New England AIDS Education and Training Center: ContentPages

In Brief: November 8, 2022

Inside This Issue: Lasting benefits of early HIV treatment; high HIV rates among people hospitalized with Monkeypox; Hep B vaccine works well for people with HIV; debt crisis threatens global HIV and COVID response; and more.

HIV Treatment

Early Diagnosis and Treatment of HIV Yield Lasting Health Benefits

Beginning antiretroviral treatment (ART) early in HIV infection – when the immune system is still relatively strong – yields improved long-term health outcomes compared with starting ART later in the course of infection, according to recent findings from the Strategic Timing of Antiretroviral Treatment (START) study. Since START began in 2009, researchers have followed the health of nearly 4,700 persons who were randomized into either early treatment or deferred treatment arms. People in the early treatment arm started ART immediately after randomization, when their CD4+ T-cell counts were greater than 500 cells per cubic millimeter (mm³). In contrast, those in the deferred treatment arm waited to begin ART until either their CD4+ counts fell below 350 cells/mm³ or they developed an AIDS diagnosis.

In 2015, START demonstrated that the early treatment group had a 57% reduced risk of AIDS and serious non-AIDS health outcomes compared to the deferred treatment group. Following the release of these 2015 findings, the participants in the deferred treatment group were advised to begin ART.

The recently published research examined how START participants fared during an extended follow-up period from 2016 through the end of 2021 – a time during which most people in the original deferred treatment group were taking ART. Although starting treatment reduced the HIV viral load to undetectable for many in the deferred treatment group, their CD4+ counts remained, on average, 155 cells/mm³ lower compared with those of individuals in the early ART group.

In addition, even though people in the deferred treatment group experienced a substantial reduction in their risk of serious health outcomes soon after starting ART, they still had some excess risk compared with those in the early treatment group. Their risk of serious health consequences or death was 21% higher, and they had more cases of AIDS (27 versus 15), more cases of serious non-AIDS health issues (88 versus 76), and more deaths (57 versus 47). The START researchers concluded that early diagnosis and treatment of HIV are key to maximizing the benefits of ART and reducing the risk of serious negative long-term health outcomes.

HIV and Viral Co-infections

High Rates of HIV Seen Among Patients Hospitalized with Severe Monkeypox

Between August 10 and October 10, 2022, the Centers for Disease Control and Prevention (CDC) provided clinical consultation for 57 patients hospitalized with severe manifestations of monkeypox. In a recent report, CDC researchers summarized the demographic characteristics and health status of these patients, as well as the cases’ implications for public health practice.

Of the 57 patients studied, the median age was 34 years old, and 95% were males. About 82% of the hospitalized patients were co-infected with HIV, and about 9% had other immunocompromising conditions. More than two-thirds (68%) of the hospitalized patients were Non-Hispanic Black or African American, while White and Hispanic/Latino persons each accounted for 14% of the patients. During the study period, 12 patients died, and monkeypox was a cause of death or contributing factor in five patients evaluated to date, with several other deaths still under investigation.

“The occurrence of severe manifestations of monkeypox in patients who were most commonly immunocompromised because of AIDS highlights the importance of engaging all persons with HIV in sustained care and ending the HIV epidemic,” the study researchers noted. “Clinicians should consider close clinical monitoring, early treatment with available medical countermeasures, and extension or escalation of therapy as indicated in patients with or at risk for severe monkeypox. Ensuring equitable access to resources for the diagnosis, treatment, and prevention of HIV and monkeypox remains a vital public health priority.”

People with HIV Protected by Three-Dose Course of Hepatitis B Vaccine

A three-dose regimen of the HEPLISAV-B hepatitis B vaccine provided full protection for adults living with HIV who had never been vaccinated against or infected with the hepatitis B virus (HBV), according to recent findings from the Phase 3 ACTG A5379 clinical trial. CDC estimates that about 10% of people with HIV in the U.S. are co-infected with HBV. People with HIV/HBV co-infection – including those receiving antiretroviral therapy – have an elevated risk of liver-related illness and death, compared to people with HIV alone.

The study researchers tested a three-dose course of HEPLISAV-B on 68 adults with HIV at 38 sites in the U.S., South Africa, and Thailand. None of the trial participants had previously been vaccinated for HBV or had evidence of prior HBV infection. All were receiving antiretroviral therapy for HIV.

All participants achieved seroprotection against HBV, and 88% had anti-HBV surface antibody levels over 1,000 milli-international units per milliliter, the researchers found. High antibody levels are thought to be associated with long-term vaccine durability. The most common side effects related to HEPLISAV-B vaccination were injection site pain, malaise, fatigue, muscle aches, and headaches.

The Global HIV Epidemic

UNAIDS: Looming Debt Crisis Endangers HIV, COVID, and Other Health Investments

Financial problems – worsened by the war in Ukraine – are severely undermining many developing nations’ capacity to invest in health. This is allowing the AIDS and COVID-19 pandemics to continue and is putting past gains at risk, according to the recent UNAIDS briefing, A Pandemic Triad: HIV, COVID-19, and Debt in Developing Countries. “Decades of progress made towards reducing poverty and hunger and improving education and health outcomes have been eroded over the last 24 months,” according to the report. “In the case of the AIDS pandemic, more than 26 million people are living with HIV in developing countries, and nearly two-thirds of them live in countries that have not received debt relief in the context of the health and fiscal crises of the pandemic triad.”

The briefing notes that the countries most affected in economic terms by COVID-19 are the countries deepest in debt. They are also the countries most affected by HIV. In 2020, for every $10 in available funding, $4 was spent on debt servicing and only $1 was invested in health. The briefing makes the following main policy recommendations:

to strengthen the multilateral response in order to provide developing countries with adequate support in the context of the COVID-19 pandemic;
to provide support for developing countries that have unsustainable debt burdens. The report notes, “A failure to do so would encourage shifting resources away from pandemic responses towards debt repayments”; and
to include health expenditures and financing requirements to end the AIDS and COVID-19 pandemics as a central consideration when providing multilateral financing and implementing debt relief initiatives.

Historically Black Colleges and Universities Receive Funding to Address the HIV Epidemic in Africa

On October 31, the Health Resources and Services Administration (HRSA) announced the awarding of $8 million in funding to Meharry Medical College to improve and expand HIV care and treatment in some U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)-supported countries. Meharry Medical College, a Historically Black College and University, is partnering with Howard University College of Medicine, Morehouse School of Medicine, and Charles Drew University of Medicine and Science to work in Malawi, Zambia, and other PEPFAR-supported countries to connect adolescent girls and young women with HIV to care and sustained treatment. The funding will also be used to increase the capacity of health facilities to provide HIV care and treatment and improve viral suppression rates.

“Today’s announcement marks the first time that we at HRSA have been able to directly fund Historically Black Colleges and Universities to support PEPFAR’s goals,” said HRSA Administrator Carole Johnson. “This funding is an example of our commitment to leveraging the expertise and capacity of leading American institutions in the global fight against HIV.”

HIV/AIDS Observances

News About World AIDS Day 2022

The 35^th annual World AIDS Day (WAD) will be observed on Thursday, December 1. HHS recently announced the U.S. theme for WAD 2022: “Putting Ourselves to the Test: Achieving Equity to End HIV.” This theme emphasizes accountability and action in U.S. initiatives to end HIV, through an approach that centers on communities disproportionately affected by the pandemic. “This year, we observe World AIDS Day in the context of two other infectious disease threats – COVID-19 and monkeypox – which have heavily impacted many of those same communities,” according to the HHS website HIV.gov. “These epidemics have further highlighted that our public health response to HIV will require us to address health disparities holistically.”

“This World AIDS Day, we acknowledge the role equity plays in either the success or failure of our Nation’s HIV response. Providing equitable access to HIV testing, prevention, care, treatment, and research is key to ending the HIV epidemic,” noted Harold Phillips, director of the White House Office of National AIDS Policy. “The COVID-19 pandemic has tested our resolve and our ability to focus on ending the HIV epidemic. This World AIDS Day, we must recommit and re-energize all sectors of society to center equity within our HIV response by ensuring that everyone with HIV and those at-risk for infection have access to appropriate HIV testing, treatment, and prevention services.”

For WAD 2022, CDC has developed a series of social media posts that organizations can use to raise HIV awareness among people worldwide and to encourage them to get tested and know their prevention options. A variety of graphics and videos are available in English and Spanish to support awareness-raising efforts.

Educational Resources

Five New HIV Symptom Evaluation Guides Now Available in National HIV Curriculum

The AIDS Education and Training Center’s National HIV Curriculum, created and updated by the University of Washington (UW), recently added five new HIV Symptom Evaluation Guides to the Curriculum. These resources were developed for novice to experienced clinicians and cover the following topics: cough and dyspnea, odynophagia, diarrhea, headache, and memory changes. According to UW, each guide “provides clinicians with a framework for evaluating certain common symptoms that individuals with HIV may experience. These guides offer a summary of important clinical questions and considerations, as well as decision trees to help with the evaluation process.”

Each downloadable, six-page guide features: a list of key clinical questions; a diagnostic approach decision tree; a table of risk factors and initial diagnostic evaluation steps for common causes; summary points; and a reference list.

Two Updated RWHAP Slide Sets from HRSA

HRSA recently added two slide sets to its resources focusing on two of the population groups served by the Ryan White HIV/AIDS Program (RWHAP).

Women Served by the Ryan White HIV/AIDS Program, 2020 – This 24-slide set includes a series of charts and graphs summarizing the demographic and socioeconomic characteristics of female RWHAP clients aged 13 years or older; overall viral suppression rates in these clients; and disparities in viral suppression among women by race/ethnicity, age, and housing status.

Youth and Young Adult Clients Served by the Ryan White HIV/AIDS Program, 2020 – This 14-slide set summarizes data about RWHAP clients between the ages of 13 and 24 years old. Demographic breakdowns are provided by gender (male, female, and trangender), race/ethnicity, transmission category, housing status, and income. In addition, information is provided on viral suppression rates, with selected breakdowns by gender, housing status, and healthcare coverage.

During the past year, HRSA has published several additional slide sets focusing on other population groups served by the RWHAP. These include: an overview of all RWHAP clients; clients aged 50 years or older; transgender clients; clients in different racial/ethnic groups; men who have sex with men; and persons who inject drugs.

Other Infectious Disease News

CDC Launches Monkeypox Reports Page

CDC’s Morbidity and Mortality Weekly Report (MMWR) recently launched a new Monkeypox Reports page that compiles recent research on Monkeypox virus epidemiology, transmission, prevention, health consequences, and health equity. Recent MMWR articles about Monkeypox include the following:

Research Updates on COVID-19 from MMWR

CDC’s COVID Data Tracker Weekly Review highlights key data from its COVID Data Tracker, narrative interpretations of the data, and visualizations from the week. Themes of recent Weekly Review issues include: improving COVID-19 vaccine equity; monitoring viral variants; what it now means to be “up to date” with COVID-19 vaccinations; and healthy habits for autumn.

CDC’s MMWR is also providing continuing coverage of COVID-19-related research. The agency is archiving its MMWR reports on a page devoted to studies about COVID-19. For your convenience, we have compiled below links to recent MMWR articles focusing on COVID-19: