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A growing population of older adults with HIV will increase demands on HIV-related healthcare. Nearly a quarter of people receiving care for HIV in Latin America are currently 50 years or older, yet little is known about the frequency of comorbidities in this population. We estimated the prevalence and incidence of non-communicable diseases (NCDs) among people 50 years of age or older (≥50yo) receiving HIV care during 2000-2015 in six centers affiliated with the Caribbean, Central and South American network for HIV epidemiology (CCASAnet). We estimated the annual prevalence, and overall prevalence and incidence of cardiovascular diseases, diabetes, hypertension, dyslipidemia, psychiatric disorders, chronic liver and renal diseases, and non-AIDS-defining cancers, and multimorbidity (more than one NCD) of people ≥50yo receiving care for HIV. Analyses were performed according to age at enrollment into HIV care (<50yo and ≥50yo). We included 3,415 patients ≥50yo, of whom 1,487(43%) were enrolled at age ≥50 years. The annual prevalence of NCDs increased from 32% to 68% and multimorbidity from 30% to 40% during 2000-2015. At the last registered visit, 53% of patients enrolled <50yo and 50% of those enrolled ≥50yo had at least one NCD. Most common NCDs at the last visit in each age-group at enrollment were dyslipidemia (36% in <50yo and 28% in ≥50yo), hypertension (17% and 18%), psychiatric disorders (15% and 10%), and diabetes (11% and 12%). The prevalence of NCDs and multimorbidity in people ≥50 years receiving care for HIV in CCASAnet centers in Latin America increased substantially in the last 15 years. Our results make evident the need of planning for provision of complex, primary care for aging adults living with HIV.

Introduction Human papillomavirus (HPV)‐associated cervical and anal cancers disproportionately affect people with HIV (PWH). This study aimed to determine the incidence trends of and risk factors for these malignancies in PWH in Latin America. Methods We included PWH from the Caribbean, Central and South America network for HIV epidemiology (CCASAnet) who contributed person‐time between 2000 and 2019. We calculated crude and age‐standardized incidence rates, examining trends over time with Poisson regression. Adjusted hazard ratios were calculated using Cox proportional hazard models with propensity score adjustment. We calculated the probability of survival after cancer diagnosis using Kaplan−Meier curves. To understand factors that influence our results, we surveyed all adult CCASAnet sites on current practices of cervical and anal cancer screening. Results Overall, 5739 females with HIV (43,417 person‐years) were included in cervical cancer analyses. There were 27 incident cervical cancers: crude incidence rate of 62.2 (95% confidence interval [CI]: 34.9−89.4) per 100,000 person years. In the anal cancer analysis, 12,489 males who have sex with men (MSM), 7324 males other than MSM and 5739 females were included for a total of 25,552 PWH, contributing 157,166 person‐years. Anal cancer was diagnosed in 56 individuals: crude incidence rates of 59.1 [95% CI: 33.2−85.0], 20.7 [95% CI: 11.6−29.7] and 15.2 [95% CI: 8.6−21.9] per 100,000 person‐years in MSM, females and males other than MSM, respectively. Age‐standardized incidence rates did not significantly change over time. Anal cancer risk decreased significantly with higher time‐updated CD4 cell count. The predicted probability of 5‐year survival after cancer diagnosis was 72.6% (95% CI: 48.4−86.8) for cervical cancer and 58.5% (95% CI: 44.0−70.5) for anal cancer. Conclusions In one of the few reports outside the United States or Europe, we did not observe a decrease in age‐standardized incidence rates for anal and cervical cancer between 2000 and 2019. These data support continued efforts for cancer prevention through access to gender‐neutral HPV vaccination and cancer screening.

Introduction We sought to investigate the association between insurance coverage history and cervical cancer screening among Davidson County, Tennessee, women diagnosed with incident cervical cancer. Methods We reviewed medical records of women diagnosed with invasive cervical cancer from 2008 through 2018 identified via the state's cancer registry and by active surveillance of diagnostic pathology reports for the HPV-IMPACT project. Per 2012 United States Preventive Services Task Force recommended cervical cancer screening guidelines, women were characterized into three screening history categories: “no screening”, “no follow-up” and “test/screening failure”. Multivariable logistic regression measured the association of prior inadequate insurance (underinsurance) and screening history (“no screening/no follow-up” compared to “test/screening failure”). Results Of 212 women, most (77%) had not undergone recommended cervical cancer screening or follow-up prior to cancer diagnosis. Overall, 28% of women had history of underinsurance in 5 years prior to diagnosis. In adjusted analyses, underinsured women were more likely to have a “no screening/no follow-up” prior to cancer diagnosis (aOR 4.26; 95% CI 1.15–15.80) compared to “test/screening failure” history. Non-white race (aOR 2.73; 95% CI 0.98–7.61), older age (aOR 1.03 per year; 95% CI 1.00–1.07), and history of smoking (aOR 4.07; 95% CI 1.54–10.74) were also associated with increased likelihood of “no screening/no follow-up”. Conclusions Previous underinsurance was independently associated with non-adherence to cervical cancer screening and follow-up guidelines among women with incident cervical cancer. Further study of factors contributing to inadequate cervical cancer screening and interventions to increase cervical cancer screening in high-risk populations is needed.

Introduction Despite its reversal in July 2019, the World Health Organization warning issued in May 2018 of potential teratogenicity associated with dolutegravir (DTG) may have produced persistent sex disparities in access to DTG. We compared DTG uptake of people with HIV (PWH) by sex in Latin America and the Caribbean (LAC) and its potential impact on virologic outcomes. Methods We evaluated DTG initiation among antiretroviral therapy (ART)‐naïve and ‐experienced cisgender PWH ≥16 years of age after DTG availability in Brazil (February/2017), Chile (August/2019), Haiti (November/2018) and Honduras (December/2018). Time was divided into pre‐ (before May/2018), during‐ (May/2018−July/2019) and post‐ (after July/2019) warning periods. We examined interactions of sex, age and calendar era with multivariable modified Poisson regression models and Cox proportional hazard models for the outcomes of DTG initiation among ART‐naïve and ART‐experienced PWH, respectively, and HIV RNA <50 copies/ml in the first year of therapy among ART‐naïve PWH, adjusting for site and tuberculosis. Results Among 4622 ART‐naïve PWH, 3853 (83%) initiated DTG. ART‐naïve females aged 16–49 years were less likely to initiate DTG compared to males of the same age both in the pre/during‐warning (adjusted prevalence ratio [aPR]: 0.75 [95% confidence interval (95% CI): 0.71−0.80]) and in the post‐warning periods (aPR: 0.97 [95% CI: 0.95−1.00]). Among 16,154 ART‐experienced PWH, 9236 (57%) initiated DTG. ART‐experienced females 16–49 years were less likely to initiate DTG compared to males of the same age in the pre/during‐warning (adjusted hazard ratio [aHR]: 0.69 [95% CI: 0.66−0.73]) and post‐warning periods (aHR: 0.79 [95% CI: 0.70−0.90]). This sex difference was not observed among older ART‐experienced females and males pre/during‐warning (aHR: 1.06 [95% CI: 0.99−1.14]). Compared to starting ART without DTG, DTG‐based ART use was associated with a higher likelihood of HIV RNA suppression in the first year (aPR = 1.10 [95% CI: 1.04−1.16]). In the post‐warning period, females aged 16–49 years had a likelihood of viral suppression similar to males of the same age (aPR: 1.03 [95% CI: 0.96−1.10]), which did not change after adjusting for DTG use (aPR: 1.03 [95% CI: 0.97−1.11]). Conclusions Despite the updated guidelines recommending DTG for all PWH, there are persistent sex disparities in the access to DTG in LAC, especially among females within the reproductive age.

While antiretroviral therapy (ART) has proven effective in suppressing viremia and disease progression among people living with human immunodeficiency virus (HIV; PLWH), suboptimal CD4 + T cell reconstitution remains a major obstacle in nearly 30% of ART-treated individuals. Epidemiological studies demonstrate that obesity, or a body mass index (BMI) ≥ 30 kg/m 2 , is positively correlated with greater CD4 + T cell recovery in PLWH on ART. Leptin is a known immunomodulator that is produced in proportion to fat mass and is increased in obese individuals, including PLWH. We hypothesized that CD4 + T cells from obese PLWH have increased cell proliferation and cytokine production compared to cells from lean PLWH, potentially modulated by differential effects of leptin signaling. To test this hypothesis, peripheral blood mononuclear cells from obese and lean PLWH with long-term virologic suppression on the same ART regimen were pretreated with recombinant leptin and then stimulated with anti-CD3/CD28 or PMA/ionomycin to measure Ki67 expression, leptin receptor (LepR) surface expression and cytokine production. In the absence of leptin, Ki67 expression and IL-17A production were significantly higher in CD4 + T cells from obese compared to lean PLWH. However, LepR expression was significantly lower on CD4 + T cells from obese compared to lean PLWH. After leptin treatment, Ki67 expression was significantly increased in CD4 + T cells from obese PLWH compared to the lean participants. Leptin also increased IL-17A production in CD4 + T cells from obese healthy controls. In contrast, leptin decreased IL-17A production in CD4 + T cells from both obese and lean PLWH. Combined, these results demonstrate that obesity is associated with greater CD4 + T cell proliferation among PLWH, and that higher circulating leptin levels in obesity may contribute to improved CD4 + T reconstitution in PLWH initiating ART.

Background This study aimed to evaluate trends and predictors of survival after cancer diagnosis in persons living with HIV in the Caribbean, Central, and South America network for HIV epidemiology cohort. Methods Demographic, cancer, and HIV-related data from HIV-positive adults diagnosed with cancer ≤ 1 year before or any time after HIV diagnosis from January 1, 2000-June 30, 2015 were retrospectively collected. Cancer cases were classified as AIDS-defining cancers (ADC) and non-AIDS-defining cancers (NADC). The association of mortality with cancer- and HIV-related factors was assessed using Kaplan-Meier curves and Cox proportional hazards models stratified by clinic site and cancer type. Results Among 15,869 patients, 783 had an eligible cancer diagnosis; 82% were male and median age at cancer diagnosis was 39 years (interquartile range [IQR]: 32–47). Patients were from Brazil (36.5%), Argentina (19.9%), Chile (19.7%), Mexico (19.3%), and Honduras (4.6%). A total of 564 ADC and 219 NADC were diagnosed. Patients with NADC had similar survival probabilities as those with ADC at one year (81% vs. 79%) but lower survival at five years (60% vs. 69%). In the adjusted analysis, risk of mortality increased with detectable viral load (adjusted hazard ratio [aHR] = 1.63, p  = 0.02), age (aHR = 1.02 per year, p  = 0.002) and time between HIV and cancer diagnoses (aHR = 1.03 per year, p  = 0.01). Conclusion ADC remain the most frequent cancers in the region. Overall mortality was related to detectable viral load and age. Longer-term survival was lower after diagnosis of NADC than for ADC, which may be due to factors unrelated to HIV.

For reasons not fully explained to date, contraception usage among women with HIV remains low. The aim of our study was to understand attitudes toward and lifetime use of contraception among women with HIV. We administered an anonymous, community-informed, voluntary survey to cisgender, English-speaking women with HIV (≥18 years of age) at a Southern urban HIV clinic. It included multiple choice and Likert-scale questions on reproductive health. Participants reported contraception use, recollection of provider conversations about contraception, and perceived empowerment and knowledge regarding reproductive health. We used chi-square and Fisher exact tests to compare attitudes and prior conversations about contraception by age (< vs ≥45 years), race (Black vs non-Black), and lifetime contraception use. The median age of the 114 participants was 52 years, and 62% of the women identified as Black and 31% as White. Women reported a median of 2 unique family planning methods used throughout life, with oral contraceptive pills being most the common (59%). Only 20% of women reported having ever used long-acting reversible contraception (LARC). Only 56% of women recalled talking with a provider about contraception. Women of non-Black race and those who had used LARC were more likely to remember (72 vs 52%; = .035; 87 vs 56%; = .022; respectively). When asked about preferences, 82% of women age <45 years wanted a nondaily method, and 60% felt uncomfortable with device insertion. Throughout life, participants reported using a diversity of contraceptives. Only half of women remembered a provider conversation about contraception. Understanding women's preferences regarding contraception should guide counseling.

As of March 31, 2023, more than 30,000 monkeypox (mpox) cases had been reported in the United States in an outbreak that has disproportionately affected gay, bisexual, and other men who have sex with men (MSM) and transgender persons (1). JYNNEOS vaccine (Modified Vaccinia Ankara vaccine, Bavarian Nordic) was approved by the Food and Drug Administration (FDA) in 2019 for the prevention of smallpox and mpox via subcutaneous injection as a 2-dose series (0.5 mL per dose, administered 4 weeks apart) (2). To expand vaccine access, an Emergency Use Authorization was issued by FDA on August 9, 2022, for dose-sparing intradermal injection of JYNNEOS as a 2-dose series (0.1 mL per dose, administered 4 weeks apart) (3). Vaccination was available to persons with known or presumed exposure to a person with mpox (postexposure prophylaxis [PEP]), as well as persons at increased risk for mpox or who might benefit from vaccination (preexposure mpox prophylaxis [PrEP]) (4). Because information on JYNNEOS vaccine effectiveness (VE) is limited, a matched case-control study was conducted in 12 U.S. jurisdictions, including nine Emerging Infections Program sites and three Epidemiology and Laboratory Capacity sites, to evaluate VE against mpox among MSM and transgender adults aged 18-49 years. During August 19, 2022-March 31, 2023, a total of 309 case-patients were matched to 608 control patients. Adjusted VE was 75.2% (95% CI = 61.2% to 84.2%) for partial vaccination (1 dose) and 85.9% (95% CI = 73.8% to 92.4%) for full vaccination (2 doses). Adjusted VE for full vaccination by subcutaneous, intradermal, and heterologous routes of administration was 88.9% (95% CI = 56.0% to 97.2%), 80.3% (95% CI = 22.9% to 95.0%), and 86.9% (95% CI = 69.1% to 94.5%), respectively. Adjusted VE for full vaccination among immunocompromised participants was 70.2% (95% CI = -37.9% to 93.6%) and among immunocompetent participants was 87.8% (95% CI = 57.5% to 96.5%). JYNNEOS is effective at reducing the risk for mpox. Because duration of protection of 1 versus 2 doses remains unknown, persons at increased risk for mpox exposure should receive the 2-dose series as recommended by the Advisory Committee on Immunization Practices (ACIP), regardless of administration route or immunocompromise status.

Case Report A man in his 50s with a history of degenerative lumbar-disk and joint disease presented with headache and neck pain that had become progressively worse over the course of 8 days. The associated symptoms included nausea, malaise, fatigue, chills, and decreased appetite. The patient reported no fevers, rash, photophobia, or vision changes. Four weeks before presentation, he had received the latest in a series of epidural injections of methylprednisolone for low back pain. The patient had no history of immunosuppressing conditions and was not taking any additional immunomodulatory medications. Assessment of vital signs on presentation revealed a temperature . . .

Introduction People living with HIV (PLHIV) on antiretroviral therapy (ART) experience high rates of non‐communicable diseases (NCDs). These co‐morbidities often accumulate and older adults may suffer from multimorbidity. Multimorbidity has been associated with loss of quality of life, polypharmacy, and increased risk of frailty and mortality. Little is known of the trends or predictors NCD multimorbidity in PLHIV in low‐ and middle‐income countries. Methods We examined NCD multimorbidity in adult PLHIV initiating ART between 2003 and 2014 using a multi‐site, observational cohort in Brazil. NCDs included cardiovascular artery disease, hyperlipidemia (HLD), diabetes, chronic kidney disease, cirrhosis, osteoporosis, osteonecrosis, venous thromboembolism and non‐AIDS‐defining cancers. Multimorbidity was defined as the incident accumulation of two or more unique NCDs. We used Poisson regression to examine trends and Cox proportional hazard models to examine predictors of multimorbidity. Results Of the 6206 adults, 332 (5%) developed multimorbidity during the study period. Parallel to the ageing of the cohort, the prevalence of multimorbidity rose from 3% to 11% during the study period. Older age, female sex (adjusted hazard ratio (aHR) = 1.30 (95% confidence interval (CI) 1.03 to 1.65)) and low CD4 nadir (<100 vs. ≥200 cells/mm3 aHR = 1.52 (95% CI: 1.15 to 2.01)) at cohort entry were significantly associated with increased risk of multimorbidity. Among patients with incident multimorbidity, the most common NCDs were HLD and diabetes; however, osteoporosis was also frequent in women (16 vs. 35% of men and women with multimorbidity respectively). Conclusions Among adult PLHIV in Brazil, NCD multimorbidity increased from 2003 to 2014. Females and adults with low CD4 nadir were at increased risk in adjusted analyses. Further studies examining prevention, screening and management of NCDs in PLHIV in low‐ and middle‐income countries are needed.