicities were more likely to be obese (OR = 2.37, 95% CI: 1.02-5.50) whereas white British women were less likely to be obese (OR = 0.34, 95% CI: 0.17-0.68). Current smoking and increasing number of comorbid conditions were associated with increased BMI. We found no association between obesity and socioeconomic status. On multivariable analysis, only ethnicity remained associated with obesity (compared with BA: white British, OR = 0.34, 95% CI: 0.17-0.68; other black, OR = 2.50, 95% CI: 1.07-5.82). CONCLUSIONS: Nearly two-fifths of women had BMI > 30 kg/m2 . Obesity was associated with black ethnicities but not with menopausal status. The combination of obesity and HIV may place women at increased risk of co-morbidities, requiring tailored and culturally appropriate interventions.

Association between health-related quality of life and menopausal status and symptoms in women living with HIV aged 45-60 years in England: An analysis of the PRIME study.

OBJECTIVES: The aim of this study was to compare the health-related quality of life between mid-life women with HIV and the general population and to investigate the association between health-related quality of life and menopausal (1) status and (2) symptoms among women with HIV. METHODS: Cross-sectional data of women with HIV aged 45-60 years from the Positive Transitions Through the Menopause Study. Health-related quality of life was assessed using the Euroqol questionnaire with utility scores categorizing health as perfect (score = 1.00), sub-optimal (0.75-0.99) or poor (< 0.75). Scores were compared between Positive Transitions Through the Menopause study participants and women (aged 45-59 years) from the Health Survey for England. Associations between health-related quality of life and menopausal status/symptoms in Positive Transitions Through the Menopause participants were assessed using a multivariable two-part regression model, the results of which are combined to produce a single marginal effect. RESULTS: In total, 813 women from the Positive Transitions Through the Menopause study were included (median age 49 (interquartile range: 47-53) years); the majority were of Black African ethnicity (72.2%). Overall, 20.9%, 43.7% and 35.3% of women were pre-, peri- and post-menopausal, respectively, and 69.7% experienced mild/moderate/severe menopausal symptoms. Approximately, 40% reported perfect health, 22.1% sub-optimal health and 39.0% poor health, similar to women from the Health Survey for England (perfect health: 36.9%, sub-optimal health: 25.2%, poor health: 37.9%). In multivariable models, we found an association between health-related quality of life and peri-menopausal status (marginal effect: 0.07 (0.02, 0.12)); however, the association with post-menopausal status was attenuated (marginal effect: 0.01 (-0.05, 0.06)). There remained a strong association between lower utility scores and moderate (marginal effect: 0.16 (0.11, 0.20)) and severe (marginal effect: 0.32 (0.27, 0.39)) menopausal symptoms. CONCLUSION: There were no differences in health-related quality of life between women with HIV (Positive Transitions Through the Menopause participants) and women from the Health Survey for England dataset. Among Positive Transitions Through the Menopause participants, health-related quality of life was reduced in peri-menopausal women and those with increasingly severe menopausal symptoms. Our findings highlight the importance of proactive assessment of menopausal status and symptoms to optimize health-related quality of life in women living with HIV as they reach mid-life and beyond.

Bone mineral density, kidney function and participant-reported outcome measures in women who switch from tenofovir disoproxil emtricitabine and a nonnucleoside reverse transcriptase inhibitor to abacavir, lamivudine and dolutegravir.

OBJECTIVES: Tenofovir disoproxil fumarate (TDF) is associated with reduced bone mineral density (BMD). The aim of the study was to evaluate changes in BMD in women who switched from TDF, emtricitabine and a nonnucleoside reverse transcriptase inhibitor (TDF/FTC/NNRTI) to abacavir, lamivudine and dolutegravir (ABC/3TC/DTG). METHODS: We conducted a randomized controlled trial in which women aged ≥ 40 years were randomized 1:2 to continue TDF/FTC/NNRTI or switch to ABC/3TC/DTG. We analysed changes in BMD at the hip and lumbar spine from baseline to week 96 using linear regression, and markers of bone turnover and kidney function using repeated measures mixed effects models with multiple imputation for missing data. We conducted exploratory analyses of weight, mental health, sleep and symptoms attributed to HIV infection and antiretroviral therapy. RESULTS: Ninety-one women [mean (standard deviation) age 50.4 (6.6) years] were randomized. Women who switched to ABC/3TC/DTG maintained viral suppression and experienced improvements in BMD at the lumbar spine (but not the neck of the femur or the total hip), bone resorption markers and proteinuria (total protein, albumin and retinol-binding protein) and modest weight gain without changes in body mass index. Although mean anxiety, depression and sleep scores did not differ between the two study arms, anxiety, depression and sleep disturbance at baseline predicted ABC/3TC/DTG discontinuation for neuropsychiatric side effects [odds ratios (95% confidence intervals) 11.9 (2.0-71.6), 16.0 (2.6-97.9) and 10.0 (1.8-56.0), respectively]. CONCLUSIONS: Switching from TDF/FTC/NNRTI to ABC/3TC/DTG improved the BMD of the lumbar spine and kidney function. These benefits need to be balanced against modest weight gain and the need for antiretroviral therapy substitutions in a proportion of participants.

Ethnic inequalities in mental health and socioeconomic status among older women living with HIV: results from the PRIME Study.

OBJECTIVES: Women living with HIV in the UK are an ethnically diverse group with significant psychosocial challenges. Increasing numbers are reaching older age. We describe psychological and socioeconomic factors among women with HIV in England aged 45-60 and explore associations with ethnicity. METHODS: Analysis of cross-sectional data on 724 women recruited to the PRIME Study. Psychological symptoms were measured using the Patient Health Questionnaire 4 and social isolation with a modified Duke-UNC Functional Social Support Scale. RESULTS: Black African (BA) women were more likely than Black Caribbean or White British (WB) women to have a university education (48.3%, 27.0%, 25.7%, respectively, p<0.001), but were not more likely to be employed (68.4%, 61.4%, 65.2%, p=0.56) and were less likely to have enough money to meet their basic needs (56.4%, 63.0%, 82.9%, p<0.001). BA women were less likely to report being diagnosed with depression than WB women (adjusted odds ratio (aOR) 0.40, p<0.001) but more likely to report current psychological distress (aOR 3.34, p<0.05). CONCLUSIONS: We report high levels of poverty, psychological distress and social isolation in this ethnically diverse group of midlife women with HIV, especially among those who were BA. Despite being more likely to experience psychological distress, BA women were less likely to have been diagnosed with depression suggesting a possible inequity in access to mental health services. Holistic HIV care requires awareness of the psychosocial needs of older women living with HIV, which may be more pronounced in racially minoritised communities, and prompt referral for support including psychology, peer support and advice about benefits.