INTRODUCTION KwaZulu-Natal (KZN), South Africa's provincial HIV epicentre with a prevalence of over 20%, strives to accelerate progress toward the global End the HIV Epidemic (EHE) 2030 goal. This modelling study aimed to maximize HIV prevention in KZN, given resource constraints. METHODS We performed allocative efficiency analyses (i.e. identifying the allocation of resources that maximizes benefits) with an HIV compartmental transmission model calibrated to HIV prevalence and incidence in KZN since 1990, under two perspectives, 1) "status quo," building on 2022 funding and coverage levels and allocating additional resources, and 2) "perfect reallocation," shifting resources toward more efficient interventions before allocating additional resources. Outcomes included infections averted, quality-adjusted life years added, time to reach the EHE goal, and annual programmatic costs. RESULTS With "status quo," KZN will fall short of the 2030 EHE goal by approximately 500,000 infections, requiring additional annual expenditures of US$355 million across 11 interventions, from greatest to least efficiency: long-acting PrEP; HIV self-testing; DREAMS; index testing; VMMC; defaulter tracing; community-based testing; differentiated care; condom distribution, ART adherence support for detectable viral load; and oral PrEP. Alternatively, a "perfect reallocation" strategy that shifts funds from lower-efficiency to higher-efficiency interventions could avert 240,000 additional infections, narrowing the EHE gap by nearly half and reducing additional annual expenditures to US$344 million to close the gap. CONCLUSIONS KZN will require additional resources to achieve its 2030 EHE goals, but strategic prioritization and reallocation toward more efficient interventions can maximize HIV prevention within resource constraints.
OBJECTIVES Quality of life (QOL), which encompasses mental and physical health and socioeconomic stability, is an important determinant of health outcomes. This analysis assessed the relationship between QOL and viral suppression among women with HIV (WWH) in the Women's Interagency HIV Study and differences across race/ethnicity. DESIGN A multi-center, prospective, observational cohort study of women living in the U.S. METHODS Longitudinal data over a 5 year period were used to fit generalized mixed effects regression models to assess the relationship between self-reported QOL (single-item; scale of 0-10) and viral suppression (<200 copies per ml). An interaction term was included to examine a moderating effect by race/ethnicity. Models included sociodemographic, substance use, and health behavior factors. RESULTS In the cohort sample (n=1,324), on average, the participants were 48 years old (SD = 9.2) and living with HIV while in the study for 16 years. Approximately 90% identified as heterosexual; 70% as Black/African American, 16% as Hispanic, and 11% as White. Roughly 20% of the cohort was not virally suppressed. QOL was positively associated with viral suppression (adjusted odds ratio (aOR)=1.10, 95% CI: 1.04, 1.16). However, the magnitude of this association varied by race/ethnicity, with the highest association among White WWH (aOR=1.36, 95% CI: 1.10, 1.63) and lowest among Black WWH (aOR= 1.08, 95% CI: 1.02, 1.15). CONCLUSION These findings highlight a positive association between QOL and viral suppression and a moderating effect by race. Future research should assess which specific QOL domains are driving this association to inform tailored interventions.
BACKGROUND Preterm birth (PTB) and small-for-gestational age (SGA) often occur in infants born to women with HIV and may influence growth among children perinatally HIV- exposed but uninfected (CHEU). SETTING U.S. cohort at 22 sites. METHODS CHEU were enrolled at birth into the SMARTT Dynamic cohort of the Pediatric HIV/AIDS Cohort Study network and followed through age 17 years. We calculated Z scores for singleton CHEU through age 7 years for weight (WAZ), length or height (LAZ/HAZ), and weight-for-length/body mass index (WFL/BMI)]; excessive catch-up growth was defined as WAZ increase >0.67 SD from birth to age 2 years. Birth weight-for-gestational age (GA) was categorized as small- (SGA), appropriate- (AGA), and large-for-GA (LGA). Piecewise linear regression models with slope changes were used to assess growth trajectories by SGA and PTB. RESULTS Among 2,765 CHEU born 2007-2022, 9.2% were SGA, 14.4% preterm, and 47% had excessive catch-up growth. Among term infants, those born SGA had the highest percent (65%) with excessive catch-up growth. Those born SGA had lower mean WAZ and WLZ/BMIZ than AGA through age 7 years. Infants with PTB had higher mean WAZ, LAZ/HAZ, and WLZ/BMIZ at birth than term infants, but were similar by age 7 years. CONCLUSIONS A high proportion of CHEU had excessive catch-up growth and obesity at age 5 years. While SGA infants had persistently lower Z-scores than AGA, obesity rates at age 5 years were comparable. These findings represent a paradigm shift from undernutrition to overnutrition, particularly in countries where obesity prevalence is high.
Background: Individuals living with HIV often experience chronic pain, which contributes to diminished physical and mental health. Skills TO Manage Pain (STOMP), a pain self-management intervention tailored for individuals with HIV, has demonstrated immediate and sustained efficacy at reducing pain and strengthening pain self-efficacy. Evaluating STOMP’s effectiveness in real-world settings remains a critical next step in advancing its implementation. Methods: This article describes how we used implementation mapping to develop strategies aimed at strengthening the delivery and long-term sustainability of STOMP in HIV care settings. Results: Through semi-structured interviews with 17 key informants, we identified several barriers to and facilitators of STOMP implementation. Examples included patients potentially feeling their pain is being invalidated because they are being offered a behavioral rather than biomedical intervention; however, STOMP was also an adaptable, evidence-based CBT intervention that people may perceive as a better option than opioids for pain management. We also held a community engagement studio in which key informants provided insights on how to promote equitable implementation of STOMP in HIV clinics. Conclusion: Using a rigorous theory-based approach, we selected ten strategies to reduce barriers and strengthen facilitators for STOMP implementation in HIV care settings. This process involved qualitative interviews and a focus group with key informants, including people with lived experience. Implementation mapping appears to be a promising approach to bolster uptake of evidence-based interventions like STOMP. In our future research, we will evaluate both our implementation strategies and the effectiveness of STOMP for improving health in people with HIV and chronic pain.
Introduction: Clinical trials for the evaluation of novel diagnostics and treatments for HIV-associated opportunistic infections have historically excluded pregnant persons. Little information is available regarding the clinical outcomes and pregnancy outcomes of pregnant persons with advanced HIV disease while taking opportunistic infection prophylaxis for tuberculosis (TB) and cryptococcosis. In this study, we describe characteristics at enrollment, clinical outcomes, and birth outcomes of pregnant people with advanced HIV in Uganda. Methods: We prospectively enrolled pregnant adults with advanced HIV disease within an on-going pragmatic cluster randomized clinical trial evaluating an enhanced screening and prophylaxis package for opportunistic infections (NCT05085171). The trial began enrollment in May 2022 and continues in 26 outpatient HIV clinics in the Kampala and Wakiso districts of Uganda. We present an analysis of pregnant participants enrolled through April 30, 2025, including their characteristics at study enrollment, opportunistic infections, and birth outcomes. Results: Overall, 15% (114/766) of female participants with advanced HIV disease were pregnant. Median CD4 cell count was 124 cells/µL (IQR: 82-170). Median time since HIV diagnosis was 7 days, and 45% were ART-naive at enrollment. Compared with non-pregnant female participants, pregnant participants were less likely to have a positive cryptococcal antigen (CrAg) test (2% vs 7%, p=0.023), to have a positive Alere tuberculosis (TB) lipoarabinomannan (LAM) test (11% vs 28%, p<0.001), and to be receiving active TB treatment (14% vs 39%, p<0.001). Overall, 18% (21/114) experienced at least one opportunistic infection during the study, of which 71% (n=15) were attributed to TB. Eighty-six percent (98/114) of pregnancies were carried to term. Participants on TB preventive therapy (TPT) had 94% of deliveries at term (51/54), compared with 80% (36/45) among participants who did not receive TPT (OR = 4.25, 95%CI:1.07-16.80), and 67% (8/12) among participants on active TB treatment (OR = 8.50, 95%CI: 1.60-45.25). Conclusions: Although the incidence of opportunistic infections is less commonly reported among pregnant women with advanced HIV disease, TB is the most frequent opportunistic infection. Participants on TPT had 4-fold higher odds of having a term delivery compared with those not on TPT and 8-fold higher odds compared with those with active TB.
