AIDS and Behavior

BackgroundAdolescents with perinatally acquired HIV in India experience a high burden of stigma and mental health distress alongside gendered social constraints that limit participation in supportive programs. While physical activity-based psychosocial interventions show promise for improving adolescent mental health, little is known about how gender norms and intersecting vulnerabilities shape engagement and outcomes among this population. This study examined gender-specific patterns of participation and associations with mental health in a peer-led running intervention in southern India using intersectionality and self-determination theory. MethodsWe conducted a convergent parallel mixed-methods evaluation between March-April 2024 among 150 adolescents and young adults with perinatally acquired HIV enrolled in a physical activity intervention (Positive Running) in Karnataka and Tamil Nadu. Surveys assessed sociodemographic characteristics, viral suppression, intervention adherence, and common mental health disorders using validated screening tools for depression (PHQ-9) and anxiety (GAD-7). Gender-disaggregated comparisons used Fishers exact tests, and logistic regression estimated prevalence odds ratios for common mental health disorders by intervention adherence. Qualitative data included four age- and gender-stratified focus group discussions (n=28) with participants, and four in-depth interviews with peer implementers. Transcripts were thematically analyzed using grounded theory and Braun & Clarkes framework. ResultsAmong 150 participants (100 males, 50 females; median age 17 years [IQR 15-19]), 91% were virally suppressed. Mean adherence to the intervention was 64%, with high attendance ([&ge;]65%) significantly lower among females than males (20% vs 57%, p<0.001). Overall, 59% screened positive for at least one common mental health disorder; with higher prevalence among females than males for depression (66% vs 43%, p=0.009), and for any mental health condition (72% vs 52%, p=0.022). Higher intervention adherence was associated with lower odds of common mental disorder overall (OR 0.44, 95% CI 0.23-0.85). In age-adjusted, gender-stratified analyses, this association was significant among males (aOR 0.33, 95% CI 0.14-0.75) but not among females. Qualitative findings identified gendered barriers to participation, including restrictive norms, modesty expectations, stigma toward women in sport, and limited decision-making autonomy. Self-determination theory-informed analyses highlighted how structured training, peer mentorship, and visible female role models supported autonomy, competence, and relatedness, while also revealing constraints that attenuated mental health gains for girls. ConclusionsPeer-led, community-embedded physical activity interventions are feasible among adolescents and young adults with perinatally acquired HIV and may confer mental health benefits, though participation effects are gender-differentiated. Findings underscore the need for gender-responsive, autonomy-supportive program designs that address intersectional vulnerabilities to ensure equitable mental health impact, particularly for adolescent girls and young women.

BackgroundDepression and anxiety have been associated with increased risk of myocardial infarction (MI) in the general population and among people with HIV (PWH) but with limited attention to MI type. We examined the association between depression and/or anxiety and incident Type 1 (T1MI) or Type 2 (T2MI) MI among PWH. MethodsWe examined data from seven NA-ACCORD clinical cohorts (1997-2019) with adjudicated first MI; outcomes included T1MI (plaque rupture or cardiac intervention) or T2MI (demand ischemia). We defined depression or anxiety as a time-varying ICD-9/10-coded diagnosis prior to incident MI. We censored participants at death, disengagement from care, or first MI (if not the outcome of interest). We used Cox proportional hazard models to estimate the association between depression or anxiety and MI by type, adjusting for demographics and risk factors for MI. ResultsOf the 32,358 study participants, 13,751 (42.5%) had a depression diagnosis, 9,132 (28.2%) had an anxiety diagnosis, and 15,970 (47.3%) never had diagnosed depression or anxiety. After adjusting for MI risk factors, depression was associated with T1MI (aHR, 1.22 [95% CI, 1.00-1.48]), and anxiety had a protective association (albeit not statistically significant) with T1MI (aHR, 0.86 [95% CI, 0.70-1.07]). Depression had a null association (aHR, 1.05 [95% CI, 0.83-1.33] with T2MI, and anxiety was non-significantly associated with T2MI (aHR, 1.16 [95% CI, 0.89-1.51]). ConclusionsDiagnosed depression was associated with T1MI but not T2MI, whereas anxiety was not statistically significantly associated with either MI type. Mental health diagnosis and treatment may play an important role in cardiovascular health among PWH.

HIV treatment can suppress viral load and prevent transmission between sex partners, a strategy known as treatment as prevention (TasP). TasP is key for ending the HIV epidemic, and it is important to understand its adoption among priority populations. We examined the TasP adoption cascade using cross-sectional survey data from 1443 U.S. men and transgender, gender-nonconforming, and nonbinary individuals who reported having sex with men. Most participants (82.4%; n = 1189/1443) reported prior awareness of TasP, but only 52.6% of them (n = 625/1189) perceived it as effective at preventing HIV transmission. Of those, 83.8% (n = 524/625) indicated being willing to rely on TasP, among whom 30.2% (n = 158/524) reported having recently done so. Among participants aware of TasP, we compared those who perceived it as effective to those who did not. Participants who did not have HIV and never used PrEP were less likely to agree with TasPs effectiveness than those who had used PrEP or had HIV. Those who had learned about TasP from a sex partner or who had a partner of different HIV status were more likely to perceive it as effective. TasP promotion appears to have achieved broad awareness, but future efforts should aim at increasing the understanding of its effectiveness, especially among those not connected to HIV-related services, organizations, or communities. Public Health SignificanceTasP is an important tool to end the HIV epidemic. Examining stages of its adoption can inform tailored promotion among priority populations. In our study, many participants were aware of TasP, but fewer perceived it as effective. Monitoring uptake over time will allow for responsive promotion strategies as attitudes continue to evolve.

BackgroundAngiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are established antihypertensive treatments that reduce cardiovascular disease (CVD) risk. However, their comparative effectiveness in people with HIV (PWH) is not well examined. This study evaluated the comparative effectiveness of ACEIs and ARBs head-to-head and versus no antihypertensive treatment in preventing primary CVD. MethodsUsing a target trial emulation framework and data from the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD), we estimated observational analogs of intention-to-treat (ITT) and per-protocol (PP) effects of antihypertensive treatments in preventing primary CVD (myocardial infarction, non-MI coronary artery disease, stroke, transient ischemic attack, peripheral vascular disease, cardiovascular death) among hypertensive PWH, with subgroup analyses for Black and White PWH. ResultsCompared with no antihypertensive treatment, ACEIs and ARBs were both associated with lower CVD risk in PWH, with similar effect sizes in ITT and PP analyses (ACEI ITT adjusted hazard ratio (HR): 0.79, 95% CI [0.70-0.89]; ACEI PP: 0.71 [0.55-0.90]; ARB ITT: 0.87 [0.65-1.16]; ARB PP: 0.37 [0.18-0.76]). Race-stratified ITT and PP analyses suggested somewhat greater risk reductions in White than Black PWH, although differences were not statistically significant. In head-to-head comparisons, ACEIs and ARBs showed comparable effectiveness overall (ITT: 1.14 [0.84-1.55]; PP: 0.54 [0.25-1.18]), and within race strata. ConclusionsOur study found that both ACEIs and ARBs were effective in reducing CVD risk among PWH, with similar effectiveness observed for both medications. The analysis did not reveal statistically significant differences in effectiveness between Black and White PWH for either drug.

IntroductionDespite improvements in treatment for people living with HIV (PWH), adherence remains a challenge for many. In this study we aimed to identify preferences for daily pill or long-acting injectable (LAI) antiretroviral therapy (ART) and for possible treatment package features, among PWH enrolled in Ryan White HIV/AIDS Program Part A (RWPA) Medical Case Management (MCM) programs. MethodsParticipants were recruited from six MCM programs from across the New York RWPA eligible metropolitan area (the five boroughs of New York City and Rockland, Putman, and Westchester counties). We developed a discrete choice experiment (DCE) with four attributes: (1) Type of ART Medication (daily pills or LAI), (2) Service Location and Mode, (3) Support, and (4) Rewards. We used an alternative-specific design in which the levels for the last three attributes were dependent on levels within the first (Type of ART). Latent class multinomial logit analysis (LCA) was used for preference estimation and hypothesis-free investigation of preference heterogeneity. ResultsFrom June 2022 through January 2023, 200 New York RWPA MCM clients completed the DCE. We selected a two-group LCA solution. A majority of participants had a higher preference for LAI regimens compared to daily pills (n=114 [57%] versus n=86 [43%]). Those who preferred LAI ART were younger (median age 49 versus 58.5 years, p<0.001), less likely to identify as straight/heterosexual (69% versus 82%, p=0.03), and more likely to identify as Latino/a (54% versus 30%; p<0.001). Preferences for service locations/mode, supports, and rewards were similar across LCA groups. Participants who preferred LAI ART were more likely to have heard of LAI ART before the survey (59% versus 41%, p=0.012). Overall, only 4% of participants self-reported having tried LAI ART. ConclusionsAssessing preferences among groups under-represented in clinical trials is essential to effective and equitable real-world implementation of innovative treatment options. Our study found that there were distinct groups that differed in their preferred ART regimen type and that New York RWPA MCM clients had limited familiarity with LAI ART. To inform regimen selection, we began pilot-testing educational materials and a patient-provider decision-making tool in 2023.

BackgroundPre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy, yet uptake remains suboptimal and ensuring access to PrEP services among young people is critical. We explored the barriers and facilitators associated with accessing PrEP among young people MethodsFocus group discussions (FGDs) were conducted in April and May 2023 in the City of Johannesburg district in South Africa. Participants were adult males and females (ages 18-35) self-reporting as HIV negative with or without previous PrEP use and exposure. We analysed transcripts using a deductive and inductive thematic approach. Two transcripts were coded by three coders to test reliability and saturation was reached when no new themes emerged. ResultsFindings were mapped to the Socio-Ecological Model (SEM). Key barriers emerged across levels. Individual level barriers included difficulty adhering to daily oral PrEP and fear of needles. Interpersonal challenges included anxiety about disclosing PrEP use to partners or family. Institutional and organisational barriers involved long clinic queues, negative staff attitudes, limited confidentiality and inadequate PrEP information. At the community level, stigma and misconceptions linking PrEP to HIV treatment deterred uptake. Several facilitators emerged. Individual motivation to remain HIV negative was a strong driver of uptake. Supportive relationships and open communication with friends and family enhanced acceptance. Organisational enablers included access to clear information, youth-friendly services, competent providers and delivery options such as home delivery or pharmacy access. Community awareness initiatives reduced stigma and structural support in a form of free PrEP improved affordability and access. ConclusionYoung peoples access to PrEP is shaped by interactions across individual, relational, institutional, community, and structural levels. Tailored interventions that address personal barriers, strengthen supportive environments, improve service delivery, and ensure affordability are likely to strengthen uptake and adherence. These findings highlight the need for multilevel strategies to optimize PrEP implementation among youth.

IntroductionFor differentiated models of care (DMOCs) that support client-centred HIV treatment (ART) in South Africa, a key next step in achieving integration is aligning clinic visits and medication dispensing for HIV treatment with other health needs like family planning. We assessed alignment between ART medication and family planning supply collection visits among DMOCs in South Africa. MethodsWe analysed self-reported data collected between September-December 2024 from women living with HIV (18-49 years, on ART [&ge;]6 months) at 24 public healthcare facilities in four provinces (Gauteng, Mpumalanga, KwaZulu-Natal, and Eastern Cape). Participants were enrolled from four service delivery models: conventional care not eligible for DMOC (CN), conventional care eligible for DMOC but not enrolled (CE), facility pickup points (FAC-PuP), and external pickup points (EXT-PuP). Surveys assessed contraceptive use, visit alignment for injectable (Depo-Provera & Nur-Isterate) and oral contraceptive users, and how misaligned visits affected family planning adherence. ResultsAmong 843 eligible women, 57% (460/843) reported current contraception use, with Depo-Provera being the most common (44%). Contraceptives users were younger (median 35 vs 38 years) and had slightly less ART experience (median 7 vs 8 years) than non-users. Contraceptive use varied by DMOC: CN (52%), CE (60%), FAC-PuP (63%), and EXT-PuP (50%). Half (131/260) of women using oral contraceptives or injectables collected their contraceptive and ART products on different days, with EXT-PuP showing the lowest level of alignment. Primary reasons for non-use were personal choice and beliefs (38%), followed by pregnancy-related factors (26%). Analysis of unmet family planning need in a subsample of 299 women found 22% had unmet need. ConclusionThe findings reveal a high proportion of misalignment between ART and family planning services across models of care. Aligning ART and family-planning guidelines and services will promote ART and contraceptive adherence and reduce the burden on clients, maintaining the benefits of differentiated models and promoting integration of multi-condition service delivery.

BackgroundFemale sex workers (FSW) are a key population for HIV prevention and care. Increasing evidence suggests that social and structural barriers are key drivers of HIV transmission. This global systematic review assesses whether experiencing violence is associated with worse HIV outcomes among FSW. Methods and FindingsWe searched MEDLINE, Embase, and PsycINFO databases for studies published from January 1st, 2010 to February 10th, 2025 assessing the impact of violence on HIV outcomes among FSW, without restriction to language and study design. Some studies had multiple estimates due to reporting on multiple outcomes or exposures of interest. We pooled data from eligible studies using multi-level random-effects meta-analyses to quantify associations between recent (past year) or lifetime exposure to violence (physical, sexual, emotional/psychological and/or financial) and HIV outcomes (prevalent and incident HIV infection, HIV testing, ART use, ART adherence, and viral suppression) among FSW. We preferentially used adjusted estimates over unadjusted estimates if both were available. We included 91 studies with 221 estimates, comprising 179,727 FSWs in 37 countries. We found higher odds of prevalent HIV infection among FSWs with recent (pooled odds ratio (pOR):1.33; 95%CI:1.17-1.51; I2:64%; n=73 estimates) and lifetime (pOR:1.36; 95%CI:1.24-1.49; I2:38%; n=67) experiences of violence. Recently experiencing violence was associated with reduced odds of ART use (pOR:0.78; 95%CI:0.64-0.94; I2:8%; n=17). Lifetime exposure to violence was associated with reduced odds of viral suppression (pOR:0.88; 95%CI:0.79-0.98; I2:20%; n=6). There was no evidence of associations between violence and HIV incidence, HIV testing and ART adherence. ConclusionsExperiencing violence may increase HIV transmission risk and worsen HIV treatment outcomes among FSW. HIV interventions for FSWs must address violence as a structural determinant of HIV.

BackgroundLoss to follow-up (LTFU) undermines the success of antiretroviral therapy (ART) programs, especially in high HIV prevalence regions like Njombe, Tanzania. Understanding factors influencing LTFU is critical to enhance patient retention. AimTo assess the prevalence and predictors of LTFU among people living with HIV (PLHIV) receiving ART in Njombe, Tanzania, from 2017 to 2021 MethodsWe conducted a retrospective cohort study using the National Care and Treatment Clinic (CTC2) database, defining LTFU as absence from care for 180 days or more. Logistic regression identified factors associated with LTFU. Data were cleaned using Microsoft Excel and analyzed using IBM SPSS Statistics version 26. Descriptive statistics were used to summarize demographic and clinical characteristics, and logistic regression was used to identify independent predictors of LTFU ResultsOf the 37,642 PLHIV initiated on ART, 13,411 (35.6%) were LTFU during the five-year study period. The highest annual incidence of LTFU occurred in 2020 (n = 4,069), coinciding with the onset of the COVID-19 pandemic. District-level disparities were substantial: Wangingombe recorded the highest disengagement prevalence (46.7%), while Makete recorded the lowest (23.7%). Multivariable analysis revealed that gender and age were not independent predictors of attrition (p > 0.05). However, significant associations with LTFU were observed for lower pharmacy refill adherence, marital status (single and divorced), and district of residence. Notably, patients in Wangingombe had more than double the odds of LTFU compared to those in Njombe (AOR 2.09; 95% CI: 1.95-2.24), whereas the 2021 initiation cohort demonstrated a significantly lower risk of disengagement (AOR 0.25; 95% CI: 0.22-0.28). ConclusionLTFU remains a critical challenge in the Njombe Region. Targeted interventions, including strengthened pharmacy refill monitoring, district-specific strategies, and psychosocial support for PLHIV, are essential to improve retention and sustain progress toward national HIV treatment goals.

BackgroundHIV exposed infants (HEIs) are at a higher risk of infant mortality compared to their counterparts who are not HIV exposed. Early Infant Diagnosis (EID) is the critical first step in reducing HIV-related infant mortality through prompt identification of HIV-infected infants and subsequent initiation of antiretroviral therapy. However, there is limited information on Uptake of EID and factors associated with its timely completion among HIV exposed infants. Therefore, this study aimed at determining the uptake of EID and factors associated with its timely completion among HIV exposed infants at Lira Regional Referral Hospital (LRRH). MethodsThe study was a retrospective cohort of 252 HEIs born in the period of 1st January 2021 to 31st December 2021 chosen through consecutive sampling. Data abstraction tools were used to collect data on uptake of 1st, 2nd, 3rd DNA-PCR and final rapid test from mother-baby pair files and EID register. The main outcome was Uptake of EID and classified as timely and untimely according to the PMTCT guideline. Data was analyzed using descriptive statistics and generalized estimating equations (GEE) with poisson family, log link and unstructured correlation structure. ResultsThe timely uptake of EID among HIV exposed infants at 4-6 weeks, 9 months, 6 weeks after cessation of breastfeeding and 18 months were 80.1% (95% CI:74.5-84.7), 84.2% (95% CI:79.0-88.3), 3.7% (95% CI:2.0-7.0) and 78.8% (95% CI:73.2-83.6) respectively. Having cotrimoxazole given was associated with timely completion of EID [aRR=2.974, 95% CI (1.45-6.10)] ConclusionUptake of EID among HEIs was sub-optimal, below the Ministry of Healths 90% target. Timely cotrimoxazole administration was associated with EID completion,

BackgroundRetention in HIV care is associated with higher rates of antiretroviral treatment adherence and viral suppression, as well as lower risk of AIDS-related morbidity and mortality. However, the multidimensional nature of retention complicates measurement standardization, limiting comparability and global evaluation. This study explored how HIV stakeholders define and assess retention, aiming to develop a patient-centred and conceptually robust understanding to inform research and practice. MethodsWe conducted a qualitative study using Interpretive Description (ID) methodology, an applied qualitative approach designed to generate practice-relevant knowledge in health research. We purposively sampled 20 stakeholders representing diverse areas of expertise and geographic regions across World Bank country income classifications. We conducted, video-recorded, and transcribed in-depth, semi-structured interviews. Using constant comparative analysis (CCA), we identified recurring, convergent, and contradictory patterns. ResultsThe analysis identified five overarching themes. The first two, exploratory themes, included: Patient-Centred Understanding of Retention in HIV Care, which captured how stakeholders conceptualized retention in their respective contexts, and Operationalization of Retention Measures, which explored the key components used to measure retention. The next two, explanatory themes, included Purpose-Driven Definitions of Retention, which described how retention measures were selected based on their intended use; and Building Capacity through Shared Understanding and Integrated Action, which emphasized retention as a cyclical, interconnected process dependent on collaboration between patients and health systems. The final, prescriptive theme, Advancements Shaping Retention, reflected stakeholders shared vision of improving retention through innovations in HIV treatment and technology. ConclusionsThe findings suggest that stakeholders operationalize retention measures in line with specific objectives and individual health goals, while remaining attentive to contextual realities. Retention measures should remain flexible and patient-centred, rather than relying on a single rigid standard.

COVID-19 disrupted global health service delivery, particularly among children and adolescents living with HIV (CALHIV), increasing the risk of poor treatment adherence. This study assessed the impact of the COVID-19 pandemic on WHO-recommended early warning indicators (EWIs) of HIV drug resistance (HIVDR) among CALHIV. We conducted a descriptive, longitudinal, retrospective study among children (0-9 years) and adolescents (10-19 years) receiving antiretroviral therapy (ART) in five health facilities in the Littoral region of Cameroon. Seven EWIs were monitored: ART attrition, viral load (VL) suppression, VL coverage, appropriate second VL, ARV medicine stock-outs, antiretroviral drug refills at the pharmacy, and appropriate switch to second-line ART. EWI were collected from January 2018 to December 2021 and classified as "poor," "fair," or "desirable" according to WHO criteria. Trend analyses were performed using Pearsons Chi-squared test with Yates correction in R (version 4.1.1). In 2021, 817 participants were included, comprising 214 children and 603 adolescents. Overall performance was poor for most EWIs in both age groups, except for ART attrition and VL coverage, which showed desirable performance across years. A slight improvement in most indicators was observed between 2018 and 2019, followed by a significant decline in 2020 (p<0.001), coinciding with strict COVID-19 restrictions, and a subsequent improvement in 2021 (p<0.01) as mitigation measures were eased. Despite this recovery, children consistently experienced worse outcomes, including higher ART attrition (9.4% vs 4.4%, p<0.05), lower VL suppression (75.3% vs 82.1%, p<0.05), and poorer access to confirmatory VL testing (15.1% vs 69.5%, p<0.001). Overall, the COVID-19 pandemic negatively affected HIV service delivery during its early phase, although the health system demonstrated adaptive capacity one year later. Targeted public health actions are therefore needed to prevent their long-term effects and improve treatment outcomes in this vulnerable population, especially among children.

BackgroundAchieving optimal adherence and retention in HIV care is essential for sustaining viral suppression. Pharmacy refill records offer an objective approach to assessing adherence in settings where routine viral load testing is limited. This study evaluated pharmacy refill adherence, loss to follow-up (LTFU), and their predictors among people living with HIV (PLHIV) in the Manyara region of Tanzania. MethodsWe conducted a retrospective cohort analysis of 22,650 PLHIV across five districts using the National CTC-2 database. LTFU was defined as no clinic visit for 180 days or more. We also analyzed a cross-sectional final status field updated by health trackers to distinguish research-defined LTFU from confirmed clinical outcomes. Predictors were evaluated using multivariable logistic regression, and spatial mapping identified geographic disparities. ResultsThe mean pharmacy refill adherence was 84.1%, with 57.9% achieving good adherence (>=85%). In the longitudinal analysis, 32.8% of patients met the research definition for LTFU (>=180-day absence) at some point during the study period. Cumulative LTFU was significantly higher in earlier initiation cohorts (2017-2019) compared to the 2021 cohort (aOR 1.89; 95% CI 1.76-2.02). However, cross-sectional system records, which health trackers update, showed that only 2.9% remained truly lost to care; 65.3% were active at their original clinic, 23.1% had eventually transferred to other facilities, and 6.7% were deceased. In multivariable regression, poor pharmacy adherence was the strongest behavioral predictor of disengagement (aOR 2.04; 95% CI 1.77-2.35). Significant geographic variation was observed, with residence in Simanjiro independently associated with the highest odds of LTFU (aOR 3.60; 95% CI 2.67-4.85). Spatial mapping confirmed a clustering of poor outcomes in districts characterized by nomadic pastoralist livelihoods. ConclusionPharmacy refill adherence is a potent predictor of disengagement and a practical early-warning indicator. The high rate of silent transfers and district-level disparities, particularly in nomadic hotspots, highlight the need for a national unique patient identifier and mobility-friendly retention strategies. Integrating automated refill alerts into the 90-day tracking window is essential to achieve 95-95-95 targets.

BackgroundHIV-related stigma among healthcare providers hinders service delivery and patient engagement, especially in low- and middle-income countries. The Intervensi Penghapusan Stigma dan Diskriminasi (IPSD) intervention employs a Community-Based Participatory Approach (CBPA) to reduce stigma among healthcare workers (HCWs) in Indonesia by involving people with HIV (PWH) and key populations (KP) as co-developers and co-implementers. MethodsThis cross-sectional study evaluated the implementation outcomes of adoption and fidelity, as defined by Proctor et al., using a validated 5-point Likert scale survey developed based on the Consolidated Framework for Implementation Research (CFIR) and Proctor et al. framework. A total of 120 physicians, nurses, midwives, and laboratory technicians from 31 primary health centres (PHCs) in Greater Jakarta participated in the survey. PHCs were categorised as either high- or average-performing based on triangulated data from PWH networks and evaluations by the Ministry of Health. Descriptive statistics and bivariate analyses, including chi-square and t-tests, were conducted at a significance level of p < 0.05. ResultsSignificant association was found between occupational role and PHC performance (p=0.012). High-performing PHCs reported stronger technical expertise (p=0.033) and better HIV/STI epidemiological knowledge (p=0.033). Organisational incentives influenced fidelity (p=0.032), with higher-performing PHCs reporting greater institutional support. ConclusionFindings underscore the need to reduce stigma through equitable services and supportive organisational climates. Agreement across PHCs showed shared recognition of involving PWH and KP as co-implementers and facilitated intervention adoption, aligning with evidence for contact-based stigma reduction. Differences between PHCs were shaped by capacity and knowledge, with higher-performing facilities showing stronger intervention fidelity. Organisational incentives facilitated sustained fidelity, while national mandates ensured adoption. By examining CFIR constructs and Proctor outcomes, this study informs scalable stigma reduction in primary healthcare. Limitations include small sample size, limited scope, self-reported data, and cross-sectional design, precluding multivariable modelling, making findings exploratory.

BackgroundAdolescent girls and young women (AGYW) are disproportionately vulnerable to HIV. Despite expanded HIV testing services (HTS), the majority of AGYW remain unaware of their HIV status. This study aimed to assess determinants of HIV testing uptake among AGYW in mainland Tanzania before and after stratifying by age group (15-19 and 20-24 years) using data from three national surveys conducted over time. MethodologyA cross-sectional secondary data analysis was conducted using data from the Tanzania HIV Impact Surveys (2016/17 and 2022/23), obtained from the Population-based HIV Impact Assessment on 23/04/2025. Data analysis was performed using STATA version 17. Modified Poisson regression models were used to identify factors associated with HIV testing uptake before and after stratifying by age group (15-19 and 20-24 years). Results were presented using the adjusted prevalence ratio (APR) with a 95% confidence interval. ResultsHIV testing uptake among adolescents remained 40% in the years 2016/17 and 2022/23, while it increased from 86% to 90% among young women, respectively. Key factors consistently associated with higher prevalence of HIV testing uptake included being in a union, cohabiting, or formerly married; having secondary or higher education levels; and a history of sexually transmitted infections (STIs). ConclusionHIV testing uptake among AGYW in Tanzania has improved over time, with significant disparities between adolescents and young women. These findings highlight the need for age-specific strategies, intensifying adolescent-focused interventions while sustaining efforts among young women and reinforcing integrated reproductive health and HIV services.

Because of its recent regulatory approval in southern and eastern Africa, CAB PrEP represents a scientific advancement with unknown implementation costs in most African countries. To our knowledge, this paper is the first study comparing PrEP costs in health facilities where clients had a choice between three PrEP methods. We collected and analyzed the direct service delivery costs for each method using the same costing approach and assumptions at three facilities in Lesotho and six facilities in Zimbabwe. On average, in Lesotho, the direct costs of providing CAB PrEP were $57.22 for an initiation visit and $54.20 for a refill visit (same PrEP product dose dispensed in both visit types), while the direct costs of oral PrEP were $22.47 (initiation visit with one month of PrEP dispensed) and $31.98 (refill visit dispensing a three-month dose of medication), and the direct costs of the dapivirine ring were $34.27 (initiation visit with one month of PrEP dispensed) and $50.70 (refill visit dispensing a three-month supply). In Zimbabwe, the average per-visit direct costs to provide CAB PrEP were $48.26 (initiation visit) and $47.40 (refill visit), to provide oral PrEP were $13.47 (initiation visit with one month of PrEP dispensed) and $21.78 (refill visit dispensing a three-month dose), and to provide the dapivirine ring were $42.56 (refill visit dispensing a three-month supply). Initiation visits for the dapivirine ring were not observed in Zimbabwe. At a time when national governments are creating budgets for the HIV response with decreased financial support from bilateral and multilateral partners, this paper will inform HIV prevention planning by providing critical client-level data from the healthcare provider perspective.

BackgroundChildren who are HIV-exposed uninfected (HEU) show greater morbidity and mortality than HIV-unexposed children (HUU). In this study we investigate sex differences in growth, infection rates and antibody response among HEU and HUU infants. MethodsThe study enrolled 107 pregnant women with HIV and 103 pregnant women without HIV with follow-up of their infants from birth to 12 months of age. Study measures assessed included growth parameters, the prevalence of children with overt disease symptoms as reported by the mother, PCR-based assessment of infections (cytomegalovirus (CMV), respiratory syncytial virus (RSV), rhinovirus, influenza A & B, rotavirus and malaria) as well as antibody profile to CMV, RSV and enterovirus infections. ResultsCompared to male HUU, male HEU infants had lower Height-for-age-z-scores ({beta} -0.75; P=0.047) in mixed-effect model accounting for age. Additionally, they showed transiently lower Weight-for-age-z-scores at 3 months (1.07 vs 0.05, P=0.04), with higher risk of rhinorrhea (RR=2.29, P=0.02) and lower enterovirus titers at birth (P=0.0066). Female HEU showed transiently higher stunting at 6 months (0% vs 21%; P=0.01) and lower CMV viremia at 6 months, with elevated CMV antibody titers at 3 months (P=0.04) compared to female HUU. With prevalence ranging from 25%-61%, CMV and Rhinovirus infections were dominant in all groups. HEU and HUU exhibited similar antibody decay and acquisition patterns for CMV, RSV, and Enterovirus across both sexes. ConclusionHEU infants show transient sex-based differences in growth, infection and immune profiles raising the relevance for considering sex as a key parameter to assess infant health.

ObjectiveTo quantify trends in annual mean healthcare costs per person living with HIV from 2003 to 2018 from a publicly funded healthcare system perspective. DesignWe conducted a retrospective population-based study using administrative health data in Ontario, Canada, including 25,842 people living with HIV diagnosed and entering care between 1992 and 2018. A nested cohort from the Ontario HIV Treatment Network Cohort Study (n=3,516) provided additional HIV-related characteristics. MethodsAnnual mean healthcare costs per person were estimated using a validated costing algorithm and inflated to 2025 Canadian dollars. Trends were examined overall and stratified by sociodemographic factors (age, sex, rurality, neighbourhood income, immigration status) and year of entry into HIV care. Within the nested cohort, trends were stratified by nadir CD4 count and any antiretroviral therapy use since diagnosis. ResultsAnnual mean cost per person increased from $11,963 in 2003 to $16,721 in 2018. Medication costs remained the largest cost component throughout (47.4-61.7%) and closely mirrored overall trends. Higher annual mean costs were consistently observed among individuals diagnosed at older ages, lower-income neighbourhood residents, long-term Ontario residents (Canadian-born or immigrated before 1985), and individuals with nadir CD4<200cells/{micro}L. ConclusionMedication expenditures continue to drive healthcare costs for people living with HIV. Cost containing strategies, including expanded generic substitution and strengthened price negotiation, may reduce costs without compromising outcomes. Persistent cost disparities highlight the need to address delayed treatment initiation and broader social determinants shaping HIV treatment access and sustained engagement in care.

BackgroundSix multi-month dispensing (6MMD) of antiretroviral therapy (ART) for HIV treatment clients has expanded rapidly in the past decade, but its effect on individual outcomes in routine (non-trial) care is still poorly documented and based on observational programmatic data. Malawi launched 6MMD in April 2019 and scaled-up implementation in 2020. We compared retention in care for clients who received 6MMD to those who did not using a target trial emulation (TTE) approach to minimize bias. MethodsWe used routine clinical data from Malawis Electronic Medical Record (EMR) system to identify ART clients eligible for 6MMD in 27 districts from 01/2020-12/2021. Eligible participants were non-pregnant adults ([&ge;]18 years), on ART for [&ge;]6 months, clinically stable as evidenced by a dispensing duration of 3 months (3MMD), and with no prior 6MMD exposure. We created four six-month trials, defined eligibility at the start of each trial period, and classified participants as either receiving 6MMD or non-6MMD (dispensing duration of 1-3 months) within the six-month interval. Follow-up started at 6MMD enrollment for the 6MMD arm or the first visit in the trial enrollment period for the non-6MMD arm. Retention at 12 and 24 months was defined as having a clinic visit within 12-24 (trial 1-4) and 24-36 (trial 1-2) months from trial enrollment. Using an intention-to-treat approach, we estimated adjusted risk differences (aRD) with 95% confidence intervals (CI) using a Poisson regression model with an identity link function and robust standard errors adjusting for age, sex, duration on ART, facility type, regional location, WHO clinical stage at ART initiation. Pooled RDs were estimated by accounting for within-subject variation in a Poisson regression model using data from all trials. ResultsOf the 159,801 unique patients eligible for this study (65% female, median age 37 years), 74% (118,910) were ever enrolled in 6MMD. Retention rates at 12 months (trials 1-4) and 24 months (trials 1-2) were consistently higher in the 6MMD group than the non-6MMD group. The pooled risk for retention was 3% higher in the 6MMD vs non-6MMD groups (aRD 3.0%; 95% CI: 2.8%-3.3%) at 12 months and 2.0% higher (aRD: 2.0%; 95% CI: 1.7%-2.4%) at 24 months. ConclusionsWe observed slightly higher retention in care rates in Malawi at 12 and 24 months among patients on 6MMD compared to those receiving shorter medication dispensing intervals. Future work to assess the impact of 6MMD on visit burden and resource use would offer a comprehensive view of the benefits to both ART clients and the health system.

The advent of antiretroviral therapy (ART) has led to substantial increases in life expectancy among persons with diagnosed HIV (PWDH), and in turn, an increasingly older population. This represents a public health challenge, as older PWDH are more susceptible to age-related health morbidities compared to the general population. In this study, we triangulate diverse data sources to reconstruct the Italian PWDH age structure over the past decade to better-understand recent trends, and provide demographic projections through 2035. We find that the PWDH population grew from approximately 112,000 persons in 2012, to 140,000 in 2024, and forecasted to reach 155,000 by 2035. This is primarily driven by decreased PWDH mortality, with such decreases forecast to continue. Persons over 60, estimated as 8.6% of the PWDH population in 2012, had increased to over 20% by 2020, and are projected to reach 47.2% by 2035. By 2030, over 10% of PWDH in Italy are projected to be over 75, compared to less than 1% in 2012. Our results demonstrate that the Italian HIV care infrastructure must prepare for a dramatic shift from managing a predominantly young-adult disease to caring for a majority-elderly population within the next decade, representing an unprecedented transformation in the nature and scope of required services.