Rachel Lutz

 offered updated recommendations to HIV treatment for adults with or at risk for HIV.

Authors from the US, Europe, and Australia outlined updates on the current knowledge surrounding initiation of antiretroviral therapy (ART), what regimen to initiate, when and how to switch to ART, considerations for when and how to use preexposure prophylaxis (PrEP), and monitoring therapy as well as issues in aging HIV populations. The study authors said that the success of ART has lead to an increase of survival of HIV patients to a near-normal life span, which in turn has lead to an aging HIV population.

The investigators reviewed new data published between January 2018 and August 2020 and discovered 5316 citations of which 336 provided additional unique citations for aging and HIV. Because of this, the new recommendations focus on adults aged 18 years or older who have or at risk for developing HIV.

Their recommendations for when to begin ART have not changed from the last communication, they said, as the goals of ART are to maintain optimal health for the individual with HIV and eliminate transmission. An important focus of this tenet of treatment is developing strategies that facilitate immediate entry into care, removing barriers to initiation of ART, and support for continuous care engagement, the authors wrote.

Optimal ART regimens should aim for a high rate of viral suppression, minimal toxicity, low pill burden, and few drug interactions, they said. For most people with HIV, that can include bictegravir/tenofovir alafenamide/emtricitabine, dolutegravir plus, and dolutegravir/lamivudine with caveats, the authors said. In the setting of opportunistic infection treatment, the authors recommended dolutegravir (50 mg twice daily), efavirenz (600 mg/d), or raltegravir (800 mg twice daily) plus 2 nucleoside reverse transcription inhibitors, in the case of initiating ART in people with HIV and active tuberculosis. The authors made separate recommendations for individuals who are pregnant.

The most common reason for switching ART regimens is simplification, management or prevention of toxic effects, avoidance or management of interactions with drugs, food or dietary supplements, and economic factors, the authors said. Before switching ART regimens, there should be a review of the patient’s ART regimen history, tolerance, co-medications, food requirements, cost, and results from prior resistance tests. 

There should also be a viral load assessment 1 month after switching regimens, the authors recommended. Patients should be able to switch ART regimens when they have achieved viral suppressions or virological failure. Another reason to switch regimens may be the development of comorbid conditions, such as kidney, liver, cardiovascular, or bone diseases, weight gain, cancer and autoimmune disease, or solid organ transplantation.

“All persons who have ever been sexually active or injected drugs should be tested for HIV at least once during their lives,” the authors recommended, adding, “Ongoing risk for HIV should be assessed regularly, and men who have sex with men (MSM), transfeminine persons, people who inject drugs outside needle sharing programs, and people newly diagnosed with other sexually transmitted infections (STIs) or hepatitis C should be tested every 3 months as long as risk continues.”

Laboratory monitoring should continue after HIV diagnosis and during ART, they also noted.

PrEP is recommended for individuals at risk for HIV infection, the recommendations said, and tenofovir disoproxil fumarate/emtricitabine is the recommended regimen for those at risk.

The aging population with HIV is at risk for cardiovascular disease, chronic kidney disease, neurocognitive impairment, and mental health disorders, and combined with loneliness, social isolation, and stigma can all produce poorer outcomes for this population, the authors wrote. Therefore, close and sustained attention to polypharmacy is recommended for this group, including those over 50 years old or those who are frail or prefrail.

“Advances in HIV prevention and management with antiretroviral drugs continue to improve clinical care and outcomes among individuals at risk for and with HIV,” the authors concluded.

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Improving clinical care and outcomes among those with and at risk for HIV was the target for updating the antiretroviral treatment regimen recommendations. 

New HIV Treatment Recommendations Released 

Risks for dying from the novel coronavirus (COVID-19) include male sex, having lower income and level of education, and being born abroad in a low- or middle-income country, according to a Swedish 

Investigators from Stockholm University in Sweden used the data from all COVID-19-related deaths in Sweden through May 7, 2020 in order to determine who is at the highest risk of death from the disease. Provisions in the Swedish government made this data accessible, the investigators said.

The study authors also said that until now, the global understanding of background characteristics associated with the risk of death has been limited to anecdotal evidence and “rudimentary inferences,” and more formal analyses are needed. Initially, these findings suggest that men, the elderly, racial and ethnic minorities, and those in lower socioeconomic positions are more likely to develop severe COVID-19 or die from it, the study authors noted.

There were 17181 relevant deaths of adults aged 20 and older between March 13 and May 7, 2020 the study authors said. The investigators then put a table together that showed the distribution of population at risk, deaths from COVID-19, and causes of deaths from all variables in their analysis. They also added a category for broad age groups.

There was an increased risk of dying from COVID-19 by increasing age, male sex, being widowed, primary education, those with low income, those from high-income countries, and those living in Stockholm county, the study authors found. All other causes of death had similar patterns, the study authors said, except for the county of residence as they explained that other counties have higher crude mortality rates than Stockholm.

The study authors also examined the data on the basis of sex. For both men and women, those who never married, divorced, or are widowed experienced about 1.5 to 2-times higher mortality from COVID-19 than those individuals who are married, they said.

Compared to Swedes, immigrants from low- and middle-income countries from the Middle East and Northern Africa had more than 3 times higher mortality if they were male, and 2 times higher for women, the study authors found. Immigrants from other low- and middle-income countries had twice as high mortality for men and about 1.5 times higher for women. Immigrants from high-income countries only had a 19% higher mortality for men and 8% higher for women, the study authors said.

For adults of working age (i.e., not retirees), males have a higher mortality rate compared to females, the study authors said, while noting that education and income are also strong predictors of dying from COVID-19 in this group. For working-aged adults, those with low income were more than 5 times as likely to die from COVID-19 compared to those in the highest income bracket. Furthermore, those with primary and secondary education were more than twice as likely to die compared to those with postsecondary education. For adults that were retirement age and older, the socioeconomic differences had a reduced impact on COVID-19 mortality, the study authors said.

“We can show that there are independent effects of various separate risk factors that have been brought up in debates and news about COVID-19,” Sven Drefahl, Associate Professor of Demography at Stockholm University Demography Unit in the Department of Sociology, and main author of the study said.

 “All of these factors are accordingly individually associated with a strongly elevated risk of dying from COVID-19.”

The investigators looked at data from all adult coronavirus-related deaths between March and May 2020.

COVID-19 Mortality Risks include Male Sex, Place of Birth, Income and Education

Young people show remarkable concern for others and themselves during the ongoing novel coronavirus (COVID-19) pandemic response, according to a 

Investigators from the United Kingdom lead a focus group with members of the Hospital Young People’s Forum in order to understand how young people see their role in the ongoing pandemic. The investigators conducted the 70-minute sessions via Zoom in May with participants aged 11 to 18 years. The interviews were transcribed and then analyzed using what the study authors described as “an inductive thematic analysis approach.”

The discussion centered around 3 questions, the study authors wrote:

How can young people get their voices heard during a pandemic?

What do young people think about the return to schools?

What do young people think about the effects of the pandemic?

After the discussion, the investigators discovered 4 major themes based on the transcripts. First, they learned that young people are aware of the impact of the pandemic on others. Some members of the discussion group cited challenges with communication and technology with the elderly, and others cited challenges for parents and those who are socially disadvantaged.
When thinking about how the pandemic affects their own lives, members of the discussion group said they were impacted in terms of their education. School closures “overwhelmed” one discussion group member, while another said their suspended exams and social isolation were a challenge introduced by the pandemic.

Returning to school was problematic for one member of the group, who said just because their age group is apparently at a lower risk for contracting and spreading COVID-19 “doesn’t mean we should be the first to have to fully go back and reintegrate.” Social distancing in classrooms may be present, another member added, but at lunchtimes and breaks there is no enforcement of social distancing, so it becomes a moot point.

The final theme identified was challenges in communication of reliable information to young people about the ongoing pandemic. One focus group member said they felt entitled to the same information as an adult, even if the presentation might be different. Another member said they felt like recipients of information only, instead of listening to young people’s concerns. A third speaker suggested that students fill out a survey to help government officials incorporate their concerns and believes into developing policy.

“The discussion held in this focus group with 15 young people provided remarkable insight on their awareness of moral issues concerning themselves, their families and the wider community, consistent with higher levels of moral development,” the study authors wrote. “They demonstrated knowledge of themselves over time in respect of future ambitions and need for education. Additionally, participants expressed willingness to participate in the response and recovery process by actively looking for both information sources and means to voice their views. However, most acknowledged the lack of opportunities to express their opinions and actively participate in the process.”

The young people in the discussion group had sophisticated opinions and medical knowledge, the study authors said, but sometimes they felt as though the information they received was complicated, confusing, and even occasionally contradictory. They also felt that if they were confused, others would surely also be confused, the study authors said.

“From this limited study, it seems clear that young people have relevant concerns about themselves (especially their future), their family and broader society,” the study authors concluded. “They feel that they should have an active part to play in both return to school and the recovery process, though they have had little mechanism as yet to do so. They do not see themselves as either pathfinders or pawns, but rather partners in society’s emergence from the pandemic.”

The response to the pandemic had a focus group of young people concerned for not only themselves but others as well.

Young People Concerned for Others, Themselves in Response to COVID-19

Black children with Kawasaki disease had more severe inflammation, received more ancillary treatments, and had longer hospitalizations compared to white children, according to a 

Investigators from the University of Alabama at Birmingham performed a retrospective analysis of 192 white and 177 Black children in order to determine if there were any determine if there were any differences in Kawasaki disease characteristics and clinical outcomes between the two groups of children.They also wanted to examine whether there were any disparities between the groups that could be explained by differences in health care delivery or biological factors, the study authors wrote. The investigators identified the patients through their admittance to the Children’s Hospital of Alabama between January 2000 and May 2015.

There were no differences between the Black and white cohorts in differences in age at admission or sex, the investigators reported. They did note that white children presented more frequently with conjunctivitis and rash compared to Black children, but there were no other significant differences in clinical presentation.

For all patients that received Intravenous Immunoglobulin (IVIG), regardless of the number of days from fever onset to infusion, there were no significant differences reported by the investigators between the white and Black children. Where 94% of Black children received IVIG within 10 days of fever onset, per the American Heart Association guidelines, 89% of white children received the infusion within 10 days of fever onset.

Black children had a lower IVIG response rate compared to white children (86% vs. 95%, respectively). More black children than white children received alternative therapies, though, and black children also had longer lengths of hospital stay (4.5 compared to 3.4 days, respectively), the study authors wrote.

The two cohorts also showed that ECHOs were performed at a similar time for groups. The study authors determined that both groups showed a similar percentage of abnormal echo, but there was a trend toward performing more subsequent ECHOs during the hospitalization stay for black children. Black children were observed to show a significantly greater proportion of persistent CA dilation or aneurysm compared to white children at follow-up, the study authors found.

“We examined children living in the same state, suggesting that differences in immune response could potentially be due to genetics, although cultural or environmental exposure discrepancies cannot be ruled out,” the study authors wrote. “Studies in adults show that African ancestry specifically predicts a stronger inflammatory response to pathogens, and this response may have an evolutionary and genetic basis that could have broad implication to health disparities.”

Putting these findings in the context of the current medical climate, the study authors said that their findings showing that black children show a greater inflammatory response to an unknown environmental trigger is particularly interesting in light of the racial disparities seen during the COVID-19 pandemic.

“Kawasaki disease produces inflammatory and cytokine responses, which resemble those noted after infection with Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2),” the study authors said. “Accordingly, multiple reports are emerging throughout the world that children are exhibiting symptoms from Multisystem Inflammatory Syndrome in Children (MIS-C), which resemble those for Kawasaki disease during the pandemic.”

The study authors said 2 smaller studies that were previously conducted found similar results; Black children in those studies had a higher prevalence of IVIG resistance or a greater persistence of CA abnormalities, too. However, another study found contradictory results, though it didn’t define criteria for CA abnormalities or include a comparable, sizable white population.

“For the most part, race has rarely been accounted for in predictive models or during statistical analyses for clinical trials,” the study authors concluded. “Therefore, evaluation of these risks scores by race, specifically in blacks is warranted.”

Putting these findings in the context of the ongoing coronavirus crisis was especially important, the study authors said.

Author | Rachel Lutz

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