This Week in HIV Research: The Racism of Perceived Risk

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The HIV epidemic persists in the U.S. largely because of racism -- and there's an insidiousness to that racism that can make it a challenge not only to pinpoint, but even to see in ourselves. Isolating examples of that unconscious bias doesn't directly solve the problem, but as today's lead study offers, it can make us more aware -- and help get us closer to devising solutions.

Here's what we've got on tap this week in our review of recently published, peer-reviewed, HIV-related research:

  • Sexual behaviors are perceived as riskier for HIV or other sexually transmitted infections if one or more of the participants is black.
  • The larger the constellation of psychosocial issues a young trans woman must work through, the higher the HIV risk becomes.
  • A two-drug regimen of dolutegravir (Tivicay, DTG) and unboosted atazanavir (Reyataz) may be a viable switch option for some patients.
  • Two case studies highlight that severe hepatotoxicity, even if rare, is still a risk worth being aware of when prescribing dolutegravir.

For a bit more on each of these findings, read onward. To beat HIV, you have to follow the science!


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Sexual Behavior Perceived as Riskier for African Americans

Young men who have sex with men (MSM) perceive sexual behavior as riskier among African Americans than whites, a social laboratory experiment published in Journal of Acquired Immune Deficiency Syndrome showed.

The 134 study participants -- university students in Illinois and Indiana -- each read the same nine vignettes describing sexual encounters between men and then rated the risk of HIV/sexually transmitted infection (STI) acquisition. Characters were described as either both white, both African American, or one white and one African American. Overall, the volunteers rated HIV transmission risk as lower if both characters were white than if one or both were African American.

Study participants were asked to self-identify their race/ethnicity. Results did not differ by the reader's own race.

"Public health messaging that only communicates racial disparities in HIV/STIs may contribute to racial biases and stigmatization, attributing STIs and HIV to a racial group rather than the sexual behaviors associated with HIV/STI transmission," study authors concluded.


Zackary Drucker via The Gender Spectrum Collection

Multiple Psychosocial Problems Increase HIV Risk Among Young Trans Women

Young transgender women with multiple psychosocial problems are more likely to engage in condomless sex than their peers who do not have similar challenges, a study published in Journal of Acquired Immune Deficiency Syndrome showed.

Researchers recruited 233 trans women between the ages of 16 and 29 years who volunteered for an HIV prevention study at a clinic in Boston or Chicago. Each volunteer had either 1) reported recent sexual behavior that carries a risk of seroconversion, such as condomless anal or vaginal sex (CAVS), multiple partners, sex work or an STI; or 2) were living with HIV. Participants completed psychosocial and behavioral surveys at baseline and every four months thereafter for a total of 12 months.

The following psychosocial problems were assessed (reported prevalence is in parentheses): recent clinically significant depression (42.1% of participants), polysubstance use (6.4%), stimulant use (15.9%), or heavy alcohol use (7.7%); lifetime child sexual abuse (10%), intimate partner violence (41.7%), or transgender-related victimization (68.6%). Participants who reported five or more of these issues had more than triple the odds of engaging in CAVS than those who reported none of them.

To combat the high HIV incidence rate among transgender youth, such psychosocial risks must be assessed and treated in gender-affirming, supportive mental health care and other services, study authors concluded.


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Study Explores Value of Switching to Dolutegravir/Atazanavir

Switching to a two-drug regimen of dolutegravir and unboosted atazanavir may be an option for people who cannot simplify to another two-drug regimen, a retrospective study published in AIDS found.

The Italian study involved 151 virologically suppressed participants who were switched to the two-drug regimen. Median age was 53 years and median time on antiretroviral therapy was 15 years. Cardiovascular concerns prompted the treatment change in 25% of participants.

Overall, total cholesterol, triglycerides, and fasting glucose decreased at slopes of ‑0.65mg/dl/month, ‑1.64.mg/dl/month, and ‑0.55mg/dl/month, respectively, on the new regimen, while CD4 cell counts remained stable.

Two virologic failures and 13 treatment failures -- including 10 discontinuations for adverse events -- occurred after the switch.

The antiviral activity and higher genetic barrier of dolutegravir may explain the greater efficacy seen in this trial compared to studies of a two-drug raltegravir (Isentress)  and unboosted atazanavir regimen, study authors hypothesized. Results show that a dolutegravir + unboosted atazanavir treatment could be used to spare both boosting agents and reverse transcriptase inhibitors in patients were this is warranted, they concluded.


Liver tissue under a microscope
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Clinicians Warn of Potential Hepatotoxicity Risk on Dolutegravir

Two cases of probable hepatotoxicity while on dolutegravir were described in AIDS by Canadian clinicians.

In clinical trials, the drug was associated with a 1-2% discontinuation rate due to liver problems. Both cases described here were characterized by grade 4 liver enzyme elevations about eight months after the patients, who were both men, switched to dolutegravir plus boosted abacavir (Triumeq).

In one case, a 57-year-old man developed jaundice and elevated transaminase levels (alanine transaminase [ALT] to 699 IU/l and aspartate transaminase [AST] to 1404 IU/l), as well as significant increases in other liver markers (alkaline phosphatase and bilirubin). In adult men, normal levels are 7-55 U/l for ALT and 8-48 U/l for AST. The liver symptoms resolved when the person switched back to his previous non-dolutegravir regimen.

In the second case, a 42-year-old man's ALT rose to 1416 IU/l. His liver enzyme levels also returned to normal after switching treatment away from dolutegravir.

Two similar cases had been previously published, with one case resolving after switching regimens while the other required a liver transplant. Study authors noted that cases of drug-induced liver injury on dolutegravir are rare, but clinicians should be aware of the potential for such problems.