Syndemic perspective of how people living with HIV faced the COVID-19 crisis in North Africa

BackgroundIn 2009, the World Health Organization’s Commission on Social Determinants of Health set out its recommendations for action, which included establishing equity from early childhood onwards by enabling all children and their mothers to benefit from a comprehensive package of quality programmes. In order to address social inequalities in health, it is recommended that action be taken from early childhood, and actions providing support for parenting are an effective lever in this respect.The aim of this review of systematic reviews is to analyse, on the one hand, the components and characteristics of effective interventions in parenting support and, on the other, the extent to which the reviews took into account social inequalities in health.MethodsA total of 796 reviews were selected from peer-reviewed journals published between 2009 and 2016 in French or English. Of these, 21 reviews responding to the AMSTAR and selected ROBIS criteria were retained. These were analysed in relation to the consideration they gave to social inequalities in health according to PRISMA-equity.ResultsThe reviews confirmed that parenting support programmes improved infants’ sleep, increased mothers’ self-esteem and reduced mothers’ anger, anxiety and stress levels. The mainly authors noted that the contexts in which the interventions had taken place were described either scantly or not at all, making it difficult to evaluate them.Only half of the reviews had addressed the question of social inequalities in health. In particular, there had been little research conducted on the relational aspect and the social link.ConclusionIn terms of addressing social inequalities in perinatal health, the approach remains both modest and reductive. Understanding how, for whom and in what conditions interventions operate is one way of optimising their results. Further research is needed to study the interactions between the interventions and their contexts.

Objective. To study the epidemiological, medical, social and clinical factors that affect the manifestations and treatment of diseases — infections caused by the immunodeficiency virus (HIV) and the new coronavirus (SARS-CoV-2), which underlie the formation of a personalized approach to the management and treatment of people living with HIV (PLHIV).Materials and methods. Epidemiological analysis of morbidity and mortality from COVID-19 in the Leningrad region for 2021–2022 was carried out. The research team conducted a questionnaire and analysis of medical documentation of 122 HIVpositive patients registered at the Leningrad Regional Center for the Prevention and Control of AIDS and Infectious Diseases who suffered a novel coronavirus infection (COVID-19) in the period from 2020 to 2022. An assessment was made of the psychological and social characteristics of patients affecting adherence to antiretroviral therapy (ART), the clinical picture of the course of HIV infection, including in combination with COVID-19. The fact of SARS-CoV-2 disease was confirmed by polymerase chain reaction (PCR) smears from the mouth and nasopharynx. Additionally, a group of 59 PLHIV hospitalized in hospitals in St. Petersburg and the Leningrad region with a severe form of COVID-19 was isolated for analysis.Results and discussion. Number of COVID-19 cases in 2020–2021 in the Leningrad region amounted to 15.553 people, of which 1.553 had a history of HIV infection (13.5% of patients registered at the dispensary). The mortality rate among PLHIV who underwent COVID-19 was 5.1%. An equal ratio of women and men was observed among 122 surveyed patients, the average age of respondents was 41 years. When assessing the social status of the respondents, it was found that 25.4% had higher education, 56.5% had specialized secondary education. 72.9% had a permanent job. 61.4% of respondents considered themselves to be in the category of material well-being of «average level», 24.6% — to «below average». The sexual route of HIV infection was established in 50.8% of patients, injectable was 29.5%, in other cases it was not unknown. The average level of CD4 lymphocytes in the blood was 544 cl/mcl, most patients (90.2%) had an undetectable indicator of HIV viral load (VL). The average duration of the disease with the new coronavirus in HIV patients was 15.6 days. At the same time, 108 (88.5%) people noted a mild course of COVID-19 and did not need hospitalization. Coverage of COVID-19 vaccination among the surveyed PLHIV was 40.9%. According to data from 59 case histories of PLHIV hospitalized as a result of the severe course of COVID-19, 55 people died, a pathoanatomic autopsy was performed in 26 cases. The autopsy revealed the following complications and concomitant diseases: miliary tuberculosis (7.7%), purulent endocarditis (11.5%), sepsis (19.2%). Improvement in the dynamics was observed only in 4 PLHIV, whose further fate is unknown.Conclusion. The study showed that the incidence of SARS-CoV-2 among PLHIV in the Leningrad region is comparable to the general population, however, the total mortality among HIV-infected patients is higher than in the region and across the country. As a result of the analysis, we came to the conclusion that HIV infection and COVID-19 are independent in terms of co-infection at the outpatient stage. The exception is severe and aggravated comorbid cases, which required a more detailed assessment of the condition, the involvement of a larger number of specialists, as well as laboratory and instrumental research methods. The results obtained determined the need for a comprehensive interdisciplinary approach to patients with HIV infection, taking into account their personal needs. Medical personnel providing care to PLHIV should take into account not only the clinical picture of the disease, but also the psychosocial status of the patient, in order to improve the outcomes of COVID-19 and HIV infection.

Injuries are responsible for 10% of the global burden of disease; however, the epidemiology of injury among people living with HIV (PLHIV) has not been well elucidated. This study seeks to characterize rates and predictors of injury among PLHIV compared to the general population in British Columbia (BC), Canada. A population-based dataset was created via linkage between the BC Centre for Excellence in HIV/AIDS and PopulationDataBC. PLHIV aged 20 years and older were compared to a random 10% sample of the adult general population. The International Classification of Diseases 9 and 10 codes were used to classify unintentional and intentional injuries based on the external cause of the injury from 1996 to 2013. Generalized estimating equation (GEE) Poisson regression models were fit to estimate the effect of HIV status on rates of unintentional and intentional injury, and to identify correlates of injury among PLHIV. The crude incidence rate of unintentional injury was 18.56/1000 person-years [95% confidence interval (CI) 17.77-19.39] among PLHIV and 8.51/1000 person-years (95% CI 8.42-8.59) in the general population. Among PLHIV, 13.45% of deaths were due to injury, compared to 5.52% of deaths in the general population. In adjusted models, PLHIV were more likely to report unintentional (incidence rate ratio 1.42, 95% CI 1.32-1.52) and intentional injury (incidence rate ratio 1.93, 95% CI 1.70-2.18) compared to the general population. We identified elevated rates of intentional and unintentional injury among PLHIV. Injuries are largely preventable; as such, targeted efforts are needed to decrease the burden of injury-related disability and death among PLHIV.

Burden of subclinical carotid atherosclerosis and vascular risk factors among people living with HIV in Ghana

BackgroundEvidence continues to demonstrate that certain marginalised populations are disproportionately affected by COVID-19. While many studies document the impacts of COVID-19 on social inequalities in health, none has examined how public health responses to the pandemic have unfolded to address these inequities in Canada. The purpose of our study was to assess how social inequalities in health were considered in the design and planning of large-scale COVID-19 testing programs in Montréal (Québec, Canada).MethodsPart of the multicountry study HoSPiCOVID, this article reports on a qualitative case study of large-scale testing for COVID-19 in Montréal. We conducted semi-structured interviews with 19 stakeholders involved in planning large-scale testing or working with vulnerable populations during the pandemic. We developed interview guides and a codebook using existing literature on policy design and planning, and analysed data deductively and inductively using thematic analysis in NVivo.ResultsOur findings suggest that large-scale COVID-19 testing in Montréal did not initially consider social inequalities in health in its design and planning phases. Considering the sense of urgency brought by the pandemic, participants noted the challenges linked to the uptake of an intersectoral approach and of a unified vision of social inequalities in health. However, adaptations were gradually made to large-scale testing to improve its accessibility, acceptability, and availability. Actors from the community sector, among others, played an important role in supporting the health sector to address the needs of specific subgroups of the population.ConclusionsThese findings contribute to the reflections on the lessons learned from COVID-19, highlighting that public health programs must tackle structural barriers to accessing healthcare services during health crises. This will be necessary to ensure that pandemic preparedness and response, including large-scale testing, do not further increase social inequalities in health.

The aim of our study was to analyze retention in care and survival at 12, 24, and 36 months among people living with HIV (PLWH) on antiretroviral therapy (ART). This is a retrospective cross-sectional analysis of a cohort of PLWH aged 15 years and older who started ART. Purposive sampling was used, taking into account the activities of different health centers and budgetary constraints (quantitative approach). In-depth individual interviews and focus groups were also conducted (qualitative approach). During the study period, 2,100 HIV-infected patients were enrolled. The median age of patients was 44 years (interquartile range (IQR) [36-51]), with a statistically significant difference according to sex (p< 0.001), with women being younger than men (42 versus 46 years). The median duration of ART was 5 years (IQR [2-8]) with no statistical difference by gender (p=0.752). At baseline, 20.5% (n=431) and 25.1% (n=509) were lost to follow-up (LTF) 90 days and 28 days after scheduled visit, respectively. There were 146 adult deaths, for a crude mortality rate of 6.9% (95% CI [5.9-8.1]). Approximately 60% of the 158 PLWH randomly selected from our LTF patients could be reached by telephone. They reported that they were still in care. Retention in care was 72.5%, and the probability of retention was 91.6% at 12 months, 87.8% at 24 months, and 78.7% at 60 months. Retention in care was more pronounced among women and more significant among PLWH aged 35 years and older when treatment was initiated in health care facilities offering the full range of activities (care and treatment, active patient search, presence of social mediators). Our study, conducted during the Covid-19 pandemic, shows acceptable retention rates in care for PLWH. These results make possible to propose solutions to improve the care program in the country: the harmonization of procedures for tracing PLWH with the implementation of their active search (with the help of community mediators) and the dispensing of ART to PLWH for three or six months.

Background: The prevalence of fatty liver disease in people living with human immunodeficiency virus (PLHIV) is significantly higher than in general population. This study aims to compare the burden of fatty liver disease in Egyptian PLHIV using both metabolic dysfunction-associated fatty liver disease (MAFLD) and steatotic liver disease (SLD) criteria. Methods: A retrospective cross-sectional study was conducted on PLHIV attending the HIV reference center at Embaba Fever Hospital in Egypt between November 2019 and July 2021. Data collection included demographics, comorbidities, physical examination, laboratory tests, liver ultrasound, controlled attenuation parameter, and liver stiffness measurement using Fibroscan®. Results: The prevalence of SLD and MAFLD was 26.92% and 21.15%, respectively. The concordance between MAFLD and SLD definitions was low (kappa = 0.465). The presence of SLD was significantly associated with increased odds of significant fibrosis (P = 0.045). However, MAFLD was not significantly associated with fibrosis (P = 0.369). Conclusion: SLD demonstrates a stronger association with significant fibrosis than MAFLD in PLHIV. This highlights the potential of SLD as a more inclusive and representative classification for steatosis in PLHIV.

Assessing the social class of children from parental information to study possible social inequalities in health outcomes.

Reasons Public health aims to improve the health of populations and reduce social inequalities in health, notably through action on social determinants of health, physical and social environments, public policies, access to health services, and community empowerment. As such, public health has a social agenda and therefore a corresponding social responsibility. However, social inequalities in health continue to be a pressing problem in Canada, as well as around the world. Growing research demonstrates that public health interventions can unintentionally contribute to increasing social inequalities in health by perpetuating social norms that stigmatize vulnerable groups, neglecting the needs of vulnerable groups, and/or replicating power dynamics that reinforce situations which disenfranchise vulnerable populations. Objectives This workshop aims to: 1) discuss how public health interventions can inadvertently contribute to increasing social inequalities in health; 2) explore strategies to develop more equitable interventions. Added value Despite growing research on the unintended contributions of public health interventions in increasing social inequalities in health, this pressing problem remains generally under acknowledged in public health research and practice. Yet in order to reverse these effects, researchers and professionals alike need to become aware of and reflect on the potential impacts of their actions on vulnerable populations. Thus, the presentations in this workshop will provide concrete examples based on innovative research findings and critical reflections of the ways in which public interventions can increase social inequalities in health. We will also suggest health equity-related considerations for future intervention evaluation and design. Coherence The two first presentations will serve to illustrate how public health interventions can increase social inequalities in health and how we might reverse these effects by drawing on examples from tobacco control and health care. Based on these examples, the last presentation will demonstrate how a theoretically-driven framework (i.e. Acting Within Contexts) can be applied for intervention evaluation and future equitable intervention design. Format A brief introduction to present the workshop topic and learning objectives (5 minutes) Three presentations by panelists (10 minutes each; 30 minutes total): The unintended effects of tobacco control policies on social inequalities in smoking: Moving forward with a health equity approach; Equality versus equity: Barriers to health care access for Indigenous populations in Canada; Applying the “Acting Within Contexts” framework to intervention evaluation and equitable intervention design. A plenary discussion with the audience to draw collective lessons (25 minutes) Key messages To raise awareness of the potential unintended effects of public health interventions on increasing social inequalities in health. To better understand how to reduce inequities by integrating the needs and contexts of vulnerable populations in intervention planning.

We investigated the contribution of physical and psychosocial work factors to social inequalities in self-rated health (SRH) in a sample of Danish 40 and 50 years old occupationally active women and men. In this longitudinal study, the study population consisted of 3338 Danish women and men. Data were collected by postal questionnaires in 2000 (baseline) and 2006 (follow-up). The independent variable, socioeconomic position (SEP), was assessed by the highest achieved educational level at baseline. We conducted gender-stratified parallel multiple mediation analyses. In the mediation analyses, SEP was categorised as SEP I, II, III, VI and V among men. Among women, SEP was dichotomised into SEP I-IV and V. The outcome, SRH, was assessed at baseline and follow-up. A wide range of physical and psychosocial work factors were included as potential mediators. We found a social gradient in SRH across all levels of SEP among men. Among women, we only found a poorer SRH among those with the lowest SEP. Mediation analyses showed that work factors together accounted for 56% of the social inequalities in SRH among men and 44% among women. In both genders, ergonomic exposures and job insecurity seemed to play the major role for social inequalities in SRH. For women only, we also found noise to contribute to the social inequalities in SRH. Physical and psychosocial work factors partially explained social inequalities in SRH among both genders. Improvement of the working environment can potentially contribute to the reduction of social inequalities in health.

Findings on how social inequality in self-rated health (SRH) has changed over time are not uniform. To inform public health policies aimed at reducing unwarranted social differences in health, we examine time trends in relative and absolute associations between SRH and three different socioeconomic measures using Norway as a case. Six rounds (2002–2019) of repeated national, cross-sectional, data from Statistics Norway’s Survey on Living Conditions (response rates 57–70%) were linked to register information on socioeconomic measures (education, household income and occupation). A set of logistic regression models of good SRH (GSRH) with blockwise inclusion of predictors were employed to 29,012 adults (25–66 years). Absolute and relative differences in GSRH across education, income and occupation were calculated across survey years, net of other sociodemographic characteristics and risk factors. Regardless of model, the probability of reporting GSRH was high (around 80%) across sex for most years. Considering only statistically significant results, men with the short education had a 2-4% points lower probability of GSRH than men with long education, across years. The time trend in income differences was also stable, albeit the difference between the highest and lowest quintile was larger (around 7% points). Those outside the labor force were substantially less likely (23% points) to report GSRH compared to men in high skilled white-collar occupations. Among women, GSRH was 6% points lower among those with short compared to long education, and 8% points lower in the 1st compared to the 5th income quintile. Being outside the labour force was associated with a 28% points lower probability of GSRH among women. Otherwise, there were minor differences in GSRH between occupational groups. On a relative scale (percent difference), differences between socioeconomic groups were slightly more pronounced, but with similar trends for men and women. Irrespective of socioeconomic measure, social inequalities in SRH have remained remarkably stable over time across socioeconomic measures in Norway, in both absolute and relative terms. The national strategy may have worked to prevent increasing social inequalities in health, but system changes and further actions appear warranted to reduce existing differences.

The authors set out to show that the Ottawa Charter of 1986 has not been sufficiently accepted over the past twenty years, even by those who use it as a strategic tool to guide interventions for reducing social inequalities in health. Although some public health policies do emphasize the reduction of social inequalities in health, only the Ottawa Charter appears to possess the status of an international declaration on the matter. Social inequalities in health are the systematic, avoidable, and unjust differences in health that persist between individuals and sub-groups of a population. Four examples from the field of health promotion serve to show that forgetting to combat social inequalities in health is not exclusive to the domain of public health. However, taking action against social inequalities in health does not equal tackling poverty. Moreover, intervening on the principle of equality of opportunity, on the basis of an ideology of meritocracy, or for the benefit of the population as a whole, without regard to sub-groups, only tends, at best, to reproduce inequalities. Although evidence is insufficient, there are studies that show that reducing social inequalities in health is not an aporia. Three explanations are advanced as to why social inequalities in health have been ignored by health promotion professionals. The Ottawa Charter had the merit of highlighting the struggle against social inequalities in health. Now, moving beyond the declarations, from the strategic framework provided by the Ottawa Charter and in accordance with the Bangkok Charter, it is time to show proof of voluntarism. Several priorities for the future are suggested and the International Union for Health Promotion and Education (IUHPE) should be responsible for advocating for them.

BackgroundLittle is currently known about HIV-related parameters that may increase the risk for oral ulcers during the COVID-19 pandemic. This study aimed to overcome this gap in research by assessing the associations between HIV viral load, antiretroviral adherence profile, co-morbidity status, SARS-CoV-2 infection and oral ulcers among people living with HIV (PLHIV).MethodsThis was a secondary analysis of data generated from 21,206 to 18 years and above, recruited from 152 countries through an online survey between July and December 2020. Data were extracted for 874 people who reported living with HIV. The dependent variable was reporting having oral ulcer. The independent variables were the viral load, adherence to antiretroviral treatment and a history of SARS-CoV-2 infection. The confounding variables were age at last birthday and sex at birth. A multivariable logistic regression analysis was conducted to determine the associations between the dependent and independent variables after adjusting for the confounding variables.ResultsOf the 874 participants, 99 (11.3%) reported having oral ulcers during the first wave of the COVID-19 pandemic. The odds of PLHIV having oral ulcers during the first wave of the COVID-19 pandemic was significantly higher for people who did not know their viral load than those who had undetectable viral load (AOR: 2.036; 95% CI: 1.204–3.443; p = 0.008); and people who did not adhere to the use of antiretroviral treatment than those who adhered (AOR: 4.113; 95% CI: 2.567–6.589; p < 0.001). Also, PLHIV who had SARS-CoV-2 infection had significantly higher odds of having oral ulcers than those who did not have the infection (AOR: 14.556; 95% CI: 4.500-47.078; p < 0.001). PLHIV who had co-morbidities had non-significantly higher odds of having oral ulcers than those without co-morbidities (AOR: 1.170; 95% CI: 0.656–2.085; p = 0.595).ConclusionOral ulcers may be an indicator of poor adherence to antiretroviral therapy and unsuppressed viral load among PLHIV. It may also be an indicator of SARS-CoV-2 infection and a signal to take prompt and critical care of affected individuals because of the risk for severe COVID-19 for these individuals.

The COVID-19 pandemic’s impact on cardiovascular health behaviors including diet, physical activity, medication adherence, and self-care among people living with HIV (PLWH) remains unknown. Using qualitative analyses, we examined the impact of the COVID-19 pandemic on cardiovascular health behaviors among PLWH. Twenty-four PLWH were enrolled in this multisite study from September to October 2020. Individuals participated in semi-structured telephone interviews that were recorded, transcribed, and coded by 4 independent coders. Codes were adjudicated and analyzed for common themes. Participants were, on average, 59.2 years old (+/−9.4), 75% African American (n = 18) and 71% male (n = 17). The pandemic altered cardiovascular disease health behaviors. PLWH changed diet based on stay-at-home orders and food access. Alterations in physical activity included transitioning from gym and group class exercise to home-based exercise. Antiretroviral adherence was maintained, even when other health behaviors wavered, suggesting resilience in PLWH that may be harnessed to maintain other health behaviors.

BackgroundThe widespread use of antiretroviral therapy (ART) has significantly increased the life expectancy of people living with HIV (PLWHIV). However, this success is accompanied by a growing burden of non-communicable diseases, particularly hypertension, which has emerged as a leading contributor to morbidity and mortality in sub-Saharan Africa. Despite this growing concern, data on the burden and care cascade of hypertension among PLWHIV in routine care settings remain limited in Cameroon.ObjectiveTo assess the prevalence, associated factors, and care cascade of hypertension among PLWHIV receiving follow-up at Yaoundé Central Hospital in Cameroon in 2024.MethodsWe conducted a cross-sectional descriptive study at the Day Hospital of Yaounde Central Hospital, a national referral center for HIV care. PLWHIV aged ≥21 years and under active follow-up were included. Hypertension was defined as systolic and/or diastolic blood pressure ≥140/90 mm Hg or current use of antihypertensive medication. Logistic regression analyses were performed to identify factors associated with hypertension, including clinical and HIV-related parameters.ResultsA total of 554 participants were enrolled, of whom 74.0% were women, with a mean age of 50.9 years. The overall prevalence of hypertension was 36.8% (95% CI: 32.9-40.9) and was higher among men than women (45.1% vs 33.9%). Among hypertensive individuals (n = 204), 66.7% had initiated antihypertensive treatment, 45.6% were retained in care, and only 22.6% had controlled blood pressure. Factors independently associated with hypertension included longer ART duration (>16 years) (adjusted OR = 1.88; P = .036), WHO clinical stage II at HIV diagnosis (adjusted OR = 1.56; P = .033), and suppressed viral load (<1000 copies/mL), which was paradoxically associated with a higher risk of hypertension (adjusted OR = 0.42 for unsuppressed viral load; P = .041). No significant association was found with ART regimen lines.ConclusionHypertension affects more than one-third of PLWHIV in this urban HIV referral center, yet important gaps persist in treatment initiation, retention, and control. These findings highlight the urgent need for integrated hypertension screening and management strategies within HIV care services in Cameroon to reduce long-term cardiovascular risks.