Long-acting injectable antiretroviral therapy (LAI-ART) is approved for treatment-naive or experienced people with human immunodeficiency virus (HIV; PWH) based on trials that only included participants with viral suppression. We performed the first LAI-ART demonstration project to include PWH unable to achieve or maintain viral suppression due to challenges adhering to oral ART. Ward 86 is a large HIV clinic in San Francisco that serves publicly insured and underinsured patients. We started patients on LAI-ART via a structured process of provider referral, multidisciplinary review (MD, RN, pharmacist), and monitoring for on-time injections. Inclusion criteria were willingness to receive monthly injections and a reliable contact method. Between June 2021 and April 2022, 51 patients initiated LAI-ART, with 39 receiving at least 2 follow-up injections by database closure (median age, 46 years; 90% cisgender men, 61% non-White, 41% marginally housed, 54% currently using stimulants). Of 24 patients who initiated injections with viral suppression (median CD4 cell count, 706 cells/mm³), 100% (95% confidence interval [CI], 86%–100%) maintained viral suppression. Of 15 patients who initiated injections with detectable viremia (median CD4 cell count, 99 cells/mm³; mean log₁₀ viral load, 4.67; standard deviation, 1.16), 12 (80%; 95% CI, 55%–93%) achieved viral suppression, and the other 3 had a 2-log viral load decline by a median of 22 days. This small demonstration project of LAI-ART in a diverse group of patients with high levels of substance use and marginal housing demonstrated promising early treatment outcomes, including in those with detectable viremia due to adherence challenges. More data on LAI-ART in hard-to-reach populations are needed.

Illicit drug use (DU) and hazardous drinking (HD) among marginalized populations may be associated with greater barriers to care. We used baseline data on the participants of the Seek, Test, Treat, and Retain data harmonization initiative. DU includes use of any illicit drugs within the past 6 months. HD was defined as scores ≥8 for men and ≥ 7 for women on Alcohol Use Disorders Identification Test within the past 12 months. Social support scores were assigned by summing scores from individual questions related to social support. Two outcomes for multivariable regression models and mediation analysis were perceived access to care and perceived barriers to care scores, calculated from summated points from individual questions within each domain. All models were adjusted for age, gender, race/ethnicity, and social support and stratified by HIV status. Among 1403 illicit drug users and 4984 non-drug users, the mean age was 39.6 ± 12.2 years old, 71% were male, 57% African Americans, and 39% Hispanic/Latinos. Over 25% reported difficulties in covering medical costs and finding transportation to health care facilities and greater proportions of drug users and hazardous drinkers reported these issues than non-DU/non-HD. In multivariable models, DU and HD were both independently associated with having greater barriers to care (β: 0.49 (95% confidence interval: 0.19 to 0.79) p < 0.01; 0.31 (0.18 to 0.45) < 0.01) in HIV-negative participants. Neither DU nor HD was strongly associated with barriers to care for HIV-positive participants. Social support was associated with better perceived access to care and fewer barriers to care in the HIV-negative participants. The current study found that financial burdens of care, logistical difficulties in accessing care, and low social support were common challenges among individuals using illicit drugs and/or drinking hazardously. Addressing structural barriers and strengthening social support may be important strategies to improve health care among marginalized populations, regardless of HIV status.

Background: The relationship of internalized HIV stigma to key care cascade metrics in the United States is not well established using large-scale, geographically diverse data. Setting: Center for AIDS Research Network of Integrated Clinical Systems (CNICS) cohort study. Methods: Beginning in February 2016, we administered a yearly, validated 4-item internalized HIV stigma scale (response scale 1 = strongly disagree to 5 = strongly agree, Cronbach's alpha 0.91) at 7 CNICS sites and obtained cohort data through November 2017. We compared mean stigma levels by sociodemographic characteristics and used multivariable logistic regression, controlling for the same sociodemographic covariates, to evaluate the association between mean stigma and (1) concurrent viremia; (2) missed visits; and (3) poor visit constancy. We used inverse probability weighting (IPW) to account for differences between patients who did and did not undergo stigma assessment. Results: Of 13,183 CNICS patients, 6448 (49%) underwent stigma assessment. Mean stigma was 1.99 (SD 1.07), and 28.6% agreed/strongly agreed with at least 1 stigma question. Patients younger than 50 years, racial/ethnic minorities, cis-women, and heterosexuals had higher mean stigma. Mean stigma score was associated with concurrent viremia [adjusted odds ratio (AOR) 1.13, 95% confidence interval (CI): 1.02 to 1.25, P 0.02], missed visits (AOR 1.10, 95% CI: 1.02 to 1.19, P 0.01), and poor visit constancy, although the effect on visit constancy was attenuated in the IPW model (AOR 1.05, 95% CI: 0.98 to 1.13, P 0.17). Conclusions: Higher internalized HIV stigma had a modest but statistically significant association with concurrent viremia and poor retention in care. Further inquiry with prospective analyses is warranted.

Background: We previously demonstrated at the Ward 86 human immunodeficiency virus (HIV) clinic in San Francisco that long-acting (LA) cabotegravir (CAB)/rilpivirine (RPV) (LA-CAB/RPV) can rapidly lead to viral suppression in people with HIV (PWH) with viremia due to adherence challenges. We now evaluate the durability of viral suppression in this population. Methods: We conducted a retrospective cohort study of PWH who started LA-CAB/RPV with viremia (HIV RNA viral load ≥50 copies/mL) before December 2022. Our primary outcome was viral suppression (viral load 14 days) at 48 weeks, using the viral load closest to 48 ± 8 weeks. We also describe viral failure, defined as a <2-log decline in viral load at 4 weeks or a viral load ≥200 copies/mL after initial viral suppression with emergent CAB- or RPV-associated resistance mutations; overall 48-week viral suppression including those switched to alternative antiretroviral therapy (ART). Results: Fifty-nine PWH initiated LA-CAB/RPV with viremia and were included in the analysis; 49% had a CD4 cell count <200/µL, and the median baseline viral load was 42 900 copies/mL (quarter 1–quarter 3, 5272–139 038). At 48 weeks, 47 PWH met the primary outcome of viral suppression with LA-CAB/RPV persistence (80% [95% confidence interval, 67%–89%]). Five had viral failure with resistance (3 with RPV-associated and 2 with CAB- and RPV-associated mutations), and 1 was lost to follow-up. At week 48, 2 of those with viral failure were suppressed on alternative regimens (lenacapavir + bictegravir/tenofovir alafenamide/emtricitabine and CAB + lenacapavir). The overall viral suppression at week 48 with either LA-CAB/RPV or alternative ART was 92% (54 of 59). Conclusions: In PWH initiating LA-CAB/RPV with initial viremia, 48-week viral suppression (<50 copies/mL) was seen in 92%. LA ART can be an important tool for improving viral suppression among patients who face adherence challenges to oral ART.

Objective: We sought to examine the prospective association between internalized HIV stigma and unsuppressed viral load and to investigate whether this relationship was sequentially mediated by depressive symptoms and antiretroviral therapy (ART) adherence. Design: Longitudinal study in a multisite observational clinical cohort. Methods: The Center for AIDS Research Network of Integrated Clinical Systems patient-reported outcomes survey measures internalized HIV stigma yearly using a four-item assessment (response scale 1 = strongly disagree to 5 = strongly agree). We obtained patient-reported outcome, lab, and appointment data from six center for AIDS research network of integrated clinical systems sites. We used multivariable logistic regression to examine the association between mean stigma and subsequent viremia. We then used Bayesian sequential mediation to fit a longitudinal sequential path model spanning four time points to test if depressive symptoms at T₁ and ART adherence at T₂ mediated the effect of stigma at T₀ on viral load at T₃, adjusting for baseline covariates. Results: Between February 2016 and November 2018, 6859 patients underwent stigma assessment and were 81% cis-men, 38% Black, 16% Latinx, 32% heterosexual-identified, and 49% at least 50 years of age. Mean stigma level was 2.00 (SD 1.08). Stigma was significantly associated with subsequent viremia (adjusted odds ratio = 1.16, 95% confidence interval: 1.05–1.28, P = 0.004), as were younger age and Black race. The chained indirect effect from stigma to unsuppressed viral load through depressive symptoms and then adherence was significant (standardized β = 0.002; SD = 0.001). Conclusion: Internalized HIV stigma positively predicts subsequent viremia through depressive symptoms and ART adherence. Addressing the link between stigma and depressive symptoms could help improve viral suppression.

Introduction: Clinic-based tracing efforts and public health surveillance data can provide different information about HIV care status for the same patients. The relative yield and how best to use these sources to identify and reengage out-of-care patients is unknown. Methods: At a large public HIV clinic in San Francisco, we selected a 10% random sample of active patients who were at least 210 days “late” for an HIV primary care visit as of April 1, 2013, for clinic-based outreach. Patients were considered out of care if they did not have an HIV primary care visit in the 210 days before April 1, 2013. We then matched the sample with the San Francisco Department of Public Health HIV surveillance registry. Patients with a CD4 or viral load result in the 210-day period were classified as in care. We compared results from both sources and estimated the cumulative incidence of disengagement from care for the full cohort of clinic patients. Results: Of 940 patients lost to follow-up, 95 were sampled. Clinic tracing found 60 (63%) in care, 23 (24%) not located, 9 (10%) out of care, 2 (2%) incarcerated, and 1 (1%) had died. Of 42 individuals surveillance classified as out of care, tracing found 22 (52%) were in care. Of 52 patients found to be in care by surveillance, 12 (23%) were out of care by clinic tracing or unable to be located. The naive estimate of the cumulative incidence of disengagement from care at 3 years for the active clinic cohort was 41.1% [95% confidence interval (CI): 37.6 to 44.5]. The use of surveillance data reduced this estimate to 12.7% (95% CI: 18.2 to 25.4), and when further corrected using tracing outcomes, the estimate dropped to only 6.4% (95% CI: 3.4 to 9.4). Conclusions: Clinic-based tracing and surveillance data together provide a better understanding of care status than either method alone. Using surveillance data to inform clinic-based outreach efforts may be an effective strategy, although tracing efforts are most likely to be successful if conducted in real time.