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Research & training, advances in hiv/aids research.

HIV virions budding and releasing from an infected cell.

For an update on what medical science is doing to fight the global HIV/AIDS pandemic, read a Parade article by NIH Director Francis S. Collins and NIAID Director Anthony S. Fauci, AIDS in 2010: How We're Living with HIV .

Over the past several decades, researchers have learned a lot about the human immunodeficiency virus (HIV) and the disease it causes, acquired immunodeficiency syndrome (AIDS). But still more research is needed to help the millions of people whose health continues to be threatened by the global HIV/AIDS pandemic.

At the National Institutes of Health, the HIV/AIDS research effort is led by the National Institute of Allergy and Infectious Diseases (NIAID). A vast network of NIAID-supported scientists, located on the NIH campus in Bethesda, Maryland, and at research centers around the globe, are exploring new ways to prevent and treat HIV infection, as well as to better understand the virus with the goal of finding a cure. For example, in recent months, NIAID and its partners made progress toward finding a vaccine to prevent HIV infection. Check out other promising areas of NIAID-funded research on HIV/AIDS at http://www.niaid.nih.gov/topics/hivaids/Pages/Default.aspx .

Other NIH institutes, including the Eunice Kennedy Shriver National Institute of Child Health and Human Development and National Institute on Alcohol Abuse and Alcoholism, also support research to better control and ultimately end the HIV/AIDS pandemic. Some of these researchers have found a simple, cost-effective way to cut HIV transmission from infected mothers to their breastfed infants. Others have developed an index to help measure the role of alcohol consumption in illness and death of people with HIV/AIDS.

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Find out more about these discoveries and what they mean for improving the health of people in the United States and all around the globe.

This page last reviewed on August 20, 2015

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A Review of Recent HIV Prevention Interventions and Future Considerations for Nursing Science

Author Contributions

As our knowledge of HIV evolved over the decades, so have the approaches taken to prevent its transmission. Public health scholars and practitioners have engaged in four key strategies for HIV prevention: behavioral-, technological-, biomedical-, and structural/community-level interventions. We reviewed recent literature in these areas to provide an overview of current advances in HIV prevention science in the United States. Building on classical approaches, current HIV prevention models leverage intimate partners, families, social media, emerging technologies, medication therapy, and policy modifications to effect change. Although much progress has been made, additional work is needed to achieve the national goal of ending the HIV epidemic by 2030. Nurses are in a prime position to advance HIV prevention science in partnership with transdisciplinary experts from other fields (e.g., psychology, informatics, and social work). Future considerations for nursing science include leveraging transdisciplinary collaborations and consider social and structural challenges for individual-level interventions.

Approximately 1.2 million people in the United States are currently living with HIV, and an estimated 14% are infected, yet unaware of their status ( Office of Infectious Disease and HIV/AIDS Policy, 2020 ). HIV and AIDS continue to have a disproportionate impact on certain populations, including youth—gay, bisexual, and other men who have sex with men (MSM)—racial and ethnic minorities, people who inject drugs, and residents of highly affected geographic regions such as the Southeastern United States ( Aral et al., 2020 ; Hill et al., 2018 ; Lanier & Sutton, 2013 ). Ending the HIV epidemic requires increasing engagement along the HIV prevention and care continua ( Kay et al., 2016 ; McNairy & El-Sadr, 2014 ). Early and repeat HIV testing are recommended strategies for early entry into HIV care and improved HIV-related outcomes ( DiNenno et al., 2017 ). Late and infrequent HIV testing may result in receiving an initial HIV diagnosis late in the disease trajectory, and individuals unaware they are living with HIV may be more likely to transmit HIV to others. It is essential for people living with HIV (PLWH) to receive a timely diagnosis so that they can begin combination antiretroviral therapy with the goal of achieving an undetectable viral load, a key HIV prevention strategy ( Cohen et al., 2016 ). To improve linkage and retention along the prevention and care continua, researchers have developed HIV prevention interventions in four key areas: behavioral-, technological-, biomedical-, and structural/community-level interventions.

Behavioral interventions are approaches that promote protective or risk-reduction behavior in individuals and social groups via informational, motivational, skill-building, and community-normative strategies ( Coates et al., 2008 ). HIV-specific examples include, but are not limited to, interventions promoting abstinence, condom use, sex communication, condom negotiation, HIV testing, reduction in number of sexual partners, stigma reduction, and use of clean needles among people who inject drugs. Behavioral interventions target various HIV risk behavior mediators and moderators, including symptoms of mental illness and emotion regulation ( Brawner et al., 2019 ), attitudes, beliefs, subjective norms, intentions ( Fishbein & Ajzen, 1975 ), and self-efficacy ( Bandura, 2001 ). The effectiveness of behavior-change interventions in reducing risk for HIV during the early stages of the HIV pandemic demonstrated the importance and utility of this approach ( Bekker et al., 2012 ). Classic approaches to behavioral interventions established in the early 1990s and 2000s paved the way for future research to build on, replicate, adapt, tailor, and disseminate a multitude of programs to meet the needs of various populations, such as women ( Jemmott et al., 2007 ; Wingood et al., 2004 ), MSM ( Crosby et al., 2009 ), and adolescents ( DiClemente et al., 2009 ; Jemmott et al, 1992 , 1998 , 1999 , 2010 ; Villarruel et al., 2007 ). To extend the reach of behavioral interventions, in recent years, researchers have begun leveraging technologies to promote protective and risk reduction behaviors.

The rapid expansion of the internet, mobile, and social computing technologies (e.g., text messaging, e-mail, chat, mobile phones, social media, video games, and geospatial networking applications) has provided new strategies for engaging populations who may be harder to reach through traditional venue-based HIV prevention interventions. Electronic health (eHealth) and mobile health (mHealth) have become especially popular for the delivery of technology-enabled HIV prevention interventions among populations reporting high technology ownership and use ( Barry et al., 2018 ; Conserve et al., 2016 ; Duarte et al., 2019 ; Henny et al., 2018; Hightow-Weidman & Bauermeister, 2020 ; Jongbloed et al., 2015 ; Maloney et al., 2020 ; Nadarzynski et al., 2017 ). In recent years, gamification, serious games, and virtual reality have been used in HIV prevention interventions to deliver highly engaged content and bolster interactions/behaviors in and outside of planned interventions ( Enah et al., 2013 ; Hightow-Weidman et al., 2017 , 2018 ; Liran et al., 2019 ; Muessig et al., 2015 , 2018 ). The potential role that technologies can play in increasing the scale of HIV prevention interventions, including those that aim to increase the adoption of biomedical HIV prevention methods, add to the appeal of these strategies ( Hightow-Weidman et al., 2020 ; Horvath et al., 2020 ; Maloney et al., 2020 ; Marcus et al., 2019 ; Muessig et al., 2015 ; Ramos et al., 2019 ; Threats & Bond 2021 ).

Efficacious biomedical advancements in HIV prevention, such as treatment as prevention (TasP) and pre-exposure prophylaxis (PrEP), remain underutilized because of structural barriers and social determinants of health ( Cahill et al., 2017 ; Jaiswal et al., 2018 ; Kuhns et al., 2019 ). TasP, postexposure prophylaxis (PEP), PrEP, and pharmacologic therapy for substance abuse treatment have proven to be effective for reducing the transmission of HIV and minimizing the risk of new HIV infection ( Coffin et al., 2015 ; El-Bassel & Strathdee, 2015 ; Hosek, Green, et al., 2013 ; Page et al., 2015 ; Springer et al., 2018 ). Although biomedical prevention methods such as PEP and TasP are highly effective, we explicitly focus on PrEP because of its status as the premiere user-controlled HIV prevention medication regimen and its ability to be taken without disclosure to sexual partner(s).

In addition to behavioral, technological, and biomedical strategies that help to mitigate risk at the individual-, structural-, and community-levels, additional intervention strategies are needed to address broader social and structural factors that contribute to inequitable geobehavioral vulnerability to HIV ( Brawner, 2014 ). Such HIV prevention interventions target contextual factors (e.g., social, political–economic, policy–legal, and cultural factors) that influence transmission of and infection with HIV ( Blankenship et al., 2015 ), with an effect that diffuses out to members of key populations. Where individual-level interventions are designed to change individual beliefs, norms, and behaviors, community-level interventions aim to change the social environment (e.g., community-level norms and collective self-efficacy) and behaviors of entire populations ( Underwood et al., 2014 ). Structural- and community-level interventions are crucial to a comprehensive HIV prevention plan because they are designed to target macrolevel contextual factors (e.g., concentrated disadvantage in neighborhoods, syringe exchange policies, community-level stigma, and limited PrEP accessibility) that shape individual risk or hamper adoption of risk reduction strategies and therapeutics ( Allen et al., 2016 ; Colarossi et al., 2016 ; Gamble et al., 2017 ; Hoth et al., 2019 ; Kerr et al., 2015 ). Researchers in this space have successfully partnered with churches to decrease stigma and increase HIV testing ( Berkley-Patton et al., 2016 ; Payne-Foster et al., 2018 ), expand access to screening and prevention resources and change provider behavior ( Bagchi, 2020 ; Bernstein et al., 2017 ; Wood et al., 2018 ), and increase HIV testing in correctional facilities ( Belenko et al., 2017 ).

In this review of the literature, we explore the evolution of HIV prevention science over the past 5 years, presenting an overview of recent advances in the United States. We focused on four intervention categories—behavioral-, technological-, biomedical- (PrEP), and structural-/community-level—given the advancement of HIV prevention approaches over time. The findings highlight areas where nurses and others can advance the science of strategies to reach the national goal of ending the HIV epidemic by 2030 ( Fauci et al., 2019 ).

In our review of recent randomized controlled trials testing the efficacy of condom use and/or abstinence interventions, most targeted vulnerable populations included MSM ( Arnold et al., 2019 ; Crosby et al., 2018 ; Rhodes et al., 2017 ), adolescents ( Donenberg et al., 2018 ; Houck et al., 2016 ; Peskin et al., 2019 ), and adolescent/caregiver dyads ( Hadley et al., 2016 ; Jemmott et al., 2019 , 2020 ). Other interventions targeted incarcerated women ( Fogel et al., 2015 ) and illicit drug users ( Tobin et al., 2017 ). Many interventions were delivered in a health care or school setting, where multiple 60- to 120-min group sessions were presented. However, some interventions used a variation of frequencies and durations, such as a single 60-min one-to-one session ( Crosby et al., 2018 ) or multiple 4-hour group sessions ( Rhodes et al., 2017 ). One intervention allowed participants to attend one or two independent learning sessions, totaling 3 hours ( Hadley et al., 2016 ). About half of the reviewed studies tested the efficacy of new interventions, whereas the other half adapted previously established behavioral interventions. Crosby et al. (2018) , Fogel et al. (2015) , and Hadley et al. (2016) each adapted a different sexual health intervention. Conversely, Donenberg et al. (2018) adapted an intervention from a combination of three evidence-based programs. Instead of adapting an intervention, Peskin et al. (2019) replicated an evidence-based intervention. All interventions, except one ( Rhodes et al., 2017 ), were delivered in English.

Although several behavioral interventions led to significant increases in condom use and/or abstinence, compared with control conditions, others found no indication of intervention efficacy. For instance, Hadley et al. (2016) reported no significant group by time differences for condom use at the 3-month follow-up. These findings may be the result of delayed effects, as seen in the Fogel et al. (2015) intervention where significant group differences in condom use occurred at the 6-month follow-up, but not at the 3-month follow-up. Conversely, neither Arnold et al. (2019) nor Donenberg et al. (2018) found significant group by time differences in condom use at or beyond the 6-month follow-up, and Peskin et al. (2019) did not find differences in sexual initiation at the 24-month follow-up. These findings show that longer follow-up periods do not always have better results compared with short (i.e., 3 months) follow-up periods.

Among efficacious behavioral interventions, there was a single-session skill-building condom buffet activity ( Crosby et al., 2018 ) and multisession programs focusing on the costs and benefits of behavior change ( Fogel et al., 2015 ), emotion regulation ( Houck et al., 2016 ), cultural values ( Rhodes et al., 2017 ), environmental stressors ( Tobin et al., 2017 ), mother–son communication ( Jemmott et al., 2019 ), and scripture- and nonscripture-based abstinence ( Jemmott et al., 2020 ). Each was rooted in theoretical foundations, including those of the Theory of Planned Behavior, Social Cognitive Theory, cognitive behavioral techniques, and the AIDS Risk Reduction Model ( Azjen, 1991 ; Bandura, 1991 ; Catania et al., 1990 ). The Jemmott et al. (2019) intervention was unique in that intervention outcomes were assessed for both mothers and their sons, although the intervention was only implemented among the mothers. All other studies reported the findings of interventions that were implemented among the same participants for which outcomes were assessed.

We unexpectedly identified a nearly equal number of efficacious and nonefficacious behavioral interventions. Many studies reported increases in constructs leading to behavior change, such as self-efficacy, intentions, and attitudes, but did not find changes in actual condom use or abstinence behaviors ( Arnold et al., 2019 ; Donenberg et al., 2018 ; Hadley et al., 2016 ; Peskin et al., 2019 ). Interventions that were effective in increasing condom use and/or abstinence varied in characteristics, showing that single-session and multisession, short- and long-duration, newly created and adapted interventions can be efficacious.

Of the four interventions adapted from existing evidence-based programs, two were efficacious ( Crosby et al., 2018 ; Fogel et al., 2015 ). These interventions adapted the Focus on the Future ( Crosby et al., 2009 ) and Sexual Awareness for Everyone ( Shain et al., 1999 ) interventions. Adaptation has been long supported as an effective way to bring evidence-based interventions to new target populations and is often preferred over the creation of new interventions ( McKleroy et al., 2006 ; Solomon et al., 2006 ). However, with only half of the adapted interventions showing increased condom use among participants, it is critical that interventionists pay close attention to fidelity, proper use of theoretical foundations, and inclusion of core components during intervention adaptation and replication to maintain efficacy of the original intervention.

In accordance with previous research, the identified studies indicate the need to move away from interventions addressing a single behavior to those focusing on a combination of behavioral, biomedical, and structural approaches ( Belgrave & Abrams, 2016 ; Kurth et al., 2011 ) and those using popular technologically advanced delivery methods.

Technological Interventions

Most of the technological intervention literature we reviewed reported on studies that were at lower levels of the hierarchy of evidence ( Melnyk & Fineout-Overholt, 2011 ). Specifically, there was an imbalance in studies favoring more formative qualitative work or pilot studies compared with fewer studies reporting on randomized control trials or meta-analysis. Many studies reporting on randomized control trials also did not report on HIV-related outcomes but focused on content, protocols, or feasibility aspects of the randomized control trials. As a result, most studies reviewed were cross-sectional descriptive studies or qualitative descriptive studies using data collection strategies such as focus groups, interviews expert panels, surveys, and mixed methods ( Rodríguez Vargas et al., 2019 ; Velloza et al., 2019 ). Many of these formative studies ( Bauermeister et al., 2019 ; Cordova et al., 2018 ; Do et al., 2018 ; Enah et al., 2019 ; Erguera et al., 2019 ; Maloney et al., 2020 ; Sullivan et al., 2017 ) focused on the appeal, usability, acceptability, and feasibility of using mHealth and eHealth HIV prevention intervention across the continuum from primary prevention to disease management.

Reviewed studies show that technological interventions in HIV prevention have been studied in various target populations. These target populations include youth and young adults ( Cordova et al., 2018 ; Do et al., 2018 ; Erguera et al., 2019 ), MSM ( Alarcón Gutiérrez et al., 2018 ; Fan et al., 2020 ; Holloway et al., 2017 ), incarcerated women ( Kuo et al., 2019 ), couples ( Mitchell, 2015 ; Velloza et al., 2019 ), adults in drug recovery ( Liang et al., 2018 ), and PLWH ( Bauermeister et al., 2018 ; Schnall et al., 2019 ). These interventions vary in the technological innovations used, duration, language, format of delivery, and target outcomes.

The technology-enabled intervention studies reviewed used varying strategies to target different areas along the continuum of HIV prevention and care. In HIV testing, the focus was on synching home test results with phone counseling support ( Wray et al., 2017 ) and ordering, scheduling, and reminders associated with testing kits (e.g., Sullivan et al., 2017 ). Some studies focused on education using interactive web-based games and social media platforms ( Bauermeister et al., 2019 ; Bond & Ramos, 2019 ; Cordova et al., 2018 ; Gabarron & Wynn, 2016 ), behavioral change interventions ( Danielsonetal.,2014 ),or linkage to care and care support ( Bauermeister et al., 2018 ) targeting people who are living without HIV. Other studies focused on similar points along the care and prevention continuum targeting PLWH ( Maloney et al., 2020 ). Studies reviewed also focused on a wide range of interventions such as provision of information, self-assessments, adherence reminders, delivery of prevention information, referrals, and service from providers ( Boni et al., 2018 ; De Boni et al., 2018 ; Maloney et al., 2020 ). A number of studies included text messaging for health education, reminders, and assessments ( Dietrich et al., 2018 ; Njuguna et al., 2016 ; Ware et al., 2016 ), whereas others focused on primary behavioral preventions such as drug use ( Cordova et al., 2018 ) and engagement in care and disease management for PLWH ( Fan et al., 2020 ; Jongbloed et al., 2015 ). Reviewed studies targeting both persons living with and without HIV also used various technological-based approaches, such as interactive web-based content ( Bauermeister et al., 2019 ), smartphone geolocators near gay venues reinforcing safer sex practices ( Besoain et al., 2015 ), immersive adventure games ( Enah et al., 2019 ), and use of eye tracking technologies to monitor use ( Cho et al., 2018 , 2019 ).

Eight studies reviewed were narrative, scoping, and systematic reviews of the use and efficacy of technology-based interventions ( Bailey et al., 2015 ; Duarte et al., 2019 ; Gabarron & Wynn, 2016 ; Henny et al., 2018; Jongbloed et al., 2015 ; Maloney et al., 2020 ; Nadarzynski et al., 2017 ; Niakan et al., 2017 ). Scoping reviews of earlier digital STI prevention interventions revealed moderate effects on sexual health knowledge, small effect of behavior change, and no significant changes in biological outcomes ( Bailey et al., 2015 ; Gabarron & Wynn, 2016 ). These reviews examined studies that incorporated interventions using various designs, content, formats, target populations, and quality of content. Taken together, these reviews suggest that more research is needed to identify or develop components that can promote changes in biological outcomes. The most recent systematic review ( Maloney et al., 2020 ) found a wealth of published literature on technology-based interventions. However, findings from this systematic review suggest that most of the studies focus on educational and behavior change interventions, whereas relatively few focused on linkage to and retention in HIV prevention and care and adherence to HIV medicines, especially PrEP.

The drug combination of tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC), widely known by its brand name Truvada, used as oral PrEP in preventing HIV infections for MSM in the United States, is a well-documented, effective prevention strategy ( Grant et al., 2010 ; Mayer et al., 2020 ). However, many communities impacted by HIV are underrepresented in research trials in the United States, including transgender populations, cisgender women, and people who inject drugs. Most of the research in these groups has occurred internationally and has not had as strong an impact on HIV incidence as that of the MSM ( Baeten et al., 2012 ; Kibengo et al., 2013 ; MacLachlan & Cowie, 2015 ; Marrazzo et al., 2015 ; Martin et al., 2017 ; Mutua et al., 2012 ; Peterson et al., 2007 ; Thigpen et al., 2012 ; Van Damme et al., 2012 ).

Despite Black MSM bearing a disproportionate burden of HIV infection in comparison to MSM of other ethnicities, they are underrepresented in PrEP studies ( Hess et al., 2017 ). Most PrEP clinical trials, open-label studies, and observational studies included less than 10% Black MSM. ( Grant et al., 2010 ; Mayer et al., 2020 ). The few studies that included higher proportions of Black MSM had small numbers, including three community studies by Chan (49%, n = 109), Project PrEPare-ATN 082 (53%, n = 31), Project PrEPare-ATN 110 (47%, n = 93), and Project PrEPare-ATN 113 (29%, n = 23; Hosek et al., 2017 ; Hosek, Siberry, et al., 2013 ). Moreover, there are study gaps in sex, and the number of studies on high-risk cisgender women and transgender women is significantly smaller compared with MSM ( Kamitani et al., 2019 )

In 2019, the U.S. Food and Drug Administration (FDA) approved tenofovir alafenamide/emtricitabine (TAF/FTC), widely known as Descovy, as the first alternative medication for PrEP for MSM and transfeminine communities (FDA, 2019). TAF/FTC was shown to be noninferior to TDF/FTC. The side-effect profiles differ in that TDF/FTC has increases in renal and bone toxicities and TAF/FTC has increases in weight and lipids ( Mayer et al., 2020 ). TAF/FTC was not studied in other communities and did not gain an FDA indication for cisgender women and transmasculine communities. Some studies have found a potential link between the use of estradiol for gender-affirming care and lower tenofovir levels in the blood ( Hiransuthikul et al., 2019 ; Shieh et al., 2019 ; Yager & Anderson, 2020 ).There have been smaller studies to verify this interaction, but reported controlling for confounding variables was difficult. Further research is needed to understand whether there is effect on the efficacy of TDF and how this may impact nondaily dosing strategies.

Currently, daily oral PrEP is the only antiretroviral medication recommended for the prevention of HIV through sexual contact and drug injection use among people without HIV by the U.S. Centers for Disease Control and Prevention (CDC; U.S. Centers for Disease Control and Prevention & U.S. Public Health Service, 2018 ). In 2015, Molina et al. (2015) published a placebo-controlled trial of an “On-Demand” or 2-1-1 dosing strategy for MSM and transfeminine communities where 2 TDF/FTC pills would be taken 2 to 24 hr before sex, followed by 1 pill every 24 hr while sex continues, and ending 2 doses after the last sex act. This study found high efficacy and acceptability with an 86% reduction in HIV incidence relative to placebo on an intention to treat basis; no one acquired HIV while using 2-1-1 dosing of this nondaily dosing strategy. Furthermore, additional prospective open-label studies also showed no HIV acquisition among study participants ( Hojilla et al., 2020 ; Siguier et al., 2019 ). Despite the lack of endorsement by the CDC, many local Departments of Public Health support PrEP 2-1-1 as a way to make PrEP more attainable for the MSM community ( Los Angeles County Department of Public Health, 2019 ; New York City Department of Health and Mental Hygiene, 2019 ; San Francisco Department of Public Health, 2019 ).

Although effective, researchers and primary care providers note the need to simplify current PrEP delivery models. The CDC recommends a follow-up visit every 3 months while on PrEP, which can often be challenging for individuals to attend visits and pay laboratory costs ( U.S. Centers for Disease Control and Prevention & U.S. Public Health Service, 2018 ). A new model of care that leverages mHealth (e.g., mobile and social computing technologies) to increase initiation, retention, and adherence to PrEP, such as electronic PrEP (ePrEP), has been introduced and found to be acceptable and effective among PrEP users ( Siegler et al., 2020 ). PrEPmate is one such multicomponent mHealth intervention that uses short-message service (SMS) and youth-tailored interactive online content to enhance PrEP adherence among at-risk young MSM ( Liu et al., 2019 ). Currently, it is the only PrEP study identified as an Evidence-Based Intervention by the CDC Prevention Research Synthesis project ( CDC, 2020 ). Siegler et al. implemented the PrEP at Home Study among 50 young Black MSM in a rural area. In the study, 42% of participants received PrEP via the ePrEP system, whereas 93% preferred to use ePrEP over standard provider visit and 67% were more likely to remain on PrEP if ePrEP were available ( Siegler et al., 2019 ).

Future biomedical HIV prevention modalities such as long-acting injectable agents have the potential to prevent HIV acquisition without relying on adherence to a daily or 2-1-1 oral dosing regimen. In MSM and transfeminine communities, an injectable form of cabotegravir given intramuscularly every 2 months had an estimated 66% lower incidence of HIV, compared with daily TDF/FTC ( Landovitz, 2020 ). Additional cabotegravir studies in cisgender women are being conducted under HPTN 084 to evaluate safety and efficacy (the LIFE Study; HIV Prevention Trials Network, 2020 ). The dapivirine (DAP) vaginal ring, for use by cis-women as a flexible silicone ring that continuously releases the antiretroviral HIV drug DAP in the vagina as a long-acting option for HIV prevention is another biomedical HIV prevention modality being studied ( Psomas et al., 2017 ). A phase 2a trial of a 25-mg DAP vaginal ring has been shown to be safe and acceptable among U.S. adolescents ages 15–17 ( Psomas et al., 2017 ). The DAP vaginal ring has been approved by the European Medicines Agency for women older than 25 years, and further studies are ongoing for women ages 15–25 years in the United States ( National Institutes of Health, 2020 ).

Although there are clear benefits to the aforementioned intervention strategies, structural- and community-level interventions are distinctly different, given their focus on macrolevel factors that influence risk versus individual beliefs and behaviors. This is imperative because in many highly affected demographics (e.g., Black women and young racial and ethnic minority MSM), broader social and structural factors drive HIV risk more than individual behavior ( Bauermeister et al., 2017 ; Brawner, 2014 ). With this wider focus, changes are seen in factors such as social diffusion of safer sex messages and comfort with being gay ( Eke et al., 2019 ), better viral suppression and continuity in care ( El-Sadr et al., 2017 ; Towe et al., 2019 ; Wohl et al., 2017 ), and increased HIV testing in populations that may not have otherwise been tested ( Belenko et al., 2017 ; Berkley-Patton et al., 2019 ; Frye et al., 2019 ).

Addressing structural barriers can reduce viral load, prevent HIV infection, and increase HIV testing. In homeless populations, researchers used a rapid rehousing intervention to place participants in stable housing faster (3 months earlier than usual service clients), doubling the likelihood of achieving or maintaining viral suppression ( Towe et al., 2019 ), and worked through primary care providers in Veterans Affairs to increase PrEP access ( Gregg et al., 2020 ). Community-level interventions that used financial incentives reduced viral load and decreased self-reported stimulant use among sexual minority men who use methamphetamine ( Carrico et al., 2016 ) and increased viral suppression and continuity in care in HIV-positive patients ( El-Sadr et al., 2017 ). The latter intervention, however, did not demonstrate an effect on increasing linkage to care.

Health care access remains a concern, and novel strategies can be used to get services to those in need. Pharmacies have also been promising locations for HIV prevention work. Persons who inject drugs were more likely to report always using a sterile syringe than not when they were connected to pharmacies that received in-depth harm reduction training and provided additional services (i.e., HIV prevention/medical/social service referrals and syringe disposal containers; Lewis et al., 2015 ). Providing a PEP informational video and direct pharmacy access to PEP also increased PEP knowledge and willingness; however, this did not translate to more PEP requests ( Lewis et al., 2020 ).

In correctional facilities, researchers have used strategies such as referral to care within 5 days after release, medication text reminders, and local change teams with external coaching to maintain viral suppression post-release and increase HIV testing among inmates ( Belenko et al., 2017 ; Wohl et al., 2017 ). High fidelity to the required institutional changes needed to improve HIV services was also noted ( Pankow et al., 2017 ). With the detrimental effects of mass incarceration, including disparate HIV outcomes while incarcerated and post-release, correctional settings are prime targets for future structural intervention work.

Success is tied to meeting people where they are—engaging them through existing programs, organizations, and institutions they are already connected to. Congregation-level interventions have demonstrated success in doubling HIV testing rates and reducing HIV stigma ( Berkley-Patton et al., 2019 ; Derose et al., 2016 ; Payne-Foster et al., 2018 ); however, effects on HIV stigma varied across studies. The studies demonstrating an effect on HIV stigma only achieved this at the individual—not congregation—level ( Payne-Foster et al., 2018 ), and in Latino—but not African American—churches ( Derose et al., 2016 ). Key to these interventions was the inclusion of multilevel activities (e.g., ministry group activities, HIV testing events during services, and pastors delivered sermons on HIV-related topics) and flexibility to accommodate church schedules and levels of comfort with covering different topics. Churches were not the only setting where addressing HIV stigma beyond the individual-level was a challenge. In a community-level intervention on HIV stigma, homophobia, and HIV testing, researchers used workshops, space-based events, and bus shelter ads in a high HIV prevalence area but did not have an effect on HIV stigma or homophobia ( Frye et al., 2019 ). They did, however, increase HIV testing by 350%.

Individuals within key systems and communities can also be pivotal to share HIV-related information and increase access to services. Integration of lay health advisors (“Navegantes”) into existing social networks (i.e., recreational soccer teams) among Hispanic/Latino men led to twice the likelihood of reporting consistent condom use in the past 30 days and HIV testing at the 18-month follow-up ( Rhodes, Leichliter, et al., 2016 ). A year after the intervention ended, 2 years after their training, 84% of the Navegantes (16 of 19) continued to conduct 9 of the 10 primary health promotion activities (e.g., talking about sexual health, describing where to get condoms, and showing segments of the intervention DVD; Sun et al., 2015 ). Furthermore, using a popular opinion leader model targeting alcohol-using social networks, researchers demonstrated a decline in composite sexual risk (e.g., having sex while high or with a partner who is high and exchanging sex for drugs or money) and an increase in HIV knowledge ( Theall et al., 2015 ). An intervention developed for college students and those in the surrounding area integrated HIV testing and education, mental health, and substance abuse services and referrals and noted a preliminary effect on social norms and sexual health messages on campus ( Ali et al., 2017 ).

Culturally situated marketing and other media approaches reach a broader audience to effect change. Successful social marketing campaigns to promote HIV testing should be performed in a way that enhances well-being (rather than fear-based messages), does not represent the target community in stigmatizing ways, and acknowledges barriers to HIV testing (e.g., stigma; Colarossi et al., 2016 ). One study evaluated a city-level, culturally-tailored media intervention combined with an individual risk reduction curriculum in comparison to no city-level media and a general health curriculum ( Kerr et al., 2015 ). Study findings suggested that all media-exposed participants had greater HIV-related knowledge at 6 months, and those who received the media intervention and risk reduction content had lower stigma scores at 3 and 12 months. A community-level intervention designed to decrease HIV risk among young MSM via persuasive media communication and peer-led networking outreach reduced anal sex risk among participants who reported binge drinking and/or marijuana use; the effect was not sustained for those who used other drugs ( Lauby et al., 2017 ). Another community mobilization intervention (e.g., publicity, groups, and outreach) addressed psychosocial factors at individual, interpersonal, social, and structural levels and documented an increase in HIV testing and a reduction in condom-less sex (although not sustained at 6 months; Shelley et al., 2017 ).

Interventions targeting providers and care delivery increase risk screening, HIV testing, timely linkage to care, and PrEP access for eligible individuals. Similar to the ways lay health workers are activated internationally, Health Promotion Advocates were employed in pediatric emergency departments to survey patients (e.g., health risks, stresses, and needs; Bernstein et al., 2017 ). Positive screens triggered critical resources (e.g., brief conversation on risks and needs and treatment as indicated), and, as a result, the intervention extended emergency services beyond the scope of the presenting complaint, engaging more than 800 youth in critical services such as mental health treatment and HIV testing. By pairing intensive medical case management with formalized relationships with local health departments and resources and addressing structural barriers (e.g., ability to access HIV prevention, testing, and medical care), researchers were able to decrease the average number of days to link to care and maintain the decline over a 6-year period ( Miller et al., 2019 ). Ninety percent of those linked to care had an initial medical visit in 42 or fewer days postdiagnosis. The integration of PrEP referrals into STI partner services led to 54% of PrEP eligible men accepting a PrEP referral and a 2.5-fold increase in PrEP use after partner services among MSM ( Katz et al., 2019 ).

Another group had health professional students (e.g., medicine and pharmacy) provide education about PrEP to public health providers, contributing to an increase in PrEP prescriptions, including for PrEP-eligible at-risk groups who previously were not given prescriptions ( Bunting et al., 2020 ). An underway pilot targets training primary care providers to better understand historical influences of structural factors, assess structural vulnerability among patients, create a more integrated system of care (e.g., opioid use and HIV risk) and empathy and nonjudgement in patient interactions ( Bagchi, 2020 ). There is strong precedent for this, given that significant effects were noted in creating affirming environments for sexual and sex minority youth, including improvements in providers’ and staff’s knowledge and attitudes, clinical practices, individual practices, and perceived environmental friendliness/safety ( Jadwin-Cakmak et al., 2020 ).

Policy changes can hinder or advance HIV prevention efforts, and modeling is an effective strategy to project outcomes and identify targeted prevention strategies. In an examination of Washington, DC’s buffer zone policy—prohibition of syringe exchange program operations within 1,000 feet of schools—researchers found that adherence to this 1,000 Foot Rule reduced syringe exchange program operational space by more than 50% a year ( Allen et al., 2016 ). These restrictions on the amount of legal syringe exchange program operational space have a significant impact on service delivery among injection drug users, which in turn affects HIV transmission through syringe sharing ( Allen et al., 2016 ). Analysis of a natural policy intervention indicated that removing a ban that prohibited the use of federal funds for syringe exchange programs potentially averted 120 HIV cases ( Ruiz et al., 2016 ).

In examining which prevention approach would achieve the greatest impact on HIV transmission, in light of available resources, study findings suggested that targeted testing by venue is more cost effective than routine emergency department testing ($31,507 vs. $59,435, respectively; Holtgrave et al., 2016 ). Modeling of interventions in 6 cities indicated that HIV incidence could be reduced by up to 50% by 2030, with cost savings of $95,416 per quality-adjusted life-year, by implementing combinations of evidence-based interventions (e.g., medication for opioid use disorder, HIV testing, ART initiation, and retention; Nosyk et al., 2020 ). Of note, nurse-initiated rapid testing was included in the optimal combination that produced that greatest health benefit while remaining cost effective across all cities. An ongoing microenterprise RCT will determine the effects of multiple strategies (e.g., weekly text on job openings, educational sessions on HIV prevention, and $11,000 start-up grant) on sexual risk behaviors, employment, and HIV preventive behaviors among economically vulnerable African American young adults ( Mayo-Wilson et al., 2019 ); a paucity of reviewed studies focus in this area. A comparable holistic health demonstration project, which engaged young Black MSM, successfully achieved viral suppression, connected participants to employment opportunities, and addressed housing discrimination ( Brewer et al., 2019 ).

Discussion and Future Considerations for Nursing Science

This review of current HIV prevention interventions provides a substantial contribution to the literature by synthesizing literature on four key areas of HIV prevention science. Nursing focuses on holistic care, assessing, diagnosing, and treating all areas that influence individual and population health. As we consider where and how to develop these programs, research indicates that more people may receive HIV prevention interventions in community-based clinics than in primary care or acute care settings ( Levy et al., 2016 ). Future nursing research should aim to address the needs of underserved populations who may benefit from robust HIV prevention strategies as outlined in this discussion section.

As we continue to generate knowledge about the multidimensional nature of HIV risk, especially for marginalized and vulnerable populations, there are increasing opportunities to learn from and use previous research to design multilevel and combination intervention strategies to better overcome barriers to HIV prevention ( Brawner, 2014 ; Frew et al., 2016 ). As suggested by the identified behavioral intervention studies, classic and current prevention programs have used useful strategies, but there remains room for improvement. These studies advance the science of HIV prevention, which helps fill gaps in the current literature and offer valuable insights that can contribute toward advancing the plan of Ending the HIV Epidemic ( U.S. Department of Health and Human Services, 2019 ; Treston, 2019 ).

As behavioral interventions continue to be created, replicated, and adapted, researchers should focus on implementing and testing these interventions in real-life settings. Implementation science strategies include planning, education, finance, restructuring, quality management, and policy strategies ( Powell et al., 2012 ). These strategies include various aspects of collecting data from stakeholders and community members, assessing setting readiness, determining realistic dosing, and assessing intervention acceptability and feasibility among target populations. The translation of science from research settings to real-life settings is imperative in the sustainability of efficacious behavioral interventions.

Technological

Although there is a plethora of technological-based HIV interventions with many in the pipeline, gaps persist in the current literature. There is a lack of precise knowledge regarding the content components of these interventions that are associated with improving clinical outcomes ( Dillingham et al., 2018 ; Ramos, 2017 ). There is also limited knowledge of optimal delivery approaches for these types of digital HIV interventions ( Côté et al., 2015 ; Schnall et al., 2015 ). In addition, there is a dearth of studies evaluating the efficacy, effectiveness, and cost effectiveness of using emerging technologies in HIV prevention interventions, such as gaming, gamification, social media, and virtual interventions ( Garett et al., 2016 ; Kemp & Velloza, 2018 ; LeGrand et al., 2018 ). Furthermore, there is a lack of resource-sharing platforms that would allow for new research to build on impactful elements of technology-based HIV prevention interventions without recreation of these components. Making these components available in an open platform would substantially reduce time and costs of developing new technological interventions and prevent wasteful use of resources on elements that do lead to desired outcomes.

In all, because technology continues to evolve and potential users of these interventions gain more access and complex skills in the use of other applications in everyday life, the demand for more user-centric HIV prevention interventions will likely continue to grow. Current interventions will need to be updated to maintain relevance, and new interventions will need to be designed to be adaptable to continuing technological advances. Policymakers have a role to play in allowing for governmental sharable databases of impactful interventions so that limited resources can be used to design predictably effective components of technological interventions leading to better health outcomes.

The nurse plays a vital role in HIV prevention and PrEP care ( O’Byrne et al., 2014 ). The University of California, San Francisco School of Nursing, recently developed and validated a set of entry-level nurse practioner competencies to provide culturally appropriate comprehensive HIV care ( Portillo et al., 2016 ). Similar programs should be implemented to train nurses and further the delivery of nursing-led biomedical HIV interventions. Magnet is a nurse-led clinic in San Francisco that has successfully leveraged expanded scopes of practice to allow for nurses to practice to the full extent of their licensure and allow for the rapid expansion of PrEP services to the community ( Holjilla et al., 2018 ). Such a unique and successful community-based PrEP delivery intervention led to the development and implementation of pharmacist-led PrEP clinics ( Havens et al., 2019 ; Lopez et al., 2020 ; Tung et al., 2018 ). More community-based, nursing-led biomedical HIV interventions are needed. Furthermore, future research should explore the efficacy of biomedical HIV prevention among transmasculine and cis-women populations, especially those of color who are underrepresented in existing research efforts ( Bond & Gunn, 2016 ; Chandler et al., 2020 ; Deutsch et al., 2015 ; Golub et al., 2019 ; Rowniak et al., 2017 ; Willie et al., 2017 ). Community-based nursing-led HIV interventions may be opportune for reaching these populations.

Structural and Community

Most HIV prevention structural- and community-level interventions still focus on developing countries, with less attention in the United States ( Adimora & Auerbach, 2010 ). However, with several communities facing limited resources, large percentages of individuals living below the federal poverty level and high HIV incidence and prevalence rates, it is time to expand these international success stories to domestic work (e.g., microfinance, credit programs, and comprehensive sexual health education). There is also a paucity of these interventions targeted to women and youth. Relative to the other reviewed strategies, very few nurses are engaged in structural-/community-level interventions. If successful, the in-progress microenterprise RCT by Mayo-Wilson et al. (2019) has the potential to serve as a blueprint for integrating multiple structural approaches that have demonstrated effectiveness abroad into U.S. contexts. The work by Werb et al. (2016) can also transform approaches to structural approaches to prevent injection drug initiation—given nursing’s focus on prevention, initiation of, and/or partnership in such work could be pivotal.

An approach to consider moving forward is applying the multiphase optimization strategy (MOST) to HIV prevention strategies ( Collins et al., 2016 ). MOST uses randomized experimentation to assess the individual performance of each intervention component. This rigorous process, based on a priori optimization criteria (e.g., cost and time), identifies whether aspects of an intervention component (e.g., presence, absence, and setting) have an impact on the performance of other components. Ultimately, this knowledge is used to engineer an intervention that is effective, efficient, and readily scalable. Multilevel interventions that target more than one level can lead to the most sustainable behavior change and can be delivered in venues known to be associated with HIV risk (e.g., bars and nightclubs; Pitpitan & Kalichman, 2016 ). An ongoing study on neighborhood contexts (e.g., poverty, HIV prevalence, and access to care) and network characteristics (e.g., size and frequency of communication) among Black MSM in the deep south will generate rich data to inform interventions for this key demographic ( Duncan et al., 2019 ). There also remains a need for explicit research with transgender populations—versus only including them in other samples—to fill gaps and meet unique needs ( Mayer et al., 2016 ).

Nursing Advancements

Nurse scientists around the globe are contributing to the development of interventions along the care continuum. Jemmott et al. have created numerous behavioral interventions over the past 30 years, which have been adapted for use in new settings and with different populations ( Advancing Health Equity: ETR, 2019 ). Behavioral interventions have been implemented using technology. Nursing exemplars in technology include the development of an immersive adventure game for African American adolescents ( Enah et al., 2019 ; Enahet al., 2015). In a series of studies in the primary prevention end of the prevention and care continuum, Enah et al. studied relevant content and design elements, evaluated an existing web-based game for relevance, developed and qualitatively studied acceptability of an individually tailored adventure game, and evaluated the potential efficacy of the game among African American adolescents ( Enah et al., 2019 ; Enah, Piper & Moneyham, 2015 ). At the care end of the continuum, Schnall et al. adapted an existing intervention for MSM ( Schnall et al., 2016 ), addressing co-morbidities for PLWH using multimodal techniques ( Schnall et al., 2019 ).

Flores developed a novel sex communication video series to support parent–child communication for gay, bisexual, and queer male adolescents ( Flores et al., 2020 ). Nurses have also collaborated on telehealth interventions to identify barriers to HIV care access and adherence and address mental health, substance use, and other issues among youth and young adults living with HIV ( Wootton et al., 2019 ). Other researchers piloted HIV/STI prevention content curated from online resources (e.g., YouTube and public and private websites) and found that youth who received links to publicly accessible online prevention content had a significant improvement in HIV self-efficacy and a significant reduction in unprotected vaginal or anal sex ( Whiteley et al., 2018 ). Nurses can partner with public health experts, computer scientists, and others to leverage these resources for population health improvement because new technologies continue to emerge ( Rhodes, McCoy, et al., 2016 ; Stevens et al., 2017 ; Stevens et al., 2020 ). Nurses, including members of the Association of Nurses in AIDS Care, have also been instrumental in the All of Us Research Program, a National Institutes of Health initiative aiming to enroll one million people across the United States to increase accessibility to data on individual variability in factors including genetics, lifestyle, and socioeconomic determinants of health to speed up medical breakthroughs ( National Institutes of Health, 2020 ).

As experts in community-engaged HIV research, partnerships that are committed to engaging key communities will lead to the development of interventions—across levels—to help achieve national goals of ending the HIV epidemic by 2030 ( Fauci et al., 2019 ). Health departments, academia, and community partners can also collaborate on policy modeling to improve resource allocation and better address HIV prevention priority setting ( Holtgrave et al., 2016 ). Investigators have also called for legal reform to address state-level structural stigma (index including density of same-sex couples and state laws protecting sexual minorities) experienced by MSM, given linkages between decreased state-level stigma and reduced condomless anal intercourse and increased PEP and/or PrEP use ( Oldenburg et al., 2015 ). Geographic information systems mapping can also be used to identify areas of greatest need and allocate necessary resources ( Brawner et al., 2017 ; Brawner, Reason, Goodman, Schensul, & Guthrie, 2015 ; Eberhart et al., 2015 ).

Recommendations to Further Advance HIV Prevention Intervention Science

Based on the literature reviewed and gaps identified, we offer three recommendations to further advance HIV prevention intervention science. First, nurses should leverage transdisciplinary partnerships to lead the development and testing of comprehensive interventions. For example, nurses could develop and test a nurse-delivered intervention model that engages pharmacists for PrEP access, psychologists and social workers for mental health treatment, librarians and health communication scholars for improving health literacy, and health informaticists to program the content for virtual delivery. Second, nurse researchers are at the cutting edge of knowledge generation in multiple fields, including HIV science (as evidenced by this review), and should be highly sought after for research collaboration accordingly. Although nursing is one of the most trusted professions, nurses are often overlooked when researchers in other disciplines search for collaborators with advanced methodological skill sets, content-specific expertise, or additional perceived benefits to their research teams. Finally, regardless of the intervention type (e.g., behavioral and biomedical), future intervention work must account for social and structural challenges experienced by the intended intervention recipients (e.g., racism, homelessness, and concentrated poverty in neighborhoods). This could include activities such as adding social service linkages to research protocols (e.g., providing participants with information on stable housing programs) or implementing structural interventions to improve neighborhood conditions (e.g., hiring community members to green vacant lots).

Nurses have made tremendous strides in behavioral interventions; however, representation in biomedical-, technological-, and structural-/community-level interventions is limited. We believe this hinders possible advancements in HIV prevention science, given the uniqueness a nursing lens contributes to research endeavors. We encourage nurses to expand the scope of their intervention work, and for individuals working in fields of HIV prevention where nurses are underrepresented, to seek out nursing collaborators. Together, these transdisciplinary teams can curb the epidemic and achieve an AIDS-free generation.

Key Considerations

  • Nurses should leverage transdisciplinary partnerships to lead the development and testing of comprehensive interventions.
  • Future intervention work must account for social and structural challenges experienced by the intended intervention recipients.
  • Nurse researchers should be used for their advanced methodological skill sets and expertise in HIV prevention science.

Disclosures

The authors report no real or perceived vested interests related to this article that could be construed as a conflict of interest.

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  • U.S. Food & Drug Administration. (2019, October 3). FDA approves second drug to prevention HIV infection as part of ongoing efforts to end the HIV epidemic . Retrieved August 3, from https://www.fda.gov/news-events/press-announcements/fda-approves-second-drug-prevent-hiv-infection-part-ongoing-efforts-end-hiv-epidemic
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HIV/AIDS Information for Researchers

NIAID-supported investigators are conducting a wide range of research on all areas of HIV/AIDS, including developing and testing preventive HIV vaccines, prevention strategies, and new treatments for HIV and associated coinfections, co-morbidities, and complications.  Through laboratories and clinics on the NIH campus in Bethesda, MD, and a vast network of research supported at universities, medical centers, and clinical trial sites around the globe, NIAID is working to better understand HIV and how it causes disease, find new tools to prevent HIV infection including a preventive vaccine, develop new and more effective treatments for people living with HIV, and hopefully, find a cure.

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HIV infections articles from across Nature Portfolio

HIV infections (human immunodeficiency virus infections) include the spectrum of infections caused by the virus HIV that range from asymptomatic seropositivity to acquired immunodeficiency syndrome (AIDS)-related complex (ARC) and AIDS.

Latest Research and Reviews

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TGF-β blockade drives a transitional effector phenotype in T cells reversing SIV latency and decreasing SIV reservoirs in vivo

Treatment with the clinical stage TGF-β inhibitor galunisertib promotes latency reversal of HIV/SIV. Here, using a treatment regimen similar to the one tested in clinical trials, the authors show how galunisertib affects immune cell function, increases SIV reactivation, and reduces the viral reservoir in macaques.

  • Deepanwita Bose
  • Elena Martinelli

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Income determines the impact of cash transfers on HIV/AIDS: cohort study of 22.7 million Brazilians

Brazil has operated a conditional cash transfer program to support families living in precarious conditions since 2004. Here, the authors use linked administrative and health data to investigate the impacts of the program on HIV/AIDS-related outcomes, demonstrating strong positive associations.

  • Andréa F. Silva
  • Inês Dourado
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Immune targeting of HIV-1 reservoir cells: a path to elimination strategies and cure

Finding a cure for HIV-1 infection, once considered elusive, now represents a major priority for the global microbiology research community. In this article, Armani-Tourret, Lichterfeld and colleagues highlight recent advances in understanding immunological vulnerabilities of virally infected cells that persist lifelong and represent the major barrier to a cure.

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  • Benjamin Bone
  • Mathias Lichterfeld

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HIV-associated gut microbial alterations are dependent on host and geographic context

Here, the authors compare the fecal microbial community of individuals in the U.S., Uganda, and Botswana, and identify significant bacterial taxa alterations with both treated and untreated HIV infection although with a high degree of uniqueness in each cohort, and also significant differences between populations that report men who have sex with men (MSM) behavior and non-MSM populations.

  • Muntsa Rocafort
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Bispecific antibodies promote natural killer cell-mediated elimination of HIV-1 reservoir cells

Siliciano and colleagues describe the generation of bispecific antibodies that target the HIV-1 envelope protein (Env) on the surface of HIV-1-infected cells and the receptor CD16 on the surface of NK cells to induce the NK cell-mediated lysis of HIV-1-infected cells and reduce the viral reservoir.

  • Nathan L. Board
  • Robert F. Siliciano

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The HIV capsid mimics karyopherin engagement of FG-nucleoporins

Dissection of the nuclear pore complex provides a model in which the HIV capsid enters the nucleus through karyopherin mimicry, a mechanism likely to be conserved across other viruses.

  • C. F. Dickson
  • D. A. Jacques

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Why have t cell-inducing vaccines for hiv failed so far.

The failure of T cell-targeted vaccines for HIV in clinical trials is likely due to impaired degranulation of low-avidity CD8 + T cells in the context of low levels of antigen presentation.

  • Alexandra Flemming

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Close the gender gap in Africa’s HIV epidemic

Improving HIV interventions for men could reduce HIV acquisition in women, close the growing gender gap in HIV infections and further reduce HIV incidence in African countries.

  • Bryan Tegomoh
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This is how the world finally ends the HIV/AIDS pandemic

Putting the specific needs of individuals and communities at the heart of HIV/AIDS care, by harnessing behavioural science, is key to building on the progress already been made.

  • John Nkengasong
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Viral, cellular and immune aspects of non-suppressible HIV-1 viremia

We find that people with non-suppressible human immunodeficiency virus (HIV) viremia despite antiretroviral therapy (ART) exhibit several distinguishing features. These include expanded CD4 + T cell clones containing HIV proviruses integrated into transcriptionally permissive regions, the presence of certain proviral defects or human leukocyte antigen (HLA)-escape mutations, enhanced survival signatures, and muted interferon and cytotoxic CD8 + T cell responses.

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Determining the longevity and dynamics of HIV-1 neutralizing activity

The induction of neutralizing antibodies is the main goal of an HIV-1 vaccine, although data on the longevity of such antibodies is lacking. By tracking neutralizing antibodies in a large cohort of individuals infected with HIV-1 who had varying viral loads, we show that the HIV-1 neutralization response can last for several years even at low antigen levels.

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Page 1 of 18

Characterization of intestinal fungal community diversity in people living with HIV/AIDS (PLWHA)

Acquired Immune Deficiency Syndrome (AIDS) is a highly dangerous infectious disease caused by the Human Immunodeficiency Virus (HIV), a virus that attacks the human immune system. To explore the correlation be...

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A call for change: addressing the implementation strategy using pre exposure Prophylaxis for combating the escalating HIV crisis in Zanzibar’s key populations

The Integrated Bio-Behavioural Surveillance Survey of 2022–2023 among key populations report from Zanzibar has been released. The prevalence of HIV is estimated to be 21.1%, 11.4%, and 9.3% among Female Sex Wo...

Outcomes of antiretroviral treatment for 0-14-year-old children living with HIV in Ganzhou, China, 2006–2023

Studies on antiretroviral therapy (ART) in children living with HIV (CLHIV) are limited due to the small population and low accession rate of ART.

Experiences of people living with HIV in low- and middle-income countries and their perspectives in self-management: a meta-synthesis

Availability of anti-retroviral treatment has changed HIV in to a manageable chronic disease, making effective self-management essential. However, only a few studies in low- and middle-income countries (LMICs)...

Satisfaction of antiretroviral therapy services and its associated factors among adult clients attending antiretroviral therapy in Woliso town, Ethiopia

Antiretroviral therapy client satisfaction is a significant tool that enables to strengthen the quality of life of the clients. The study aimed to assess the satisfaction of clients with antiretroviral therapy...

Hypertension among persons living with HIV/AIDS and its association with HIV-related health factors

Human Immunodeficiency Virus ( HIV) infection remains a public health concern in many countries. The increased life expectancy in the post-Antiretroviral Therapy (ART) era has led to an increased risk of cardiovas...

Effect of dolutegravir-based versus efavirenz-based antiretroviral therapy on excessive weight gain in adult treatment-naïve HIV patients at Matsanjeni health center, Eswatini: a retrospective cohort study

There is limited data on dolutegravir (DTG)-associated weight gain from settings with a dual burden of HIV and overnutrition.

Bifocal malakoplakia in a patient living with HIV: case report

Malakoplakia is a rare chronic granulomatous disease characterized by the presence of Michaelis-Gutmann bodies (MGBs) within histiocytic aggregates. It predominantly affects immunocompromised individuals, incl...

Empyema caused by Streptococcus constellatus in a patient infected with HIV: a case report and literature review

Empyema caused by Streptococcus constellatus (S. constellatus) is rare in patients with HIV. To analyze the clinical data of a patient living with HIV (PLHIV), who got empyema caused by S. constellatus, invest...

Brief communications: changes in inflammatory biomarkers and lipid profiles after switching to long-acting cabotegravir plus rilpivirine

We assessed whether the impact of cabotegravir plus rilpivirine on inflammation reduction differs from that of oral antiretrovirals, using real-world data. Inflammatory biomarkers and lipid profiles were follo...

Adolescent’s and youth’s adherence to antiretroviral therapy for better treatment outcome and its determinants: multi-center study in public health facilities

Low-adherence to Anti-retroviral therapy (ART) negatively affects the clinical, immunological, and virologic outcomes of patients. Adherence is the most important factor in determining Antiretroviral Therapy (...

Risk factors for unsuppressed viral load after intensive adherence counseling among HIV infected persons in Kampala, Uganda: a nested case–control study

Intensive adherence counseling (IAC) is the global standard of care for people living with human immunodeficiency virus (PLHIV) who have unsuppressed VL after ≥ 6 months of first-line anti-retroviral therapy (...

Prevalence of depression among people living with HIV in rural hospitals in South-Western Nigeria-Association with clinico-demographic factors

Major depression is the most common neuropsychiatric disorder among people living with HIV (PLWH) and is predictive of high morbidity and mortality among them. This study estimated the prevalence and explored ...

Determinants of survival of adolescents receiving antiretroviral therapy in the Centre Region of Cameroon: a multi-centered cohort-analysis

In spite of the global decreasing mortality associated with HIV, adolescents living with HIV (ADLHIV) in sub-Saharan Africa still experience about 50% mortality rate. We sought to evaluate survival rates and d...

Addressing HIV stigma in healthcare, community, and legislative settings in Central and Eastern Europe

Surging HIV prevalence across countries of Central and Eastern Europe (CEE) is largely a result of poor HIV care engagement and a lack of comprehensive support for key populations. This is fostered by widespre...

Research priorities in HIV, aging and rehabilitation: building on a framework with the Canada-International HIV and Rehabilitation Research Collaborative

In 2016, the Canada-International HIV and Rehabilitation Research Collaborative established a framework of research priorities in HIV, aging and rehabilitation. Our aim was to review and identify any new emerg...

Clinical, molecular, and histological characteristics of severely necrotic and fatal mpox in HIV-infected patients

This case series of 5 patients with severely necrotic mpox highlights the predominantly necrotic nature of lesions seen in cases of severe mpox as shown by skin and lung biopsy, as well as the extensive dissem...

Predictors of HIV status disclosure among people living with HIV (PLHIV) in Ghana: the disclosure conundrum and its policy implications in resource limited settings

Globally, over 40 million lives have been claimed by HIV/AIDS. In Ghana, more than 350,000 people are living with HIV. Non-disclosure of HIV status is a major barrier to HIV/AIDS eradication; yet, little is kn...

Standard of care in advanced HIV disease: review of HIV treatment guidelines in six sub-Saharan African countries

The World Health Organization (WHO) recommends an evidence-based package of care to reduce mortality and morbidity among people with advanced HIV disease (AHD). Adoption of these recommendations by national gu...

HIV gp120/Tat protein-induced epithelial–mesenchymal transition promotes the progression of cervical lesions

Human immunodeficiency virus (HIV) infection is associated with an elevated incidence of cervical cancer, and accelerated disease progression, but the underlying mechanisms are not well understood. This study ...

“Sex without fear”: exploring the psychosocial impact of oral HIV pre-exposure prophylaxis on gay men in England

Gay, bisexual, and other men who have sex with men (GBMSM) experience a high prevalence of psychosocial health problems, such as harmful substance use and depression, as well as being disproportionately affect...

Qualitative study of barriers and facilitators to HIV detection and treatment among women who inject drugs during the war against Ukraine

The Russian Federation’s invasion in Ukraine has resulted social hardship, millions of internally displaced persons, the destruction of medical infrastructure, and limited access to HIV services. There is no a...

Readmission rates in HIV-associated burkitt lymphoma patients in the USA: a nationwide readmission database (NRD) analysis

People with human immunodeficiency virus have an increased risk of developing AIDS-defining malignancies including Burkitt lymphoma. Survival outcomes in HIV-associated Burkitt lymphoma remain worse than non-H...

Association between psychological discomforts and sleep quality among people living with HIV/AIDS

Psychological discomfort and sleep problems are considered separate disorders. Due to the high prevalence of both disorders among people living with HIV (PLWH), this study was designed to evaluate how those ch...

Uptake of retroviral pre-exposure prophylaxis and its associated factors among female sex workers, Northwest Ethiopia

Pre-exposure prophylaxis is the use of antiretroviral medications by HIV-negative individuals to prevent infection before exposure. Ethiopia has made progress in reducing new HIV infections, but the burden rem...

Strategies to improve the care of older adults 50 years and above living with HIV in Uganda

With effective antiretroviral therapy (ART), many persons living with HIV (PLHIV) live to old age. Caring for aged PLHIV necessitates the engagement of caregivers and patients to establish agreed-upon goals of...

Mixed methods implementation research to understand success of intensive combination approach to roll back the epidemic in Nigerian adolescents) (iCARE Nigeria) HIV testing uptake and linkage to care among young men focusing on young men who have sex with men in Ibadan

HIV seroprevalence in Nigeria is increasing among men who have sex with men (MSM) from 14% to 2007 to 23% in 2014, threatening progress towards ending the epidemic in the country. Expanding access to HIV testi...

Current ART, determinants for virologic failure and implications for HIV drug resistance: an umbrella review

The purpose of this study is to investigate the incidence of determinants for virologic failure and to identify predisposing factors to enhance treatment efficacy. Tackling this global public health issue is t...

Preventative behaviours and COVID-19 infection in a Canadian cohort of people living with HIV

Few studies have examined preventative behaviour practices with respect to COVID-19 among people living with HIV (human immunodeficiency virus). Using a cross-sectional survey from a Canadian Institutes of Hea...

The hidden effects of COVID-19 on HIV services in Zanzibar: country report

The COVID-19 pandemic has had a major effect on HIV-related healthcare services. Zanzibar has experienced several interruptions of HIV services in the areas of testing and counselling, prevention of mother-to-...

Understanding health outcome drivers among adherence club patients in clinics of Gauteng, South Africa: a structural equation modelling (SEM) approach

There has been growing interest in understanding the drivers of health outcomes, both in developed and developing countries. The drivers of health outcomes, on the other hand, are the factors that influence th...

Estimating prevalence and modelling correlates of HIV test positivity among female sex workers, men who have sex with men, people who inject drugs, transgender people and prison inmates in Sierra Leone, 2021

Key populations (KPs) are particularly vulnerable to HIV infection and efforts to prevent HIV infections among KPs have been less successful, largely due to existing laws and legislation that classify the grou...

Understanding the social and structural context of oral PrEP delivery: an ethnography exploring barriers and facilitators impacting transgender women who engage in street-based sex work in Baltimore, Maryland

Transgender women who sell sex (TWSS) experience high rates of HIV acquisition. Antiretrovirals for pre-exposure prophylaxis (PrEP) represent an efficacious HIV prevention strategy. The social and structural f...

HIV viral load suppression among people with mental disorders at two urban HIV clinics in Uganda: a parallel convergent mixed methods study using the social ecological model

Uganda adopted and implemented the Universal Test and Treat (UTT) guidelines in 2017, which require HIV-infected persons to be initiated on antiretroviral therapy (ART) at any CD4 + cell count, and to be routi...

Tenofovir diphosphate in dried blood spots and HIV-1 resistance in South Africa

Suboptimal antiretroviral (ART) adherence can lead to virologic failure with consequent HIV-1 resistance. Tenofovir diphosphate (TFV-DP) in dried blood spots (DBS) is a powerful biomarker of cumulative adheren...

HIV-1-related factors interact with p53 to influence cellular processes

Human immunodeficiency virus type 1 (HIV-1) is the primary epidemic strain in China. Its genome contains two regulatory genes ( tat and rev ), three structural genes ( gag , pol , and env ), and four accessory genes ( n...

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  • ISSN: 1742-6405 (electronic)

AIDS Research and Therapy

ISSN: 1742-6405

The AIDS Epidemic in the United States, 1981-early 1990s

AIDS installation

A New Pattern Emerges

On June 5, 1981, CDC published a report in the MMWR describing requests for the drug pentamidine to treat a deadly disease called Pneumocystis carinii pneumonia (PCP) in five previously healthy young men in Los Angeles. After the report’s publication, health officials also noticed a spike in cases of Kaposi’s sarcoma (KS) external icon among gay men in New York. Health officials were alarmed that outbreaks of both PCP and KS, which were rare, deadly diseases associated with immune suppression, appeared in the same part of the population.

AIDS installation detail

CDC Investigates

In response, CDC formed a Task Force on KS/OI in the summer of 1981. From the very beginning, investigators thought the problem was most likely due to an infectious agent that could be transmitted through sexual contact, although some speculated that recreational drugs or other environmental factors could also be causes. In late 1981, cases began to be seen in injection drug users who were heterosexual, suggesting a pattern of infection that could be transmitted through blood. By early 1982, health experts were concerned that transmission through heterosexual contact, transmission to newborns, or transmission through the blood supply could come next.  These predictions came true. Transmission through the blood supply was confirmed when immunosuppression was reported in three people with hemophilia . Representatives from CDC, other health organizations, other scientists, and representatives from blood banks, gay rights organizations, and hemophiliacs, met in Washington D.C. to determine ways to prevent the transmission and develop guidelines to screen the blood supply.

body fluids barrier kit

New Guidelines: The “Universal Precautions”

CDC issued guidelines for health workers providing care to AIDS patients and for laboratory technicians performing tests on potentially infectious materials from AIDS patients. The recommendations became known as “ universal precautions ,” and included wearing gloves when exposed to blood and other bodily fluids. In a poster promoting health workers using safety precautions, a group of five health workers are shown wearing gloves, masks, and goggles. Since the universal precautions also established using safe needle disposal cases, a needle disposal container is on display with the body fluids barrier kit. The disposal case is a red sealed plastic container with the biohazard symbol displayed prominently on all sides and an opening at the top into which used needles are disposed.

ELISA: The First HIV Blood Test

Rosemary Ramsey

In CDC’s immunology lab, scientists began working with AIDS specimens as early as July 1981 to understand how the immune systems of young, healthy men were so compromised by the mystery illness. In a photograph from 1983 displayed here, a female CDC research chemist conducts tests on biological fluids from AIDS patients. This work contributed to the theory that an infectious agent , not a genetic defect, was the cause of the disease. CDC’s virology labs were among a network of international research centers searching for the virus believed to be the cause of AIDS.

eliza lab scientist

By the next year, the U.S Food and Drug Administration licensed the first commercial blood test, ELISA, to detect HIV . Blood banks begin screening the U.S. blood supply. In a photograph on display, a different CDC lab technician is performing the ELISA test. Using a plastic plate with 96 wells, the lab technician adds the patient’s blood to different enzymes. Certain reactions between the blood and the enzymes indicated the presence of HIV antibodies.

Ryan White poster

Stigma: Educating a Nation

  The first year of the AIDS epidemic seemed isolated to a few individuals in a few cities, so it received little media attention. When cases were reported in infants and people with hemophilia, widespread panic struck Americans. Those with AIDS were often stigmatized. In 1985, Ryan White, a teenage hemophiliac living in Indiana, contracted AIDS from a blood transfusion. Parents in his community feared he would expose their children to AIDS, resulting in Ryan being barred from attending school.

Understanding AIDS

In 1986, U.S. Surgeon General C. Everett Koop issued the Surgeon General’s Report on AIDS . In it, he called for a comprehensive program of sex and AIDS education, urged the widespread use of condoms , and dispelled myths that HIV could be spread by mosquitoes. In 1987, CDC launched an unprecedented national campaign, America Responds to AIDS (ARTA). The goal of ARTA was to increase awareness and understanding of AIDS, to prevent HIV infection, and to encourage people to seek more information and counseling. CDC also began a program to support HIV prevention efforts with national minority organizations that provided HIV prevention expertise to community-based organizations, developed HIV prevention programs targeting minorities, especially African Americans and Hispanics, and supported groups that used culturally sensitive AIDS prevention programs to address their communities’ needs.

AIDS slides

Prevention: The Best Strategy

  Even before CDC was designated in 1986 as the lead federal agency to inform and educate Americans about AIDS, the agency worked “with uncommon flexibility” with state and local public health agencies and community-based organizations to reach people most at risk. Science-based guidelines were translated into messages for target groups about how to make healthy choices, and how to prevent the spread of the disease. Other campaigns were designed to fight against stigma and fear by informing people about the nature of the disease, teaching tolerance and compassion for those who were HIV positive.

Displayed here are a set of slides from the HIV/AIDS Library and Narrative used by the Wisconsin Department of Health and Human Services in 1989 to train community-based AIDS service organizations. Furthermore, since testing became available in 1985, CDC began providing federal funds to establish an extensive system of alternate testing and counseling sites, leading to the first nationwide HIV- and AIDS-related prevention program. Today, testing —knowing one’s HIV status—is a key strategy in AIDS prevention.

In the 21 st Century, AIDS has become one of our greatest public health challenges . The epidemic’s global impact has been staggering, claiming the lives of more than 39 million people worldwide, including 500,000 people in the United States. In the United States, an estimated 1.1 million people live with HIV/AIDS and every year, about 38,000 new HIV infections occur. While AIDS can be managed with antiretroviral drug treatments, there is still no cure or vaccine for AIDS. Prevention is still the best strategy.

Take a closer look:

  • Learn about the basics of HIV and explore a wealth of CDC factsheets about how HIV affects specific populations in the U.S. For a global perspective, check out the World Health Organization external icon information hub for HIV/AIDS.
  • What does it mean to have “undetectable” HIV infection? Learn more in this CDC video external icon .
  • Explore the scope and impact pdf icon of HIV in the U.S., as well as who is at higher risk for HIV infection and why.
  • Examine this illustration of HIV. To get a closer look, check out a scanning electron microscope image and thin-section transmission electron microscope image .
  • Looking for HIV educational materials for patients, clinicians, and everyone in between? CDC’s HIV Nexus has comprehensive resources, tools, and guidelines.
  • Explore CDC’s role in ending the HIV Epidemic .
  • Want a more detailed breakdown of HIV and its global impact? Explore a comprehensive library of charts and graphs external icon about HIV.

From the source:

  • Find photographs, oral histories, and original documents from CDC’s early response to HIV/AIDS through Global Health Chronicles external icon .
  • Read firsthand accounts from World AIDS Day 2017.
  • See how Let’s Stop HIV Together external icon partners are working together to increase awareness of HIV testing, treatment, screening, and prevention options.
  • Find video stories from CDC’s Let’s Stop HIV Together campaign.
  • Why is it so hard to cure HIV/AIDS? Watch this Ted-Ed video external icon exploring just that.
  • Hear from CDC experts about different paths to public health and their work in HIV/AIDS at CDC in the CDC Museum Public Health Academy Teen Newsletter: December 2020 – Domestic HIV/AIDS Zoom external icon .

Then and now:

  • Explore a comprehensive library of charts and graphs about HIV through the CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention resource, AtlasPlus .
  • Read about CDC’s HIV Prevention Progress in the U.S. from the Division of HIV/AIDS Prevention.
  • Learn more about PEPFAR , the U.S. President’s Emergency Plan for AIDS Relief, and how CDC is helping drive progress against global HIV/AIDS.
  • Public health, art, and poetry have a lot in common. Explore the parallels between the artistic technique of cubism (breaking objects into parts and reassembling) and HIV in this issue of Emerging Infectious Diseases .
  • How has our understanding of HIV/AIDS evolved over the years? Take a deep dive into this timeline external icon spanning from the first reported cases in 1981 to the present.
  • Stay up-to-date with HIV/AIDS news with HIV-related Morbidity and Mortality Weekly Reports .
  • What comes next? Learn about prevention and care outcomes pdf icon of HIV in the U.S.
  • Find the latest updates about HIV/AIDS from CDC’s Division of HIV/AIDS Prevention.

Give it a try:

  • How much do you know about HIV/AIDS? Explore prevention tips, key facts, and more with CDC’s Disease of the Week HIV feature , then try your hand at a short quiz.
  • Take a deep dive into the past, present, and future of CDC’s HIV/AIDS work in the CDC Museum Public Health Academy Teen Newsletter: December 2020 – Domestic HIV/AIDS .
  • Find out how to get involved with the next World AIDS Day .
  • Interested in taking your knowledge a step further? Find free continuing education opportunities focused on HIV/AIDS through CDC’s HIV Nexus.
  • Has a friend or loved one been diagnosed with HIV? Find FAQ and materials about living well with HIV .
  • Looking for social media toolkits to promote HIV prevention, testing, treatment, and anti-stigma messaging?
  • Want to see the inside of the HIV virus? Check out this 3D rendering of the internal composition and nucleocapsid of HIV — and 3D print your own — through the National Institutes of Health 3D Print Exchange external icon .
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Regions & Countries

How americans view the conflicts between russia and ukraine, israel and hamas, and china and taiwan.

Odesa Technical College in Odesa, Ukraine, damaged in a nighttime Russian drone attack on Feb. 8. (Nina Liashonok/Ukrinform/Future Publishing via Getty Images)

Two years on from Russia’s invasion of Ukraine , 74% of Americans view the war there as important to U.S. national interests – with 43% describing it as very important.

Similar shares see the war between Israel and Hamas (75%) and tensions between China and Taiwan (75%) as important to U.S. national interests, according to a Pew Research Center survey conducted Jan. 22-28.

Pew Research Center conducted this analysis to understand Americans’ views of three ongoing global conflicts: the war between Russia and Ukraine, the war between Israel and Hamas and tensions between China and Taiwan. We first asked respondents to rate how important each conflict is to them personally. We then asked them to rate how important each conflict is to U.S. national interests.

For this analysis, we surveyed 5,146 U.S. adults from Jan. 22 to 28, 2024. Everyone who took part in this survey is a member of the Center’s American Trends Panel (ATP), an online survey panel that is recruited through national, random sampling of residential addresses. This way, nearly all U.S. adults have a chance of selection. The survey is weighted to be representative of the U.S. adult population by gender, race, ethnicity, partisan affiliation, education and other categories. Read more about the ATP’s methodology.

Here are the questions used for this analysis , along with responses, and its methodology .

Bar chart showing that majorities of Americans see the Israel-Hamas war, tensions between China and Taiwan, and the war between Russia and Ukraine as important to U.S. interests and to them personally

When asked how important each conflict is to them personally , 59% of Americans say the war between Russia and Ukraine is important to them.

This is similar to the share who say tensions between China and Taiwan (57%) are important to them personally. But it is lower than the share who see the Israel-Hamas war as personally important (65%).

Roughly a third of Americans describe the Israel-Hamas war as very important to them personally, compared with around a quarter for the other two conflicts we asked about.

Differences by party

Dot plot chart by party showing that Democrats are more likely than Republicans to see Russia-Ukraine war as important, both to U.S. interests and to them personally

Democrats and Democratic-leaning independents are more likely than Republicans and Republican leaners to see the Russia-Ukraine war as important to U.S. national interests (81% vs. 69%).

Related: About half of Republicans now say the U.S. is providing too much aid to Ukraine

However, Democrats and Republicans are about equally likely to see the Israel-Hamas war (76% vs. 77%) and China-Taiwan tensions (76% vs. 78%) as important to U.S. interests.

Americans at the ideological poles – that is, conservative Republicans and liberal Democrats – are more likely than their more moderate counterparts in each party to view both the Israel-Hamas war and China-Taiwan tensions as important to U.S. interests.

When it comes to the importance of each conflict to them personally , Democrats are more likely than Republicans to say the Russia-Ukraine war is important to them (65% vs. 56%), while Republicans are more likely than Democrats to say this about China-Taiwan tensions (62% vs. 56%). Roughly equal shares of Democrats (67%) and Republicans (66%) say the Israel-Hamas war is personally important to them.

Related: Americans’ Views of the Israel-Hamas War

Differences by age

Dot plot chart showing that the oldest Americans are more likely than younger Americans to see the Israel-Hamas war, tensions between China and Taiwan, and the war between Russia and Ukraine as important to U.S. interests and to them personally

For all three conflicts we asked about, the oldest Americans are more likely than younger Americans to perceive them as important to both U.S. national interests and to them personally.

However, even among U.S. adults under 30, a majority (58%) see the Israel-Hamas war as personally important. This is not the case for the Russia-Ukraine war or for the ongoing tensions between China and Taiwan.

Note: Here are the questions used for this analysis , along with responses, and its methodology .

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About Pew Research Center Pew Research Center is a nonpartisan fact tank that informs the public about the issues, attitudes and trends shaping the world. It conducts public opinion polling, demographic research, media content analysis and other empirical social science research. Pew Research Center does not take policy positions. It is a subsidiary of The Pew Charitable Trusts .

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DOD Official Restates Why Supporting Ukraine Is in U.S. Interest

As Congress once again addresses U.S. military aid to Ukraine, a DOD official said helping Ukraine defeat Russian aggression is in the United States' interest.  

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Celeste Wallander, assistant secretary of defense for international security affairs, told Clifford May, president of the Foundation for the Defense of Democracies, that U.S. aid to Ukraine has global impacts. 

Russia invaded neighboring Ukraine on Feb. 22, 2021. Russian forces were larger and better equipped, but Ukrainian forces stopped them from capturing the capital of Kyiv and decapitating the government and installing a puppet regime that answered to Russian President Vladimir Putin.  

The Ukrainians also held Kharkiv, the country's second largest city, and fought Russian forces to a standstill in the south and east.  

The United States has provided $43 billion in support to Ukraine, covering everything from Javelin missiles to tanks to ambulances to long-range strike missiles to air defense capabilities and much, much more. U.S. service members are training Ukrainian forces in Europe and the United States. Secretary of Defense Lloyd J. Austin III formed and still leads the Ukraine Defense Security Group which now has 50 nations that contribute to Ukraine's defense.  

This aid is key to helping Ukrainian forces take on and, in many areas, push back the Russians. U.S. government officials said in January that more than 300,000 Russians have been killed or wounded in Ukraine. 

Spotlight: Support for Ukraine

Wallander said the United States wants a Ukraine that is sovereign, independent and secure, adding that the Ukrainian people do not want Russian overlords and are fighting for their freedom. "We want the Ukrainian people to be able to live the European life they have chosen," she said during the discussion. 

While supporting Ukraine is the right thing to do, U.S. support is about more than just Ukraine, Wallander said. "[Our support] is about the international order that keeps all countries and all populations safe, including Russia," she said. 

Putin is seeking to "shred" the international order, the assistant secretary said. Putin wants the ability for large countries to intimidate and dominate smaller neighbors.  

And Russian actions have implications around the world, she said. "It's not just a European security issue, it is a global security issue," Wallander said. 

Built into the fabric of the Nuclear Non-Proliferation Treaty is the agreement that nuclear powers will respect the territorial integrity and sovereignty of other countries and agree to support the peaceful use of nuclear energy for their prosperity. "All of that is at stake in Russia's invasion and occupation of Ukraine," she said. 

Further afield, Chinese leaders are watching the war in Ukraine closely and have "a huge stake in Russia['s] success," Wallander said.  

A soldier boresights an M1A2 Abrams main gun.

If Putin is successful in shredding the United Nations Charter and benefiting from the use of force in Europe, "What's to stop China from following that path when it is ready?" she asked.  

China has supported Russia in its illegal invasion, and the Asian nation has benefited from Russia's increasing isolation. "The Chinese leadership doesn't want Putin to lose, because of what that would mean about the strength of the international community in pushing back against a bully," she said.  

Beyond the geopolitical reasons for supporting Ukraine, there are very human reasons, as well. The Russian invasion has been incredibly brutal, with indiscriminate attacks on civilians throughout the country. Wallander noted that Russian brutality has not been limited to Ukraine. The Russian military has used the same tactics in Chechnya and Georgia.  

But in Ukraine, Russia has gone beyond merely targeting civilian infrastructure. Russia has been taking Ukrainian children from their families or taking orphans and sending them to Russia. It is an almost "Nazi-like idea of ethnic purity that they need to be educated as Russians and that they are somehow going to be re-educated and brought back to benefit the Russian Federation," Wallander said. "It is just astonishing to think that a Europe, which faced the horror of such a leadership doing that to populations in the 1940s, is now confronted with another leadership that is doing that … in the 2020s."

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Ross Douthat

The Best Case for Ukraine Aid

A destroyed Russian tank on the side of a dirt road in Ukraine.

By Ross Douthat

Opinion Columnist

The first year of the war in Ukraine seemed to vindicate Russia hawks. The belief that Vladimir Putin was a careful chess player whose ambitions could be constrained through negotiation, the belief that Ukraine couldn’t plausibly defend itself against Moscow and therefore didn’t merit support from an already overstretched America — these ideas seemed to dissolve in the first months of war, with Putin gambling and rambling while Ukrainian arms threw his forces back.

The second year of war has been kinder to realists and doves. Russia, as in many wars before, seems stronger in a grinding conflict than it did in the initial thrusts. Putin’s regime proved resilient against the West’s economic weapons, and against internal opposition as well; the death in prison of Russia’s leading dissident, Aleksei Navalny, looks like the latest example of the dictator’s ruthless settling of accounts. Meanwhile, the Ukrainian counteroffensive of spring and summer failed: A year ago there was still hope that a Russian retreat would turn into a rout, but since then stalemate has ruled the front.

The changed situation has created a division in the hawkish argument, visible as the U.S. Congress wrangles over further aid to Ukraine. On the one hand you still have rhetoric that seems to belong more to the first year of war, claiming that Putin is clearly losing the war (“This guy is on life support,” Senator Thom Tillis, Republican of North Carolina, told his colleagues in the Senate debate), that aid to Ukraine is a cheap, effective way to degrade and defeat an American rival without fighting the Russians ourselves.

On the other you have arguments that suggest that the tide is turning against Ukraine, that Putin is getting ever stronger (“Russia’s capacity to produce military equipment has increased tremendously,” Denmark’s defense minister warned recently), that he’ll be ready to attack the Baltics or some other NATO country soon. The strange events this week on Capitol Hill, in which Representative Mike Turner, Republican of Ohio and a Ukraine hawk, teased secret intelligence about Russian superweapons in space, felt like an attempt to boost this narrative — emphasizing Russia’s increasing strength as the reason to keep on sending money and weapons to Ukraine.

The problem with the first argument is that it doesn’t match the changing situation on the ground. The problem with the second argument is that it raises a big strategic question: If Russia has gotten only stronger since we started funding the Ukrainian war effort, doesn’t that suggest that we’ve ended up overstretched after all, just as critics warned?

I think there is a good case for continued aid to Ukraine that doesn’t rely on either exaggerating Ukrainian successes or hyping Russia’s military-industrial complex. But it’s a case that’s hard to make under the sweeping terms that have framed our support for Ukraine to date.

The legislation that passed the Senate includes, ostensibly as a concession to skeptics, a provision requiring the Biden administration to submit to Congress a detailed strategic plan explaining how the aid will “hasten Ukrainian victory.” But as Keith Gessen of The New Yorker puts it, mildly, at this point most military observers are “a little hard-pressed to describe an actual military victory for Ukraine.” It’s more likely that there simply is no plausible path to a full Ukrainian triumph — or at least not one that’s compatible with defending America’s other interests around the world.

We are not giving Ukraine money, in other words, because we see a likely future in which Russia can be pushed back to the prewar lines of control. Instead, the best reason to continue sending aid is to make it easier to negotiate an armistice on terms favorable to Ukraine’s survival and resilience — since any such terms will become less and less favorable if we’re seen as abandoning the Ukrainians in advance.

I hope and believe that this is what the White House, beneath its wartime rhetoric, is currently seeking: not outright victory but the best possible deal to end the war. And certainly there are reasons, if that’s your goal, that you wouldn’t want to say so openly — you’d want to present yourself as planning for victory even if you’re actually ready to negotiate.

But the Biden administration has a domestic audience as well as an international one, and it might be easier to persuade domestic doubters — wavering House Republicans, especially — if the current aid package weren’t being presented as the clincher for a Russian defeat that isn’t actually in evidence, or the key to the sweeping victory that our prior investments have conspicuously failed to bring about.

These days that kind of promise — Triumph just around the corner! Victory waiting just beyond the next offensive! — evokes memories of Afghanistan and Vietnam, rather than confidence in American strategic prowess. What’s needed instead is something much subtler: a public argument that doesn’t concede too much to Russian aggression, but concedes enough to military reality to persuade Americans that they’re making an investment that will actually help bring the conflict to an end.

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Ross Douthat has been an Opinion columnist for The Times since 2009. He is the author, most recently, of “The Deep Places: A Memoir of Illness and Discovery.” @ DouthatNYT • Facebook

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