Publications by authors named "Kate Buchacz"

121 Publications

The CDC HIV Outbreak Coordination Unit: Developing a Standardized, Collaborative Approach to HIV Outbreak Assessment and Response.

Public Health Rep 2021 May 28:333549211018678. Epub 2021 May 28.

1242 Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA.

The Centers for Disease Control and Prevention (CDC) and state, territorial, and local health departments have expanded efforts to detect and respond to HIV clusters and outbreaks in the United States. In July 2017, CDC created the HIV Outbreak Coordination Unit (OCU) to ensure consistent and collaborative assessment of requests from health departments for consultation or support on possible HIV clusters and outbreaks of elevated concern. The HIV OCU is a multidisciplinary, cross-organization functional unit within CDC's Division of HIV/AIDS Prevention. HIV OCU members have expertise in areas such as outbreak detection and investigation, prevention, laboratory services, surveillance and epidemiology, policy, communication, and operations. HIV OCU discussions facilitate problem solving, coordination, and situational awareness. Between HIV OCU meetings, designated CDC staff members communicate regularly with health departments to provide support and assessment. During July 2017-December 2019, the HIV OCU reviewed 31 possible HIV clusters and outbreaks (ie, events) in 22 states that were detected by CDC, health departments, or local partners; 17 events involved HIV transmission associated with injection drug use, and other events typically involved sexual transmission or overall increases in HIV diagnoses. CDC supported health departments remotely or on site with planning and prioritization; data collection, management, and analysis; communications; laboratory support; multistate coordination; and expansion of HIV prevention services. The HIV OCU has augmented CDC's support of HIV cluster and outbreak assessment and response at health departments and had important internal organizational benefits. Health departments may benefit from developing or strengthening similar units to coordinate detection and response efforts within and across public health agencies and advance the national Ending the HIV Epidemic initiative.
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http://dx.doi.org/10.1177/00333549211018678DOI Listing
May 2021

INSTI-BASED INITIAL ANTIRETROVIRAL THERAPY IN ADULTS WITH HIV, THE HIV OUTPATIENT STUDY, 2007-2018.

AIDS Res Hum Retroviruses 2021 May 25. Epub 2021 May 25.

CDC, Division of HIV/AIDS Prevention, 1600 Clifton Road, MS E-45, Atlanta, Georgia, United States, 30329;

Background: We evaluated treatment duration and viral suppression (VS) outcomes with integrase strand transfer inhibitor (INSTI)-based regimens versus other contemporary regimens among adults in routine HIV care.

Methods: Eligible participants were seen during January 1, 2007 to June 30, 2018 at nine U.S. HIV clinics, initiated antiretroviral therapy (ART) (baseline date), and had ≥2 clinic visits thereafter. We assessed the probability of remaining on a regimen and achieving HIV RNA < 200 copies/mL on initial INSTI versus non-INSTI ART by Kaplan-Meier analyses and their correlates by Cox regression.

Results: Among 1005 patients, 335 (33.3%) were prescribed an INSTI-containing regimen and 670 (66.7%) a non-INSTI regimen, which may have included non-nucleoside reverse transcriptase inhibitors (NNRTIs), protease inhibitors (PIs) and other agents. In both groups, most patients were male, non-white, and aged <50 years. Comparing the INSTI with non-INSTI group, the median baseline log10 HIV viral load (copies/mL) was 4.6 vs. 4.5 and the median CD4+ cell count (cells/mm3) was 352 vs. 314. In Kaplan-Meier analysis, the estimated probabilities of remaining on initial regimens at 2 and 4 years were 58% and 40% for INSTI and 51% and 33% for non-INSTI group, respectively (log-rank test p = 0.003. In multivariable models, treatment with an INSTI (vs. non-INSTI) ART was negatively associated with a regimen switch (Hazard Ratio [HR], 0.67, 95% Confidence Interval [CI] 0.56, 0.81, p < 0.001), and was positively associated with achieving viral suppression (HR 1.52; CI 1.29, 1.79, p < 0.001), both irrespective of baseline viral load levels.

Conclusions: Initial INSTI-based regimens were associated with longer durations and better viral suppression than non-INSTI regimens. Results support INSTI regimens as the initial therapy in U.S. treatment guidelines.
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http://dx.doi.org/10.1089/AID.2020.0286DOI Listing
May 2021

Hepatitis C Virus Testing Among Men With Human Immunodeficiency Virus Who Have Sex With Men: Temporal Trends and Racial/Ethnic Disparities.

Open Forum Infect Dis 2021 Apr 17;8(4):ofaa645. Epub 2021 Apr 17.

Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

Background: National guidelines recommend that sexually active people with human immunodeficiency virus (PWH) who are men who have sex with men (MSM) be tested for hepatitis C virus (HCV) infection at least annually. Hepatitis C virus testing rates vary by race/ethnicity in the general population, but limited data are available for PWH.

Methods: We analyzed medical records data from MSM in the HIV Outpatient Study at 9 human immunodeficiency virus (HIV) clinics from January 1, 2011 through December 31, 2019. We excluded observation time after documented past or current HCV infection. We evaluated HCV antibody testing in each calendar year among HCV-seronegative MSM, and we assessed testing correlates by generalized estimating equation analyses.

Results: Of 1829 eligible MSM who were PWH, 1174 (64.2%) were non-Hispanic/Latino white (NHW), 402 (22.0%) non-Hispanic black (NHB), 187 (10.2%) Hispanic/Latino, and 66 (3.6%) of other race/ethnicity. Most were ≥40 years old (68.9%), privately insured (64.5%), with CD4 cell count/mm (CD4) ≥350 (77.0%), and with HIV viral load <200 copies/mL (76.9%). During 2011-2019, 1205 (65.9%) had ≥1 HCV antibody test and average annual HCV percentage tested was 30.3% (from 33.8% for NHB to 28.5% for NHW; < .001). Multivariable factors positively associated ( < .05) with HCV testing included more recent HIV diagnosis, public insurance, lower CD4, prior chlamydia, gonorrhea, syphilis, or hepatitis B virus diagnoses, and elevated liver enzyme levels, but not race/ethnicity.

Conclusions: Although we found no disparities by race/ethnicity in HCV testing, low overall HCV testing rates indicate suboptimal uptake of recommended HCV testing among MSM in HIV care.
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http://dx.doi.org/10.1093/ofid/ofaa645DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8052496PMC
April 2021

Trends in Hepatocellular Carcinoma Incidence and Risk Among Persons With HIV in the US and Canada, 1996-2015.

JAMA Netw Open 2021 02 1;4(2):e2037512. Epub 2021 Feb 1.

Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland.

Importance: People with HIV (PWH) are often coinfected with hepatitis B virus (HBV) and/or hepatitis C virus (HCV), leading to increased risk of developing hepatocellular carcinoma (HCC), but few cohort studies have had sufficient power to describe the trends of HCC incidence and risk among PWH in the combination antiretroviral therapy (cART) era.

Objective: To determine the temporal trends of HCC incidence rates (IRs) and to compare rates by risk factors among PWH in the cART era.

Design, Setting, And Participants: This cohort study used data from the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) study, which was conducted between 1996 and 2015. NA-ACCORD pooled individual-level data from 22 HIV clinical and interval cohorts of PWH in the US and Canada. PWH aged 18 years or older with available CD4 cell counts and HIV RNA data were enrolled. Data analyses were completed in March 2020.

Exposures: HBV infection was defined as detection of either HBV surface antigen, HBV e antigen, or HBV DNA in serum or plasma any time during observation. HCV infection was defined by detection of anti-HCV seropositivity, HCV RNA, or detectable genotype in serum or plasma at any time under observation.

Main Outcomes And Measures: HCC diagnoses were identified on the basis of review of medical records or cancer registry linkage.

Results: Of 109 283 PWH with 723 441 person-years of follow-up, the median (interquartile range) age at baseline was 43 (36-51) years, 93 017 (85.1%) were male, 44 752 (40.9%) were White, 44 322 (40.6%) were Black, 21 343 (19.5%) had HCV coinfection, 6348 (5.8%) had HBV coinfection, and 2082 (1.9%) had triple infection; 451 individuals received a diagnosis of HCC by 2015. Between the early (1996-2000) and modern (2006-2015) cART eras, the crude HCC IR increased from 0.28 to 0.75 case per 1000 person-years. HCC IRs remained constant among HIV-monoinfected persons or those coinfected with HBV, but from 1996 to 2015, IRs increased among PWH coinfected with HCV (from 0.34 cases/1000 person-years in 1996 to 2.39 cases/1000 person-years in 2015) or those with triple infection (from 0.65 cases/1000 person-years in 1996 to 4.49 cases/1000 person-years in 2015). Recent HIV RNA levels greater than or equal to 500 copies/mL (IR ratio, 1.8; 95% CI, 1.4-2.4) and CD4 cell counts less than or equal to 500 cells/μL (IR ratio, 1.3; 95% CI, 1.0-1.6) were associated with higher HCC risk in the modern cART era. People who injected drugs had higher HCC risk compared with men who had sex with men (IR ratio, 2.0; 95% CI, 1.3-2.9), adjusted for HBV-HCV coinfection.

Conclusions And Relevance: HCC rates among PWH increased significantly over time from 1996 to 2015. PWH coinfected with viral hepatitis, those with higher HIV RNA levels or lower CD4 cell counts, and those who inject drugs had higher HCC risk.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.37512DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7890526PMC
February 2021

CD4 count at entry into HIV care and at antiretroviral therapy prescription in the US, 2005-2018.

Clin Infect Dis 2020 Dec 31. Epub 2020 Dec 31.

Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA.

From 2005 to 2018, among 32013 adults entering HIV care in the US, median time to ART prescription declined from 69 to 6 days, median CD4 count at entry into care increased from 300 to 362 cells/µL, and median CD4 count at ART prescription increased from 160 to 364 cells/µL.
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http://dx.doi.org/10.1093/cid/ciaa1904DOI Listing
December 2020

Current and Past Immunodeficiency are Associated with Higher Hospitalization Rates among Persons on Virologically Suppressive Antiretroviral Therapy for up to Eleven Years.

J Infect Dis 2020 Dec 26. Epub 2020 Dec 26.

School of Medicine, Johns Hopkins University, Baltimore, MD, USA.

Background: Persons with HIV (PWH) with persistently low CD4 counts despite efficacious antiretroviral therapy could have higher hospitalization risk.

Methods: In six US and Canadian clinical cohorts, PWH with virologic suppression for ≥1 year in 2005-2015 were followed until virologic failure, loss to follow-up, death, or study end. Stratified by early (Years 2-5) and long-term (Years 6-11) suppression and lowest pre-suppression CD4 count <200 and ≥200 cells/µL, Poisson regression models estimated hospitalization incidence rate ratios (aIRR) comparing patients by time-updated CD4 count category, adjusted for cohort, age, gender, calendar year, suppression duration, and lowest pre-suppression CD4 count.

Results: The 6997 included patients (19 980 person-years) were 81% cisgender men and 40% White. Among patients with lowest pre-suppression CD4 <200 cells/μL (44%), patients with current CD4 200-350 versus >500 cells/μL had an aIRR of 1.44 during early suppression (95% CI 1.01-2.06), and 1.67 (1.03-2.72) during long-term suppression. Among patients with lowest pre-suppression CD4 ≥200 (56%), patients with current CD4 351-500 versus >500 cells/μL had an aIRR of 1.22 (0.93-1.60) during early suppression and 2.09 (1.18-3.70) during long-term suppression.

Conclusions: Virologically suppressed patients with lower CD4 counts experienced higher hospitalization rates, and could potentially benefit from targeted clinical management strategies.
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http://dx.doi.org/10.1093/infdis/jiaa786DOI Listing
December 2020

Hospitalization Rates and Causes among Persons with HIV in the US and Canada, 2005-2015.

J Infect Dis 2020 Oct 21. Epub 2020 Oct 21.

School of Medicine, Johns Hopkins University, Baltimore, MD, USA.

Background: To assess the possible impact of antiretroviral therapy improvements, aging, and comorbidities, we examined trends in all-cause and cause-specific hospitalization rates among persons with HIV (PWH) from 2005 to 2015.

Methods: In six clinical cohorts, we followed PWH in care (≥1 outpatient CD4 count or HIV viral load [VL] every 12 months) and categorized ICD codes of primary discharge diagnoses using modified Clinical Classifications Software. Poisson regression estimated hospitalization rate ratios for calendar time trends, adjusted for demographics, HIV risk factor, and annually-updated age, CD4, and VL.

Results: Among 28 057 patients (125 724 person-years), from 2005 to 2015, the median CD4 increased from 389 to 580 cells/µL and virologic suppression from 55% to 85% of patients. Unadjusted all-cause hospitalization rates decreased from 22.3 per 100 person-years in 2005 (95% CI 20.6-24.1) to 13.0 in 2015 (12.2-14.0). Unadjusted rates decreased for almost all diagnostic categories. Adjusted rates decreased for all-cause, cardiovascular, and AIDS-defining conditions, increased for non-AIDS-defining infection, and were stable for most other categories.

Conclusions: Among PWH with increasing CD4 counts and viral suppression, unadjusted hospitalization rates decreased for all-cause and most cause-specific hospitalizations, despite the potential effects of aging, comorbidities, and cumulative exposure to HIV and antiretrovirals.
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http://dx.doi.org/10.1093/infdis/jiaa661DOI Listing
October 2020

HIV-positive persons who inject drugs experience poor health outcomes and unmet needs for care services.

AIDS Care 2020 Sep 27:1-9. Epub 2020 Sep 27.

Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA.

Comparison of social determinants of health and clinical outcomes between HIV-positive persons who inject drugs (PWID) and HIV-positive persons who do not inject drugs is essential to understanding disparities and informing HIV prevention and care efforts; however, nationally representative estimates are lacking. Interview and medical record data were collected for the Medical Monitoring Project during 2015-2018 among U.S. adults with diagnosed HIV. Among HIV-positive PWID (=340) and HIV-positive persons who do not inject drugs (=11,475), we reported weighted percentages and prevalence ratios with predicted marginal means to compare differences between groups (<.05). Associations with clinical outcomes were adjusted for age, race/ethnicity, and gender. HIV-positive PWID were more likely to be homeless (29.1% vs. 8.1%) and incarcerated (18.3% vs. 4.9%). HIV-positive PWID were less likely to be retained in HIV care (aPR: 0.85 [95% CI: 0.77-0.94]), and were more likely to have poor HIV outcomes, have unmet needs for care services (aPR: 1.50 [1.39-1.61]), seek non-routine care, and experience healthcare discrimination (aPR: 1.42 [1.17-1.73]). Strengthening interventions supporting (1) continuity of care given high levels of incarceration and housing instability, (2) early ART initiation and adherence support, and (3) drug treatment and harm reduction programs to limit transmission risk may improve outcomes among HIV-positive PWID.
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http://dx.doi.org/10.1080/09540121.2020.1826396DOI Listing
September 2020

Human Immunodeficiency Virus (HIV) Outbreak Investigation Among Persons Who Inject Drugs in Massachusetts Enhanced by HIV Sequence Data.

J Infect Dis 2020 09;222(Suppl 5):S259-S267

Massachusetts Department of Public Health, Bureau of Infectious Disease and Laboratory Sciences, Jamaica Plain, Massachusetts, USA.

Background: The Massachusetts Department of Public Health and the Centers for Disease Control and Prevention collaborated to characterize a human immunodeficiency virus (HIV) outbreak in northeastern Massachusetts and prevent further transmission. We determined the contributions of HIV sequence data to defining the outbreak.

Methods: Human immunodeficiency virus surveillance and partner services data were analyzed to understand social and molecular links within the outbreak. Cases were defined as HIV infections diagnosed during 2015-2018 among people who inject drugs with connections to northeastern Massachusetts or HIV infections among other persons named as partners of a case or whose HIV polymerase sequence linked to another case, regardless of diagnosis date or geography.

Results: Of 184 cases, 65 (35%) were first identified as part of the outbreak through molecular analysis. Twenty-nine cases outside of northeastern Massachusetts were molecularly linked to the outbreak. Large molecular clusters (75, 28, and 11 persons) were identified. Among 161 named partners, 106 had HIV; of those, 40 (38%) diagnoses occurred through partner services.

Conclusions: Human immunodeficiency virus sequence data increased the case count by 55% and expanded the geographic scope of the outbreak. Human immunodeficiency virus sequence and partner services data each identified cases that the other method would not have, maximizing prevention and care opportunities for HIV-infected persons and their partners.
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http://dx.doi.org/10.1093/infdis/jiaa053DOI Listing
September 2020

Responding to Outbreaks of Human Immunodeficiency Virus Among Persons Who Inject Drugs-United States, 2016-2019: Perspectives on Recent Experience and Lessons Learned.

J Infect Dis 2020 09;222(Suppl 5):S239-S249

Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

In 2015, a large human immunodeficiency virus (HIV) outbreak occurred among persons who inject drugs (PWID) in Indiana. During 2016-2019, additional outbreaks among PWID occurred across the United States. Based on information disseminated by responding health departments and Centers for Disease Control and Prevention (CDC) involvement, we offer perspectives about characteristics of and public health responses to 6 such outbreaks. Across outbreaks, injection of opioids (including fentanyl) or methamphetamine predominated; many PWID concurrently used opioids and methamphetamine or cocaine. Commonalities included homelessness or unstable housing, previous incarceration, and hepatitis C virus exposure. All outbreaks occurred in metropolitan areas, including some with substantial harm reduction and medical programs targeted to PWID. Health departments experienced challenges locating case patients and contacts, linking and retaining persons in care, building support to strengthen harm-reduction programs, and leveraging resources. Expanding the concept of vulnerability to HIV outbreaks and other lessons learned can be considered for preventing, detecting, and responding to future outbreaks among PWID.
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http://dx.doi.org/10.1093/infdis/jiaa112DOI Listing
September 2020

Clinical effectiveness of integrase strand transfer inhibitor-based antiretroviral regimens among adults with human immunodeficiency virus: a collaboration of cohort studies in the United States and Canada.

Clin Infect Dis 2020 Aug 11. Epub 2020 Aug 11.

Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Background: Integrase strand transfer inhibitor (InSTI)-based regimens are now recommended as first-line antiretroviral therapy (ART) for adults with human immunodeficiency virus. But evidence on long-term clinical effectiveness of InSTI-based regimens remains limited. We examined whether InSTI-based regimens improved longer-term clinical outcomes.

Methods: We included participants from clinical cohorts in the North American AIDS Cohort Collaboration who initiated their first ART regimen, containing either InSTI (i.e., raltegravir, dolutegravir, and elvitegravir/cobicstat) or efavirenz (EFV) as an active comparator, between 2009 and 2016. We estimated observational analogs of 6-year intention-to-treat and per-protocol risks, risk differences (RD), and hazard ratios (HR) for the composite outcome of AIDS, acute myocardial infarction, stroke, end-stage renal diseases, end-stage liver diseases, or death.

Results: Of 15,993 participants, 5,824 (36%) initiated an InSTI-based, and 10,169 (64%) initiated an EFV-based, regimen. During the 6-year follow-up, 440 of the InSTI group and 1,097 of the EFV group incurred the composite outcome. The estimated 6-year intention-to-treat risks were 14.6% for the InSTI group and 14.3% for the EFV group, corresponding with a RD of 0.3 percentage point (95% CI: -2.7, 3.3), and HR was 1.08 (95% CI: 0.97, 1.19); the estimated 6-year per-protocol risks were 12.2% for the InSTI group and 11.9% for the EFV group, corresponding with a RD was 0.3 percentage point (95% CI: -3.0, 3.7), and HR was 1.09 (95% CI: 0.96, 1.25).

Conclusions: InSTI- and EFV-based initial ART regimens had similar 6-year composite clinical outcomes. The risk of adverse clinical outcomes remains substantial even when initiating modern ART.
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http://dx.doi.org/10.1093/cid/ciaa1037DOI Listing
August 2020

Trends in Indicators of Injection Drug Use, Indian Health Service, 2010-2014 : A Study of Health Care Encounter Data.

Public Health Rep 2020 Jul/Aug;135(4):461-471. Epub 2020 Jul 7.

Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA.

Objectives: Hepatitis C virus (HCV) and HIV transmission in the United States may increase as a result of increasing rates of opioid use disorder (OUD) and associated injection drug use (IDU). Epidemiologic trends among American Indian/Alaska Native (AI/AN) persons are not well known.

Methods: We analyzed 2010-2014 Indian Health Service data on health care encounters to assess regional and temporal trends in IDU indicators among adults aged ≥18 years. IDU indicators included acute or chronic HCV infection (only among adults aged 18-35 years), arm cellulitis and abscess, OUD, and opioid-related overdose. We calculated rates per 10 000 AI/AN adults for each IDU indicator overall and stratified by sex, age group, and region and evaluated rate ratios and trends by using Poisson regression analysis.

Results: Rates of HCV infection among adults aged 18-35 increased 9.4% per year, and rates of OUD among all adults increased 13.3% per year from 2010 to 2014. The rate of HCV infection among young women was approximately 1.3 times that among young men. Rates of opioid-related overdose among adults aged <50 years were approximately 1.4 times the rates among adults aged ≥50 years. Among young adults with HCV infection, 25.6% had concurrent OUD. Among all adults with arm cellulitis and abscess, 5.6% had concurrent OUD.

Conclusions: Rates of HCV infection and OUD increased significantly in the AI/AN population. Strengthened public health efforts could ensure that AI/AN communities can address increasing needs for culturally appropriate interventions, including comprehensive syringe services programs, medication-assisted treatment, and opioid-related overdose prevention and can meet the growing need for treatment of HCV infection.
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http://dx.doi.org/10.1177/0033354920937284DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7383762PMC
August 2020

Assessing Solid Organ Donors and Monitoring Transplant Recipients for Human Immunodeficiency Virus, Hepatitis B Virus, and Hepatitis C Virus Infection - U.S. Public Health Service Guideline, 2020.

MMWR Recomm Rep 2020 06 26;69(4):1-16. Epub 2020 Jun 26.

The recommendations in this report supersede the U.S Public Health Service (PHS) guideline recommendations for reducing transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) through organ transplantation (Seem DL, Lee I, Umscheid CA, Kuehnert MJ. PHS guideline for reducing human immunodeficiency virus, hepatitis B virus, and hepatitis C virus transmission through organ transplantation. Public Health Rep 2013;128:247-343), hereafter referred to as the 2013 PHS guideline. PHS evaluated and revised the 2013 PHS guideline because of several advances in solid organ transplantation, including universal implementation of nucleic acid testing of solid organ donors for HIV, HBV, and HCV; improved understanding of risk factors for undetected organ donor infection with these viruses; and the availability of highly effective treatments for infection with these viruses. PHS solicited feedback from its relevant agencies, subject-matter experts, additional stakeholders, and the public to develop revised guideline recommendations for identification of risk factors for these infections among solid organ donors, implementation of laboratory screening of solid organ donors, and monitoring of solid organ transplant recipients. Recommendations that have changed since the 2013 PHS guideline include updated criteria for identifying donors at risk for undetected donor HIV, HBV, or HCV infection; the removal of any specific term to characterize donors with HIV, HBV, or HCV infection risk factors; universal organ donor HIV, HBV, and HCV nucleic acid testing; and universal posttransplant monitoring of transplant recipients for HIV, HBV, and HCV infections. The recommendations are to be used by organ procurement organization and transplant programs and are intended to apply only to solid organ donors and recipients and not to donors or recipients of other medical products of human origin (e.g., blood products, tissues, corneas, and breast milk). The recommendations pertain to transplantation of solid organs procured from donors without laboratory evidence of HIV, HBV, or HCV infection. Additional considerations when transplanting solid organs procured from donors with laboratory evidence of HCV infection are included but are not required to be incorporated into Organ Procurement and Transplantation Network policy. Transplant centers that transplant organs from HCV-positive donors should develop protocols for obtaining informed consent, testing and treating recipients for HCV, ensuring reimbursement, and reporting new infections to public health authorities.
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http://dx.doi.org/10.15585/mmwr.rr6904a1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7337549PMC
June 2020

The HIV Outpatient Study-25 Years of HIV Patient Care and Epidemiologic Research.

Open Forum Infect Dis 2020 May 11;7(5):ofaa123. Epub 2020 Apr 11.

Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

Background: The clinical epidemiology of treated HIV infection in the United States has dramatically changed in the past 25 years. Few sources of longitudinal data exist for people with HIV (PWH) spanning that period. Cohort data enable investigating new exposure and disease associations and monitoring progress along the HIV care continuum.

Methods: We synthesized key published findings and conducted primary data analyses in the HIV Outpatient Study (HOPS), an open cohort of PWH seen at public and private HIV clinics since 1993. We assessed temporal trends in health outcomes (1993-2017) and mortality (1994-2017) for 10 566 HOPS participants.

Results: The HOPS contributed to characterizing new conditions (eg, lipodystrophy), demonstrated reduced mortality with earlier HIV treatment, uncovered associations between select antiretroviral agents and cardiovascular disease, and documented remarkable shifts in morbidity from AIDS opportunistic infections to chronic noncommunicable diseases. The median CD4 cell count of participants increased from 244 cells/mm to 640 cells/mm from 1993 to 2017. Mortality fell from 121 to 16 per 1000 person-years from 1994 to 2017 ( < .001). In 2010, 83.7% of HOPS participants had a most recent HIV viral load <200 copies/mL, compared with 92.2% in 2017.

Conclusions: Since 1993, the HOPS has been detecting emerging issues and challenges in HIV disease management. HOPS data can also be used for monitoring trends in infectious and chronic diseases, immunologic and viral suppression status, retention in care, and survival, thereby informing progress toward the Ending the HIV Epidemic initiative.
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http://dx.doi.org/10.1093/ofid/ofaa123DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7235508PMC
May 2020

The HIV Outpatient Study-25 Years of HIV Patient Care and Epidemiologic Research.

Open Forum Infect Dis 2020 May 11;7(5):ofaa123. Epub 2020 Apr 11.

Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

Background: The clinical epidemiology of treated HIV infection in the United States has dramatically changed in the past 25 years. Few sources of longitudinal data exist for people with HIV (PWH) spanning that period. Cohort data enable investigating new exposure and disease associations and monitoring progress along the HIV care continuum.

Methods: We synthesized key published findings and conducted primary data analyses in the HIV Outpatient Study (HOPS), an open cohort of PWH seen at public and private HIV clinics since 1993. We assessed temporal trends in health outcomes (1993-2017) and mortality (1994-2017) for 10 566 HOPS participants.

Results: The HOPS contributed to characterizing new conditions (eg, lipodystrophy), demonstrated reduced mortality with earlier HIV treatment, uncovered associations between select antiretroviral agents and cardiovascular disease, and documented remarkable shifts in morbidity from AIDS opportunistic infections to chronic noncommunicable diseases. The median CD4 cell count of participants increased from 244 cells/mm to 640 cells/mm from 1993 to 2017. Mortality fell from 121 to 16 per 1000 person-years from 1994 to 2017 ( < .001). In 2010, 83.7% of HOPS participants had a most recent HIV viral load <200 copies/mL, compared with 92.2% in 2017.

Conclusions: Since 1993, the HOPS has been detecting emerging issues and challenges in HIV disease management. HOPS data can also be used for monitoring trends in infectious and chronic diseases, immunologic and viral suppression status, retention in care, and survival, thereby informing progress toward the Ending the HIV Epidemic initiative.
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http://dx.doi.org/10.1093/ofid/ofaa123DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7235508PMC
May 2020

Non-AIDS comorbidity burden differs by sex, race, and insurance type in aging adults in HIV care.

AIDS 2019 12;33(15):2327-2335

aNorthwestern University Feinberg School of Medicine, Chicago, Illinois bCerner Corporation, Kansas City, Missouri cTemple University School of Medicine, Philadelphia, Pennsylvania dInfectious Disease Research Institute, Inc., Tampa, Florida eUniversity of Illinois at Chicago, Chicago, Illinois fColorado School of Mines, Golden, Colorado gDupont Circle Physicians Group, Washington, District of Columbia hU.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

Objective: To understand the epidemiology of non-AIDS-related chronic comorbidities (NACMs) among aging persons with HIV (PWH).

Design: Prospective multicenter observational study to assess, in an age-stratified fashion, number and types of NACMs by demographic and HIV factors.

Methods: Eligible participants were seen during 1 January 1997 to 30 June 2015, followed for more than 5 years, received antiretroviral therapy (ART), and virally suppressed (HIV viral load <200 copies/ml ≥75% of observation time). Age was stratified (18-40, 41-50, 51-60, ≥61 years). NACMs included cardiovascular disease, cancer, hypertension, diabetes, dyslipidemia, arthritis, viral hepatitis, anemia, and psychiatric illness.

Results: Of 1540 patients, 1247 (81%) were men, 406 (26%) non-Hispanic blacks (NHB), 183 (12%) Hispanics/Latinos, 575 (37%) with public insurance, 939 (61%) MSM, and 125 (8%) with injection drug use history. By age strata 18-40, 41-50, 51-60, and at least 61 years, there were 180, 502, 560, and 298 patients, respectively. Median HIV Outpatient Study observation was 10.8 years (range: min-max = 5.0-18.5). Mean number of NACMs increased with older age category (1.4, 2.1, 3.0, and 3.9, respectively; P < 0.001), as did prevalence of most NACMs (P < 0.001). Age-related differences in NACM numbers were primarily due to anemia, hepatitis C virus infection, and diabetes. Differences (all P < 0.05) in NACM number existed by sex (women >men, 3.9 vs. 3.4), race/ethnicity (NHB >non-NHB, 3.8 vs. 3.4), and insurance status (public >private, 4.3 vs. 3.1).

Conclusions: Age-related increases existed in prevalence and number of NACMs, with disproportionate burden among women, NHBs, and the publicly insured. These groups should be targeted for screening and prevention strategies aimed at NACM reduction.
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http://dx.doi.org/10.1097/QAD.0000000000002349DOI Listing
December 2019

Opioid Use Fueling HIV Transmission in an Urban Setting: An Outbreak of HIV Infection Among People Who Inject Drugs-Massachusetts, 2015-2018.

Am J Public Health 2020 01 14;110(1):37-44. Epub 2019 Nov 14.

Charles Alpren and Amanda Burrage are with the Epidemic Intelligence Service, Division of Scientific Education and Professional Development, Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC), Atlanta, GA. Philip J. Peters, Sheryl B. Lyss, William M. Switzer, Ashley Murray, Christine Agnew-Brune, Erica L. Dawson, Nivedha Panneer, Paul McClung, Ellsworth M. Campbell, Sharoda Dasgupta, Kischa Hampton, William Adih, Susie P. Danner, Hongwei Jia, and Kate Buchacz are with the Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), CDC. Betsey John, Kevin Cranston, H. Dawn Fukuda, Kathleen Roosevelt, R. Monina Klevens, Janice Bryant, Tracy Stiles, Courtney Breen, Liisa M. Randall, Shauna Onofrey, Katherine K. Hsu, Barry Callis, Linda R. Goldman, Matthew Tumpney, Catherine Brown, and Alfred DeMaria Jr are with the Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, Boston, MA. Danae Bixler is with the Division of Viral Hepatitis, NCHHSTP, CDC. Jenifer Leaf Jaeger is with the Infectious Disease Bureau, Boston Public Health Commission, Boston. Amy Board is with the Oak Ridge Institute of Science and Education, Oak Ridge, TN.

To describe and control an outbreak of HIV infection among people who inject drugs (PWID). The investigation included people diagnosed with HIV infection during 2015 to 2018 linked to 2 cities in northeastern Massachusetts epidemiologically or through molecular analysis. Field activities included qualitative interviews regarding service availability and HIV risk behaviors. We identified 129 people meeting the case definition; 116 (90%) reported injection drug use. Molecular surveillance added 36 cases to the outbreak not otherwise linked. The 2 largest molecular groups contained 56 and 23 cases. Most interviewed PWID were homeless. Control measures, including enhanced field epidemiology, syringe services programming, and community outreach, resulted in a significant decline in new HIV diagnoses. We illustrate difficulties with identification and characterization of an outbreak of HIV infection among a population of PWID and the value of an intensive response. Responding to and preventing outbreaks requires ongoing surveillance, with timely detection of increases in HIV diagnoses, community partnerships, and coordinated services, all critical to achieving the goal of the national Ending the HIV Epidemic initiative.
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http://dx.doi.org/10.2105/AJPH.2019.305366DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6893347PMC
January 2020

Chlamydia and Gonorrhea Incidence and Testing Among Patients in the Human Immunodeficiency Virus Outpatient Study (HOPS), 2007-2017.

Clin Infect Dis 2020 11;71(8):1824-1835

Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

Background: Although chlamydia (CT) and gonorrhea (GC) infections are increasing in the United States, there are limited data on their incidence, testing rates, and associated risk factors among persons living with HIV (PLWH), including by anatomic site among men who have sex with men (MSM).

Methods: We analyzed 2007-2017 medical records data from Human Immunodeficiency Virus (HIV) Outpatient Study (HOPS) participants in care at 9 HIV clinics. We calculated CT (and GC) incidence and testing rates and assessed associations with sociodemographic and clinical factors using log-linear regression.

Results: Among 4727 PLWH, 397 had 881 CT infections and 331 had 861 GC infections, with an incidence of 2.95 and 2.88 per 100 person-years, respectively. From 2007 to 2017, incidence and testing rates increased by approximately 3.0- and 1.9-fold for CT and GC, respectively. Multivariable factors associated with incident CT (GC) included younger age, MSM, and prior diagnoses of sexually transmitted diseases (STDs). Among 1159 MSM, 583 (50.3%) had 844 CT and 843 GC tests during 2016-2017, and 26.6% of tests were 3-site (urethra, rectum, and pharynx), yielding the highest rates of CT (GC) detection. Multivariable factors associated with CT (GC) testing included younger age, non-Hispanic/Latino black race, and having prior STDs.

Conclusions: Recent CT and GC incidence and testing increased among PLWH; however, only half of MSM were tested for CT or GC during 2016-2017 and less than a third of tests were 3-site. To promote sexual health and STD prevention among PLWH who are MSM, research regarding the added value of CT and GC testing across 3 anatomic sites is needed.
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http://dx.doi.org/10.1093/cid/ciz1085DOI Listing
November 2020

HIV prescriptions on the frontlines: Primary care providers' use of antiretrovirals for prevention in the Southeast United States, 2017.

Prev Med 2020 01 31;130:105875. Epub 2019 Oct 31.

Department of Obstetrics and Gynecology, Morehouse School of Medicine, Atlanta, GA, United States of America.

HIV disproportionately affects persons in Southeast United States. Primary care providers (PCPs) are vital for HIV prevention. Data are limited about their prescribing of antiretrovirals (ARVs) for prevention, including non-occupational post-exposure prophylaxis (nPEP), pre-exposure prophylaxis (PrEP), and antiretroviral therapy (ART). We examined these practices to assess gaps. During April-August 2017, we conducted an online survey of PCPs in Atlanta, Baltimore, Baton Rouge, Miami, New Orleans, and Washington, DC to assess HIV-related knowledge, attitudes and practices. Adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) were used to estimate correlates of nPEP, PrEP and ART prescribing practices. Adjusting for MSA and specialty, the weighted sample (n = 820, 29.6% adjusted response rate) comprised 60.2% white and 59.4% females. PCPs reported ever prescribing nPEP (31.0%), PrEP (18.1%), and ART (27.2%). Prescribing nPEP was associated with nPEP familiarity (aPR = 2.63, 95% CI 1.59, 4.35) and prescribing PrEP (aPR = 3.57, 95% CI 2.78, 4.55). Prescribing PrEP was associated with PrEP familiarity (aPR = 4.35, 95% CI 2.63, 7.14), prescribing nPEP (aPR = 5.00, 95% CI 2.00, 12.50), and providing care for persons with HIV (aPR = 1.56, 95% CI 1.06, 2.27). Prescribing ART was associated with nPEP familiarity (aPR = 1.89, 95% CI 1.27, 2.78) and practicing in outpatient public practice versus hospital-based facilities (aPR = 2.14 95% CI 1.51, 3.04), and inversely associated with collaborations involving specialists (aPR = 0.60, 95% CI 0.42, 0.86). A minority of PCPs surveyed from the Southeast report ever prescribing ARVs for prevention. Future efforts should include enhancing HIV care coordination and developing strategies to increase use of biomedical tools.
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http://dx.doi.org/10.1016/j.ypmed.2019.105875DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6930335PMC
January 2020

Excess heart age in adult outpatients in routine HIV care.

AIDS 2019 10;33(12):1935-1942

Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, & TB Prevention, Centers for Disease Control and Prevention, Atlanta.

Objective: Cardiovascular disease (CVD) is a common cause of morbidity and mortality among persons living with HIV (PLWH). We used individual cardiovascular risk factor profiles to estimate heart age for PLWH in medical care in the United States.

Design: Cross-sectional analyses of HIV Outpatient Study (HOPS) data METHODS:: Included in this analysis were participants aged 30-74 years, without prior CVD, with at least two HOPS clinic visits during 2010-2017, at least 1-year of follow-up, and available covariate data. We calculated age and race/ethnicity-adjusted heart age and excess heart age (chronological age - heart age), using a Framingham risk score-based model.

Results: We analyzed data from 2467 men and 619 women (mean chronologic age 49.3 and 49.1 years, and 23.6% and 54.6% Non-Hispanic/Latino black, respectively). Adjusted excess heart age was 11.5 years (95% confidence interval, 11.1-12.0) among men and 13.1 years (12.0-14.1) among women. Excess heart age was seen among all age groups beginning with persons aged 30-39 years [men, 7.8 (6.9-8.8); women, 7.7 (4.9-10.4)], with the highest excess heart age among participants aged 50-59 years [men, 13.7 years (13.0-14.4); women, 16.4 years (14.8-18.0)]. More than 50% of participants had an excess heart age of at least 10 years.

Conclusions: Excess heart age is common among PLWH, begins in early adulthood, and impacts both women and men. Among PLWH, CVD risk factors should be addressed early and proactively. Routine use of the heart age calculator may help optimize CVD risk stratification and facilitate interventions for aging PLWH.
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http://dx.doi.org/10.1097/QAD.0000000000002304DOI Listing
October 2019

Brief Report: Durability of the Effect of Financial Incentives on HIV Viral Load Suppression and Continuity in Care: HPTN 065 Study.

J Acquir Immune Defic Syndr 2019 07;81(3):300-303

Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA.

Background: Results from the HPTN 065 study showed that financial incentives (FI) were associated with significantly higher viral load suppression and higher levels of engagement in care among patients at HIV care sites randomized to FI versus sites randomized to standard of care (SOC). We assessed HIV viral suppression and continuity in care after intervention withdrawal to determine the durability of FI on these outcomes.

Setting: A total of 37 HIV test and 39 HIV care sites in the Bronx, New York, and Washington, DC, participated in the study.

Methods: Laboratory data reported to the US National HIV Surveillance System were used to determine site-level viral suppression and continuity in care outcomes. Postintervention effects were assessed for the 3 quarters after discontinuation of FI. Generalized estimation equations were used to compare FI and SOC site-level outcomes after intervention withdrawal.

Results: After FI withdrawal, a trend remained for an increase in viral suppression by 2.7% (-0.3%, 5.6%, P = 0.076) at FI versus SOC sites, decreasing from the 3.8% increase noted during implementation of the intervention. The significant increase in continuity in care during the FI intervention was sustained after intervention with 7.5% (P = 0.007) higher continuity in care at FI versus SOC sites.

Conclusions: After the withdrawal of FI, findings at the 9-months postintervention withdrawal from this large study showed evidence of durable effects of FI on continuity in care, with trend for continued higher viral suppression. These findings are promising for adoption of such interventions to enhance key HIV-related care outcomes.
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http://dx.doi.org/10.1097/QAI.0000000000001927DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6587372PMC
July 2019

HIV-Related Training and Correlates of Knowledge, HIV Screening and Prescribing of nPEP and PrEP Among Primary Care Providers in Southeast United States, 2017.

AIDS Behav 2019 Nov;23(11):2926-2935

Division of HIV/AIDS Prevention, National Centers for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Mailstop E-45, Atlanta, GA, 30329, USA.

The Southeast accounted for most HIV diagnoses (52%) in the United States in 2015. Primary care providers (PCPs) play a vital role in HIV prevention for at-risk persons and treatment of persons living with HIV. We studied HIV-related training, knowledge, and clinical practices among PCPs in the Southeast to address knowledge gaps to inform HIV prevention strategies. Between April and August 2017, we conducted an on-line survey of a representative sample of PCPs in six Southeast jurisdictions with high rates of HIV diagnoses (Atlanta; Baltimore; Baton Rouge; District of Columbia; Miami; New Orleans). We defined HIV-related training as self-reported completion of any certified HIV/STD course or continuing education in past 24 months (prior to survey completion). We assessed associations between training and HIV testing practices, familiarity with nonoccupational post-exposure prophylaxis (nPEP) and pre-exposure prophylaxis (PrEP), and ever prescribing nPEP or PrEP. There were 820 participants after fielding 4595 surveys (29.6% adjusted response rate). In weighted analyses, 36.3% reported HIV-related training. Using adjusted prevalence ratio (aPR) and confidence intervals (CI), we found that PCPs with HIV-related training (compared to those with no training) were more likely to be familiar with nPEP (aPR = 1.32, 95% CI 1.05, 1.67) and PrEP (aPR = 1.67, 95% CI 1.19, 2.38); and to have ever prescribed PrEP to patients (aPR = 1.75, 95% CI 1.10, 2.78). Increased HIV-related trainings among PCPs in high HIV prevalence Southeast jurisdictions may be warranted. Strengthening nPEP and PrEP familiarity among PCPs in Southeast may advance national HIV prevention goals.
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http://dx.doi.org/10.1007/s10461-019-02545-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6803031PMC
November 2019

Sleep disturbances in HIV-infected patients associated with depression and high risk of obstructive sleep apnea.

SAGE Open Med 2019 8;7:2050312119842268. Epub 2019 Apr 8.

Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA.

Objective: To evaluate sleep disturbances in a diverse, contemporary HIV-positive patient cohort and to identify demographic, clinical, and immune correlates.

Methods: A convenience sample of 176 patients from a racially and ethnically diverse HIV-positive patient cohort in an urban population. This was a cross-sectional, epidemiologic study. We surveyed participants using multiple standardized instruments to assess depression, sleep quality, and risk for sleep apnea. We analyzed demographic, behavioral, and clinical correlates.

Results: A total of 56% of participants were female, 75% Black and 64% had heterosexual HIV risk. The median age was 49 years. Poor sleep quality (Pittsburgh Sleep Quality Index > 5) was reported by 73% of patients and 52% met insomnia diagnosis criteria. A single question about self-reported sleep problems predicted a Pittsburgh Sleep Quality Index > 5 with a sensitivity and specificity of 82% and 81%, respectively. Female sex was significantly associated with higher risk of poor sleep quality, depression, and insomnia, whereas higher risk of obstructive sleep apnea was significantly associated with older age, male sex, obesity (body mass index ⩾ 30 kg/m), and metabolic comorbidities. High risk for obstructive sleep apnea, high rate of depression, and poor sleep hygiene represent treatment targets for sleep problems in HIV patients.

Conclusion: Sleep disturbances were common in this patient cohort, although largely undiagnosed and untreated. Sleep problems are linked to worse disease progression and increased cardiovascular mortality. Screening for sleep problems with a single question had high sensitivity and specificity. In those patients with self-reported sleep problems, screening for obstructive sleep apnea, depression, and sleep hygiene habits should be part of routine HIV care.
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http://dx.doi.org/10.1177/2050312119842268DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6454647PMC
April 2019

Disparities in Viral Suppression and Medication Adherence among Women in the USA, 2011-2016.

AIDS Behav 2019 Nov;23(11):3015-3023

Division of HIV/AIDS Prevention, DHAP/NCHHSTP/CDC, Centers for Disease Control and Prevention, 1600 Clifton Rd NE MS E-45, Atlanta, GA, 30333, USA.

We assessed disparities in viral suppression (VS) and antiretroviral therapy (ART) adherence among women of the HIV Outpatient Study to inform HIV treatment strategies. We used adjusted prevalence ratios (aPR) with 95% confidence intervals (CI) to assess VS by race/ethnicity and generalized estimating equations to investigate factors associated with not achieving VS and ART non-adherence. Among 426 women (median age = 46 years), at baseline, VS was less prevalent among black women (63%) compared with Hispanic women/Latinas (73%) and white women (78%). In the multivariable analysis, factors significantly associated with not achieving VS included the following social and behavioral determinants of care: using public insurance (aPR = 1.69, CI 1.01-2.82, p = 0.044) compared to using private insurance, seeking care in a public clinic (aPR = 1.60, CI 1.03-2.50, p = 0.037) compared to seeking care in a private clinic, and ART non-adherence (aPR = 2.79, CI 1.81-4.29), p < 0.001). Although race was not a significant factor in not achieving VS, race was associated with ART non-adherence; black women were more likely to miss a dose of ART medication (aPR = 2.07, CI 1.19-3.60, p = 0.010) when compared to white women and Hispanic women/Latinas. Interventions and resources disseminated to address social barriers to care and improve VS and ART adherence among HIV-positive women, particularly black women, are warranted.
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http://dx.doi.org/10.1007/s10461-019-02494-9DOI Listing
November 2019

Increased HIV diagnoses in West Virginia counties highly vulnerable to rapid HIV dissemination through injection drug use: a cautionary tale.

Ann Epidemiol 2019 06 6;34:12-17. Epub 2019 Mar 6.

Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Electronic address:

Purpose: To investigate HIV transmission potential from a cluster of HIV infections among men who have sex with men to persons who inject drugs in 15 West Virginia counties. These counties were previously identified as highly vulnerable to rapid HIV dissemination through injection drug use (IDU) associated with high levels of opioid misuse.

Methods: We interviewed persons with 2017 HIV diagnoses about past-year risk behaviors and elicited sexual, IDU, and social contacts. We tested contacts for HIV and assessed risk behaviors. To determine HIV transmission potential from persons with 2017 diagnoses to persons who inject drugs, we assessed viral suppression status, HIV status of contacts, and IDU risk behaviors of persons living with HIV and contacts.

Results: We interviewed 78 persons: 39 with 2017 diagnoses and 39 contacts. Overall, 13/78 (17%) injected drugs in the past year. Of 19 persons with 2017 diagnoses and detectable virus, 9 (47%) had more than or equal to 1 sexual or IDU contacts of negative or unknown HIV status. During the past year, 2/9 had injected drugs and shared equipment, and 1/9 had more than or equal to 1 partner who did so.

Conclusions: We identified IDU risk behavior among persons with 2017 diagnoses and their contacts. West Virginia HIV prevention programs should continue to give high priority to IDU harm reduction.
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http://dx.doi.org/10.1016/j.annepidem.2019.02.012DOI Listing
June 2019

HIV Diagnoses and the HIV Care Continuum Among Women and Girls Aged ≥13 Years-39 States and the District of Columbia, 2015-2016.

J Acquir Immune Defic Syndr 2019 07;81(3):251-256

Office on Women's Health, US Department of Health and Human Services, Washington, DC.

Background: In 2017, 19% of new HIV diagnoses in the United States were in women. HIV acquisition can be prevented with pre-exposure prophylaxis, and HIV transmission with viral suppression. HIV viral suppression is achieved by linking women to care and supporting adherence to antiretroviral medications. The national HIV prevention goal for viral suppression is 80%.

Setting: United States.

Methods: We analyzed data reported by 40 US jurisdictions to the Centers for Disease Control and Prevention's National HIV Surveillance System to determine the number and rate of HIV diagnoses per 100,000 women in 2016. We also determined the percentages of women with diagnosed HIV who were linked to care within 1 and 3 months, received HIV care, were retained in HIV care, and were virally suppressed in 2015. Findings were stratified by demographic characteristics and HIV transmission category.

Results: In 2016, 6407 women were diagnosed with HIV. Black women had a rate of 783.7 per 100,000, Hispanic/Latino women 182.7, and white women 43.6. In 2015, 190,735 women were living with diagnosed HIV. Viral suppression increased with age, ranging from 46.5% among women aged 13-24 years to 62.3% among women aged ≥45 years. Black women had the lowest rate of viral suppression (55.5%). No age group of women achieved 80% viral suppression.

Conclusions: Pre-exposure prophylaxis implementation for women at high risk for HIV infection can help to decrease new infections. Women living with HIV would benefit from interventions that support linkage to HIV care and antiretroviral medication adherence to increase viral suppression.
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http://dx.doi.org/10.1097/QAI.0000000000002023DOI Listing
July 2019

Contributions of traditional and HIV-related risk factors on non-AIDS-defining cancer, myocardial infarction, and end-stage liver and renal diseases in adults with HIV in the USA and Canada: a collaboration of cohort studies.

Lancet HIV 2019 02 22;6(2):e93-e104. Epub 2019 Jan 22.

University of North Carolina, Chapel Hill, NC, USA.

Background: Adults with HIV have an increased burden of non-AIDS-defining cancers, myocardial infarction, end-stage liver disease, and end-stage renal disease. The objective of this study was to estimate the population attributable fractions (PAFs) of preventable or modifiable HIV-related and traditional risk factors for non-AIDS-defining cancers, myocardial infarction, end-stage liver disease, and end-stage renal disease outcomes.

Methods: We included participants receiving care in academic and community-based outpatient HIV clinical cohorts in the USA and Canada from Jan 1, 2000, to Dec 31, 2014, who contributed to the North American AIDS Cohort Collaboration on Research and Design and who had validated non-AIDS-defining cancers, myocardial infarction, end-stage liver disease, or end-stage renal disease outcomes. Traditional risk factors were tobacco smoking, hypertension, elevated total cholesterol, type 2 diabetes, renal impairment (stage 4 chronic kidney disease), and hepatitis C virus and hepatitis B virus infections. HIV-related risk factors were low CD4 count (<200 cells per μL), detectable plasma HIV RNA (>400 copies per mL), and history of a clinical AIDS diagnosis. PAFs and 95% CIs were estimated to quantify the proportion of outcomes that could be avoided if the risk factor was prevented.

Findings: In each of the study populations for the four outcomes (1405 of 61 500 had non-AIDS-defining cancer, 347 of 29 515 had myocardial infarctions, 387 of 35 044 had end-stage liver disease events, and 255 of 35 620 had end-stage renal disease events), about 17% were older than 50 years at study entry, about 50% were non-white, and about 80% were men. Preventing smoking would avoid 24% (95% CI 13-35) of these cancers and 37% (7-66) of the myocardial infarctions. Preventing elevated total cholesterol and hypertension would avoid the greatest proportion of myocardial infarctions: 44% (30-58) for cholesterol and 42% (28-56) for hypertension. For liver disease, the PAF was greatest for hepatitis C infection (33%; 95% CI 17-48). For renal disease, the PAF was greatest for hypertension (39%; 26-51) followed by elevated total cholesterol (22%; 13-31), detectable HIV RNA (19; 9-31), and low CD4 cell count (13%; 4-21).

Interpretation: The substantial proportion of non-AIDS-defining cancers, myocardial infarction, end-stage liver disease, and end-stage renal disease outcomes that could be prevented with interventions on traditional risk factors elevates the importance of screening for these risk factors, improving the effectiveness of prevention (or modification) of these risk factors, and creating sustainable care models to implement such interventions during the decades of life of adults living with HIV who are receiving care.

Funding: National Institutes of Health, US Centers for Disease Control and Prevention, the US Agency for Healthcare Research and Quality, the US Health Resources and Services Administration, the Canadian Institutes of Health Research, the Ontario Ministry of Health and Long Term Care, and the Government of Alberta.
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http://dx.doi.org/10.1016/S2352-3018(18)30295-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6589140PMC
February 2019

Viral suppression among persons in HIV care in the United States during 2009-2013: sampling bias in Medical Monitoring Project surveillance estimates.

Ann Epidemiol 2019 03 22;31:3-7. Epub 2018 Nov 22.

SUNY, Department of Epidemiology and Biostatistics, University at Albany School of Public Health, Rensselaer, NY.

Purpose: To assess sampling bias in national viral suppression (VS) estimates derived from the Medical Monitoring Project (MMP) resulting from use of an abbreviated (four-month) annual sampling period. We aimed to improve VS estimates using cohort data from the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) and a novel cohort-adjustment method.

Methods: Using full calendar years of NA-ACCORD data, we assessed timing of HIV care attendance (inside vs. exclusively outside MMP's four-month sampling period), VS status at last test (<200 vs. ≥200 copies/mL), and associated demographics. These external estimates were used to standardize MMP to NA-ACCORD data with multivariable regression models of care attendance and VS, yielding adjusted 2009-2013 VS estimates with 95% confidence intervals.

Results: Weighted percentages of VS among persons in HIV care were 67% in 2009 and 77% in 2013. These estimates are slightly lower than previously published MMP estimates (72% and 80% in 2009 and 2013, respectively). The number of persons receiving HIV care was previously underestimated by 20%, because patients receiving care exclusively outside the MMP sampling period did not contribute toward the weighted population estimate.

Conclusions: Careful examination of national surveillance estimates using data triangulation and novel methodologies can improve the robustness of VS estimates.
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http://dx.doi.org/10.1016/j.annepidem.2018.11.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6420358PMC
March 2019

Time spent with HIV viral load above 1500 copies/ml among patients in HIV care, 2000-2014.

AIDS 2018 09;32(14):2033-2042

Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, Atlanta, Georgia.

Objective: Sexual HIV transmission is more likely to occur when plasma HIV RNA level (viral load) exceeds 1500 copies/ml. We assessed the percentage of person-time spent with viral load above 1500 copies/ml (pPT >1500) among adults with HIV in care.

Design: Observational cohort in eight United States HIV clinics.

Methods: Participants had at least one HIV Outpatient Study (HOPS) clinic visit and at least two viral loads during 2000-2014. We assessed pPT above 1500 in time intervals between consecutive viral load pairs, overall and by ART status. Trends in pPT above 1500 and associations between pPT above 1500 and chosen baseline demographics and clinical characteristics were analyzed using generalized estimating equations.

Results: There were 5873 patients contributing 37 794 person-years; 86.0% person-years had prescribed ART, with increasing coverage over time. Over 2000-2014 pPT above 1500 was 24.2%, decreasing from 38.3% in 2000-2002 to 11.3% in 2012-2014. During observation time with ART prescribed, pPT above 1500 was 16.4% overall, decreasing from 29.9% in 2000-2002 to 8.0% in 2012-2014. pPT above 1500 was higher in patients less than 35 vs. at least 50 years old (31.5 vs. 15.6%), women vs. men (30.8 vs. 22.3%), and black vs. white and Latino/Hispanic patients (32.7 vs. 19.9 and 23.7%, respectively). Multivariable correlates of higher pPT above 1500 included no prescribed ART, being younger, non-Hispanic black vs. white, baseline viral load above 1500 copies/ml or lower CD4 count, and baseline public vs. private insurance.

Conclusion: pPT above 1500 declined during 2000-2014. Results support decreasing HIV transmission risk from persons in HIV care over the last decade, and the need to focus interventions on patient groups more consistently viremic.
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http://dx.doi.org/10.1097/QAD.0000000000001921DOI Listing
September 2018