AbstractThe objective of this study was to characterize HIV-serodiscordant heterosexual couples and to evaluate acceptance for HIV testing and HIV prevalence in nonindex partners. We conducted a cross-sectional study with quantitative and qualitative components. Two cohorts of 1767 HIV-positive people were screened to identify heterosexual HIV-serodiscordant couples. HIV-positive partners (index) were administered a questionnaire; CD4, viral load (VL), and antiretroviral therapy (ART) history were gathered from clinical records. HIV-negative/unknown status partners (nonindex) were invited for a similar questionnaire and HIV testing. In-depth interviews with three HIV-serodiscordant couples were conducted. Two hundred and ninety-seven index partners agreed to enroll in this study. The median duration of the relationship was 10 years, and 81% were sexually active. All but two index partners were on ART, and 98% had VL < 1000 copies/mL. Only 111 (37%) nonindex partners came for HIV testing, and all of them tested HIV-negative. In addition, only 41% of nonindex partners had HIV testing in the last one year. The main reasons for the nonindex partners not to come for HIV testing were "no interest" (n = 117, 63%) and "nondisclosure of HIV status" (n = 46, 25%). The latter was substantiated and explained by the qualitative outcome of this study, suggesting relation to stigma against HIV-positive people. Our results support the WHO recommendation for starting ART for treatment and prevention in HIV-serodiscordant couples at any CD4 count. Furthermore, we recommend the dissemination of data showing that no HIV transmission in heterosexual couples through sex practice has been observed provided VL is suppressed. This could be a powerful tool for effective fight against stigma and self-stigma in people living with HIV.Keywords: heterosexual HIV-serodiscordant couplesART and HIV transmissionHIV testingstigma AcknowledgmentsWe are grateful to all the study participants, as well as to the research and clinical staff and clients at the HIV-NAT Clinic and at the Thai Red Cross Anonymous Clinic for their contribution to this study. The team appreciated the support of Narukjaporn Thammajaruk and Apicha Mahanontharit for their help in the laboratory, Paristaporn Sarachat for helping with data collection, Theeradej Boonmangum and his team for helping with data entry, and Chatsuda Auchieng and Piraporn June Ohata for dealing with administrative issues. The authors have no conflict of interest.Additional informationFundingThis study was funded by Ratchadapiseksompotch Endowment Fund, Faculty of Medicine, Chulalongkorn University [grant number RA 55/53] and the HIV Netherlands Australia Thailand Research Collaboration.
This study assessed the attitudes toward, and interest in, the test-and-treat strategy, comprising regular HIV testing and immediate antiretroviral treatment (ART) among men who have sex with men (MSM) in Bangkok, Thailand. A total of 363 participants completed the questionnaires before and after learning about their HIV status. Previous HIV testing reported by 69.8% and 34.7% tested at least annually. Before pretest counseling, 83.2% expressed interest in regular HIV testing and 78.8% in immediate ART. MSM who tested HIV-positive at enrollment were less likely than those who tested HIV-negative to have been tested for HIV before (45.7% vs. 60.8%, p < 0.0001). Among MSM who tested HIV-positive (n = 69, 15.9%), the median level of willingness to take ART immediately increased significantly after learning about their positive results (90 vs.100%, p < 0.0001). Interest in regular HIV testing remained high among HIV-negative MSM after becoming aware of their status (70.9% before vs. 71.9% after, p = 0.55). MSM participants have a strong desire and willingness to start ART immediately upon receiving an HIV-positive test result; it is important to provide the necessary information on the health benefits of early ART and education to the community to maintain their health and prevent HIV transmission.
The aim of the study was to determine the incidence of, and risk factors for, nevirapine (NVP)-associated hepatotoxicity and rash in HIV-infected Thai men and women, including pregnant women, receiving NVP-containing highly active antiretroviral therapy (HAART).NVP-containing HAART was prescribed to eligible men and women enrolled in the Prevention of Mother-To-Child Transmission of HIV (PMTCT) and MTCT-Plus programmes. All pregnant women received zidovudine (ZDV)/lamivudine (3TC)/NVP from >14 weeks of gestational age if their CD4 cell count was 28 weeks if their CD4 cell count was >200 cells/microL. Patients followed for at least 8 weeks after starting HAART or until delivery were included in the analyses.Of 409 patients, 244 were pregnant women, 87 were nonpregnant women and 78 were men. Hepatotoxicity occurred in 15.6% of all patients. Men had a significantly higher rate of asymptomatic hepatotoxicity (P=0.021). Pregnant women receiving HAART for PMTCT (92% had CD4 cell counts >250 cells/microL) had a significantly higher rate of symptomatic hepatotoxicity (P=0.0003) than pregnant women receiving HAART for therapy. Rash occurred in 16.1% of all patients. The patients' sex and baseline CD4 cell count were not associated with the risk of hepatotoxicity or rash. NVP was discontinued in 4.2% and 6.8% of patients because of hepatotoxicity and rash, respectively.The incidence of NVP-related hepatotoxicity and rash in Thai adults is similar to incidences reported for other populations. While larger studies are needed, our data support continued use of NVP-containing regimens as first-line treatment in developing countries for HIV-infected patients, including pregnant women. Pregnant women with high CD4 cell counts may experience higher rates of symptomatic hepatotoxicity and thus require careful clinical and laboratory monitoring.
Background: WHO has recommended rapid antiretroviral therapy (ART) initiation, including same-day ART (SDART). However, data on the feasibility in real-world settings are limited. We implemented a cohort study at a stand-alone HIV testing center using initiation hub model to examine its applicability and effectiveness. Methods: We collected data from the Thai Red Cross Anonymous Clinic in Bangkok, Thailand, from clients who were ART-naïve and could return for follow-up visits (logistical criteria). Baseline laboratory tests and chest x-ray were performed according to national guidelines, and clinical eligibility was determined based only on physical examination and chest x-ray finding. Acceptability and care linkage were assessed, as well as viral load (VL) suppression and retention in care three, six, and 12 months after ART initiation. Historical data from clients at the same venue between February 2015 to June 2017 were used to compare ART initiation after HIV diagnosis and VL suppression with SDART clients by using Cox proportional-hazards model. Findings: Between July 2017 and July 2018, 2,427 people tested HIV-positive at the clinic, and 2,107 met logistical criteria. Of these, 1,904 (90·4%) agreed to SDART. 1,624 (85·3%) were placed on ART, and 77·4% (1,251/1,624) received same-day initiation. 92·8% (1,198/1,291) were successfully referred to sustained ART sites. Retention at month three, six, and 12 was 93·3% (1,211/1,289), 89·0% (757/851), and 92·1% (70/76), respectively. When compared to historical data, the hazard ratios to ART initiation after HIV diagnosis and viral load suppression among SDART clients were 3·6 (95%CI:3·4-3·8;p<0·001), and 2·1 (95%CI:1·8- 2·3;p<0·001), respectively. Interpretation: Same-Day ART at a stand-alone HIV testing center in an urban setting in Bangkok, Thailand, is highly feasible, and improves ART uptake and viral load suppression. Funding Statement: The United States Agency for International Development (USAID), the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), and the Thai Red Cross AIDS Research Centre. Declaration of Interests: All authors declare no competing interests related to this work.Ethics Approval Statement: This study was approved by the Institutional Review Board of Chulalongkorn University.
Limited data are available on circumcision prevalence and acceptability among Thai men to prevent human immunodeficiency virus. Of 408 high-risk heterosexual men, 12.3% were circumcised. 14.2% and 24.9% expressed willingness to be circumcised before and after circumcision education, respectively. Neonatal circumcision acceptability was relatively high. One participant underwent circumcision at 3-month follow-up.
Disclosure of HIV status to family members could improve communication, relationship, and cohesion. We evaluated the impact of a family-centered program designed to increase the readiness/willingness of parents to disclose HIV status to their children. People living with HIV (PLWH) with children ≥8 years were surveyed regarding HIV knowledge, family relationship, attitudes, willingness/readiness to disclose, and they were then invited to participate in group education and family camps. Of 367 PLWH surveyed, 0.8% had disclosed, 14.7% had not yet disclosed but were willing/ready to disclose, 50.4% were willing but not ready, and 33.2% did not wish to disclose. The educational sessions and camps led to significant improvements of HIV knowledge and disclosure techniques, and readiness/willingness to disclose. Given the benefits of group education and family camps in supporting PLWH to improve their communication with their families and disclose their HIV status, these supporting activities should be included in HIV programs.
To the Editor: Delayed hypersensitivity skin testing (DTH) is a widely available, cost-effective, and relatively easy-to-use tool for detection of cell-mediated immunity (CMI). A response to DTH signifies intact CMI, whereas a negative response may represent a possible defect in CMI or a lack of previous exposure. In HIV infection, DTH predicts clinical progression (1,2) and has been shown to correlate with CD4 cell count (1,3). Highly active antiretroviral therapy (HAART) has significantly improved clinical progression of HIV infection (4,5). HAART with protease inhibitors (PIs) has also rapidly restored immunologic abnormalities in HIV infection (6,7). Although studies have shown the virologic efficacy of non-PI HAART (8–10), data on the recovery of immunologic functions with these regimens is scarce. Indeed, it has been postulated by some that PI-based regimens may result in better immune reconstitution compared with regimens without PIs. In this prospective, nonrandomized, cross-sectional study, HIV-infected subjects with and without HAART were recruited between August 1 and September 30, 2001. Recruitment was done at the Thai Red Cross AIDS Research Center and the Immune Clinic at Chulalongkorn Hospital in Bangkok, Thailand. Inclusion criteria for subjects on HAART were viral load (VL) <50 copies/mL for at least 6 months and maintenance on one of these regimens: triple nucleoside reverse transcriptase inhibitor (NRTI), dual NRTI plus nonnucleoside reverse transcriptase inhibitor (NNRTI), or dual NRTI plus PIs during the period of viral suppression. HIV-infected untreated subjects served as controls. The most recent CD4 cell count within 6 months of the recruitment date was used. The multitest CMI (11) used in this study includes the following antigens:Candida, Trichophyton, Proteus mirabilis, old tuberculin, Streptococcus group C, diphtheria, and tetanus (MULTITEST CMI; Aventis Pasteur Thailand, Ltd, Thailand). The DTH was placed by trained personnel and read at 48 to 72 hours after placement by 2 immunologists. The average of combined horizontal and vertical diameters in millimeters represented the DTH response to each antigen. Subjects with response of ≥5 mm to tuberculin were advised to obtain chest radiography (CXR). Subjects with normal CXR were advised to take isoniazid for 9 months, whereas subjects with abnormal CXR were advised to visit their physician for further investigation for tuberculosis. The primary outcome was the summed DTH response, defined as the summation of induration in millimeters to each antigen divided by the number of antigens with induration. Furthermore, the percentage of subjects with intact CMI, defined as a positive DTH response (≥2 mm) to at least two antigens, and the ability of individual antigens to elicit a DTH response were investigated. For the groups of subjects compared (PI-HAART, non-PI–HAART, HAART-treated, and HAART-untreated), stratified analysis was performed based on a CD4 count of <350 or ≥350 cells/mm3, according to the current recommendation for the initiation of HAART (12). Differences between groups were calculated using the Mann-Whitney U test at an α value of 0.05. For three-group comparison, the Kruskal-Wallis H test was performed. Multiple linear regression was used to determine factors related to DTH response. A total of 142 subjects underwent DTH. Ninety-three subjects were treated with HAART, and 49 were untreated. Subjects on HAART were divided into a group of PI-HAART (n = 22) and a group of non-PI–HAART (n = 71; 10 triple NRTI and 61 dual NRTI plus NNRTI). There were significant differences between HAART-untreated and HAART-treated groups in age (younger in untreated group, 33.2 ± 7.9 years versus 38.1 ± 5.4 years in treated group;p < .01) and median CD4 cell count (lower in the <350 cells/mm3 strata for untreated subjects, 149 (53–225) versus 242 (176–291) for treated subjects;p < .002). Between the HAART-treated groups, baseline differences were Centers for Disease Control and Prevention (CDC) clinical class (more subjects in CDC class A for non-PI–HAART, 55.1% versus 22.7% for PI-HAART;p < .001) and time on HAART (longer for patients with PIs, 2.41 ± 0.7 years versus 1.67 ± 0.92 years without PIs;p < .01). Otherwise, the groups were well balanced. Table 1 demonstrates the summed DTH response and the percentages of subjects with intact CMI and with a positive old tuberculin test according to HAART status, CD4 categories, and treatment regimens. Overall, there was no statistically significant difference between the summed DTH response in subjects on HAART with and without PIs. This also applied when subjects were stratified within the <350 cells/mm3 and ≥350 cells/mm3 groups. The percentage of subjects with intact CMI was higher in the non-PI group, however. When comparing subjects on HAART with subjects without HAART, summed DTH response was significantly better in the CD4 <350 cells/mm3 category for subjects with HAART. Overall, DTH response and chance for intact CMI were significantly better in subjects who had CD4 ≥350 cells/mm3 compared with subjects with CD4 <350 cells/mm3. In the univariate linear regression analysis, summed DTH response was significantly and positively associated with a viral load <50 copies/mL, the absolute CD4 cell count, and HAART. In the multivariable analysis, only the absolute CD4 cell count remained significantly and positively associated with the summed DTH response, although there was a trend for the association between summed DTH response and viral load <50 copies/mL (p = .149). The antigens that elicited DTH response from largest to smallest were as follows: diphtheria, tetanus, old tuberculin, Candida, Proteus mirabilis, Streptococcus group C, and trichophyton.TABLE 1: Summed delayed hypersensitivity skin testing (DTH) response, and percentages of subjects with intact cell-mediated immunity (CMI) and with positive old tuberculin reaction stratified by CD4 counts and HAARTOur results show that the immune recovery measured by summed DTH response is independent of the HAART regimen. These findings are in accordance with recent studies showing that immune reconstitution achieved after therapy with a PI-sparing or PI-containing regimen was similar (13) and independent of virologic efficacy (13,14). Summed DTH response in our study was positively associated with increasing CD4 cell count independent of the HAART regimen or any antiretroviral treatment. A positive correlation between CD4 cell count and DTH response is well known; however, the CD4 cutoff differs between studies (1,3,15,16). Brown et al. (3) reported complete anergy in 38% of 73 subjects with CD4 counts of 0 to 200 cells/mm3 and in 6% of 78 subjects with 201 to 400 cells/mm3. Suwanagool et al. (16) showed that tuberculin reactions of HIV-seropositive patients were 6.4 mm versus 11.0 mm among those with CD4 counts of 200 to 299 cells/mm3 and ≥300 cells/mm3, respectively. Intact CMI was found more frequently in subjects with PI-sparing HAART. There were higher percentages of subjects in the non-PI–HAART group with less advanced clinical status and with positive tuberculin reactions compared with the PI-HAART group, however. Interestingly, in the subgroup of subjects with a CD4 cell count <350 cells/mm3, the DTH response was significantly better in subjects treated with HAART compared with untreated subjects. This was probably due to the higher median CD4 count in the treated subjects in this subgroup. Indeed, French et al. (17) showed that even a small increase in CD4 cell count achieved by azidothymidine monotherapy had a positive effect on DTH response. It has been shown that, at least in advanced HIV infection, viral replication impairs immune functions (18). Our data show a positive trend between summed DTH response and VL <50 copies/mL. Diphtheria, tetanus, and tuberculin were the most likely antigens to elicit differences in DTH response between the two CD4 groups, suggesting that in a resource-constrained setting, the choice of antigens can be limited to these antigens. In summary, no differences between PI-based and non-PI–based HAART in in vivo immune reconstitution can be found in subjects who have achieved virologic undetectability and an identical CD4 cell response. Jintanat Ananworanich Reto Nuesch Somsong Teeratakulpisarn Preeyaporn Srasuebkul Theshinee Chuenyam Umaporn Siangphoe Chaiwat Ungsedhaphand Praphan Phanuphak Kiat Ruxrungtham
Abstract Introduction Differentiated service delivery (DSD) for antiretroviral therapy (ART) maintenance embodies the client‐centred approach to tailor services to support people living with HIV in adhering to treatment and achieving viral suppression. We aimed to assess the preferences for HIV care and attitudes towards DSD for ART maintenance among ART clients and providers at healthcare facilities in Thailand. Methods A cross‐sectional study using self‐administered questionnaires was conducted in September‐November 2018 at five healthcare facilities in four high HIV burden provinces in Thailand. Eligible participants who were ART clients aged ≥18 years and ART providers were recruited by consecutive sampling. Descriptive statistics were used to summarize demographic characteristics, preferences for HIV services and expectations and concerns towards DSD for ART maintenance. Results Five hundred clients and 52 providers completed the questionnaires. Their median ages (interquartile range; IQR) were 38.6 (29.8 to 45.5) and 37.3 (27.3 to 45.1); 48.5% and 78.9% were females, 16.8% and 1.9% were men who have sex with men, and 2.4% and 7.7% were transgender women, respectively. Most clients and providers agreed that ART maintenance tasks, including ART refill, viral load testing, HIV/sexually transmitted infection monitoring, and psychosocial support should be provided at ART clinics (85.2% to 90.8% vs. 76.9% to 84.6%), by physicians (77.0% to 94.6% vs. 71.2% to 100.0%), every three months (26.7% to 40.8% vs. 17.3% to 55.8%) or six months (33.0% to 56.7% vs. 28.9% to 80.8%). Clients agreed that DSD would encourage their autonomy (84.9%) and empower responsibility for their health (87.7%). Some clients and providers disagreed that DSD would lead to poor ART retention (54.0% vs. 40.4%), increased loss to follow‐up (52.5% vs. 42.3%), and delayed detection of treatment failure (48.3% vs. 44.2%), whereas 31.4% to 50.0% of providers were unsure about these expectations and concerns. Conclusions Physician‐led, facility‐based clinical consultation visit spacing in combination with multi‐month ART refill was identified as one promising DSD model in Thailand. However, low preference for decentralization and task shifting may prove challenging to implement other models, especially since many providers were unsure about DSD benefits. This calls for local implementation studies to prove feasibility and governmental and social support to legitimize and normalize DSD in order to gain acceptance among clients and providers.
ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Jantarapakde J, Chaturawit P, Mathajittiphan P, et al. 'Let Food Be Your Medicine': a model for HIV nutrition services. HIV & AIDS Review. International Journal of HIV-Related Problems. 2017;16(2):124-129. doi:10.5114/hivar.2017.68020. APA Jantarapakde, J., Chaturawit, P., Mathajittiphan, P., Pengnonyang, S., Takamtha, P., & Dungjun, N. et al. (2017). 'Let Food Be Your Medicine': a model for HIV nutrition services. HIV & AIDS Review. International Journal of HIV-Related Problems, 16(2), 124-129. https://doi.org/10.5114/hivar.2017.68020 Chicago Jantarapakde, Jureeporn, Panita Chaturawit, Pornpen Mathajittiphan, Supabhorn Pengnonyang, Piyaporn Takamtha, Narunat Dungjun, and Karen Humphries-Waa et al. 2017. "'Let Food Be Your Medicine': a model for HIV nutrition services". HIV & AIDS Review. International Journal of HIV-Related Problems 16 (2): 124-129. doi:10.5114/hivar.2017.68020. Harvard Jantarapakde, J., Chaturawit, P., Mathajittiphan, P., Pengnonyang, S., Takamtha, P., Dungjun, N., Humphries-Waa, K., Teeratakulpisarn, S., and Phanuphak, P. (2017). 'Let Food Be Your Medicine': a model for HIV nutrition services. HIV & AIDS Review. International Journal of HIV-Related Problems, 16(2), pp.124-129. https://doi.org/10.5114/hivar.2017.68020 MLA Jantarapakde, Jureeporn et al. "'Let Food Be Your Medicine': a model for HIV nutrition services." HIV & AIDS Review. International Journal of HIV-Related Problems, vol. 16, no. 2, 2017, pp. 124-129. doi:10.5114/hivar.2017.68020. Vancouver Jantarapakde J, Chaturawit P, Mathajittiphan P, Pengnonyang S, Takamtha P, Dungjun N et al. 'Let Food Be Your Medicine': a model for HIV nutrition services. HIV & AIDS Review. International Journal of HIV-Related Problems. 2017;16(2):124-129. doi:10.5114/hivar.2017.68020.
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