Treatment options are currently limited for persons with HIV-1 (PWH) who are heavily treatment-experienced and/or have multidrug-resistant HIV-1. Three agents have been approved by the U.S. Food and Drug Administration (FDA) since 2018, representing a significant advancement for this population: ibalizumab, fostemsavir, and lenacapavir. However, there is a paucity of recommendations endorsed by national and international guidelines describing the optimal use (e.g., selection and monitoring after initiation) of these novel antiretrovirals in this population. To address this gap, a modified Delphi technique was used to develop these consensus recommendations that establish a framework for initiating and managing ibalizumab, fostemsavir, or lenacapavir in PWH who are heavily treatment-experienced and/or have multidrug-resistant HIV-1. In addition, future areas of research are also identified and discussed in the main document.

Treatment options are currently limited for persons with HIV-1 (PWH) who are heavily treatment-experienced and/or have multidrug-resistant HIV-1. Three agents have been approved by the U.S. Food and Drug Administration (FDA) since 2018, representing a significant advancement for this population: ibalizumab, fostemsavir, and lenacapavir. However, there is a paucity of recommendations endorsed by national and international guidelines describing the optimal use (e.g., selection and monitoring after initiation) of these novel antiretrovirals in this population. To address this gap, a modified Delphi technique was used to develop these consensus recommendations that establish a framework for initiating and managing ibalizumab, fostemsavir, or lenacapavir in PWH who are heavily treatment-experienced and/or have multidrug-resistant HIV-1. In addition, future areas of research are also identified and discussed.

OBJECTIVE: This guideline provides an update on the care of pregnant women living with HIV and the prevention of perinatal HIV transmission. This guideline is a revision of the previous guideline, No. 310 Guidelines for the Care of Pregnant Women Living With HIV and Interventions to Reduce Perinatal Transmission, and includes an updated review of the literature with contemporary recommendations.
METHODS: Pregnant women newly diagnosed with HIV during antenatal screening and women living with HIV who become pregnant. This guideline does not include specific guidance for girls/women of reproductive age living with HIV who are not pregnant.
RESULTS: Prevention of perinatal HIV transmission is a key indicator of the success of a health care system and requires multidisciplinary care of pregnant women living with HIV. Intended outcomes include guidance on best practice in perinatal management for Canadian health care providers for pregnant women living with HIV; reduction of perinatal transmission of HIV toward a target of eradication of perinatal transmission; provision of optimal antenatal care for pregnant women to ensure the best maternal health outcomes and HIV suppression; and evidence-based support and recommendations for pregnant women living with HIV, maintaining awareness and consideration of the complex psychosocial impacts of living with HIV.
RESULTS: The perinatal transmission of HIV has significant morbidity and mortality implications for the child, with associated lifelong health care costs. Pregnancy presents an emotionally and physically vulnerable time for pregnant women as well as an opportunity to engage them in health promotion. This guidance does not include recommendations with additional costs to health care facilities compared with the previous guideline. Application of the recommendations is aimed at health benefits to both mother and child by optimizing maternal health and preventing perinatal HIV transmission.
METHODS: Published and unpublished literature was reviewed with a focus on publications post-2013. OVID-Medline, Embase, PubMed and the Cochrane Library databases were searched for relevant publications available in English or French for each section of this guideline. Results included systematic reviews, randomized controlled trials, and observational studies published from 2012 to 2022. Searches were updated on a regular basis and incorporated in the guideline until May 2023. Unpublished literature, protocols, and international guidelines were identified by accessing the websites of health-related agencies, clinical practice guideline collections, and national and international medical specialty societies.
METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional recommendations).
UNASSIGNED: The intended users of this guideline include obstetric care providers and infectious disease clinicians who provide care for pregnant women living with HIV.
UNASSIGNED: Updated Canadian HIV in pregnancy guideline informed by global research and tailored to Canadian healthcare needs and goals for pregnant women living with HIV and their families.
CONCLUSIONS: RECOMMENDATIONS.

BACKGROUND: The syndemic nature of gonococcal infections and HIV provides an opportunity to develop a synergistic intervention tool that could address the need for adequate treatment for gonorrhea, screen for HIV infections, and offer pre-exposure prophylaxis (PrEP) for persons who meet the criteria. By leveraging information available on electronic health records, a clinical decision support (CDS) system tool could fulfill this need and improve adherence to Centers for Disease Control and Prevention (CDC) treatment and screening guidelines for gonorrhea, HIV, and PrEP.
OBJECTIVE: The goal of this study was to translate portions of CDC treatment guidelines for gonorrhea and relevant portions of HIV screening and prescribing PrEP that stem from a diagnosis of gonorrhea as an electronic health record-based CDS intervention. We also assessed whether this CDS solution worked in real-world clinic.
METHODS: We developed 4 tools for this CDS intervention: a form for capturing sexual history information (SmartForm), rule-based alerts (best practice advisory), an enhanced sexually transmitted infection (STI) order set (SmartSet), and a documentation template (SmartText). A mixed methods pre-post design was used to measure the feasibility, use, and usability of the CDS solution. The study period was 12 weeks with a baseline patient sample of 12 weeks immediately prior to the intervention period for comparison. While the entire clinic had access to the CDS solution, we focused on a subset of clinicians who frequently engage in the screening and treatment of STIs within the clinical site under the name \"X-Clinic.\" We measured the use of the CDS solution within the population of patients who had either a confirmed gonococcal infection or an STI-related chief complaint. We conducted 4 midpoint surveys and 3 key informant interviews to quantify perception and impact of the CDS solution and solicit suggestions for potential future enhancements. The findings from qualitative data were determined using a combination of explorative and comparative analysis. Statistical analysis was conducted to compare the differences between patient populations in the baseline and intervention periods.
RESULTS: Within the X-Clinic, the CDS alerted clinicians (as a best practice advisory) in one-tenth (348/3451, 10.08%) of clinical encounters. These 348 encounters represented 300 patients; SmartForms were opened for half of these patients (157/300, 52.33%) and was completed for most for them (147/300, 89.81%). STI test orders (SmartSet) were initiated by clinical providers in half of those patients (162/300, 54%). HIV screening was performed during about half of those patient encounters (191/348, 54.89%).
CONCLUSIONS: We successfully built and implemented multiple CDC treatment and screening guidelines into a single cohesive CDS solution. The CDS solution was integrated into the clinical workflow and had a high rate of use.

BACKGROUND: Population size, prevalence, and incidence are essential metrics that influence public health programming and policy. However, stakeholders are frequently tasked with setting performance targets, reporting global indicators, and designing policies based on multiple (often incongruous) estimates of these variables, and they often do so in the absence of a formal, transparent framework for reaching a consensus estimate.
OBJECTIVE: This study aims to describe a model to synthesize multiple study estimates while incorporating stakeholder knowledge, introduce an R Shiny app to implement the model, and demonstrate the model and app using real data.
METHODS: In this study, we developed a Bayesian hierarchical model to synthesize multiple study estimates that allow the user to incorporate the quality of each estimate as a confidence score. The model was implemented as a user-friendly R Shiny app aimed at practitioners of population size estimation. The underlying Bayesian model was programmed in Stan for efficient sampling and computation.
RESULTS: The app was demonstrated using biobehavioral survey-based population size estimates (and accompanying confidence scores) of female sex workers and men who have sex with men from 3 survey locations in a country in sub-Saharan Africa. The consensus results incorporating confidence scores are compared with the case where they are absent, and the results with confidence scores are shown to perform better according to an app-supplied metric for unaccounted-for variation.
CONCLUSIONS: The utility of the triangulator model, including the incorporation of confidence scores, as a user-friendly app is demonstrated using a use case example. Our results offer empirical evidence of the model\'s effectiveness in producing an accurate consensus estimate and emphasize the significant impact that the accessible model and app offer for public health. It offers a solution to the long-standing problem of synthesizing multiple estimates, potentially leading to more informed and evidence-based decision-making processes. The Triangulator has broad utility and flexibility to be adapted and used in various other contexts and regions to address similar challenges.

More than 62,000 individuals are currently on antiretroviral treatment within the public health system in Argentina. In 2019, more than 50% of people on ART received non-nucleoside reverse transcriptase inhibitors (NNRTIs). In this context, the second nationwide HIV-1 pretreatment drug resistance surveillance study was carried out between April and December 2019 to assess the prevalence of HIV-1 drug resistance in Argentina using the World Health Organization guidelines. This was a nationwide cross-sectional study enrolling consecutive 18-year-old and older individuals starting ARVs at 19 ART-dispensing centers. This allowed us to estimate a point prevalence rate of resistance-associated mutations (RAMs) with a confidence interval (CI) of 5% (for the total population and for those without antiretroviral exposure). Four-hundred forty-seven individuals were included in the study. The prevalence of mutations associated with resistance was detected in 27.7% (95% CI 25.6-34.9%) of the population. For NNRTI, it was 19.6% (95% CI 16.3-24.5%), for integrase strand transfer inhibitor (INSTI) 6.1% (95% CI 6.1-11.9%), for nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) 3% (95% CI 1.9-5.9%), and for protease inhibitors 1.5% (95% CI 0.7-3.6%). Naive individuals had variants of resistance to NRTIs in 16.8% (95% CI 12.8-21.4) and 5.7% (95% CI 2.9-15.9) to INSTI. For experienced individuals, the prevalence of variants associated with resistance was 30.38% (95% CI 20.8-42.2) for NRTIs and 7.7% (95% CI 2.9-15.9) for INSTI. This study shows an increase in the frequency of nonpolymorphic RAMs associated with resistance to NNRTI. This study generates the framework of evidence that supports the use of schemes based on high genetic barrier integrase inhibitors as the first line of treatment and the need for the use of resistance test before prescribing schemes based on NNRTI. We report for the first time the presence of a natural polymorphism associated with the most prevalent recombinant viral form in Argentina and the presence of a mutation linked to first-line integrase inhibitors such as raltegravir.

Women living with human immunodeficiency virus (HIV) today have life expectancies comparable to the general female population, leading to a growing number transitioning through menopause. Recent studies have highlighted healthcare professionals\' lack of confidence in managing menopause in women with HIV, raising concerns about potential mismanagement. This review explores and compares information on menopause management in HIV-specific and general guidelines, with the aim of identifying disparities and assessing the comprehensiveness of HIV guidelines. The focus is on three key areas: the diagnosis of menopause, and the assessment and treatment of menopausal symptoms. Additionally, the review evaluates the usage and characteristics of menopausal symptom assessment scales known to have been used in studies involving women living with HIV. In total, five HIV and six general menopause management guidelines, published between 2015 and 2023, were identified through medical databases, internet search engines and searches of reference lists. Five menopausal symptom assessment scales were also included for review. The findings suggest minimal differences in recommendations for treating menopausal symptoms. The HIV guidelines include recommendations on screening for menopause, and some raise awareness of the possibility of drug-to-drug interactions, but none offers guidance on how to diagnose menopause or how to differentiate between HIV-related and menopause-related symptoms. Upon examining the characteristics of the menopausal symptom assessment scales, we found that none had been validated specifically for women with HIV. In conclusion, this review advocates for the development of a comprehensive guideline that addresses all relevant factors in managing menopause in women with HIV.

UNASSIGNED: Worldwide, more than 39 million individuals are living with human immunodeficiency virus (HIV), 296 million with chronic hepatitis B (HBV), and 58 million with chronic hepatitis C (HCV). Despite successful treatments for these blood-borne viruses (BBVs), >1.7 million people die per annum. To combat this, the World Health Organization recommended implementing triple testing for HIV, HBV, and HCV. This systematic review aims to provide evidence for this policy, by identifying the prevalence of these BBVs and discussing the costs of available triple tests.
UNASSIGNED: Medline, Embase, and Global Health were searched to identify articles published between 1 January and 24 February 2023. Included studies reported the prevalence of HIV (anti-HIV 1/2 antibodies), HBV (hepatitis B surface antigen) and HCV (anti-HCV antibodies). Results were stratified into risk groups: blood donors, general population, healthcare attendees, individuals experiencing homelessness, men who have sex with men, people who use drugs, pregnant people, prisoners, and refugees and immigrants.
UNASSIGNED: One hundred seventy-five studies sampling >14 million individuals were included. The mean prevalence of HIV, HBV, and HCV was 0.22% (standard deviation [SD], 7.71%), 1.09% (SD, 5.80%) and 0.65% (SD, 14.64%) respectively. The mean number of individuals testing positive for at least 1 BBV was 1.90% (SD, 16.82%). Therefore, under triple testing, for every individual diagnosed with HIV, another 5 would be diagnosed with HBV and 3 with HCV. Testing for all 3 viruses is available for US$2.48, marginally more expensive than the lowest-priced isolated HIV test ($1.00).
UNASSIGNED: This article highlights a potential avenue for healthcare improvement by implementing combination testing programs. Hopefully, this will help to achieve the Sustainable Development Goal of elimination of these BBV epidemics by 2030.

In this viewpoint, we discuss retention in care for people with human immunodeficiency virus (HIV) and call into question the methodology used to characterize retention, as well as the definitions themselves. Optimal retention for people with HIV (PWH) is defined in multiple ways by major healthcare leaders in the United States, typically focusing on appointment attendance or laboratory work. Yet, these definitions rely on in-person encounters, an approach to care that is becoming less common due to the rise of telehealth visits, particularly in light of the coronavirus disease 2019 pandemic. Our recent work showed that relying on electronic health records to identify PWH who were not retained in care not only failed to capture the nuances of modern HIV medical treatment engagement, but also led to misidentification of patients\' retention status due to limitations in the record system. As such, we recommend a reevaluation of how HIV medical care retention is defined and reported.

Patients often present to emergency departments after potential or confirmed exposure to human immunodeficiency virus (HIV) asking for recommendations concerning the initiation of post-exposure prophylaxis (PEP). These presentations may occur after occupational as well as non-occupational exposure. PEP entails taking a triple antiretroviral therapy for 28-30 days. If taken early (ideally within 2 h, but no later than 72 h) and as indicated, HIV infection can be prevented with a high level of probability. Since these presentations occur around the clock, they require basic expertise on the part of the emergency department staff regarding its indication and its side effects as well as standardized procedures in the emergency department to not delay initiation. Patients should present to an infectious disease outpatient clinic or practice specialized in HIV in order to have the indication reviewed by a specialist and, if necessary, adapted to complex cases with the aim of making individual case decisions. This review article aims to summarize core statements of the 2022 German-Austrian guideline on HIV post-exposure prophylaxis and to give emergency department staff necessary knowledge to safely and correctly begin PEP.
In zentralen Notaufnahmen stellen sich regelmäßig Patienten nach vermutetem oder gesichertem Kontakt mit dem humanen Immundefizienzvirus (HIV) vor, um dort bezüglich der Indikation einer Postexpositionsprophylaxe (PEP) beraten zu werden. Diese Vorstellungen können nach Risikokontakten im Rahmen einer Tätigkeit im Gesundheitswesen oder aber nach Kontakten im privaten Umfeld erfolgen. Bei der PEP handelt es sich um eine Dreifachkombination antiretroviraler Substanzen, die über 28–30 Tage eingenommen werden müssen. Bei frühzeitiger (im Idealfall innerhalb von 2 h, jedoch nicht später als 72 h) und indikationsgerechter Einnahme kann eine Infektion mit HIV mit hoher Wahrscheinlichkeit verhindert werden. Da derartige Vorstellungen rund um die Uhr erfolgen können, erfordern sie neben einer Grundexpertise des Notaufnahmepersonals bezüglich der PEP-Indikation, ihrer Nebenwirkungen und ihrer Durchführung standardisierte Abläufe in der Notaufnahme, um den Beginn nicht zu verzögern. Am nächsten Werktag sollte eine Vorstellung in einer infektiologischen Ambulanz bzw. einer HIV-Schwerpunktpraxis erfolgen, um die Indikation fachärztlich zu prüfen und sie ggf. im Sinne von Einzelfallentscheidungen an komplexe Fälle anzupassen. Dieser Übersichtsartikel soll die Kernaussagen der 2022 überarbeiteten deutsch-österreichischen Leitlinie zur medikamentösen Postexpositionsprophylaxe nach HIV-Exposition zusammenfassen und dem Personal in Notaufnahmen Sicherheit beim Beginn der PEP geben.