HIV-Associated Complications: A Systems-Based Approach.

Persons with human immunodeficiency virus (HIV) infection often develop complications related directly to the infection, as well as to treatment. Aging, lifestyle factors, and comorbidities increase the risk of developing chronic conditions such as diabetes mellitus and chronic kidney disease. HIV-associated neurologic complications encompass a wide spectrum of pathophysiology and symptomatology. Cardiovascular and pulmonary conditions are common among persons with HIV infection. Although some specific antiretroviral medications have been linked to disease development, traditional risk factors (e.g., smoking) have major roles. Prevention and management of viral hepatitis coinfection are important to reduce morbidity and mortality, and new anti-hepatitis C agents produce high rates of sustained virologic response. Antiretroviral-associated metabolic complications include dyslipidemia, hyperglycemia, and loss of bone mineral density. Newer options generally pose less risk of significant systemic toxicity and are better tolerated. Family physicians who care for patients with HIV infection have a key role in identifying and managing many of these chronic complications.

2023 updated guidelines on infant feeding and HIV in the United States: what are they and why have recommendations changed.

The US Department of Health and Human Services guidelines on infant feeding among people with HIV have changed in response to (1) evidence of low risk of transmission via breast milk among individuals with consistent viral suppression, (2) considerations of equity and cultural norms, and (3) community desires. The 2023 guidelines recommend patient-centered shared decision-making. Individuals with HIV who are receiving antiretroviral therapy (ART) and have consistent viral suppression should be counseled on the options of for-mula feeding, feeding with banked donor milk, or breast (or chest) feeding, and nonjudgmentally supported in their decision. Individuals who choose to breastfeed should be counseled on and supported in adherence to ART, viral suppression, and engagement in postpartum care for themselves and their babies. Exclusive breastfeeding is recommended, with the understanding that brief periods of replacement feeding may be necessary. Data are lacking on ideal infant prophylaxis regimens.

Tilting the Scale: Current Provider Perspectives and Practices on Breastfeeding with HIV in the United States.

The risk of vertical transmission from breastfeeding with HIV (BFHIV) has been found to be very low in optimal scenarios with sustained maternal viral suppression during pregnancy and postpartum. Medical providers must account for the risk of this serious adverse event alongside parental autonomy, breastfeeding benefits, and patient values. To assess provider practices, comfort, and challenges with BFHIV, an online mixed-method survey was sent to breastfeeding and HIV provider listservs from June to July 2021. The target population was US medical professionals from diverse practice settings with experience in clinical issues associated with BFHIV, including physicians, advanced practice providers, nurses, and lactation consultants. Data analysis utilized nonparametric hypothesis testing, ordinal regression, and reflexive thematic analysis. Most providers reported counseling pregnant people with HIV on infant feeding choices, but fewer specifically endorsed counseling about breastfeeding. Of 84 unique institutions identified by 100 included respondents, 10% had an institutional protocol supporting BFHIV. Institutional protocols were associated with higher degrees of provider comfort with BFHIV in optimal scenario clinical vignettes. Providers perceived that White patients faced fewer BFHIV barriers than patients with other racial identities. Discomfort balancing the goals to protect infants from infection risk and support the parent's role in infant feeding decisions was a key theme in free text responses; this manifested in a spectrum of management styles ranging from patient's informed choice to paternalism. This study highlights the tension providers navigate regarding BFHIV discussions, calling for patient care guidelines and protocols grounded in risk reduction and respect of patient autonomy.

Growth into manhood: identity development among female-to-male transgender youth.

This study aims to understand the process by which female-to-male transgender young people come to identify as transgender through in-depth interviews with 13 self-identified female-to-male transgender youth. A grounded theory was created of the process that young people go through in coming to identify as transgender. We identified three stages: (1) a growing sense of gender: school, puberty, sexuality and exposure to diverse gender options impact upon each young person's sense of his own gender; (2) recognition of transgender identity: a young person experiences a growing sense of discomfort with his female birth gender and comes to recognise himself as transgender; and (3) social adjustment: after becoming aware of himself as transgender, a young person adapts to life as a male. Although individual experiences may vary, understanding the typical trajectory of the female-to-male transgender experience can help inform appropriate health care and support services.

Missed Opportunities for HIV Prevention in Perinatal Care Settings in the United States.

Universal opt-out HIV screening in pregnancy is an essential intervention toward eliminating perinatal HIV transmission in the US. However, it fails to identify pregnant people who are HIV negative at the time of testing but are at ongoing risk for HIV acquisition. Those of us involved in caring for women living with HIV are acutely aware of the many diagnoses of HIV that might have been prevented if only a partner had been tested for HIV or preexposure prophylaxis (PrEP) had been offered to a patient. This perspective article will review current recommendations and evidence-based interventions to evaluate missed opportunities for HIV prevention in US perinatal care settings. We identified three barriers to implementation of HIV prevention strategies during pregnancy and breastfeeding: (1) HIV risk for women is underestimated and poorly defined in clinical practice; (2) Partner testing is challenging and implementation studies in the US are lacking; and (3) PrEP remains underutilized. In March 2020, the National Perinatal HIV Hotline convened a group of clinicians and researchers specializing in perinatal HIV care to a case-based discussion of missed opportunities in perinatal HIV prevention. From our review of the literature via PubMed search as well as expert opinions gathered in this discussion, we make recommendations for addressing these barriers.

Role of Preexposure Prophylaxis in the Reproductive Health of Women at Risk for Human Immunodeficiency Virus Infection.

Women in the United States and especially women of color continue to acquire human immunodeficiency virus (HIV) infection. During reproductive health visits, health care providers are ideally positioned to assess HIV risk and offer HIV prevention strategies, including preexposure prophylaxis (also known as "PrEP"), a once-daily fixed-dose combination of emtricitabine with tenofovir disoproxil fumarate approved by the U.S. Food and Drug Administration for use to prevent HIV acquisition in persons at risk. Family planning, pregnancy, and postpartum visits provide an opportunity to ask sensitive questions about sexual and reproductive health and to help women navigate preference-sensitive decisions, including an individualized plan for HIV prevention. Exposure to a fixed-dose combination of emtricitabine with tenofovir disoproxil fumarate during pregnancy and breastfeeding appears to be safe with respect to maternal and infant outcomes. This article reviews the critical issues, challenges, and opportunities when implementing preexposure prophylaxis for women at risk for HIV who are seeking family planning services or pregnancy or postpartum care.

'You should build yourself up as a whole product': Transgender female identity in Lima, Peru.

Transgender women in Lima, Peru have, until recently, been grouped together with gay and bisexual men in the category MSM, or men who have sex with men, with little consideration of their unique situation and needs. Transgender women, self-identified in Peru as travesti, are a socially vulnerable population with many unmet health needs, including an HIV prevalence of 30%. Understanding specific transgender identities and their contexts will contribute to the improvement and development of HIV prevention programs. Through qualitative open-ended interviews with trans-identified women in Lima, Peru, this study found that the non-normative travesti identity is constructed within a conservative homophobic and heteronormative social context. Participants strive towards appearances and relationships perceived as feminine, seeking out silicone injections and abusive men as social markers of this femininity. Sex work is the primary economic activity available and travestis are often alienated from their families and communities. Work is needed to increase self-esteem and decrease violence, stigma, and discrimination. There is a need for multilevel HIV prevention campaigns prioritising travesti in Lima, utilising a human rights framework.

Concepts of the advantages and disadvantages of teenage childbearing among pregnant adolescents: a qualitative analysis.

OBJECTIVE: We sought to enhance our understanding of pregnant adolescents' concepts of the advantages and disadvantages of teen pregnancy and childbearing. METHODOLOGY: This is a qualitative study of 247 pregnant adolescents recruited during their first prenatal health care visit to a women's primary care clinic in Providence, Rhode Island. Participants responded in writing to open-ended questions assessing their ideas about what was advantageous and disadvantageous about having an infant during their teen years rather than waiting until they were older. Themes and patterns in responding were coded, and subgroup differences based on age, ethnicity, intendedness of current pregnancy, and pregnancy/parenting history were assessed. RESULTS: Themes related to advantages of teen pregnancy included enhancing connections, positive changes/benefits, and practical considerations. Themes related to disadvantages included lack of preparedness, changes/interference, and others' perceptions. Differences among groups based on age, ethnicity, intendedness of the current pregnancy, and pregnancy/parenting history were examined and noted. CONCLUSIONS: Pregnant adolescents do not represent a homogeneous group. Considering differences in how pregnancy and childbearing are conceptualized along developmental, cultural, attitudinal, and experiential lines will strengthen our ability to tailor pregnancy-prevention messages.