Predictors of HIV Care Outcomes among Recently Out-of-Care Individuals in The Massachusetts Cooperative Re-engagement Controlled Trial Cohort.

A cohort of individuals in care for HIV infection who were identified as being recently out-of-care (OOC) was recruited for a trial using a data-to-care approach and an intervention to facilitate re-engagement and retention in care. This allowed for analysis of demographic and clinical characteristics correlated with recently being OOC, re-engagement, and successful retention in care and viral suppression. Recently OOC persons with HIV infection (PWH) were identified for enrollment in the Cooperative Re-engagement Controlled Trial (CoRECT). CoRECT employed a data-to-care strategy, using both clinical and surveillance data, and an active public health re-engagement intervention. We estimated relative risks (RRs), unadjusted and with multivariate log binomial regression models, to analyze associations between sociodemographic and clinical predictors of being OOC, re-engagement, retention in care, and viral suppression. Of the 630 OOC PWH enrolled in CoRECT, most were male (72.7%) and over 30 years old (91.3%). Almost 40.0% were Black non-Hispanic, 29.7% were non-US born, and 41.6% were men who have sex with men (MSM). Possible predictors of re-engagement, retention in care, and viral suppression included younger age, Hispanic race/ethnicity, birth in a US dependency, AIDS status, and HIV exposure mode. Viral suppression status within 1-year pre-enrollment was significantly associated with all outcomes: re-engagement (aRR 1.28), retention (aRR 1.72), viral suppression (aRR 1.81), and durable viral suppression (aRR 3.30). Findings elucidate factors associated with care engagement and continuity for recently OOC PWH which can be used to inform targeted re-engagement activities for priority populations and guide future data-to-care interventions.

A Risk Prediction Model to Identify People Living with HIV Who are High-risk for Disengagement from Care after HIV Diagnosis in South Africa.

The provision of ART in South Africa has transformed the HIV epidemic, resulting in an increase in life expectancy by over 10 years. Despite this, nearly 2 million people living with HIV are not on treatment. The objective of this study was to develop and externally validate a practical risk assessment tool to identify people with HIV (PWH) at highest risk for attrition from care after testing. A machine learning model incorporating clinical and psychosocial factors was developed in a primary cohort of 498 PWH. LASSO regression analysis was used to optimize variable selection. Multivariable logistic regression analysis was applied to build a model using 80% of the primary cohort as a training dataset and validated using the remaining 20% of the primary cohort and data from an independent cohort of 96 participants. The risk score was developed using the Sullivan and D'Agostino point based method. Of 498 participants with mean age 35.7 years, 192 (38%) did not initiate ART after diagnosis. Controlling for site, factors associated with non-engagement in care included being < 35 years, feeling abandoned by God, maladaptive coping strategies using alcohol or other drugs, no difficulty concentrating, and having high levels of confidence in one's ability to handle personal challenges. An effective risk score can enable clinicians and implementers to focus on tailoring care for those most in need of ongoing support. Further research should focus on potential strategies to enhance the generalizability and evaluate the implementation of the proposed risk prediction model in HIV treatment programs.

RESUMEN: La provisión de TAR (Terapia Antirretroviral) en Sudáfrica ha transformado la epidemia del VIH, resultando en un aumento de la esperanza de vida de más de 10 años. Los últimos objetivos de tratamiento del VIH se sitúan en 94-75-92, con brechas notables después de las pruebas. El objetivo de este estudio fue desarrollar y validar externamente una herramienta práctica de evaluación de riesgos para identificar a las personas con VIH (PVH) con mayor riesgo de deserción del cuidado después de las pruebas. Se desarrolló un modelo sencillo de aprendizaje automático que incorpora factores clínicos y psicosociales en una cohorte primaria de 498 PVH. Se utilizó el análisis de regresión LASSO para optimizar la selección de variables. Se aplicó un análisis de regresión logística multivariable para construir un modelo usando el 80% de la cohorte primaria como conjunto de datos de entrenamiento y validado usando el 20% restante de la cohorte primaria y datos de una cohorte independiente de 96 participantes. El puntaje de riesgo se desarrolló utilizando el método basado en puntos de Sullivan y D'Agostino. De los 498 participantes con una edad media de 35,7 años, 192 (38%) no iniciaron TAR después del diagnóstico. Controlando por sitio, los factores asociados con la no participación en el cuidado incluyeron tener menos de 35 años, sentirse abandonado por Dios, estrategias de afrontamiento desadaptativas usando alcohol u otras drogas, no tener dificultades para concentrarse y tener altos niveles de confianza en la capacidad de manejar desafíos personales. Un puntaje de riesgo efectivo puede permitir a los clínicos y ejecutores enfocarse en personalizar el cuidado para aquellos que más necesitan apoyo continuo. Las investigaciones futuras deben centrarse en estrategias potenciales para mejorar la generalización y evaluar la implementación del modelo de predicción de riesgo propuesto en los programas de tratamiento del VIH.

Barriers and facilitators to engagement in care and medication adherence for women living with HIV in the Southern United States.

Women living in the South have the second highest rate of HIV and the lowest rate of viral suppression among women in all regions in the United States (U.S.). Viral suppression is achieved by successfully linking women to HIV care and supporting adherence to antiretroviral therapy (ART). We aimed to qualitatively explore perceived barriers and facilitators to HIV care engagement and ART adherence among women living with HIV in the South. Participants (N = 40) were recruited across a broad geographic area of the South, assisted by a location-specific Community/Clinician Advisory Board (CCAB). Qualitative research methods were used to generate in-depth descriptions of women's experiences in accessing HIV care and adhering to ART. Intrapersonal qualities expressed through resilience and self-efficacy were amongst the most prominent themes for both engagement in care and adherence to medications. Structural barriers such as transportation and distance to care continued to be a barrier to engagement, while medication delivery facilitated adherence. Conclusion: Our findings highlight the complexity and interrelated nature of factors impacting care and adherence. Multilevel interventions that incorporate structural factors in addition to individual-level behavioral change are needed to facilitate engagement in care and adherence to ART.

Addressing food insecurity in HIV care: perspectives from healthcare and social service providers in New York state.

Ending the HIV epidemic in the United States will require addressing social determinants contributing to poor care engagement among people living with HIV (PLH), such as food insecurity. Food insecurity is associated with poor care engagement among PLH. Yet, few studies have examined the perspectives of healthcare and social services providers on addressing food insecurity in HIV care. Guided by the Social Ecological Model, we conducted semi-structured interviews with 18 providers in New York State to understand barriers and facilitators to addressing food insecurity in HIV care. Thematic analysis illustrated eight themes across various levels of the Social Ecological Model. At the patient-level, providers perceived patients' feelings of embarrassment, shame, and judgement, and low health literacy as barriers. At the provider-level, challenges included limited time. Facilitators included fostering strong, patient-provider relationships. Barriers at the clinic-level included limited funding, while clinic resources served as facilitators. At the community-level, challenges included intersecting stigmas arising from community norms towards PLH and people who receive food assistance and limited access to healthy food. Findings suggest the need to incorporate their insights into the development of interventions that address food insecurity in HIV care.

The Inherent Violence of Anti-Black Racism and its Effects on HIV Care for Black Sexually Minoritized Men.

The goal of this study was to examine the effects of racial discrimination, depression, and Black LGBTQ community support on HIV care outcomes among a sample of Black sexually minoritized men living with HIV. We conducted a cross-sectional survey with 107 Black sexually minoritized men living with HIV in Chicago. A path model was used to test associations between racial discrimination, Black LGBTQ community support, depressive symptoms, and missed antiretroviral medication doses and HIV care appointments. Results of the path model showed that men who had experienced more racism had more depressive symptoms and subsequently, missed more doses of HIV antiretroviral medication and had missed more HIV care appointments. Greater Black LGBTQ community support was associated with fewer missed HIV care appointments in the past year. This research shows that anti-Black racism may be a pervasive and harmful determinant of HIV inequities and a critical driver of racial disparities in ART adherence and HIV care engagement experienced by Black SMM. Black LGBTQ community support may buffer against the effects of racial discrimination on HIV care outcomes by providing safe, inclusive, supportive spaces for Black SMM.

First Demonstration Project of Long-Acting Injectable Antiretroviral Therapy for Persons With and Without Detectable Human Immunodeficiency Virus (HIV) Viremia in an Urban HIV Clinic.

BACKGROUND: Long-acting injectable antiretroviral therapy (LAI-ART) is approved for treatment-naive or experienced people with human immunodeficiency virus (HIV; PWH) based on trials that only included participants with viral suppression. We performed the first LAI-ART demonstration project to include PWH unable to achieve or maintain viral suppression due to challenges adhering to oral ART. METHODS: Ward 86 is a large HIV clinic in San Francisco that serves publicly insured and underinsured patients. We started patients on LAI-ART via a structured process of provider referral, multidisciplinary review (MD, RN, pharmacist), and monitoring for on-time injections. Inclusion criteria were willingness to receive monthly injections and a reliable contact method. RESULTS: Between June 2021 and April 2022, 51 patients initiated LAI-ART, with 39 receiving at least 2 follow-up injections by database closure (median age, 46 years; 90% cisgender men, 61% non-White, 41% marginally housed, 54% currently using stimulants). Of 24 patients who initiated injections with viral suppression (median CD4 cell count, 706 cells/mm3), 100% (95% confidence interval [CI], 86%-100%) maintained viral suppression. Of 15 patients who initiated injections with detectable viremia (median CD4 cell count, 99 cells/mm3; mean log10 viral load, 4.67; standard deviation, 1.16), 12 (80%; 95% CI, 55%-93%) achieved viral suppression, and the other 3 had a 2-log viral load decline by a median of 22 days. CONCLUSIONS: This small demonstration project of LAI-ART in a diverse group of patients with high levels of substance use and marginal housing demonstrated promising early treatment outcomes, including in those with detectable viremia due to adherence challenges. More data on LAI-ART in hard-to-reach populations are needed.

Systematic Review and Meta-analysis of Linkage to HIV Care Interventions in the United States, Canada, and Ukraine (2010-2021).

We conducted a systematic review and meta-analysis of interventions targeting linkage to HIV care in the US, Canada, and Europe. We searched six databases (PubMed, Embase, Cochrane Library, Web of Science and CINAHL). Inclusion criteria were English language studies in adults in the US, Canada, or Europe, published January 1, 2010 to January 1, 2021. We synthesized interventions by type and linkage to care outcome. The outcome was cumulative incidence of 3-month linkage. We estimated cumulative incidence ratios of linkage with 95% confidence intervals (CIs). We screened 945 studies; 13 met selection criteria (n = 1 from Canada, n = 1 from Ukraine, n = 11 from the US) and were included after full text review (total 37,549 individuals). The cumulative incidence of 3-month linkage in the intervention group was 0.82 (95% CI 0.68-0.94) and control group 0.71 (95% CI 0.50-0.90); cIR of linkage for intervention versus control was 1.30 (95% CI 1.13, 1.49). Interventions to improve linkage to care after HIV diagnosis warrant further attention.

Impact of the COVID-19 Pandemic on HIV Healthcare Service Engagement, Treatment Adherence, and Viral Suppression in the United States: A Systematic Literature Review.

The COVID-19 pandemic has necessitated adaptations in how healthcare services are rendered. However, it is unclear how these adaptations have impacted HIV healthcare services across the United States. We conducted a systematic review to assess the impacts of the pandemic on service engagement, treatment adherence, and viral suppression. We identified 26 total studies spanning the beginning of the pandemic (March 11, 2020) up until November 5, 2021. Studies were conducted at the national, state, and city levels and included representation from all four CDC HIV surveillance regions. Studies revealed varying impacts of the pandemic on HIV healthcare retention/engagement, medication adherence, and viral suppression rates, including decreases in HIV healthcare visits, provider cancellations, and inability to get prescription refills. Telehealth was critical to ensuring continued access to care and contributed to improved retention and engagement in some studies. Disparities existed in who had access to the resources needed for telehealth, as well as among populations living with HIV whose care was impacted by the pandemic.

Variation in local Ryan White HIV/AIDS program service use and impacts on viral suppression: informing quality improvement efforts.

The U.S. Ryan White HIV/AIDS Program (RWHAP) funds comprehensive services for people living with HIV to support viral suppression (VS). We analyzed five years of RWHAP data from the Minneapolis-St. Paul region to (1) assess variation and (2) evaluate the causal effect of each RWHAP service on sustained VS by race/ethnicity. Sixteen medical and support services were included. Descriptive analyses assessed service use and trends over time. Causal analyses used generalized estimating equations and propensity scores to adjust for the probability of service use. Receipt of AIDS Drug Assistance Program and financial aid consistently showed higher probabilities of sustained VS, while food aid and transportation aid had positive impacts on VS at higher levels of service encounters; however, the impact of services could vary by race/ethnicity. For example, financial aid increased the probability of sustained VS by at least 3 percentage points for white, Hispanic and Black/African American clients, but only 1.6 points for Black/African-born clients. This study found that services addressing socioeconomic needs typically had positive impacts on viral suppression, yet service use and impact of services often varied by race/ethnicity. This highlights a need to ensure these services are designed and delivered in ways that equitably serve all clients.

"I am scared, I do not want to lie": exploring the impacts of COVID-19 on engagement in care, perceived health, relationship dynamics, and parenting among postpartum women with HIV in South Africa.

BACKGROUND: COVID-19 and efforts to manage widespread infection may compromise HIV care engagement. The COVID-19-related factors linked to reduced HIV engagement have not been assessed among postpartum women with HIV, who are at heightened risk of attrition under non-pandemic circumstances. To mitigate the effects of the pandemic on care engagement and to prepare for future public health crises, it is critical to understand how COVID-19 has impacted (1) engagement in care and (2) factors that may act as barriers to care engagement. METHODS: A quantitative assessment of COVID-19-related experiences was added to a longitudinal cohort study assessing predictors of postpartum attrition from HIV care among women in South Africa. Participants (N = 266) completed the assessment at 6, 12, 18, or 24 months postpartum between June and November of 2020. Those who endorsed one or more challenge related to engagement in care (making or keeping HIV care appointments, procuring HIV medications, procuring contraception, and/or accessing immunization services for infants; n = 55) were invited to complete a brief qualitative interview, which explored the specific factors driving these challenges, as well as other impacts of COVID-19 on care engagement. Within this subset, 53 participants completed an interview; qualitative data were analyzed via rapid analysis. RESULTS: Participants described key challenges that reduced their engagement in HIV care and identified four other domains of COVID-19-related impacts: physical health, mental health, relationship with a partner or with the father of the baby, and motherhood/caring for the new baby. Within these domains, specific themes and subthemes emerged, with some positive impacts of COVID-19 also reported (e.g., increased quality time, improved communication with partner, HIV disclosure). Coping strategies for COVID-19-related challenges (e.g., acceptance, spirituality, distraction) were also discussed. CONCLUSIONS: About one in five participants reported challenges accessing HIV care, medications, or services, and they faced complex, multilayered barriers to remaining engaged. Physical health, mental health, relationships with partners, and ability to care for their infant were also affected. Given the dynamic nature of the pandemic and general uncertainty about its course, ongoing assessment of pandemic-related challenges among postpartum women is needed to avoid HIV care disruptions and to support wellbeing.

An adapted algorithm for patient engagement in care for young people living with perinatal HIV in England.

BACKGROUND: Evidence suggests that engagement in care (EIC) may be worse in young people living with perinatal HIV (YPLPHIV) compared to adults or children living with HIV. We took a published EIC algorithm for adults with HIV, which takes patients' clinical scenarios into account, and adapted it for use in YPLPHIV in England, to measure their EIC. METHODS: The adult algorithm predicts when in the next 6 months the next clinic visit should be scheduled, based on routinely collected clinical indicators at the current visit. We updated the algorithm based on the latest adult guidelines at the time, and modified it for young people in paediatric care using the latest European paediatric guidelines. Paediatric/adolescent HIV consultants from the UK reviewed and adapted the resulting flowcharts. The adapted algorithm was applied to the Adolescent and Adults Living with Perinatal HIV (AALPHI) cohort in England. Data for 12 months following entry into AALPHI were used to predicted visits which were then compared to appointment attendances, to measure whether young people were in care in each month. Proxy markers (e.g. dates of CD4 counts, viral loads (VL)) were used to indicate appointment attendance. RESULTS: Three hundred sixteen patients were in AALPHI, of whom 41% were male, 82% of black African ethnicity and 58% born abroad. At baseline (time of AALPHI interview) median [IQR] age was 17 [15-18] years, median CD4 was 597 [427, 791] cells/µL and 69% had VL ≤50c/mL. 10 patients were dropped due to missing data. 306 YPLPHIV contributed 3,585 person months of follow up across the 12 month study in which a clinic visit was recorded for 1,204 months (38/1204 dropped due to missing data). The remaining 1,166 months were classified into 3 groups: Group-A: on ART, VL ≤ 50c/mL-63%(734/1,166) visit months, Group-B: on ART, VL > 50c/mL-27%(320/1,166) Group-C: not on ART-10%(112/1,166). Most patients were engaged in care with 87% (3,126/3,585) of months fulfilling the definition of engaged in care. CONCLUSIONS: The adapted algorithm allowed the varying clinical scenarios of YPLPHIV to be taken into account when measuring EIC. However availability of good quality surveillance data is crucial to ensure that EIC can be measured well.

Peer advice for women living with HIV in the Southern USA.

Peer advice can provide emotional, social and practical assistance for the sustained self-management of chronic conditions. For stigmatised diseases such as HIV, finding support can be challenging. Women living with HIV in the Southern USA are additionally impacted upon by region-specific barriers such as stigma, poverty and limited access to services. The effectiveness of peer advice has been studied, yet little is known about the advice shared amongst women living with HIV. Therefore, we aimed to qualitatively explore the context and content of the advice participants offered to other women. With the assistance of a Community Clinician Advisory Board, women were recruited from across the US Centers for Disease Control and Prevention South Census Region. In-depth interviews were conducted with (N = 40) participants, aged 23 to 72 years (M = 51.2). Qualitative inductive thematic analysis was used to explore both the solicited and unprompted advice shared during individual interviews. Analysis of interview transcripts revealed three advice themes: Consistency in disease management Practical, non-medical advice; and Emotional and social support. The findings are valuable in shaping future peer-delivered programmes and interventions to enhance HIV care engagement, medication adherence, and the well-being of women living with HIV in the Southern USA.

Expanding the Evidence on the Safety and Efficiency of 2-Way Text Messaging-Based Telehealth for Voluntary Medical Male Circumcision Follow-up Compared With In-Person Reviews: Randomized Controlled Trial in Rural and Urban South Africa.

BACKGROUND: There is a dearth of high-quality evidence from digital health interventions in routine program settings in low- and middle-income countries. We previously conducted a randomized controlled trial (RCT) in Zimbabwe, demonstrating that 2-way texting (2wT) was safe and effective for follow-up after adult voluntary medical male circumcision (VMMC). OBJECTIVE: To demonstrate the replicability of 2wT, we conducted a larger RCT in both urban and rural VMMC settings in South Africa to determine whether 2wT improves adverse event (AE) ascertainment and, therefore, the quality of follow-up after VMMC while reducing health care workers' workload. METHODS: A prospective, unblinded, noninferiority RCT was conducted among adult participants who underwent VMMC with cell phones randomized in a 1:1 ratio between 2wT and control (routine care) in North West and Gauteng provinces. The 2wT participants responded to a daily SMS text message with in-person follow-up only if desired or an AE was suspected. The control group was requested to make in-person visits on postoperative days 2 and 7 as per national VMMC guidelines. All participants were asked to return on postoperative day 14 for study-specific review. Safety (cumulative AEs ≤day 14 visit) and workload (number of in-person follow-up visits) were compared. Differences in cumulative AEs were calculated between groups. Noninferiority was prespecified with a margin of -0.25%. The Manning score method was used to calculate 95% CIs. RESULTS: The study was conducted between June 7, 2021, and February 21, 2022. In total, 1084 men were enrolled (2wT: n=547, 50.5%, control: n=537, 49.5%), with near-equal proportions of rural and urban participants. Cumulative AEs were identified in 2.3% (95% CI 1.3-4.1) of 2wT participants and 1.0% (95% CI 0.4-2.3) of control participants, demonstrating noninferiority (1-sided 95% CI -0.09 to ∞). Among the 2wT participants, 11 AEs (9 moderate and 2 severe) were identified, compared with 5 AEs (all moderate) among the control participants-a nonsignificant difference in AE rates (P=.13). The 2wT participants attended 0.22 visits, and the control participants attended 1.34 visits-a significant reduction in follow-up visit workload (P<.001). The 2wT approach reduced unnecessary postoperative visits by 84.8%. Daily response rates ranged from 86% on day 3 to 74% on day 13. Among the 2wT participants, 94% (514/547) responded to ≥1 daily SMS text messages over 13 days. CONCLUSIONS: Across rural and urban contexts in South Africa, 2wT was noninferior to routine in-person visits for AE ascertainment, demonstrating 2wT safety. The 2wT approach also significantly reduced the follow-up visit workload, improving efficiency. These results strongly suggest that 2wT provides quality VMMC follow-up and should be adopted at scale. Adaptation of the 2wT telehealth approach to other acute follow-up care contexts could extend these gains beyond VMMC. TRIAL REGISTRATION: ClinicalTrials.gov NCT04327271; https://www.clinicaltrials.gov/ct2/show/NCT04327271.

A systematic review of engagement in care and health care utilization among older adults living with HIV and non-communicable diseases.

It is critical to understand health care engagement and utilization among older persons living with HIV (OPWH) who may have greater burden for non-communicable diseases. Following the PRISMA guidelines, a systematic review using 5 electronic databases was conducted to appraise and synthesize the current literature on the relationship of non-communicable diseases on engagement in care and health care utilization among OPWH. Original studies published in English between 2009 and 2019 were included, yielding 16 relevant articles. Overall, having co-morbid non-communicable diseases was associated with a decreased likelihood of initiating and adhering to ART. Being on ART and viral suppression were associated with better engagement in non-communicable disease care. Findings also suggest that an increasing number of co-morbidities is associated with higher health care utilization and financial burden. This review underscores the need for preventing and managing co-morbidities to enhance engagement in HIV care and that health care practitioners need to ensure that OPWH are engaged in care for both HIV and their co-morbid conditions by providing coordinated and integrated care.

Engagement in care promotes durable viral suppression among persons newly diagnosed with HIV infection.

We characterize the association between engagement in care and durable viral suppression among persons newly diagnosed with HIV infection. Persons newly diagnosed with HIV with unsuppressed viral loads when they initiated care at one of six HIV clinics in the US were observed for up to 24 months. We describe the percentage who achieved durable viral suppression and number of days to achieve durable viral suppression. These outcomes were examined by the proportion of scheduled primary care appointments kept and demographic variables. Overall, 62% of patients achieved durable viral suppression and it took 174 days for 50% of patients to reach the beginning of the event. As the proportion of kept medical appointments increased, the proportion who achieved durable viral suppression increased, with 84% of patients who kept >75% of their appointments achieving the outcome. Higher adherence to appointments shortened the time to the beginning of durable viral suppression. Age, race/ethnicity, and risk factor for acquiring HIV infection were correlated with the outcomes. Adherence to primary care appointments is strongly associated with achieving durable viral suppression in persons newly diagnosed with HIV. Identifying and addressing patient barriers and unmet needs may increase the number who achieve durable viral suppression.

"If he doesn't buy in, it's a waste of time": Perspectives from diverse parents and adolescents on engaging children in ADHD treatment.

Engaging children and adolescents in ADHD care is critical for future independent disease management. However, there is a lack of evidence guiding health professionals and parents on how best to engage their children and adolescents in ADHD care. We recruited 41 diverse parents of children and adolescents with ADHD and 11 adolescents with ADHD from an urban, safety-net hospital to participate in in-depth, semi-structured qualitative interviews and then analyzed this data using thematic analysis. Children's level of illness insight about ADHD and self-esteem emerged as two major contributors to engagement of children and adolescents in ADHD care, and their intersection created four styles of engagement: proactive (high insight, high self-esteem), anxious (high insight, low self-esteem), apathetic (low insight, high self-esteem), and resistant (low insight, low self-esteem). This framework can help health professionals engage children and adolescents in care for ADHD and guide development of interventions to improve engagement in care.

The Human Immunodeficiency Virus (HIV) Index: Using a Patient-Reported Outcome on Engagement in HIV Care to Explain Suboptimal Retention in Care and Virologic Control.

BACKGROUND: We investigated the prospective association between a brief self-report measure of engagement in human immunodeficiency virus (HIV) care (the Index of Engagement in HIV Care; hereafter "Index") and suboptimal retention and viral suppression outcomes. METHODS: The Centers for AIDS Research Network of Integrated Clinical Systems cohort study combines medical record data with patient-reported outcomes from 8 HIV clinics in the United States, which from April 2016 to March 2017 included the 10-item Index. Multivariable logistic regression was used to estimate the risk and odds ratios of mean Index scores on 2 outcomes in the subsequent year: (1) not keeping ≥75% of scheduled HIV care appointments; and (2) for those with viral suppression at Index assessment, having viral load >200 copies/mL on ≥1 measurement. We also used generalized linear mixed models (GLMMs) to estimate the risk and odds ratios of appointment nonattendance or unsuppressed viral load at any given observation. We generated receiver operating characteristic curves for the full models overlaid with the Index as a sole predictor. RESULTS: The mean Index score was 4.5 (standard deviation, 0.6). Higher Index scores were associated with lower relative risk of suboptimal retention (n = 2576; logistic regression adjusted risk ratio [aRR], 0.88 [95% confidence interval, .87-.88]; GLMM aRR, 0.85 [.83-.87]) and lack of sustained viral suppression (n = 2499; logistic regression aRR, 0.75 [.68-.83]; GLMM aRR, 0.74 [.68-.80]). The areas under the receiver operating characteristic curve for the full models were 0.69 (95% confidence interval, .67-.71) for suboptimal retention and 0.76 (.72-.79) for lack of sustained viral suppression. CONCLUSIONS: Index scores are significantly associated with suboptimal retention and viral suppression outcomes.

HIV and COVID-19: Intersecting Epidemics With Many Unknowns.

As of July 2020, approximately 6 months into the pandemic of novel coronavirus disease 2019 (COVID-19), whether people living with human immunodeficiency virus (HIV; PLWH) are disproportionately affected remains an unanswered question. Thus far, risk of COVID-19 in people with and without HIV appears similar, but data are sometimes contradictory. Some uncertainty is due to the recency of the emergence of COVID-19 and sparsity of data; some is due to imprecision about what it means for HIV to be a "risk factor" for COVID-19. Forthcoming studies on the risk of COVID-19 to PLWH should differentiate between 1) the unadjusted, excess burden of disease among PLWH to inform surveillance efforts and 2) any excess risk of COVID-19 among PLWH due to biological effects of HIV, independent of comorbidities that confound rather than mediate this effect. PLWH bear a disproportionate burden of alcohol, other drug use, and mental health disorders, as well as other structural vulnerabilities, which might increase their risk of COVID-19. In addition to any direct effects of COVID-19 on the health of PLWH, we need to understand how physical distancing restrictions affect secondary health outcomes and the need for, accessibility of, and impact of alternative modalities of providing ongoing medical, mental health, and substance use treatment that comply with physical distancing restrictions (e.g., telemedicine).

Association of Substance Use Disorders with Engagement in Care and Mortality among a Clinical Cohort of People with HIV in Washington, DC.

Substance use disorders (SUDs) are common among people with HIV and can prevent achievement of optimal health outcomes. Using data from a longitudinal HIV cohort study in the District of Columbia (2011-2018), we calculated the prevalence and correlates of SUD (alcohol, stimulant, and/or opioid use disorders) and determined the association of SUD with engagement in HIV care, ART prescription, viral suppression, and mortality. Of 8420 adults, 3168 (37.6%) had a history of any SUD, most commonly history of alcohol use disorder (29.6%). SUDs disproportionately affected Black individuals (aOR 1.33) and heterosexuals (aOR 1.18), and women had a lower risk of SUD (aOR 0.65). SUD was not associated with engagement in care, ART prescription, or viral suppression. SUD was associated with mortality (aHR 1.31). Addressing alcohol use disorder and preventable causes of death among people with HIV and substance use disorders should be priorities for clinical care and public health.

RESUMEN: Los trastornos por uso de sustancias (TUS) son comunes entre las personas con VIH y pueden impedir el logro de resultados óptimos de salud. Utilizando datos de un estudio sobre VIH de cohorte longitudinal en el Distrito de Columbia (2011­2018), calculamos la prevalencia y los correlatos de TUS (trastornos por consumo de alcohol, estimulantes y/o opioides) y determinamos la asociación de los TUS con la vinculación a cuidado de VIH, prescripción de terapia antirretroviral, supresión viral y mortalidad. De 8420 adultos, 3168 (37.6%) tenían historial de algún TUS, más comúnmente historial de trastorno por consumo de alcohol (29.6%). Los TUS afectaron de manera desproporcionada a las personas negras (aOR 1.33) y a los heterosexuales (aOR 1.18) y las mujeres tenían un riesgo menor de TUS (aOR 0.65). TUS no tuvo asociación estadísticamente significativa con la vinculación a cuidado de VIH, la prescripción de terapia antirretroviral o la supresión viral. TUS se asoció con mortalidad (aHR 1.31). Abordar el trastorno por consumo de alcohol y las causas prevenibles de muerte entre personas con VIH y trastornos por consumo de sustancias debe ser una prioridad para el cuidado clínico y la salud pública.

Disclosure, Social Support, and Mental Health are Modifiable Factors Affecting Engagement in Care of Perinatally-HIV Infected Adolescents: A Qualitative Dyadic Analysis.

Adolescents living with perinatally acquired HIV in South Africa face significant barriers to successful transition from pediatric to adult care. We performed in-depth qualitative interviews with 41 adolescents living with HIV and 18 of their caregivers to investigate modifiable factors to improve engagement in care prior to transition to adult care. Based on dyadic, inductive content analysis, findings suggest that HIV status disclosure, social support, and mental health are targets for improvement in engagement in care. Early disclosure and a sense of belonging facilitated engagement in care, while barriers included delayed or inadequate disclosure, denial, and lack of disclosure to others. Adherence support improved by having a biological mother as a direct supervisor. Barriers to care included changing caregivers, abandonment, undiagnosed mental health problems and learning difficulties. Despite these factors, the majority of adolescents showed resilience and remained engaged in care despite difficult circumstances.