Publications

Pre-exposure prophylaxis (PrEP) with oral tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) prevented HIV acquisition among men and women in several trials and is broadly recommended. In the VOICE and FEM-PrEP trials, however, TDF/FTC-based PrEP did not prevent HIV acquisition among women in eastern and southern Africa. Tenofovir was detected in plasma, reflecting exposure and adherence in recent days, in fewer than one-third of participants. Drug concentrations in hair, which represent cumulative exposure and adherence over weeks to months, have never previously been examined among women on PrEP. We compared tenofovir hair concentrations among women assigned to oral TDF/FTC in the VOICE trial to those among men and transgender women enrolled in 2 open-label PrEP studies, the iPrEx open-label extension (OLE) study and the U.S. PrEP Demonstration Project (PrEP Demo). Tenofovir hair concentrations were detectable in 55% of person-visits in VOICE, 75% of person-visits in iPrEx OLE (p = .006), and 98% of person-visits in PrEP Demo (p < .001). Median tenofovir hair concentrations corresponded to an estimated 0.2, 2.9, and 6.0 TDF/FTC doses taken per week in the three studies, respectively. In VOICE, combining tenofovir concentration data from plasma and hair suggested inconsistent, low-level product use. Incorporation of both short- and long-term adherence measures may allow for an improved understanding of patterns of drug-taking among women during global PrEP roll-out.

BACKGROUND

The 2014-15 Ebola virus disease (EVD) epidemic strained health systems in west Africa already overburdened with other diseases, including malaria. Because EVD and malaria can be difficult to distinguish clinically, and rapid testing was not available in many Ebola Treatment Units (ETUs), guidelines recommended empirical malaria treatment. Little is known, however, about the prevalence and characteristics of patients entering an ETU who were infected with malaria parasites, either alone or concurrently with Ebola virus.

METHODS

Data for sociodemographics, disease characteristics, and mortality were analysed for patients with suspected EVD admitted to three ETUs in Sierra Leone using a retrospective cohort design. Testing for Ebola virus was done by real-time PCR and for malaria by a rapid diagnostic test. Characteristics of patients were compared and survival analyses were done to evaluate the effect of infection status on mortality.

FINDINGS

Between Dec 1, 2014, and Oct 15, 2015, 1524 cases were treated at the three ETUs for suspected EVD, of whom 1368 (90%) had diagnostic data for malaria and EVD. Median age of patients was 29 years (IQR 20-44) and 715 (52%) were men. 1114 patients were EVD negative, of whom 365 (33%) tested positive for malaria. Of 254 EVD positive patients, 53 (21%) also tested positive for malaria. Mortality risk was highest in patients diagnosed with both EVD and malaria (35 [66%] of 53 died) and patients diagnosed with EVD alone (105 [52%] of 201 died). Compared with patients presenting to ETUs without malaria or EVD, mortality was increased in the malaria positive and EVD positive group (adjusted hazard ratio 9·36, 95% CI 6·18-14·18, p<0·0001), and the malaria negative and EVD positive group (5·97, 4·44-8·02, p<0·0001), but reduced in the malaria positive and EVD negative group (0·37, 0·20-1·23, p=0·0010).

INTERPRETATION

Malaria parasite co-infection was common in patients presenting to ETUs and conferred an increased mortality risk in patients infected with Ebola virus, supporting empirical malaria treatment in ETUs. The high mortality among patients without EVD or malaria suggests expanded testing and treatment might improve care in future EVD epidemics.

FUNDING

International Medical Corps.

Syndrome of inappropriate anti-diuretic hormone (SIADH) has been reported to be associated with systemic Strongyloides stercoralis. Here, we report a case of a stem cell transplant (SCT) recipient who developed severe SIADH secondary to systemic S Stercoralis. The SIADH resolved quickly after treating the systemic S Stercoralis with ivermectin. A systematic review of the literature was performed by PubMed, Scopus, and Cochrane database search. Only eight cases of S Stercoralis in allogeneic SCT recipients have been previously reported. To our knowledge, ours is the first reported case of SIADH secondary to S Stercoralis infection in an allogeneic SCT recipient. Prior to transplantation, even if asymptomatic, patients from endemic regions should be screened with strongyloides immunoglobulin (Ig)G serology. Pretransplantation eosinophilia should be evaluated by screening multiple stool samples for ova and parasites. Transplant candidates with positive serology or stool tests can be treated pretransplantation to eradicate infection. Patients at risk for S Stercoralis who develop nonspecific gastrointestinal complaints, rash, pulmonary infiltrates, or gram-negative bacteremia or meningitis may have S Stercoralis hyperinfection syndrome. Our case indicates that the development of SIADH may be an additional clue to this diagnosis. Appropriate diagnostic studies, including repeat stool and other body fluid sampling, should be expedited and ivermectin therapy initiated rapidly to prevent significant morbidity and mortality.

BACKGROUND

Trans*female youth (TFY) carry a disproportionate burden of HIV. Few longitudinal studies have analyzed both proximal and upstream predictors of changes in HIV-related risk behaviors for TFY. The aim of the present analysis was to identify psychosocial predictors of changes in sexual risk behavior over time for TFY in the San Francisco Bay Area.

METHODS

Data come from the SHINE cohort study conducted at the San Francisco Department of Public Health from 2012 to 2014 (n = 263). The relationship between hypothesized psychosocial factors and changes in engagement in condomless receptive anal intercourse over 12-month follow-up was modeled using generalized estimating equations, after adjusting for participant age, race/ethnicity, and education level.

RESULTS

TFY who were ever in a serious relationship since identifying as trans* [adjusted odds ratio (aOR) = 1.89, 95% confidence interval (CI): 1.16 to 3.08], those who reported recent crack/cocaine use (aOR = 2.01, 95% CI: 1.05 to 3.85), and those with a monthly income of more than $500 (aOR = 0.55, 95% CI: 0.35 to 0.85) had significantly higher odds of condomless receptive anal intercourse over the 12-month study period compared to TFY without these exposures. Those who reported high exposure to gender-based discrimination had increased adjusted odds of engagement in condomless receptive anal intercourse compared to those who had low exposure over the study period (aOR = 1.70, 95% CI: 1.10 to 2.63).

CONCLUSIONS

Both proximal and structural factors predicted increased engagement in sexual risk behavior among TFY. Results demonstrate the need for a multilevel approach to HIV prevention strategies for this population.