Department of Psychology, University of Miami, Coral Gables, FL, USA.
The Fenway Institute at Fenway Health, Boston, MA, USA.
J Int AIDS Soc. 2021 Mar;24(3):e25679. doi: 10.1002/jia2.25679.
Little is known about onward HIV transmissions from people living with HIV (PLWH) in care. Antiretroviral therapy (ART) has increased in potency, and treatment as prevention (TasP) is an important component of ending the epidemic. Syndemic theory has informed modelling of HIV risk but has yet to inform modelling of HIV transmissions.
Data were from 61,198 primary HIV care visits for 14,261 PLWH receiving care through the Centers for AIDS Research (CFAR) Network of Integrated Clinical Systems (CNICS) at seven United States (U.S.) sites from 2007 to 2017. Patient-reported outcomes and measures (PROs) of syndemic conditions - depressive symptoms, anxiety symptoms, drug use (opiates, amphetamines, crack/cocaine) and alcohol use - were collected approximately four to six months apart along with sexual behaviours (mean = 4.3 observations). Counts of syndemic conditions, HIV sexual risk group and time in care were modelled to predict estimated HIV transmissions resulting from sexual behaviour and viral suppression status (HIV RNA < 400/mL) using hierarchical linear modelling.
Patients averaged 0.38 estimated HIV transmissions/100 patients/year for all visits with syndemic conditions measured (down from 0.83, first visit). The final multivariate model showed that per 100 patients, each care visit predicted 0.05 fewer estimated transmissions annually (95% confidence interval (CI): 0.03 to 0.06; p < 0.0005). Cisgender women, cisgender heterosexual men and cisgender men of undisclosed sexual orientation had, respectively, 0.47 (95% CI: 0.35 to 0.59; p < 0.0005), 0.34 (95% CI: 0.20 to 0.49; p < 0.0005) and 0.22 (95% CI: 0.09 to 0.35; p < 0.005) fewer estimated HIV transmissions/100 patients/year than cisgender men who have sex with men (MSM). Each within-patient syndemic condition predicted 0.18 estimated transmissions/100 patients/year (95% CI: 0.12 to 0.24; p < 0.0005). Each between-syndemic condition predicted 0.23 estimated HIV transmissions/100 patients/year (95% CI: 0.17 to 0.28; p < 0.0005).
Estimated HIV transmissions among PLWH receiving care in well-resourced U.S. clinical settings varied by HIV sexual risk group and decreased with time in care, highlighting the importance of TasP efforts. Syndemic conditions remained a significant predictor of estimated HIV transmissions notwithstanding the effects of HIV sexual risk group and time in care.
人们对接受治疗的艾滋病毒感染者（PLWH）中艾滋病毒的后续传播知之甚少。抗逆转录病毒疗法（ART）的疗效有所提高，治疗即预防（TasP）是终结艾滋病流行的重要组成部分。综合疾病理论为艾滋病毒风险建模提供了信息，但尚未为艾滋病毒传播建模提供信息。
数据来自 2007 年至 2017 年期间，美国七个地点的艾滋病研究中心（CFAR）网络综合临床系统（CNICS）为 14261 名接受护理的 PLWH 进行的 61198 次首次 HIV 护理就诊。患者报告的结果和综合疾病状况的测量（抑郁症状、焦虑症状、药物使用（阿片类药物、安非他命、快克/可卡因）和酒精使用）大约每四个月至六个月收集一次，同时还收集性行为（平均= 4.3 次观察）。使用分层线性建模，对综合疾病状况、艾滋病毒性传播风险组和护理时间进行建模，以预测性行为和病毒抑制状态（HIV RNA <400/mL）导致的估计艾滋病毒传播。
所有有综合疾病状况测量的就诊患者平均每年估计有 0.38 次艾滋病毒传播/ 100 名患者（从第一次就诊的 0.83 次下降）。最终的多变量模型显示，每 100 名患者，每次就诊预测每年估计传播减少 0.05 次（95%置信区间（CI）：0.03 至 0.06；p < 0.0005）。顺性别女性、顺性别异性恋男性和顺性别未公开性取向的男性，分别估计每年 HIV 传播减少 0.47（95% CI：0.35 至 0.59；p < 0.0005）、0.34（95% CI：0.20 至 0.49；p < 0.0005）和 0.22（95% CI：0.09 至 0.35；p < 0.005）次。与顺性别男男性接触者（MSM）相比，每例患者的综合疾病状况预测每年估计有 0.18 次艾滋病毒传播/100 名患者（95% CI：0.12 至 0.24；p < 0.0005）。每个综合疾病状况之间预测每年估计有 0.23 次艾滋病毒传播/100 名患者（95% CI：0.17 至 0.28；p < 0.0005）。
在美国资源充足的临床环境中接受护理的 PLWH 中，估计的艾滋病毒传播因艾滋病毒性传播风险组而异，并随护理时间的延长而减少，这突出了 TasP 工作的重要性。尽管艾滋病毒性传播风险组和护理时间的影响，综合疾病状况仍然是估计艾滋病毒传播的重要预测因素。
