The HIV Empowering Adults' Decisions to Share: UK/Uganda (HEADS-UP) Study-A Randomised Feasibility Trial of an HIV Disclosure Intervention for Young Adults with Perinatally Acquired HIV.

Young adults with perinatally acquired HIV (PAH) face numerous challenges, including antiretroviral therapy (ART) adherence, managing onward HIV transmission risks and maintaining wellbeing. Sharing one's HIV status with others (onward HIV disclosure) may assist with these challenges but this is difficult. We developed and tested the feasibility of an intervention to help HIV status sharing decision-making for young adults with PAH. The study used a randomised parallel group feasibility design with 18-25-year-olds in Uganda and 18-29 year-olds in the UK. Participants were randomly assigned to intervention or standard of care (SOC) condition. The intervention consisted of four sessions (3 group, 1 individual) with follow-up support, delivered in person in Uganda and remotely in the UK. Assessments were carried out at: Pre-intervention /baseline; Post-intervention (intervention group only); Six-month follow-up. 142 participants were recruited (94 Uganda, 48 UK; 89 female, 53 male). At six-month follow-up, 92/94 (98%) participants were retained in Uganda, 25/48 (52%) in the UK. Multivariate analysis of combined data from both countries, showed a non-significant effect of intervention condition on HIV disclosure cognitions and affect (p = 0.08) and HIV disclosure intention (p = 0.09). There was a significant intervention effect on well-being (p = 0.005). This study addressed important gaps in understanding acceptable and feasible ways of delivering HIV status sharing support for young people living with PAH across two very different settings. The intervention was acceptable in both countries and feasible in Uganda. In the UK, retention may have been affected by its remote delivery.Trial registration: ISRCTN Registry, ISRCTN31852047, Registered on 21 January 2019.

Cultural Adaption, Translation, Preliminary Reliability and Validity of Key Psychological and Behavioural Measures for 18 to 25 Year-Olds Living with HIV in Uganda: A Multi-Stage Approach.

HIV remains a significant public health issue among young adults living in Uganda. There is a need for reliable and valid measures of key psychological and behavioural constructs that are related to important outcomes for this population. We translated, adapted and tested the psychometric properties of questionnaires measuring HIV stigma, HIV disclosure cognitions and affect, antiretroviral therapy (ART) adherence, social support, personal values, and hope, using a multi-step process. This included: translation, back-translation, expert review, cognitive interviewing, readability and assessments of internal consistency with 93 young adults (18-25 years) living with perinatally acquired HIV in Uganda. Preliminary criterion validity was assessed by examining relationships between the adapted measures and wellbeing, HIV disclosure behaviour, HIV disclosure intention and viral load suppression. The measures all showed acceptable reliability and every questionnaire apart from the Agentic and Communal Value Scale was easy to read. Those scales measuring HIV disclosure affect and cognitions, social support, HIV stigma and hope showed relationships with other constructs suggestive of validity. There is preliminary evidence to support the use of these measures in research and clinical contexts for young adults living with perinatally acquired HIV in Uganda.

Impact of SARS-CoV-2 pandemic on viral suppression for young adults living with perinatally acquired HIV infection.

We compared virological and immunological outcomes for young adults with perinatally-acquired HIV infection (YAPaHIV) in the year preceding, and year of, UK SARS-CoV-2 lockdown restrictions, in a service that maintained face-to-face appointments. Retrospective single-centre cohort analysis from; Period 1(P1) twelve months before the first national lockdown - 23rd March 2019-23rd March 2020, period 2(P2) twelve months of varied restrictions - 24th March 2020-24th March 2021. Data collected from electronic records included age, ethnicity, sex, HIV viral load (VL) (suppression ≤ 200 copies/ml), CD4 count (cells/µL), clinical events, and appointment frequency/modality. Descriptive analysis was comparative between periods. Of 177 YAPaHIV: 56% were female, 86.9% were black, median age at lockdown 23 years (IQR: 21-27). One individual was lost to follow up and excluded from subsequent analysis. 147/176 (83.5%) had a suppressed VL in P1 compared with 156/176 (88.6%) in P2. Of those detectable, median VL was 3200 copies/ml (IQR: 925-36500) in P1, and 911copies/ml (IQR: 317-52300) in P2. In P1, median CD4 was 675 (IQR: 447-845.25). 32(18%) had a CD4 < 350 (median 216.5 [IQR: 94.25-269.75]). 110 (59.5%) had a CD4 count in P2, median 551.5cells/µL (IQR: 329.25-761.25). Thirty one had CD4 < 350 (median 202 [IQR: 134.5-296]). Maintaining face-to-face appointments for vulnerable patients, with remote consultation for stable patients, maintained high levels of care engagement and suppression in a YAPaHIV cohort despite pandemic restrictions.

'We're touching the topic, but we're not opening the book:' A grounded theory study of sibling relationships in young people with perinatally acquired HIV.

HIV-related stressors affecting young adults with perinatally acquired HIV (PHIV+) and their siblings include parental and sibling ill-health and death, own ill-health, HIV disclosure, and stigma. Young people with PHIV+ typically share their HIV status with family members. We explored sibling relationships in young people with PHIV+. Ten participants (six females, 17-23 years old) with PHIV+ took part in a semi-structured interview, analysed using Grounded Theory. The data were condensed into three theoretical codes: (1) HIV disclosure in sibling relationship; (2) Patterns of communication about HIV between siblings; and (3) Patterns of coping and support in sibling relationship.

Clinical outcomes post transition to adult services in young adults with perinatally acquired HIV infection: mortality, retention in care and viral suppression.

OBJECTIVE: Adolescence is the only age group globally where HIV-associated mortality is rising, with poorer outcomes at all stages of the care cascade compared with adults. We examined post transition outcomes for young adults living with perinatal HIV. DESIGN: Retrospective cohort analysis. SETTING: A tertiary Youth Friendly Service London, UK. PARTICIPANTS: A total of 180 young adults living with perinatal HIV registered between 1 January 2006 and 31 December 2017 contributed 921 person-years of follow-up post transition to adult services. INTERVENTION: Youth Friendly Service with multidisciplinary care and walk-in access. MAIN OUTCOME MEASURES: Mortality, morbidity, retention in care, antiretroviral therapy (ART) uptake and HIV-viral load suppression. Crude incidence rates are reported per 1000 person-years. RESULTS: Of 180 youth registered, four (2.2%) died, 14 (7.8%) transferred care and four (2.2%) were lost to follow-up. For the 158 retained in care, the median age was 22.9 years [interquartile ranges (IQR) 20.3-25.4], 56% were female, 85% Black African, with a median length of follow-up in adult care of 5.5 years (IQR 2.9-7.3). 157 (99.4%) ever received an ART prescription, 127/157 (81%) with a latest HIV-viral load less than 200 copies RNA/ml, median CD4 cell count of 626 cells/µl (IQR 441-820). The all-cause mortality was 4.3/1000 person-years [95% confidence interval (CI) 1.2-11.1], 10 fold the aged-matched UK HIV-negative population [0.43/1000 person-years (95% CI 0.41-0.44)]. Post transition, 17/180 (9.4%) developed a new AIDS diagnosis; crude incidence rates 18.5/1000 person-years (95% CI 10.8-29.6). CONCLUSION: While this youth-friendly multidisciplinary service achieved high engagement and coverage of suppressive ART, mortality remains markedly increased compared with the general UK population.

Intimate relationships in young adults with perinatally acquired HIV: a qualitative study of strategies used to manage HIV disclosure.

An increasing number of children born with perinatally acquired HIV (PAH) are surviving into late adolescence and early adulthood. At this developmental stage, forming and sustaining intimate relationships is important. Young adults with PAH face both normative challenges and additional, HIV-related, relationship stressors. One key issue is the decision about whether and how to share their HIV status with others. Being able to disclose one's HIV status to sexual partners may reduce the risk of onward HIV transmission but is associated with the fear of rejection. There has been little research on how young people with PAH manage such disclosure-related stressors in intimate relationships. This study examined how disclosure challenges are managed by young adults with PAH in the UK within their intimate relationships. Seven participants (five females and two males) currently or previously in an intimate relationship, aged 18-23 years, were recruited from a UK hospital clinic. The majority of participants were of sub-Saharan African origins. They took part in in-depth interviews, with data analysed according to the principles of interpretative phenomenological analysis. Four themes were elicited: (1) decisions about starting, continuing or resuming relationships shaped by disclosure, (2) disclosing early to avoid the pain of future rejection, (3) using condoms to avoid disclosure and (4) testing likely partner reactions to disclosure. The study revealed the significant extent to which HIV disclosure affected the experience of relationships in this population. Interventions to support adolescents and young adults with PAH to disclose to their partners should be developed alongside guidance for professionals. Future research should include older samples of adults with PAH and studies in sub-Saharan African settings.

"Payment by Results"--financial incentives and motivational interviewing, adherence interventions in young adults with perinatally acquired HIV-1 infection: a pilot program.

Emerging evidence suggests financial incentives (FIs) improve medication adherence in select populations. A small proportion of adolescents with perinatal HIV (PaHIV) transfer to adult services with established poor adherence and advanced disease. We describe a single center adherence intervention combining FIs with motivational interviewing (MI). Eligible patients (PaHIV,16-25 years, CD4 count ≤ 200, off ART despite multiple attempts) received MI, and FI dependent on viral load (VL) reduction for 1 year. Outcome measures compared CD4 gain from baseline at 1 year and 12 months post cessation of FI/MI. Eleven young people enrolled; median age 19 years, 8 female. Baseline median CD4 count 30 cells/µL (IQR 10-160), VL 12,870 c/mL. Outcomes at 12 months: 9/11 ever achieved VL < 50, 5 sustained undetectable VL, median CD4 140, mean CD4 gain 90 cells/µL at 1 year. Twelve months post cessation of MI/FI; six VL < 50, median CD4 75, mean CD4 gain 122 cells/µL. Total FI expenditure £1,350: £68 per 50 CD4 cells at 1 year, £55 at 24 months. To prevent death, adolescents with PaHIV require novel interventions to reverse poor patterns of adherence established since childhood. FI/MI improved virological and immunological outcomes with minimal expenditure. Extension of this pilot work for vulnerable individuals is now indicated.

Parenting considerations in young adults with perinatally acquired HIV.

An increasing number of children born with perinatally acquired HIV (PAH) are surviving into late adolescence and early adulthood. At this developmental stage, developing intimate relationships and having children are potentially important goals with associated normative challenges. Young people with PAH face a variety of additional HIV-related stressors that may be associated with relationships and parenting. These may include managing HIV disclosure to their partner and adherence to antiretroviral medication to (a) prevent transmission to partners and future offspring and (b) maintain their own health. Some of these challenges may be impacted upon by issues associated with having been born with HIV, for example, managing long-standing secrecy about HIV and having been told from a young age that life expectancy could be shortened. To date, there has been limited research into the procreational and parenting reflections of young people with PAH. This study examined the hopes and the concerns that a group of young people with PAH have regarding having children. Seven participants (five females and two males) currently or previously in an intimate relationship, aged 18-23 years, two of whom were parents, were recruited from a UK hospital clinic. They were interviewed using a semi-structured interview, with data analysed according to the principles of Interpretative Phenomenological Analysis. Four main themes were elicited: the perceived impact of having a child on intimate relationships, the effect of normative beliefs on parenting intentions and expectations, the thoughts and feelings about disclosing parental HIV status to one's children in the future, and the perceived impact of HIV on procreational intentions. Implications for supporting young people with PAH in parenting decision-making are explored.

Intimate relationships in young adults with perinatally acquired HIV: partner considerations.

Due to developments in anti-retroviral treatment, an increasing number of children with perinatally acquired HIV are now surviving into late adolescence and young adulthood. This cohort is facing normative challenges in terms of their intimate relationships as well as challenges that face all individuals with HIV regardless of the route of transmission (for example, concerns about disclosure). There may be additional issues specific to having grown up with HIV that affect intimate relationships, for example, the awareness of being HIV positive before the onset of intimate relationships and the way that identity is shaped by having lived with HIV from a young age. To date there has been some limited research on the experience of intimate relationships in perinatally infected adolescents but none in young adults. This exploratory study examined, in depth, experiences of intimate relationships in perinatally acquired young adults and how they perceived having grown up with HIV to have affected such relationships. Seven participants (five females, two males) aged 18-23 years, were interviewed, with the data analysed according to the principles of interpretative phenomenological analysis (IPA). Three themes emerged that related to partners' perceptions of HIV: (1) HIV being viewed by partners as being linked to AIDS and sexual transmission, (2) discrepancy between young people and their partners' views of HIV, (3) partner views of risk of HIV transmission. There were strong links between participants' personal experiences of HIV-related challenges, for example, disclosure and HIV-related stigma, and their thinking about the perceptions of partners. These findings have important implications for supporting young people in disclosing their HIV status to intimate partners in appropriate ways. Suggestions for future research are offered.

Letrozole versus testosterone. a single-center pilot study of HIV-infected men who have sex with men on highly active anti-retroviral therapy (HAART) with hypoactive sexual desire disorder and raised estradiol levels.

INTRODUCTION: Since the advent of Highly Active Anti-Retroviral Therapy (HAART), men with HIV experience good quality of life and expect to have normal sexual function. However, it appears that men infected with HIV commonly complain of sexual problems. There is evidence that men on HAART develop low sexual desire that is associated with raised estradiol levels. It has been postulated that abnormal metabolism seen in this group of men increases the aromatization of testosterone to estradiol. We hypothesized that letrozole, an aromatase inhibitor that inhibits the conversion of testosterone to estradiol, would be beneficial in these men. AIM: The aim of this study was to compare the effects of testosterone vs. an aromatase inhibitor, letrazole, in HIV-infected men with raised estradiol and low sexual desire. METHODS: Thirteen men who have sex with men on HAART with low sexual desire as well as raised estradiol levels (>120 pmol/L) were randomly allocated to receive either parenteral testosterone (Sustanon 250 intramuscular injection) (N = 6) or letrozole 2.5 mg orally daily (N = 7) for 6 weeks. MAIN OUTCOME MEASURES: Sex steroid hormone assays, sex hormone-binding globulin, virological, hematological, and biochemical parameters were measured before and after treatment. Each subject was given the Spector Sexual Desire Inventory and the Depression/Anxiety Stress Scale before and immediately after treatment. Subjects were also asked to estimate the number of actual sexual acts before and after treatment. Results. Inventory data showed a rise in dyadic desire in both treatment arms. Mean actual sexual acts rose from 0.33 to 1.5 in the testosterone group and from 0.43 to 1.29 for the letrozole group. Luteinizing hormone increased in seven of seven men on letrozole. Serum testosterone increased in seven of seven men on letrozole. There were no adverse events from either medication. CONCLUSION: Letrozole may be useful in the management of men on HAART who have low sexual desire.