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      Risk Factors for HIV sero-conversion in a high incidence cohort of men who have sex with men and transgender women in Bangkok, Thailand

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          Abstract

          Background

          We measured Human Immunodeficiency (HIV) incidence, retention, and assessed risk factors for seroconversion among two previously unreported cohorts of men who have sex with men (MSM) and Transgender Women (TGW) in Bangkok, Thailand between 2017 and 2019.

          Methods

          We conducted an 18-month prospective cohort study of HIV-uninfected Thai cisgender men and TGW aged between 18 and 35 years who reported sex with men in the past six months and at least one additional risk factor for HIV infection. HIV and syphilis testing and computer-based behavioral questionnaires were administered at each visit. We utilized Poisson regression to calculate HIV incidence rates. A survival random forest model identified the most predictive risk factors for HIV sero-conversion and then used in a survival regression tree model to elucidate hazard ratios for individuals with groups of selected risk factors. Cox proportional hazards (pH) regression evaluated the strength of association between individual covariates and risk of sero-conversion.

          Findings

          From April 2017-October 2019, 1,184 participants were screened, 167 were found ineligible, and 1,017 enrolled. Over the 18-month study, visit retention was 93·4% (95% CI 91·6%–94·8%) and HIV incidence was 3·73 per 100 person-years (95% CI 2·79–5·87). Utilizing survival regression tree modeling, those who were 18–20 years of age, reported sexual attraction to mostly or only men, and had five or more lifetime sexual partners were 4·9 times more likely to seroconvert compared to other cohort participants. Factors associated with HIV incidence utilizing Cox pH regression included sexual attraction to mostly or only men (adjusted hazard ratio (aHR) 14·9 (95% CI 20·1–107·9), younger age (18–19 years, aHR 10·88 (95% CI 4·12–28·7), five or greater lifetime sexual partners (aHR 2·0, 95%CI 1·1–3·6), inconsistent condom use with casual partners (aHR 2·43, 95% CI 1·3–4·5), and prior HIV testing (adjusted HR 2·0, 95% CI 1·1–3·5).

          Interpretation

          Interpretation HIV incidence remains high among Bangkok-based MSM and TGW. These key populations expressed high interest in participating in efficacy evaluation of future prevention strategies and had high retention in this 18 month study.

          Funding

          Funding US National Institute of Allergy and Infectious Diseases (NIAID), Division of AIDS Interagency Agreements (DAIDS) and U.S. Department of the Army.

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          Most cited references16

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          Random survival forests

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            Vaccination with ALVAC and AIDSVAX to prevent HIV-1 infection in Thailand.

            The development of a safe and effective vaccine against the human immunodeficiency virus type 1 (HIV-1) is critical to pandemic control. In a community-based, randomized, multicenter, double-blind, placebo-controlled efficacy trial, we evaluated four priming injections of a recombinant canarypox vector vaccine (ALVAC-HIV [vCP1521]) plus two booster injections of a recombinant glycoprotein 120 subunit vaccine (AIDSVAX B/E). The vaccine and placebo injections were administered to 16,402 healthy men and women between the ages of 18 and 30 years in Rayong and Chon Buri provinces in Thailand. The volunteers, primarily at heterosexual risk for HIV infection, were monitored for the coprimary end points: HIV-1 infection and early HIV-1 viremia, at the end of the 6-month vaccination series and every 6 months thereafter for 3 years. In the intention-to-treat analysis involving 16,402 subjects, there was a trend toward the prevention of HIV-1 infection among the vaccine recipients, with a vaccine efficacy of 26.4% (95% confidence interval [CI], -4.0 to 47.9; P=0.08). In the per-protocol analysis involving 12,542 subjects, the vaccine efficacy was 26.2% (95% CI, -13.3 to 51.9; P=0.16). In the modified intention-to-treat analysis involving 16,395 subjects (with the exclusion of 7 subjects who were found to have had HIV-1 infection at baseline), the vaccine efficacy was 31.2% (95% CI, 1.1 to 52.1; P=0.04). Vaccination did not affect the degree of viremia or the CD4+ T-cell count in subjects in whom HIV-1 infection was subsequently diagnosed. This ALVAC-HIV and AIDSVAX B/E vaccine regimen may reduce the risk of HIV infection in a community-based population with largely heterosexual risk. Vaccination did not affect the viral load or CD4+ count in subjects with HIV infection. Although the results show only a modest benefit, they offer insight for future research. (ClinicalTrials.gov number, NCT00223080.) 2009 Massachusetts Medical Society
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              Classification and regression tree analysis in public health: methodological review and comparison with logistic regression.

              Audience segmentation strategies are of increasing interest to public health professionals who wish to identify easily defined, mutually exclusive population subgroups whose members share similar characteristics that help determine participation in a health-related behavior as a basis for targeted interventions. Classification and regression tree (C&RT) analysis is a nonparametric decision tree methodology that has the ability to efficiently segment populations into meaningful subgroups. However, it is not commonly used in public health. This study provides a methodological overview of C&RT analysis for persons unfamiliar with the procedure. An example of a C&RT analysis is provided and interpretation of results is discussed. Results are validated with those obtained from a logistic regression model that was created to replicate the C&RT findings. Results obtained from the example C&RT analysis are also compared to those obtained from a common approach to logistic regression, the stepwise selection procedure. Issues to consider when deciding whether to use C&RT are discussed, and situations in which C&RT may and may not be beneficial are described. C&RT is a promising research tool for the identification of at-risk populations in public health research and outreach.
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                Author and article information

                Contributors
                Journal
                EClinicalMedicine
                EClinicalMedicine
                EClinicalMedicine
                Elsevier
                2589-5370
                17 July 2021
                August 2021
                17 July 2021
                : 38
                : 101033
                Affiliations
                [a ]US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, United States
                [b ]Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, United States
                [c ]Vaccine Trial Centre, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
                [d ]Royal Thai Army Component, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
                [e ]Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
                [f ]US Army Medical Research Development Command (USAMRDC) Office of Regulated Activities (ORA) Special Operations Branch, Fort Detrick, Fort Detrick, MD, USA
                [g ]US Army Medical Research and Development Command, Fort Detrick, Maryland, USA
                [h ]US Army Medical Materiel Development Activity, Fort Detrick, Maryland, USA
                [i ]Current affiliation: HIV-NAT, Thai Red Cross AIDS Research Centre, and Dreamlopments Social Enterprise and Foundation, Bangkok, Thailand
                Author notes
                [* ]Corresponding author. svasan@ 123456hivresearch.org
                Article
                S2589-5370(21)00313-8 101033
                10.1016/j.eclinm.2021.101033
                8413240
                43249120-c974-4bf5-b3f4-fae8f0cf3444
                © 2021 Henry M. Jackson Foundation for the Advancement of Military Medicine

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                : 8 May 2021
                : 1 July 2021
                : 2 July 2021
                Categories
                Research Paper

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