Liver steatosis is increasingly recognized as a major comorbidity in people living with HIV (PLWH), with growing evidence suggesting an increased risk of progression to advanced liver disease. We assessed predictors of liver steatosis progression over 36 months in PLWH from low- and middle-income countries.
Between 2020 and 2023, we enrolled PLWH aged ≥40 years who had been on antiretroviral therapy (ART) for ≥6 months at nine HIV clinics in the IeDEA Sentinel Research Network (SRN) across the Asia-Pacific, the Americas and African IeDEA regions, and followed them prospectively for 36 months. Participants with available and reliable controlled attenuation parameter (CAP) measurements at both enrolment and the 36-month visits were included in the analysis. Steatosis progression was defined as incident steatosis (CAP ≥248 dB/m) or a transition to a higher steatosis grade (moderate ≥268 dB/m; severe ≥280 dB/m) among those with a lower steatosis grade at enrolment. Logistic regression was used to assess predictors of progression.
We included 923 participants (63% female; median age 50 years, interquartile range 45–55) in this analysis. At enrolment, 51% were overweight or obese, 10% had type 2 diabetes mellitus (T2DM), 94% had HIV RNA <1000 copies/mL and 72% were on integrase strand inhibitor (INSTI)-based ART. During the 36-month follow-up, 190 (20%) participants showed steatosis progression, including 147 (74%) with incident steatosis and 49 (26%) with worsening of steatosis grades. The progression rate was significantly higher in Asia-Pacific (33% [95% CI, 24−44]) and the Americas (36% [95% CI, 26−46]) compared to the African regions (17% [95% CI, 14−20]). Independent predictors of steatosis progression were overweight/obesity (aOR: 2.97, 95% CI: 2.03−4.40), T2DM (aOR: 2.41, 95% CI: 1.45−3.96) and dyslipidaemia (aOR: 1.46, 95% CI: 1.01−2.12). In females, INSTI use for ≥2 years at enrolment was additionally associated (aOR 3.19, 95% CI: 1.35−8.01).
Metabolic disorders—including T2DM, overweight/obesity and dyslipidaemia—were associated with steatosis progression in PLWH in our cohort. These findings underscore the need for targeted monitoring and prevention strategies to address this significant public health issue.
Children exposed to HIV but uninfected (CHEU) number approximately 15.7 million globally. In Zambia, an estimated 56,000 CHEU are born annually, representing a substantial proportion of the national birth cohort. CHEU experience a higher risk of neurodevelopmental delay compared to their peers born HIV-unexposed. It is unknown whether the increased neurodevelopment delay burden of CHEU has been diminished by maternal combination antiretroviral therapy.
This prospective observational study analysed a subset of participants from the Zambian Infant Cohort Study (ZICS), which included 1500 pregnant women–infant dyads enrolled at a peri-urban hospital in Zambia. Infants aged 6−24 months were enrolled in a 1:1 ratio of CHEU to CHU and were followed for 18 months. Neurodevelopment was evaluated using the Malawi Developmental Assessment Tool (MDAT) at 6- and 18-month follow-ups. Anthropometrics, Caregiver-Reported Early Development Instruments assessments, eye-tracking and additional assessments were conducted at 6-, 12- and 18-month follow-ups. The primary outcomes were MDAT domain-specific Z-scores for gross motor, fine motor, language and social-adaptive. A series of regression models were fitted with MDAT domain-specific Z-scores as dependent variables, and CHEU versus CHU status as the primary independent variable. All models were adjusted for child birth year, age at assessment, sex, mother's age, education, household size and socioeconomic status.
Between March 2022 and October 2024, a total of 316 mother−infant pairs were enrolled in the study (CHEU, n = 155; CHU, n = 161). MDAT assessments at the 18-month follow-up were done for a total of 286 infants (139 CHEU [89.7%] and 147 CHU [91.3%]). The mean age at 18-month follow-up was comparable between CHEU and CHU (29.1 vs. 28.0 months, respectively). Mean MDAT Z-scores were comparable between CHEU and CHU for all domains, with adjusted mean differences in Z-scores of 0.00 (95% CI: −0.23, 0.23) for gross motor, 0.00 (95% CI: −0.28, 0.27) for fine motor, −0.10 (95% CI: −0.48, 0.28) for language and −0.01 (95% CI: −0.32, 0.30) for social-adaptive.
Neurodevelopmental outcomes at endline were comparable between CHEU and CHU across all the MDAT domains in this peri-urban Zambian cohort.
The BREATHER-Plus trial was an open-label, randomized non-inferiority trial comparing weekends off antiretroviral therapy (ART) (short cycle therapy [SCT]) with daily oral ART (continuous therapy [CT]) for adolescents aged 12–19 years. We present findings from the qualitative sub-study on the factors influencing trial participants’ decisions to take/not take ART in accordance with their randomized arm.
Qualitative data collection was conducted in South Africa and Uganda from December 2022 to July 2024 using in-depth interviews (IDIs) and focus group discussions (FGDs). We purposively recruited 29 trial participants (14 SCT/15 CT arm) to take part in IDIs in South Africa. From the trial sites in both countries, 47 trial participants, 17 non-trial participants, 15 caregivers and 16 healthcare providers took part in FGDs. Data collection with trial participants focused on adherence to SCT compared to daily ART; the acceptability of SCT and the experience of taking part in the trial. All FGDs explored the feasibility of SCT and preferences for alternative approaches to accessing therapy. Data were analysed thematically.
Both IDI and FGD data showed that the opportunity to have weekends off from treatment was welcomed by participants, caregivers and healthcare providers. However, the understanding of “2 days off” treatment was interpreted flexibly by some participants. Trial participants in both arms described their fluctuating adherence practices both prior to and during the trial. The introduction of SCT as a possibility through the trial prompted some to talk about previously concealed missed doses. Participants reported that they only mentioned missed doses in the clinic if they had a raised viral load result or had returned to the clinic with too many pills. Many participants relied on their viral load result to confirm that non-adherent behaviour was not problematic.
Our findings offer insights into the factors that shape ART adherence among adolescents living with HIV. Adherence is not a static behaviour but a socially embedded and relational practice, shaped by adolescents’ interpretations of treatment, interpersonal relationships and the structure of care environments. Regimen modification alone does not resolve the broader social and emotional challenges adolescents face.
This scoping review aimed to characterize the prevalence and determinants of HIV acquisition among transgender women in Southwest Asia and North Africa (SWANA), to describe HIV preventive activities and measures, and to examine barriers to HIV and gender-affirming care, including experiences of stigma, discrimination and mental health challenges among transgender women in the region.
We searched PubMed, PsycINFO and CINAHL for any articles published through 12 June 2026, that included transgender women, used primary or secondary data and were published in Arabic or English. Studies meeting these criteria were screened in Covidence. Discrepancies were resolved following data extraction.
A total of 276 articles were identified (152 duplicates removed). After screening titles and abstracts, 49 full texts were assessed for eligibility. The articles included (N = 23) were primarily cross-sectional studies (N = 20) conducted in Iran, Lebanon, Turkey, Morocco and Tunisia. Three were non-randomized experimental studies; one intervention was designed specifically for transgender women, focusing on gender affirmation and social support. Cross-sectional studies examined HIV prevention, sexual activities and mental health. Condomless receptive anal intercourse and low HIV testing rates were most common among those engaged in sex work, which was attributed to coercion, perceived low risk for HIV acquisition or fear of disclosing one's HIV status. Stigma, physical and sexual violence, anxiety, depression and suicidality were highly prevalent among transgender women in SWANA and served as barriers to accessing healthcare services, including HIV and gender-affirming care.
This review highlights critical areas for trans-specific interventions addressing transgender women's needs in SWANA, where HIV incidence remains on the rise.
Future longitudinal research is needed to evaluate the effectiveness of interventions in reducing HIV rates, improving mental health outcomes and mitigating structural barriers hindering healthcare access among transgender women in SWANA.
Eswatini is rapidly approaching the conditions needed to achieve and sustain HIV epidemic control. Repeating diagnostic testing of people living with HIV (PLHIV) already on antiretroviral therapy (ART) is not typically indicated, can lead to misidentification of new HIV diagnoses and distorts estimates of progress towards epidemic control. This study aimed to quantify retesting among PLHIV on ART and identify associated characteristics, using biomarker-based Recent Infection Surveillance data from routine HIV testing in Eswatini.
The Eswatini HIV-1 Recent Infection Surveillance (EHRIS) programme, launched in July 2019, offered a rapid test for recent infection (RTRI) to PLHIV 15 years and older who tested HIV-positive during routine HIV testing. We analysed survey data collected from 208 HIV testing locations (facility- and community-based) between July 2019 and February 2024. The analysis included data of PLHIV who did not disclose a prior HIV diagnosis during pre-test counselling and subsequently underwent an RTRI. We defined retesting among PLHIV with RTRI recent and VL <1000 copies/mL. Data were analysed to evaluate characteristics of retesting using Rao−Scott chi-square, bivariable and multivariable logistic regression.
Of 1925 adults who provided blood specimens for RTRI and VL testing, 781 (40.6%: 95% CI, 37.1–44.1) had suppressed VLs and were classified as retesting and likely on ART. The adjusted odds ratio (aOR) of retesting was higher if testing occurred at community locations (aOR = 1.9, p = 0.0007), during periods of more restrictive stay-at-home policy (aOR = 1.7, p = 0.005, aOR 2.6, p<0.0001, aOR = 2.1, p<0.0001), among females (aOR = 1.6, p = 0.002), pregnant females (aOR = 1.8, p = 0.001), co-habiting (aOR = 1.8, p = 0.02) or self-reported prior HIV testing (aOR = 1.3, p = 0.03).·
Retests for HIV account for over a third of PLHIV with RTRI recent results in Eswatini. These findings can be used to improve the accuracy of models used to estimate national epidemic trends. Possible mitigation strategies could include strengthening client-centred care, better pre-test counselling, and integrated data systems to confirm previous HIV care status and minimize unnecessary HIV testing of PLHIV who are already on ART.
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