This Week in HIV Research: Gender Disparities Among the Formerly Incarcerated
Another week, another set of clinically relevant research findings that incrementally advance our efforts to better prevent HIV and provide care to people living with the virus. On tap this week, we take a brief look at the following study results:
- Following incarceration, HIV outcomes appear to be poorer among women than men.
- Even in rare cases where people prescribed pre-exposure prophylaxis (PrEP) become HIV positive, drug resistance doesn't occur.
- In the long run, a nurse-led HIV treatment adherence self-management program appears to be worth its slightly higher cost.
- Much like the general population, HIV-positive cancer survivors are at risk for developing additional cancers.
Let's examine each of these findings in a little more detail. To beat HIV, you have to follow the science!
Barbara Jungwirth is a freelance writer and translator based in New York. Follow Barbara on Twitter: @reliabletran.
Myles Helfand is the executive editor and general manager of TheBody and TheBodyPRO. Follow Myles on Twitter: @MylesatTheBody.
Women With HIV Fare Worse Than Men With HIV After Incarceration
Women experience worse HIV outcomes than men after release from prison or jail, a U.S.-focused literature review published in AIDS found. Specifically, women were less likely to be engaged in care, adhere to their treatment regimen, or be virally suppressed.
Researchers compared data from 24 studies, all but one of which had been conducted in the U.S. They noted the scarcity of research specific to criminal justice-involved women living with HIV (WLWH), and even less data on transgender women.
Compared to men, women were more likely to have been homeless, used illicit substances, or have a history of past trauma before being arrested, all of which may have increased the HIV outcome gender gap. Mental and physical illnesses more commonly occurred among women as well. Women were also less likely to be imprisoned for violent crimes, and hence served shorter sentences -- a fact that may impair HIV outcomes by causing a greater number of treatment interruptions, researchers suggested.
Study authors noted the disproportionate number of African Americans in the U.S. correctional system as a result of structural racism, economic marginalization, and over-policing of communities of color. Research on the unique vulnerabilities of African-American women leaving prison or jail is needed, they said. In addition, they called for enhanced discharge planning, trauma-informed care, and gender-informed interventions for WLWH.
No Drug Resistance When HIV is Acquired After Taking PrEP
None of the people who seroconverted during the IPERGAY pre-exposure prophylaxis (PrEP) trial had mutations that confer resistance to either component of the study drug, an analysis published in AIDS showed.
IPERGAY used tenofovir disoproxil fumarate/emtricitabine (TDF/FTC, Truvada). Participants were initially randomized to PrEP or placebo; in a second phase everyone was offered on-demand PrEP. Researchers hypothesized that the resulting fluctuation in drug levels caused by non-daily PrEP use could have given rise to the development of some resistance.
The analysis found that all but six of the 31 HIV acquisitions during the trial were among those who did not take TDF/FTC. During resistance testing, no study drug was detected in four of these remaining six, suggesting little to no PrEP adherence. The lack of resistance mutations is likely explained by this low treatment adherence, study authors observed. Furthermore, frequent and sensitive HIV testing allowed seroconversions to be detected early, curbing any use of PrEP during acute infection and thereby further reducing the risk of developing resistance, they added.
Adherence Self-Management Program Appears Cost-Effective in Long-Term
Over the course of 15 months, a program known as the Adherence Improving Self-Management Strategy (AIMS) was slightly more expensive than treatment as usual (TAU), but also more effective, a Dutch trial published in Clinical Infectious Diseases showed.
AIMS is a nurse-led individual self-management intervention to improve treatment adherence among people living with HIV (PLWH); prior research has shown AIMS to be effective. The current trial randomized 223 PLWH to AIMS or TAU and measured the cost of viral load reductions, treatment failure, and quality-adjusted life-years (QALYs).
While in the relative short term the cost of AIMS was higher than what the Netherlands is generally considered to be willing to pay for HIV prevention, the intervention became cost-effective when the seroconversions prevented by having more people virally suppressed were considered. AIMS was also cheaper than TAU when its cost was calculated from a health care perspective.
A prior modeling study had also shown AIMS to be cost-effective over the long term. "Combined, these studies suggest that incorporating AIMS in routine HIV care could lead to relevant benefits for only a modest investment," study authors concluded.
Non-AIDS Defining Second Cancers Becoming More Common Among People Living With HIV
Among PLWH, AIDS-defining cancer incidence dropped over time, but non-AIDS defining second cancers became more common, a record-linkage study published in The Lancet found.
Between 1990 and 2010, 22,623 people were diagnosed with HIV in San Francisco, California. Among them, 4,545 cancers were diagnosed, of which 372 were second cancers, 26 third cancers, and three later cancers. At 9%, the rate of second cancers was similar to that in the general population.
AIDS-defining cancer rates dropped after the introduction of protease inhibitors in 1995, but overall cancer risk remained elevated among PLWH. These excess cancers were at least partly related to oncologic viruses, reflecting the higher prevalence of such viruses among PLWH.
While these U.S. study results are illuminating, HIV is much more common in sub-Saharan Africa, where antiretrovirals are relatively new and different cancers are common, Silvia Franceschi of the Centro di Riferimento Oncologico di Aviano in Italy noted in a related comment. The observed trends are likely to continue as more PLWH survive into old age, she added, while calling for more research into the relationship between impaired immunity and cancer outcomes.