Maggie L. Shaw

 sequence (HXB2 position 2550-3356) data from 1397 

-1 infected patients at diagnosis in Germany shows they are increasingly demonstrating drug resistance mutations (DRMs) to certain classes of drugs used as antiretroviral therapy (ART), 

The drug classes are nucleoside reverse transcriptase inhibitors (NRTIs) and nonnucleoside reverse transcriptase inhibitors (NNRTIs), and the most common shared mutation was K103N (47.4%). Coupled with the lack of data on the dynamics and patterns of HIV transmission in these areas is the public health concern around DRMs, which prompted the investigators’ analysis.

Patients from the study were receiving routine care at 7 university hospitals in 6 metropolitan areas in Germany between 2001 and 2018: Boon, Cologne, Frankfurt, Hamburg, Hannover, and Munich. Most were men (82.9%; n = 1158), from Germany (69.6%), infected with HIV-1 subtype B (72.9%), and men having sex with men (MSM; 56.7%). All had to be ART-naïve with a newly diagnosed case of HIV-1.

“This conservative approach excluded participants for whom the exact start date of ART or history of prior ART was not accurately documented,” the report noted.

Using blood samples collected before ART began, the investigators found that at diagnosis, an overall 17.8% (95% CI, 15.7%-19.8%) had any DRM. Per region analyzed (

 < .001), Hannover had the highest individual rate, at 31.4% (95% CI, 24%-38%), and Munich the lowest, at 9.1% (95% CI, 5%-13%).

Of the DRMs noted, the most common were associated with NRTIs (12.3%) and NNRTIs (8.9%). Within these classes, the most common mutations were K103N (25%) and G190A (6.5%) for NNRTIs and M41L (14.5%) and T215S (10.5%) for NRTIs.

Further analysis revealed there were 102 transmission clusters. Among these clusters, the following were identified:

Bonn, Cologne, Munich, and Frankfurt combined had the largest cluster: 12 patients.

Likely ages of clustering were younger than 25 years (adjusted OR [aOR], 4.38; 95% CI, 2.55-7.52; 

< .001) and 25 to 45 years (aOR, 1.91; 95% CI, 1.36-2.678; 

Among patients younger than 25 years, a higher proportion shared DRMs (3.5%) compared with older patients, both those 24 to 45 years (1.5%) and those older than 45 years (0.5%).

Clustering was more common among cases of HIV-1 subtype B vs non-B subtype (aOR, 4.05; 95% CI, 2.37-6.90; 

Despite the cities’ proximity, Bonn participants were genetically linked more often than Cologne participants (aOR, 1.63; 95% CI, 1.06-2.49; 

Cologne patients shared 16 of the 47 sequences with a DRM.

The second most common shared DRM was D67N (31.6%).

Of the cities investigated, Munich, Cologne, and Frankfurt had the top 3 highest rated of new HIV-1 infections, as of 2017, at 17.3, 13.3, and 12.3 cases per 100,000 population, respectively.

“Such resistance might be an upcoming challenge as PrEP use increases,” the report concluded. “Monitoring for HIV infections with these mutations is of utmost importance for preventing an epidemic among high-risk PrEP users; one mitigation is to consider alternative PrEP regimens in regions with high resistance.”

Stecher M, Chaillon A, Stephan C, et al. Drug resistance spread in 6 metropolitan regions, Germany, 2001-2018. 

. 2020;26(10):2439-2443. doi:10.3201/eid2610.191506

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Despite the known benefits of antiretroviral therapy, the treatment may prove more difficult to use among clusters of patients with HIV exhibiting resistance to certain drug classes.

Drug Resistance Mutations Increasingly Showing Up in Germany Among HIV-Positive Individuals

Aspirin as a chemopreventive medication in 

 was recently studied among African American women, and 

 show its potential for use among these patients who have estrogen receptor (ER)-negative or triple-negative disease, according to an article published in 

“Few studies have investigated these associations among African American women,” the authors noted, “nor have any previous studies in African American women evaluated whether associations differ by ER subtype.”

The investigators gathered data from the 

, an ongoing nationwide cohort study, to conduct a prospective analysis of 53,126 African American women who answered questionnaires regarding their aspirin use and duration of use (<1, 1, 2, 3-4, or 

5 years), at baseline in 1995 and follow-up. All of the women were aged 21 to 69 years, and the follow-up questionnaires were sent every 2 years.

For the purposes of this study, regular aspirin use was defined as “use at least 3 days per week.”

Over 22 years of follow-up (1995-2017), there were 1919 diagnoses of invasive breast cancer, and ER status was available for 1681 (88%):

368 of the ER-negative cases had a known HER2 status, and

284 of the cases with a known HER status were triple-negative breast cancer (TNBC).

Compared with nonuse of aspirin, results show that its regular use was associated with an 8% overall lower risk of breast cancer (HR, 0.92; 95% CI, 0.81-1.04). Although this risk remained relatively unchanged for women with ER-positive disease (HR, 0.98; 95% CI, 0.84-1.15), regular aspirin use was associated with a noticeable 19% decline in risk of disease among those with ER-negative breast cancer (HR, 0.81; 95% CI, 0.64-1.04) and 30% for those with TNBC (HR, 0.70; 95% CI, 0.49-0.99).

Current aspirin users were older and had a higher mean body mass index vs nonusers: 44 vs 38 years and 29.1 vs 27.7 kg/m

Current users were more likely to drink alcohol: 39% vs 28%.

Current users were more likely to have no more than a high-school education: 83% vs 72%.

When looking at aspirin use for at least 10 years, the women in the study with ER-positive breast cancer did have a 19% reduced risk of disease (HR, 0.81; 95% CI, 0.60-1.09).

No trend in duration of aspirin use was seen for the patients with TNBC.

Past aspirin use had no association with overall breast cancer risk.

Adjusting for patient use of other nonsteroidal anti-inflammatory drugs (NSAIDs) had no effect on the study results.

There was an inverse association with disease risk among current aspirin users with ER-positive or -negative disease if they had a high waist-to-hip ratio (

 women with ER-negative disease who breastfed, there was an inverse association with their risk compared with women who never breastfed: HR, 0.69 (95% CI, 0.45-1.05) vs 0.84 (0.59-1.19).

The authors believe that their results require confirmation in studies that have larger populations of African American women. Limitations to their findings include that the data were self-reported, information on aspirin dose was not available, and they did not evaluate nonaspirin NSAIDs separately. Study strengths include its 20-plus years of follow-up and the detailed characterization of breast cancer risk factors.

“The results of this study support the hypothesis that regular aspirin use is associated with reduced breast cancer risk, particularly for ER[-negative] and TN breast cancer, in African American women,” the investigators concluded. “If findings from this study are confirmed, aspirin may represent a potential opportunity for chemoprevention of ER[-negative] and TN breast cancer.”

Bertrand KA, Bethea TN, Gerlovin H, et al. Aspirin use and risk of breast cancer in African American women. 

. Published online September 4, 2020. doi:10.1186/s13058-020-01335-1

Aspirin is a known anti-inflammatory agent, but few studies have investigated its use among African American women to reduce the risk of breast cancer.

Aspirin May Have Potential as a Chemopreventive Medication Among African American Women

 mortality over the previous 2 decades can partially be explained by social determinants of health (SDOH) prevalent in the counties in which patients live, particularly the level of socioeconomic deprivation, notes 

It is important that this is understood and known, the authors add, because medication regimens for heart failure typically are expensive, so higher poverty levels could equate to lack of access to health care.

"Analysis of trends in heart failure mortality shows that these disparities have persisted throughout the last two decades," Graham Bevan, MD, a resident physician at University Hospitals in Cleveland, Ohio, and the study’s first author, 

Using the 2015 Area Deprivation Index (ADI) and the 2015 Social Deprivation Index (SDI)—both ranging from 0 to 100, so that the higher the total, the worse the socioeconomic deprivation—the authors analyzed the following data:

County-level mortality data from the US National Center for Health Statistics, age-adjusting the rates by deaths per 100,000 individuals

nternational Classification of Diseases, Tenth Edition

 diagnoses for death from heart failure that used code 150

Urbanization from the 2013 National Center for Health Statistics urban-rural classification

Heart failure mortality change in 2 periods: 1999 to 2002 and 2015 to 2018

Of the 1,254,991 heart failure–related deaths from 3048 counties, most (58.2%; 729,990) were among women and in rural counties (22.9%; 287,258). By race, the highest totals were seen among African Americans (9.5%) and Hispanics (3.3%). There were an average 25.5 heart failure deaths/100,000 across all counties, with the median ADI being 61.6 (first quartile, 49.2; third quartile, 71.5) and the median SDI, 43.0 (22.0 and 64.0, respectively).

Analyses revealed that age-adjusted mortality increased across all quartiles of the ADI and SDI and for several indicators of level of socioeconomic deprivation:

ADI: quartile 1, 20.0 (95% CI, 19.4-20.5); quartile 2, 23.3 (95% CI, 22.6-24.0); quartile 3, 26.4 (95% CI, 25.5-27.3); quartile 4: 33.1 (95% CI, 31.8-34.4)

SDI: quartile 1, 22.1 (95% CI, 21.4-22.7); quartile 2, 23.8 (95% CI, 23.1-24.4); quartile 3, 27.1 (95% CI, 25.9-28.2); quartile 4, 30.2 (95% CI, 29.0-31.4)

Nonmetropolitan areas: ADI quartiles 1-4: 20.5, 23.3, 26.3, 32.9; SDI quartiles 1-4: 22.4, 25.1, 29.0, 32.8

Metropolitan areas: ADI quartiles 1-4: 19.7, 23.3, 26.8, 35.1; SDI quartiles 1-4: 21.7, 22.0, 23.9, 32.8

Caucasian: ADI quartiles 1-4: 20.1, 23.5, 26.7, 33.3; SDI quartiles 1-4: 22.3, 24.1, 27.4, 25.6

African American: ADI quartiles 1-4: 22.0, 28.6, 34.1, 43.7; SDI quartiles 1-4: 23.7, 26.1, 32.0, 34.6

Male: ADI quartiles 1-4: 22.0, 26.1, 30.1, 38.2; SDI quartiles 1-4: 25.2, 26.1, 29.9, 33.6

Female: ADI quartiles 1-4: 18.8, 21.9, 25.2, 31.9; SDI quartiles 1-4: 21.2, 22.4, 25.7, 28.0

Overall, even when accounting for race/ethnicity, sex, and urbanization level, higher socioeconomic deprivation in a county still pointed to higher totals of heart failure mortality. Proposed reasons for this persistent relationship include low health literacy, poor social support, and substandard care, noted the authors.

“Regardless of the contributing factors, the association between communities with high socioeconomic deprivation and [heart failure] mortality is strong, and it suggests that targeting social deprivation may be impactful in reducing 

 mortality,” they concluded. “Additionally, the yield of intensive 

 preventive strategies may be higher in areas with high social deprivation.”

Limitations to generalizing these study results are 2-fold: the use of death certificate data and converting ADI data from a census tract level to a county level.

Bevan GH, Josephson R, Al-Kindi SG. Socioeconomic deprivation and heart failure mortality in the United States. 

 Published online August 2, 2020. doi:10.1016/j.cardfail.2020.07.014

Differences in heart failure mortality over the previous 2 decades can partially be explained by social determinants of health prevalent in the patients’ counties.

Higher Heart Failure Mortality, Lower Socioeconomic Status Linked in New Study 

Adult and adolescent men who have sex with men (MSM) continue to represent a disproportionate number of annual 

 diagnoses each year—almost 70% in 2017 alone, according to the CDC—but testing for the virus remains at a suboptimal level in the population. 

 investigated the utility of remote testing and phone delivery of test results among this patient group.

The results demonstrate the potential of remote testing to reduce barriers to the provision of HIV care-including confidentiality in a health care facility, stigma, and fear of testing positive—and increase access testing and support services.

“Improving HIV testing rates and increasing early detection among men who have sex with men (MSM) are critical strategies for enhancing overall health and decreasing HIV transmission,” the authors stated. “Remote testing and phone delivery of HIV test results may reduce barriers such as geographic isolation or HIV-related stigma.”

The study population of 50 cisgender men, transgender men, and transgender women who have sex with men were participants in the 

. All were enrolled between October 2017 and June 2018. In this trial, 195 participants originally received positive HIV results but just these 50 chose to complete a qualitative interview 3 months after phone delivery of their results. Their mean (SD) age was 31.7 (8.0) years, and a majority (52%) were men of color (Black, 16%; Latino, 24%; Asian/Pacific Islander, 12%). Just 34% were tested for HIV in the past year, with 52% having been previously tested more than a year ago and 14% never tested.

Results show that 39% preferred to receive their positive results over the phone compared with 45% who identified the delivery method as simply “acceptable.” Fifteen percent would have preferred to receive their results another way (eg, in person, online portal) because they viewed the phone experience as negative.

The following strengths of phone delivery were cited by the participants:

The time, space, and comfort they had to digest their potential diagnosis

The support they received from staff members who delivered their results

The HIV information and referrals they received

The convenience vs having difficulty scheduling an in-person medical visit

Increased confidentiality compared with receiving results via email or letter

Among those who expressed dislike of the phone delivery method, these were the principal concerns:

The timing of the call, especially if at work or in another nonprivate location

Screening for unknown number could be a potential barrier to receiving results

Lack of confidentiality (ie, confirming the identity of the caller, was the call being recorded)

Personal safety, especially for those who don’t take their results well and could self-harm

Feeling awkward or unprepared at receiving results over the phone

Suggestions for improving phone delivery were also suggested, and they included the following:

There needs to be more frequent follow-up after the first call that delivers HIV-positive results

Provide more emotional support is necessary, even if it’s just to listen

Reiterate that HIV is a treatable, chronic disease with adherence to antiretroviral therapies

“The emergence of an array of testing options call for greater understanding of the acceptability of novel avenues of HIV results delivery,” the authors conclude. “Phone delivery of HIV-positive results may obviate some of the hurdles to in-person testing, while maintaining direct linkage to care and some of the features of emotional support afforded by in-person counseling.”

They suggest additional study in expanding telehealth into the HIV testing space, especially in light of the 

 disease pandemic; investigating the acceptability of remote delivery of HIV-positive results among diverse populations with a higher risk of contracting the virus; and determining the optimal level of contact for MSM receiving results over the phone.

D’Angelo AB, Morrison CA, Lopez-Rios J, et al. Experiences receiving HIV-positive results by phone: acceptability and implications for clinical and behavioral research. AIDS Behav. Published online September 11, 2020. doi:10.1007/s10461-020-03027-5​ 

Because men who have sex with men continue to represent a disproportionate number of annual HIV diagnoses each year, a recent study investigated the utility of remote testing and phone delivery of test results among the patient group.

Author | Maggie L. Shaw

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