BACKGROUND:People with HIV disproportionately experience homelessness and other forms of housing instability. Understanding how housing status influences HIV clinical outcomes remains limited, especially among individuals engaged in care. METHODS:We evaluated associations between housing status and HIV care markers using clinical data and patient-reported measures from the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) cohort of adults receiving HIV care across the US, between 2019-2025. We used relative risk regression and linear regression to estimate associations between self-perceived housing instability and outcomes including HIV viral suppression (<200 copies/mL), self-reported antiretroviral therapy (ART) use and adherence (visual analog scale), and CD4 cell count, adjusted for demographic characteristics, year, and site. RESULTS:Among 6,873 individuals in clinical care, nearly 10% reported some form of housing instability at their most recent visit: 4.6% "Unstable," 3.3% "Homeless," and 1.7% "Don't know." Compared to stably housed individuals, the prevalence of viral suppression was lower among those experiencing homelessness (PR=0.82, 95% CI: 0.77-0.89) and unstable housing (PR=0.94, 95% CI: 0.90-0.98), as was the prevalence of ART use, mean ART adherence, and mean CD4 count. Results were similar when stratified by substance use and depression and when compared to a community-based cohort of people with HIV. CONCLUSION:Housing instability is associated with a lower prevalence of HIV viral suppression even among individuals engaged in clinical care. These results highlight lack of access to stable housing as a structural barrier to successful management of HIV and to ending the HIV epidemic in the US.

ABSTRACT:People with HIV (PWH) are at an increased risk of venous thromboembolism (VTE), and cannabis use is common in this population. However, evidence of cannabis impact on VTE risk has been conflicting and not well evaluated in PWH. Using data from five Centers for AIDS Research Network of Integrated Clinical Systems sites (2009-2020), we assessed the association between cannabis use and VTE risk. Among 13,646 PWH, 30% reported current cannabis use. In adjusted Cox models, neither former (adjusted hazard ratio [aHR] 0.78, 95% confidence interval (CI) 0.57-1.07) nor current (aHR 0.74, 95% CI 0.51-1.06) cannabis use showed a significant increase in VTE incidence compared with never use. Additionally, no dose-dependent relationship was observed between cannabis use frequency and VTE. Among PWH, cannabis use does not appear to be associated with an elevated risk of VTE. Further research is needed to elucidate the relationship between cannabis and VTE risk in this population.

Objectives To understand the trade-offs between different statistical modeling approaches, using real world data with small sub-populations, with rare exposures and increasingly rare outcomes. In particular, to compare adjusted regression, inverse probability weighting, and matching. Methods Data for these analyses came from the RADAR (N=1,134) and combined CNICS/JHHCC (N=14,434) cohorts. We estimated prevalence ratios (PRs) for self-reported use of specific substances comparing subpopulations (SP), SP-1 vs SP-3 and SP-2 vs SP-3, where SP-1 was the largest proportion (92% in RADAR, 81% in CNICS/JHHCC), SP2 was moderate proportion (18% in CNICS/JHHCC) and SP-3 was the smallest proportion (8% in RADAR, 1% in CNICS/JHHCC) of the population. We calculated PRs using 1) unadjusted relative risk regression (RR); and adjusted estimates controlling for age, race/ethnicity, study site, and year of interview using: 2) standard adjustment in RR; 3) stabilized inverse probability of treatment weighting (IPTW); and 4) matching with up to 3 matches from SP-1 or SP-2 per SP-3 participant. Results For most substances, all methods yielded consistent estimates. There were large weights in some of the IPTW analyses and in three cases these resulted in substantially divergent estimates. For the comparison between SP-1 and SP-3, the estimate for smoking was 1.3-fold greater in the matched analysis (PR=1.33, 95% CI: 1.02-1.75) than in IPTW (PR=1.03, 95% CI: 0.78-1.37 ATE and PR=1.05, 95% CI: 0.88-1.26 ATT). Even more extreme divergence in estimates was observed for differences between SP-2 and SP-3 with respect to methamphetamine/amphetamine, (IPTW-ATE: PR=1.51, 95% CI: 0.79-2.89; IPTW-ATT: PR=2.36, 95% CI: 1.36-4.12); vs Matching: PR=2.71, 95%CI: 1.47-4.99) and cocaine (IPTW-ATE: PR=1.15, 95% CI: 0.55-2.38; IPTW-ATT: PR=1.81, 95% CI: 1.03-3.18); vs Matching: PR=1.38, 95%CI: 0.76-2.53). Conclusion The combination of a rare exposure and a rare outcome can produce challenges for commonly used confounding adjustment strategies, and it is often best to compare different modeling approaches to gain greater insight.

BACKGROUND:Pain is common in persons with HIV, who often report mental health symptoms and substance use, all of which may affect viral suppression. OBJECTIVE:To investigate correlates of self-reported pain and associations with viral suppression among people with HIV. METHODS:We analysed data from 3422 self-interviews contributed by 1626 unique patients in continuity care in the Johns Hopkins HIV Clinical Cohort between October 2013 and December 2018. Self-reported pain was measured using the EuroQol-5D-3L ("Have you had any pain or discomfort today?"). The correlations included PTSD, anxiety, depressive symptoms, and substance use. Viral suppression (HIV RNA ≤ 200 copies/mL) is routinely collected for clinical care and was abstracted between 9 months prior to 1 week after the self-interview. RESULTS:Pain was more prevalent in patients who were older, female, white, and who reported mental health symptoms or who had a recent or past prescription for an opioid. The prevalence ratio between pain and viral non-suppression was consistent with no association and also a weak positive association (1.07, 95% CI: 0.95, 1.21). CONCLUSIONS:Tailored interventions for mental health may improve pain and HIV outcomes.

OBJECTIVE:Evaluate the impact of initiating integrase strand transfer inhibitor (INSTI) - vs. nonnucleoside reverse transcriptase inhibitor (NNRTI) - or protease inhibitor-based regimens on weight and glycemia among people with HIV (PWH) and type 2 diabetes. DESIGN:Cohort study. METHODS:From multisite HIV cohorts in the United States and Canada (2007-2022), we identified PWH with diabetes who newly initiated INSTI-based, NNRTI-based, or protease inhibitor-based therapy. We used inverse probability of treatment-weighted (IPTW) generalized linear models to compare changes in weight and hemoglobin A1c (HbA1c) at approximately 12 months after antiretroviral therapy (ART) initiation. We assessed time to at least 5% weight gain and to glucose-lowering therapy augmentation or HbA1c increase at least 0.5 percentage points with IPTW Cox regression. RESULTS:Among 1279 PWH with diabetes, 548 initiated an INSTI-based regimen, 511 an NNRTI-based regimen, and 220 a protease inhibitor-based regimen. Compared with NNRTI users, INSTI users had greater adjusted mean weight gain [2.1 kg; 95% confidence interval (CI), 1.1-3.1], while the difference in HbA1c change was modest (0.2%; 95% CI, 0.0-0.5); both changes were similar between INSTI and protease inhibitor users. INSTI users had higher risk of at least 5% weight gain [adjusted hazard ratio (aHR), 1.35; 95% CI, 1.15-1.59] and glucose-lowering therapy augmentation or HbA1c increase at least 0.5% (aHR, 1.19; 95% CI, 1.02-1.41) compared with NNRTI users although similar risk vs. protease inhibitor users. CONCLUSION:Among PWH with diabetes, initiating INSTIs conferred modestly greater weight gain and worse glycemic outcomes vs. NNRTIs, but outcomes comparable to PIs, which is recognized for adverse metabolic effects. These findings inform the metabolic implications of INSTIs and support clinical monitoring after ART initiation.

Objectives. To examine the associations of routinely collected measures of socioeconomic disadvantage with HIV care continuum outcomes in 2024. Methods. In a cohort of people with HIV in Baltimore, Maryland, we compared restricted mean time spent in 4 states of the longitudinal care continuum (viral suppression, nonsuppression, having a 12-month gap in viral load monitoring, and death) by income, housing status, incarceration, insurance, and neighborhood deprivation. Results. All measures of socioeconomic disadvantage were associated with fewer days spent alive and more days with a nonsuppressed viral load. Individual income and neighborhood deprivation were independently associated with survival and viral suppression: among participants in low-deprivation neighborhoods, those with lower income spent 7 more days with a nonsuppressed viral load (95% confidence interval [CI] = 0, 16) and 2 fewer days alive (95% CI = 0, 4); among participants with higher income, those living in higher-deprivation neighborhoods spent 14 more days with a nonsuppressed viral load (95% CI = 4, 24) and 2 fewer days alive (95% CI = 0, 5). Conclusions. The routine collection of data on socioeconomic disadvantage can help assess risk of poor clinical outcomes among persons with HIV. (Am J Public Health. Published online ahead of print August 13, 2026:e1-e10. https://doi.org/10.2105/AJPH.2026.308484).

OBJECTIVE:Patient-reported outcomes (PROs) provide important information to improve healthcare and facilitate research but can be difficult to implement in busy care settings. DESIGN:We integrated PRO collection into HIV care (2008-2024) with results summarized for providers to improve clinical care. METHODS:PWH presenting for HIV care at nine clinics across the United States in the CFAR Network of Integrated Clinical Systems (CNICS) were asked to complete a touch-screen-based PRO assessment at routine clinic visits using a web-based application. RESULTS:21 725 PWH completed the CNICS clinical PRO assessment 132 240 times (mean 6.1 assessments per PWH). Mean age at initial assessment was 43.8  years, 24.9% screened in for depression, 35.5% reported heavy episodic (binge) drinking, 38.9% smoking, 10.9% methamphetamine use, 11.7% recent intimate partner violence, and 8.4% reported unstable housing in the prior 30 days. DISCUSSION:We implemented a PRO assessment into HIV care at nine geographically dispersed clinics. PRO responses in domains known to drive adverse outcomes such as substance use were identified as were situational concerns such as unstable housing. This study demonstrated that use of a well designed PRO platform can address many of the barriers of paper and interview-based collection and be sustainable over time even as clinic flow and content priorities evolve. It demonstrated that PROs done for clinical care are useful to address clinically relevant research questions and institutional needs. Finally, this study demonstrated the feasibility of wide-spread implementation of a clinical PRO assessment into busy HIV clinical care settings with >130 000 assessments completed to date.

BACKGROUND:Stagnating decreases in Kaposi sarcoma (KS) among men with HIV (MWH) following Treat-All policies necessitate evaluating changes in clinical drivers of KS. We examined clinical factors and their associations with KS rates among MWH in North America. METHODS:Among MWH in the North American AIDS Cohort Collaboration on Research and Design, we estimated annual KS rates (per 100 000 person-years [PY]) by viral suppression (<200 copies/mL), CD4 count (<500 vs ≥500 cells/mm3), and time since ART initiation (<1 year/naive vs ≥1 year) from 2009-2019. We quantified associations between clinical factors and KS rates using negative binomial regression, estimating incidence rate ratios (IRRs) with 95% CIs. Among MWH with KS, we estimated average annual percentage changes (AAPCs) in clinical factor distribution using joinpoint regression. RESULTS:There were 61 155 MWH (370 624 PY) contributing 262 KS diagnoses. KS decreased from 132 to 43 cases per 100 000 PY between 2009 and 2019. Viral suppression (IRR2009: .09 [95% CI: .04-.20]; IRR2019: .69 [.31-1.54]), recent/no ART initiation (IRR2009: .14 [.07-.30]; IRR2019: 1.16 [.53, 2.56]), and CD4 count ≥500 cells/mm3 (IRR2009: .13 [.05-.31]; IRR2019: .44 [.18-1.10]) were associated with reduced KS rates, attenuating over time. Unsuppressed viral load at KS diagnosis decreased by 10.6% (-15.8%, -4.8%) as did those on ART ≤1 year/naive (70%-40%; AAPC: -6.3% [-13.8%, 2.1%]). CONCLUSIONS:Our findings underscore the importance of early HIV diagnosis/treatment in reducing KS burden. Attenuating associations with HIV factors indicate that those successfully managing HIV increasingly represent KS patients. KS drivers are evolving, requiring patient/population-level monitoring.

BACKGROUND:Psychological distress (eg, depression) and social stressors (eg, HIV-related stigma) can affect HIV-related outcomes such as antiretroviral therapy adherence and health-related quality of life (HRQL). Limited research on adverse childhood experiences such as childhood household violence (CHV) has shown a similar impact on HIV-related outcomes, particularly virologic suppression, although little is known about mediating pathways with factors such as psychological distress and social stressors. SETTING:Data from the Centers for AIDS Research Network of Integrated Clinical Systems cohort were analyzed. This article examines the relationship between CHV and HIV-related outcomes, and potential differences between those with and without CHV by age (<50 vs. ≥50 years). METHODS:Bivariate comparisons, linear regressions, and mediation analyses between CHV and other variables were used to assess association with outcome measures. RESULTS:Among 7705 people with HIV, CHV was reported by 19% (n = 1498). CHV was associated with lower antiretroviral therapy adherence (P < 0.001), more HIV symptoms (P < 0.001), and lower HRQL (P < 0.001). In addition, CHV exposure was associated with worse depressive symptoms (P < 0.001), increased panic symptoms (P < 0.001), lower social support (P < 0.001), greater self-report of HIV stigma (P < 0.001), and more exposure to intimate partner violence (P < 0.001). Psychological distress and social stressors mediated the relationship between CHV and adherence, HIV symptoms, and HRQL, with depressive and panic symptoms accounting for the greatest proportion mediated. CONCLUSIONS:CHV has an adverse impact on social and psychological factors in adulthood for people with HIV. Depressive symptoms and panic symptoms are potential targets for interventions.

BACKGROUND:Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are nephroprotective but are associated with early eGFR decline, also termed "eGFR dip." Despite elevated risk of kidney disease, this phenomenon is understudied among people with HIV (PWH). METHODS:In a 1:1 propensity score-matched cohort study using data from 9 Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) sites, we compared new SGLT2i users with new users of other antihyperglycemic classes. We estimated adjusted hazard ratios (aHRs) for time to ≥10% and ≥30% eGFR decline using multivariable Cox proportional hazards models and analyzed eGFR change using multivariable linear mixed models. In addition, longer-term eGFR trends over 24 months were visualized using locally weighted scatterplot smoothing (LOWESS) curves. RESULTS:Among 1554 eligible PWH, we obtained 295 matched pairs. Over 6 months, eGFR decline incidence of ≥10% and ≥30% was higher among users of SGLT2i versus other antihyperglycemic classes (58.2% vs. 37.4%; aHR: 1.79; 95% CI: 1.40%-2.28%; and 17.3% vs. 9.8%; aHR: 1.69; 95% CI: 1.05-2.73; respectively). The adjusted mean eGFR change at 6 months was -2.62 mL/min/1.73 m 2 for SGLT2i versus 0.05 mL/min/1.73 m 2 for other classes. Long-term eGFR trends revealed an expected initial decline after SGLT2i initiation, followed by stabilization and a slower subsequent decline compared with other classes. CONCLUSIONS:Acute eGFR dips were more common among PWH initiating SGLT2i relative to other antihyperglycemic classes, although overall declines were small, transient, and consistent with the general population. Further research is needed to explore the long-term effects of SGLT2i in PWH.

BACKGROUND:Integrase strand transfer inhibitor (INSTI) initiation has been associated with diabetes in antiretroviral therapy (ART)-naive people with HIV. We aimed to examine the effect of switching to INSTIs on incident diabetes in ART-experienced people with HIV. METHODS:In this target trial emulation, we retrospectively used individual-level data from 27 longitudinal cohorts of people with HIV in the USA and Canada. We included participants aged at least 18 years without diabetes who had used non-nucleoside reverse transcriptase inhibitors (NNRTIs) or protease inhibitors for at least 180 days (in 2016-22) but had never used an INSTI. We used data from any clinical encounters in which participants continued an NNRTI or protease inhibitor versus switched to an INSTI, with a follow-up period of up to 5 years. The effect of switching to INSTIs on incident diabetes was estimated with weighted Cox regression with robust variance. We further assessed whether the effect varied by time since the switch and was explained by weight gain in the first year. FINDINGS:13 071 participants were followed up from 2702 encounters in which they switched to an INSTI from an NNRTI, 54 766 encounters in which they continued an NNRTI, 1714 encounters in which they switched to an INSTI from a protease inhibitor, and 26 599 encounters in which they continued a protease inhibitor. Switching from protease inhibitors to INSTIs conferred an adjusted hazard ratio (HR) of 1·38 (95% CI 1·06-1·80) for incident diabetes, whereas switching from NNRTIs to INSTIs conferred an adjusted HR of 1·10 (0·87-1·39). The diabetes risk was higher during the first 2 years after switching from protease inhibitors to INSTIs (HR 1·67, 95% CI 1·21-2·30), but not thereafter (1·08, 0·75-1·57; pinteraction=0·064). The effect of switching from protease inhibitors to INSTIs on diabetes did not appear to be explained by weight gain. In the sensitivity analysis in which weight gain did not exceed 5% in the first year after, the switch from NNRTIs to INSTIs had a HR of 1·03 (95% CI 0·79-1·36) and the switch from protease inhibitors to INSTIs had a HR of 1·37 (1·02-1·84). INTERPRETATION:The increased diabetes risk after switching from protease inhibitors to INSTIs highlights a metabolic implication of regimen change and could warrant close monitoring early after switch, regardless of weight gain. FUNDING:US National Institutes of Health.

Background:Internalized HIV stigma (IHS) is associated with reductions in antiretroviral therapy (ART) adherence and HIV viremia mediated through depression. However, there is still a need to quantify the direct impact of IHS on ART adherence to inform interventions to improve medication adherence.Methods:The Center for AIDS Research Network of Integrated Clinical Systems is a longitudinal, US-based, multisite cohort of people with HIV who complete patient-reported outcome assessments as part of HIV-care visits. Patient-reported outcome data include IHS items, ART adherence, depression assessments, substance use, and other outcomes. We examined associations between IHS and ART adherence using generalized linear latent and mixed models with a nonparametric random effects intercept to accommodate repeated measures. Results were compared with analyses using generalized estimating equations and marginal structural models.Results:Among 13,119 people with HIV, the mean age was 47.4 years, 17.6% were women, and 59.3% were non-White. Across 33,139 observations, controlled for repeated measures on individuals, HIV medication adherence was reduced by 1.07% for every point increase in IHS after controlling for age, sex, ethnicity, geographic location, and substance use, and 0.58% when additionally adjusted for depression score. Marginal structural models and generalized estimating equations provided similar results.Conclusions:Our study demonstrates that IHS has a direct association with reductions in ART adherence, which could affect other comorbid health outcomes that are influenced by unsuppressed viremia over time. Developing a thorough understanding of the mechanisms through which IHS affects ART adherence is critical for developing interventions to mitigate IHS and improve health outcomes across the lifespan.

BACKGROUND:We explored whether self-reported current cannabis use is associated with inflammatory biomarkers among people with HIV (PWH), given high rates of cannabis use and chronic immune activation among PWH. METHODS:At seven Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) cohort sites, which integrate data on participant characteristics including demographic and clinical information, and substance use behaviors, we used linear regression to estimate the average difference in biomarkers associated with cannabis use, adjusted for demographic characteristics and sampling weights. Cannabis use was considered as Never, Former, or Current (past 3-month) use. Thirteen plasma biomarkers were measured once on or after 2010 among a subset of PWH on antiretroviral therapy with HIV viral suppression within CNICS. Cannabis use was assessed within 1 year prior to biomarker collection. Biomarkers were log-transformed and scaled by standard deviation to standardize estimates. RESULTS:Among 532 PWH, the average age at biomarker collection date was 47 years, 84% were male, 61% non-White, 30% reported current cannabis use, 35% former use, and 35% never using cannabis. In adjusted linear regression, current cannabis use was associated with higher soluble CD14 (sCD14) levels (β = 0.35; 95% confidence interval [CI]: 0.09, 0.61). Former cannabis use was associated with lower C-reactive protein (CRP) (β = -0.25; 95% CI: -0.47, -0.04), although current use was not (β = -0.25; 95% CI: -0.51, 0.01) compared to never use. CONCLUSIONS:Cannabis use may be related to lower CRP and elevated markers of microbial translocation (e.g., sCD14), which could have implications in increasing the risk of vascular events and should be investigated in a longitudinal setting.

BACKGROUND:Previous studies suggest that internalized HIV stigma (IHS) results in HIV viral nonsuppression via directly increasing depression, which then reduces adherence leading to nonsuppression; however, the dynamics between IHS and mental health are likely more complex. We sought to better understand IHS-mental health dynamics using data from a longitudinal clinical cohort of people with HIV (PWH) receiving healthcare across 10 US primary care clinics. METHODS:Among 8,506 PWH who had ≥2 timepoints in which IHS, depression, and anxiety were measured, we examined changes over time in both two-state (i.e., impact of IHS on depression or anxiety and vice versa) and four-state combinations of depression-IHS (i.e., no depression or IHS, depression/no IHS, no depression/IHS, both depression/IHS) and anxiety-IHS. Transition probabilities between states and factors influencing transitions were identified using multistate Markov models. RESULTS:The impact of IHS on the transition rates of mental health measures (i.e., depression, anxiety) and vice versa were almost the same, suggesting that each influences the other. Over 50% of PWH remained in the same IHS-depression or IHS-anxiety state. PWH with IHS had almost twice the rate of transitioning from no depression/anxiety to having depression/anxiety compared to PWH without IHS; with similar results for the depression or anxiety with no IHS to reporting IHS transition. CONCLUSIONS:We demonstrate that IHS and mental health dynamics are more complex than previously suspected and that the associations are bidirectional, which has implications for both future analyses and optimal management of these conditions among PWH.

BACKGROUND:Weight gain is common following antiretroviral therapy (ART) initiation. Integrase strand transfer inhibitors (INSTIs) and tenofovir alafenamide (TAF) have been associated with greater weight gain, though prior analyses may have been confounded by the weight-suppressive effects of efavirenz (EFV) and tenofovir disoproxil fumarate (TDF). METHODS:Treatment-naïve adults in the North American AIDS Cohort Collaboration on Research and Design initiating ART between 2007-2020 were analyzed. Predicted weight change was modeled using linear mixed effects models adjusted for demographic and clinical factors, and nucleoside reverse transcriptase inhibitor (NRTI) backbone, with sub-analyses excluding EFV and stratifying by INSTI agent, NRTI, sex, and race. RESULTS:32,514 persons were included. At 2 years, INSTIs (4.9 kg, 95%CI 4.6-5.2) and protease inhibitors (PIs) (4.7 kg, 95%CI 4.4-5.1) were associated with greater mean predicted weight gain compared to non-nucleoside reverse transcriptase inhibitors (NNRTIs) (2.7 kg, 95%CI 2.4-2.9). Differences persisted when limiting analyses to TDF-containing regimens and excluding EFV. Among INSTIs, mean predicted weight gain was numerically highest with bictegravir (6.9 kg, 95%CI 5.8-7.9), followed by dolutegravir (5.3 kg, 95%CI 4.8-5.9), raltegravir (4.5 kg, 95%CI 3.8-5.3), and elvitegravir (4.0 kg, 95%CI 3.6-4.5). Participants receiving TAF with INSTIs gained more than those on TDF. Black females on bictegravir or dolutegravir with TAF had the highest gain at 2 years (10.0 kg, 95%CI 7.4-12.6). CONCLUSIONS:Weight gain with non-EFV NNRTIs was lower than with PIs and INSTIs, with the greatest increases observed among Black females starting TAF with contemporary INSTIs.

Type 2 diabetes (T2D) risk prediction remains a challenge, particularly in underrepresented populations, including people living with HIV (PWH) and those of non-European ancestry. We evaluated the performance of two metaPRS (polygenic risk score) models, integrating genetic markers related to inflammation and lipid metabolism, in predicting T2D risk across ancestry groups (African and European), with and without HIV. The metaPRS were generated in a subset from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study (6,034 Black; 11,972 White) and validated in 7,580 (4,120 Black; 3,460 White) PWH from the Centers for AIDS Research of Integrated Clinical Systems (CNICS), as well as an additional 4,152 (2,586 Black; 1,566 White) seronegative participants from REGARDS. Incorporating the metaPRS into models provided non-significant improvements in T2D risk prediction compared to single-trait T2D PRS and clinical risk factors. Performance was similar in PWH and in people without HIV, suggesting that these general population-derived genetic scores are transferable to PWH. Future studies should focus on refining PRS models in diverse populations and exploring genetic factors specific to PWH regarding T2D risk.

Background:Availability of the hepatitis B virus (HBV) vaccine in the United States since 1982 and recommendations for universal/catch-up vaccination of infants and children since the 1990s may be associated with lower HBV prevalence among people with human immunodeficiency virus (HIV; PWH) born after 1980. Methods:Active HBV infection prevalence, defined as the proportion of patients with a positive hepatitis B surface antigen result, was assessed among PWH at entry into a clinical cohort. Patients were categorized into birth-year cohorts of 1940-1959, 1960-1979, or 1980-1999 and then further dichotomized into pre- and post-1980 birth-year cohorts. Log binomial regression was used to assess the association of birth-year cohort with hepatitis B surface antigen positivity, adjusting for race/ethnicity, HIV infection risk factor, baseline HIV viral load and CD4+ cell count, HBV active therapy, and year of/age at cohort entry. Results:Among 5598 PWH, most were male (67%) and Black (77%), with a mean age (SD) of 39.7 (9.6) years at cohort entry. Approximately a third of the participants (30%) identified as men who have sex with men, and 39% reported a history of injection drug use. At cohort entry, the majority had a CD4+ cell count <350/µL and a viral load >1000 copies/mL. The HBV prevalence was 6.7% overall but varied by birth-year cohort: 6.2% for 1940-1959, 7.9% for 1960-1979, and 2.6% for 1980-1999. The risk of HBV infection was lower in the post-1980 than in the pre-1980 cohort (adjusted prevalence ratio, 0.19 [95% confidence interval, .09- .42]). Conclusions:PWH born after 1980 had a lower prevalence of HBV coinfection than those born before 1980, supporting the potential impact of universal childhood HBV vaccination.

BACKGROUND:Depression is a common psychiatric condition and an independent stroke risk factor among people with HIV (PWH). The impacts of depressive symptom severity on stroke are not clear in PWH. METHODS:We studied adult PWH in clinical care at 5 Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) sites with ≥1 assessment for depressive symptoms (Patient Health Questionnaire-9) from 2010 to 2022. We used Cox models to evaluate (1) associations between time-varying depressive symptom severity and adjudicated incident stroke, serially adjusted for clinical factors and (2) modification of this association by age and sex. Participants were followed from 6 months after first CNICS visit or date the CNICS site began stroke adjudication (baseline) (whichever later) until the first stroke, death, loss to follow-up, last clinic visit, or study end. RESULTS:Among 13,817 PWH (mean age 45 years, 19% women, 58% non-White race/ethnicity), 23% screened positive for depression at baseline and 173 had an incident stroke during follow-up (mean follow-up 7.6 years). Time-varying depressive symptom severity (per 5 points Patient Health Questionnaire-9 score) was associated with higher stroke risk (adjusted Hazard Ratio 1.16, P = 0.01) with greater impact in PWH <50 years than ≥50 years (interaction P = 0.02) but no significant difference by sex. Adjusting for combinations of sociodemographic, cardiovascular, HIV, and substance use factors only slightly attenuated estimates. CONCLUSIONS:Depressive symptom severity was an independent risk factor for stroke with higher severity depressive symptoms predicting higher stroke risk and greater impact in PWH <50 years. Depression may be a modifiable risk factor for stroke and should be studied further to understand, develop, and target interventions to reduce stroke risk, especially in younger PWH.

Objective:To estimate the effect of antidepressant initiation on viral nonsuppression among people with HIV (PWH) with clinically recognized, untreated depression. Design:Retrospective, observational cohort study. Methods:We included clinical diagnoses of depression from January 2012 to June 2022 among PWH in the Johns Hopkins HIV Clinical Cohort without another serious psychiatric illness who had initiated antiretroviral therapy. We excluded diagnoses less than 90 days from a prior diagnosis, antidepressant prescription, or greater than one mental health visits. We estimated the association between initiating an antidepressant within 1 month of the index depression diagnosis and viral load nonsuppression (>200 copies/ml) on the first viral load 3-12 months subsequent. We adjusted for a comprehensive set of demographic and clinical confounders. Results:We included 2346 depression diagnoses among 946 patients; patients initiated an antidepressant following 16%. The risk of viral nonsuppression in the absence of antidepressant treatment was 15.6% [95% confidence interval (CI): 13.1-18.4]. Antidepressant initiation was not associated with viral nonsuppression (risk difference: 0.5%; 95% CI: -3.7 to 4.8) or secondary outcomes: improvement or resolution of depressive symptoms or adherence to scheduled clinic visits. Conclusion:In this sample of patients with as-yet-untreated depression, in a setting with co-located, low-barrier psychiatric services, antidepressant treatment was not associated with improved viral suppression. Pharmacologic management of depression has documented benefits in other studies. However, there may be a subset of PWH with depression who have been previously unsuccessfully treated with antidepressants who are less likely to respond to approved pharmacologic options and who require different interventions to improve their viral suppression.

Abstract Background Due to shared modes of transmission, people with HIV (PWH) have disproportionately high rates of hepatitis B virus (HBV) infection. Availability of the HBV vaccine in the US since 1982 and recommendations for universal and catch-up vaccination of infants and children since the 1990s may be associated with lower HBV prevalence among PWH born after 1980. To study how HBV vaccination availability impacted co-infection rates in PWH, we compared the prevalence of active HBV infection at entry into an HIV cohort by birth year groups.Table 1.Baseline characteristics of patients by birth cohort Methods We included PWH from the Johns Hopkins HIV Clinical Cohort who had HBsAg testing within one year of cohort entry. HBV infection was defined as a positive HBsAg test. Patients were categorized into birth cohorts of 1940-1959, 1960-1979 and 1980-1999 and then further dichotomized to pre- and post-1980 cohorts. Descriptive statistics were used to assess HBsAg prevalence by birth cohort and HIV infection risk factors [men who have sex with men (MSM) and injection drug use (IDU)]. Log binomial regression was used to assess the association of birth cohort (pre-1980 vs post-1980) with HBsAg positivity adjusting for race/ethnicity, HIV infection risk factors (MSM, IDU), baseline viral load, and year of and age at cohort entry.Figure 1.Timeline of HBV vaccination recommendations by the Advisory Committee of Immunization Practices and the corresponding age of patients in pre- and post-1980 birth cohort Results Of the 5608 PWH enrolled in the cohort between 1993 and 2023, 77% were Black, 30% were MSM, and 39% had a history of IDU. Mean age at cohort entry was 39.6 (9.6). Overall HBV prevalence was 6.7% and prevalence by birth cohort was 6.2% (1940-1959), 7.8% (1960-1979) and 2.5% (1980-1999). Among MSM, HBV prevalence was higher at 10.6% (1940-1959), 11.4% (1960-1979) and 2.9% (1980-1999) compared to non-MSM at 5.0% (1940-1959), 6.3% (1960-1979) and 1.8% (1980-1999). HBV prevalence was similar in IDU and non-IDU groups. The risk of HBV infection was significantly lower in the post-1980 birth cohort vs the pre-1980 birth cohort (adjusted RR= 0.17; 95% CI 0.08, 0.34; adjusted RD= -0.06; 95% CI -0.07, -0.04). Conclusion PWH born after 1980 had a lower risk of HBV co-infection than PWH born before 1980, highlighting the potential impact of HBV vaccination on HBV prevalence in PWH. PWH identifying as MSM continue to have disproportionately high HBV prevalence. Additional efforts are needed to implement universal HBV vaccination of adults as recommended in 2021. Disclosures Mark S. Sulkowski, MD, AbbVie: Advisor/Consultant|Aligos Therapeutics: Advisor/Consultant|Gilead: Advisor/Consultant|GSK: Advisor/Consultant|GSK: Grant/Research Support|Janssen: Grant/Research Support|Precision Biosciences: Advisor/Consultant|Vir: Grant/Research Support|Virion: Advisor/Consultant Oluwaseun Falade-Nwulia, MBBS ,MPH, Abbvie Inc: Grant/Research Support|Gilead Sciences: Advisor/Consultant