A methanotrophic bacterium to enable methane removal for climate mitigation.

The rapid increase of the potent greenhouse gas methane in the atmosphere creates great urgency to develop and deploy technologies for methane mitigation. One approach to removing methane is to use bacteria for which methane is their carbon and energy source (methanotrophs). Such bacteria naturally convert methane to CO2 and biomass, a value-added product and a cobenefit of methane removal. Typically, methanotrophs grow best at around 5,000 to 10,000 ppm methane, but methane in the atmosphere is 1.9 ppm. Air above emission sites such as landfills, anaerobic digestor effluents, rice paddy effluents, and oil and gas wells contains elevated methane in the 500 ppm range. If such sites are targeted for methane removal, technology harnessing aerobic methanotroph metabolism has the potential to become economically and environmentally viable. The first step in developing such methane removal technology is to identify methanotrophs with enhanced ability to grow and consume methane at 500 ppm and lower. We report here that some existing methanotrophic strains grow well at 500 ppm methane, and one of them, Methylotuvimicrobium buryatense 5GB1C, consumes such low methane at enhanced rates compared to previously published values. Analyses of bioreactor-based performance and RNAseq-based transcriptomics suggest that this ability to utilize low methane is based at least in part on extremely low non-growth-associated maintenance energy and on high methane specific affinity. This bacterium is a candidate to develop technology for methane removal at emission sites. If appropriately scaled, such technology has the potential to slow global warming by 2050.

The HI V O pen Call on I nformed C onsent and E thics in Research (VOICE) for Adolescents and Young Adults: A Digital Crowdsourcing Open Call in Low- and Middle-Income Countries.

BACKGROUND: Many adolescents and young adults (AYAs; 10-24 years old) are excluded from HIV research because of social, ethical, and legal challenges with informed consent, resulting in limited AYA-focused data. We use a participatory approach to identify strategies for improving AYA consent processes in HIV research in low- and middle-income countries (LMICs). METHODS: We conducted a digital crowdsourcing open call for ideas to improve AYA consent to HIV research in LMICs. Crowdsourcing involves engaging a group of people in problem-solving, then sharing emergent solutions. Submissions were evaluated by 3 independent judges using predefined criteria, with exceptional strategies receiving prizes. Demographic data were collected, and textual data were qualitatively analyzed for emergent themes in barriers and facilitators for improving AYA consent in HIV research, guided by a socioecological model. RESULTS: We received 110 strategies total; 65 were eligible for evaluation, 25 of which were identified as finalists. Fifty-eight participants from 10 LMICs submitted the 65 eligible submissions, of which 30 (52%) were 18 to 24 years old. Thematic analysis identified 10 barriers to AYA consent, including HIV stigma, limited education, and legal/regulatory barriers. Strategies for improving AYA consent processes revealed 7 potential facilitators: enhancing AYA engagement in research, involving parents/guardians, improving education/awareness, improving institutional practices/policy, making research participation more AYA-friendly, enhancing engagement of other key communities of interest, and empowering AYA. CONCLUSIONS: Diverse communities of interest in LMICs developed compelling strategies to enhance informed consent that may improve AYA inclusion in HIV research. These data will be used to develop practical guidance on improving AYA consent processes.

Beyond Education: What is required to support staff to promote equity-oriented health care in EDs?

Context: Staff in Canadian Emergency Departments (EDs) face increasing workplace demands arising in part from system-wide shortages in primary and community care. Patients experiencing stigmatizing conditions such as chronic pain, substance use, and psychiatric disorders may turn to the ED as the only open "door" to access care in the community. Objective: To examine staff perceptions about their work and role, including how they may be prepared or not to address issues of health and health care inequities in EDs. Study Design and Analysis: Paper and online surveys were administered to staff. Data were collected as part of a larger mixed-methods organization-level intervention study aimed at enhancing capacity to provide equity-oriented health care in EDs. Pooled, cross-sectional survey data (n=393) were analyzed to examine work experiences, team effectiveness, and domains of equity- oriented care. Descriptive results from survey data are complemented by illustrative excerpts from qualitative interviews conducted with staff and administrative leadership. Setting: Three EDs in British Columbia. Population Studied: All staff working in EDs participating in the EQUIP ED study. Intervention: N/a. Outcome Measures: N/a. Results: Levels of stress, the extent of control over work, sufficient time to complete work, receive feedback about work, and ratings of the quality of care provided in the ED highlight workplace pressures, constraints, and impact on staff. The proportion of staff who have received training on and have confidence in being able to provide equity-oriented care in the ED has implications for how staff may be able to contribute to improved care for patients already experiencing the harmful effects of stigma and other forms of discrimination including fragmentation of care. Conclusions: The impacts of shortages in primary care reverberate throughout the system. EDs often prioritize efficiency, a focus which cannot adequately equip staff to promote equity. Attention and commitment to addressing structural inequities within EDs could support patients and staff to move closer to the quintuple aim.

Disparities in HIV Testing and PrEP Awareness for Black Women who Inject Drugs in San Francisco, California.

HIV disproportionately affects Black/African Americans (AA), while PrEP is under-utilized by Black/AA, women, and people who inject drugs (PWID). In San Francisco, California's National HIV Behavioral Surveillance among PWID in 2022, Black/AA women were the least likely to be tested for HIV among all groups by sex and race/ethnicity and the least likely to be aware of PrEP among women. Yet, Black/AA women were no less likely to see a healthcare provider in the last year. Data suggest that providers' failure to discuss and address HIV risk with Black/AA female PWID is a major barrier to accessing effective care and prevention. El VIH afecta de manera desproporcionada a Black/afroamericanos (AA), mientras que la PrEP está infrautilizada por los Black/AA, las mujeres y las personas que se inyectan drogas (PWID). En la National HIV Behavioral Surveillance de PWID de San Francisco, California en 2022, las mujeres Black/AA eran las que menos probabilidades tenían de someterse a la prueba del VIH entre todos los grupos por sexo y raza/etnia y las que menos probabilidades tenían de conocer la PrEP entre las mujeres. Sin embargo, las mujeres Black/AA no tenían menos probabilidades de acudir a un profesional sanitario en el último año. Los datos sugieren que el hecho de que los proveedores no hablen ni aborden el riesgo de VIH con las PWID de raza Black/AA es un obstáculo importante para acceder a una atención y prevención eficaces.

Continuing Low Awareness and Use of Pre-exposure Prophylaxis (PrEP) for HIV among People Who Inject Drugs (PWID), San Francisco, 2022.

Clinical trials provide evidence that pre-exposure prophylaxis (PrEP) prevents HIV acquisition including through sharing of injection equipment among people who inject drugs (PWID). However, uptake among many populations at risk for HIV has been slow, particularly among PWID. We examined data from the National HIV Behavioral Surveillance (NHBS) from San Francisco in 2022 to measure PrEP uptake and identify factors associated with PrEP awareness among PWID. Of 479 PWID with HIV-negative or unknown HIV status, 54.9% were aware of PrEP, 5.9% had discussed PrEP with a healthcare provider, and 1.5% had used PrEP in the past year. Lack of PrEP awareness was associated with being age 50 years and older (adjusted odds ratio [aOR] 0.40, 95% CI 0.27-0.60), being men who have sex with women (vs. men who have sex with men, aOR 0.47, 95% CI 0.24-0.92), having a disability (aOR 0.58, 95% CI 0.35-0.95), using heroin as their most frequently injected drug (aOR 0.51, 95% CI, 0.34-0.78), not having tested for HIV, HCV, or an STD in the past year (aOR 0.43, 95% CI 0.28-0.64), and not having access to new sterile needles in the past year (aOR 0.28, 95%CI 0.08-1.00). We found negligible change in the awareness and uptake of PrEP among PWID since previously measured in NHBS in 2018. Low PrEP use among PWID may be addressed by increasing provider discussion of PrEP with their PWID patients and clients during routine care, expanding testing for injection-related infections among PWID, and integrating PrEP access into harm reduction programs.

Detectable viral load associated with unmet mental health and substance use needs among trans women living with HIV in San Francisco, California.

BACKGROUND: Substance use and mental distress are known barriers to HIV care engagement among trans women. Less is known about access and utilization of mental health and substance use care among trans women and the relationship between unmet behavioral health needs and HIV viral suppression. We examined the relationship between mental health and substance use on HIV viral load among trans women living with HIV. We also examined the relationship between mental health and substance use services needs with HIV care engagement and having a detectable viral load by comparing engagement in care cascades. METHODS: Data are from a 2022 baseline assessment for an intervention with trans women living with HIV (n = 42) in San Francisco. Chi-Squared or Fisher's exact tests were conducted to determine associations between HIV viral load, mental health, and substance use. We also examine characteristics associated with each step in the HIV, mental health, and substance use care cascades. RESULTS: Most participants were trans women of color (85.7%), 40 years of age or older (80.9%), with low income (88.1%), and almost half were unstably housed (47.6%). Of the 32 participants who screened positive for depression, anxiety and/or psychological distress, 56.3% were referred for mental health services in the past 12 months. Of those who were referred, 44.4% received mental health services. Of the 26 participants who screened positive for a substance use disorder, 34.6% were referred to substance use services in the past 12 months. Of those referred, 33.3% received substance use services in the past 3 months. Latina trans women had a low referral rate to meet their mental health needs (50%) and only 16.7% of African American/Black trans women who screened positive for a substance use disorder were referred for services, while trans women of other race/ethnicities had high referral and services utilization. No significant results were found between HIV viral load and screening positive for a mental health disorder. Methamphetamine use was statistically associated with having a detectable HIV viral load (p = 0.049). CONCLUSIONS: We identified significant unmet mental health and substance use services needs and noted racial/ethnic disparities in the context of high HIV care engagement among trans women living with HIV. We also found that methamphetamine use was a barrier to having an undetectable viral load for trans women living with HIV. To finally end the HIV epidemic, integration of behavioral health screening, linkage, and support are needed in HIV care services for populations most impacted by HIV, especially trans women. TRIAL REGISTRATION: NCT, NCT 21-34,978. Registered January 19, 2022.

Impact of HCV Testing and Treatment on HCV Transmission Among Men Who Have Sex With Men and Who Inject Drugs in San Francisco: A Modelling Analysis.

BACKGROUND: Men who have sex with men who ever injected drugs (ever MSM-IDU) carry a high hepatitis C virus (HCV) burden. We estimated whether current HCV testing and treatment in San Francisco can achieve the 2030 World Health Organization (WHO) HCV elimination target on HCV incidence among ever MSM-IDU. METHODS: A dynamic HCV/HIV transmission model among MSM was calibrated to San Francisco data, including HCV antibody (15.5%, 2011) and HIV prevalence (32.8%, 2017) among ever MSM-IDU. MSM had high HCV testing (79%-86% ever tested, 2011-2019) and diagnosed MSM had high HCV treatment (65% ever treated, 2018). Following coronavirus disease 2019 (COVID-19)-related lockdowns, HCV testing and treatment decreased by 59%. RESULTS: Among all MSM, 43% of incident HCV infections in 2022 were IDU-related. Among ever MSM-IDU in 2015, HCV incidence was 1.2/100 person-years (95% credibility interval [CrI], 0.8-1.6). Assuming COVID-19-related declines in HCV testing/treatment persist until 2030, HCV incidence among ever MSM-IDU will decrease by 84.9% (95% CrI, 72.3%-90.8%) over 2015-2030. This decline is largely attributed to HCV testing and treatment (75.8%; 95% CrI, 66.7%-89.5%). Slightly greater decreases in HCV incidence (94%-95%) are projected if COVID-19 disruptions recover by 2025 or 2022. CONCLUSIONS: We estimate that HCV incidence will decline by >80% over 2015-2030 among ever MSM-IDU in San Francisco, achieving the WHO target.

Trends in perinatal mental health within a tertiary institution from 2013 to 2022.

Perinatal mental health (PMH) disorders affect about one in seven women in the peripartum period with significant maternal and neonatal effects. It is important to understand trends in PMH to plan for necessary resource allocation. This study reviews the PMH trends in a major tertiary obstetric centre over 10 years from 2013 to 2022. Over this period there was a significant increase in the rates of anxiety from 7.4 to 18.4% (P < 0.001), depression from 13.6 to 16.3% (P < 0.001) and anxiety and/or depression from 16.5 to 22.6% (P < 0.001). These findings provide further information for resource allocation to improve long-term outcomes.

Impact of feminizing hormone therapy on tenofovir and emtricitabine plasma pharmacokinetics: a nested drug-drug interaction study in a cohort of Brazilian transgender women using HIV pre-exposure prophylaxis.

OBJECTIVES: Potential interactions between feminizing hormone therapy (FHT) and pre-exposure prophylaxis (PrEP) may be a barrier to PrEP use among transgender women (TGW). We aimed to assess the impact of FHT on PrEP plasma pharmacokinetics (PK) among TGW. METHODS: This was a PK substudy of the effects of FHT on tenofovir disoproxil fumarate/emtricitabine nested to a trans-specific PrEP demonstration study (NCT03220152). Participants were assigned to receive PrEP only (noFHT) or standardized FHT (sFHT; oestradiol valerate 2-6 mg plus spironolactone 100-300 mg) plus PrEP for 12 weeks, after which they could start any FHT (aFHT). Short- and long-term PK assessment occurred at Weeks 12 and 30-48, respectively (plasma samples prior and 0.5, 1, 2, 4, 6, 8 and 24 h after dose). Non-compartmental PK parameters of tenofovir and emtricitabine were compared as geometric mean ratios (GMRs) between noFHT and PrEP and FHT (sFHT at short-term PK; aFHT at long-term PK) participants. RESULTS: No differences in tenofovir and emtricitabine plasma PK parameters were observed between the short-term PK of noFHT (n = 12) and sFHT participants (n = 18), except for emtricitabine Cmax [GMR: 1.15 (95% CI: 1.01-1.32)], or between noFHT short-term PK and aFHT long-term PK (n = 13). Most participants were on oestradiol valerate 2 mg at the short-term PK (56%) and 4 mg at the long-term PK (54%). Median (IQR) oestradiol levels were 56.8 (43.2-65.4) pg/mL at short-term PK (sFHT) and 44.8 (24.70-57.30) pg/mL at long-term PK (aFHT). No participants in this analysis seroconverted during the study. CONCLUSIONS: Our results indicate no interaction of FHT on tenofovir levels, further supporting PrEP use among TGW using FHT.

Improved PrEP Awareness and Use among Trans Women in San Francisco, California.

Transgender women face a serious risk of HIV infection. Despite this, there is limited knowledge and use of Pre-exposure prophylaxis (PrEP). We measured the continuity of prevention across services in the PrEP cascade and correlates of PrEP use among trans women in San Francisco enrolled in the 2019/20 National HIV Behavioral Surveillance Study. Knowledge and use of PrEP among trans women in San Francisco increased in recent years; almost all (94.0%) had heard about PrEP, 64.7% had discussed PrEP with a healthcare provider, and 44.8% had taken PrEP in the past 12 months. PrEP use was associated with participation in a PrEP demonstration project (aOR = 31.44, p = 0.001) and condomless receptive anal intercourse (aOR = 3.63, p = 0.024). Injection drug use was negatively associated (aOR = 0.19, p = 0.014). Efforts are needed to combat the gender-based stigma and discrimination faced by trans women, which can result in avoidance and mistrust of the medical system.

RESUMEN: Las mujeres trans enfrentan un grave riesgo de infección por el VIH. A pesar de ello, hay conocimiento y utilización limitada de la profilaxis previa a la exposición (PrEP). Medimos la continuidad de prevención a través de los servicios en la cascada de PrEP y los correlatos del uso de PrEP entre mujeres trans en San Francisco inscritas en el Estudio Nacional de Vigilancia del Comportamiento del VIH en 2019/20. El conocimiento y el uso de PrEP entre las mujeres trans en San Francisco aumentó en los últimos años; casi todas (94.0%) habían escuchado sobre PrEP, el 64.7% habían hablado de PrEP con un proveedor de atención médica y el 44.8% había tomado PrEP en los últimos 12 meses. El uso de PrEP se asoció con el uso actual con participación en un proyecto de demostración de PrEP (ORa = 31.44, p = 0.001) y el coito anal receptivo sin condón (ORa = 3.63, p = 0.024). El uso de drogas inyectables se asoció negativamente (ORa = 0.19, p = 0.014). Se necesitan esfuerzos para combatir el estigma y la discriminación basados en el género que enfrentan las mujeres trans, que pueden resultar en la evitación y desconfianza en el sistema medico.".

In Their Own Words: How Trans Women Acquired HIV Infection.

Despite high HIV prevalence, the reasons trans women acquire HIV are not well understood. Trans women are often mis-classified or aggregated with men who have sex with men (MSM) in epidemiologic studies and HIV surveillance data. Trans women enrolled in the 2019/2020 National HIV Behavioral Surveillance Study in San Francisco were asked an open-ended question about how they were infected with HIV. The most common responses were "Sex with a straight cisgender man partner when the respondent identified as a trans woman" (43.0%); "Sexual assault" (13.9%); "Injection drug use (IDU)" (10.1%); "IDU or sexual contact" (7.6%) and "Sex with a partner who injected drugs" (7.6%). Sex with a cisgender man partner prior to identifying as a trans women (MSM contact) was not mentioned by any respondent. HIV prevention strategies targeting MSM will fail to reach trans women and many of their cisgender men partners.

RESUMEN: A pesar de la alta prevalencia del VIH, las razones por las que las mujeres trans adquieren el VIH no se comprenden bien. Las mujeres trans a menudo se clasifican erróneamente o se agregan a los hombres que tienen sexo con hombres (HSH) en los estudios epidemiológicos y en los datos de vigilancia del VIH. A las mujeres trans inscritas en el Estudio Nacional de Vigilancia del Comportamiento del VIH 2019/2020 en San Francisco se les hizo una pregunta abierta sobre cómo se infectaron con el VIH. Las respuestas más comunes fueron "Sexo con una pareja heterosexual de hombre cisgénero cuando el encuestado se identificó como una mujer trans" (43,0%); "Agresión sexual" (13,9%); "Uso de drogas inyectables (UDI)" (10,1%); "UDI o contacto sexual" (7,6%) y "Sexo con pareja que se inyecta drogas" (7,6%). Ningún encuestado mencionó el sexo con una pareja hombre cisgénero antes de identificarse como mujer trans (contacto HSH). Las estrategias de prevención del VIH dirigidas a los HSH no llegarán a las mujeres trans ni a muchas de sus parejas masculinas.

Prevalence and correlates of substance use and associations with HIV-related outcomes among trans women in the San Francisco Bay Area.

BACKGROUND: Trans women face tremendous social inequities as well as disproportionate rates of HIV and substance use, yet disaggregated substance use data specific to trans women remain limited. METHODS: We conducted a secondary analysis of baseline data from the Trans*National Study (2016-2017) surveying trans women in the San Francisco Bay Area (n = 629). Multivariable logistic regression was used to analyze socio-demographic and environmental correlates of substance use, and bivariate associations between substance use and HIV-associated outcomes are presented alongside prevalence data. RESULTS: Over half (52.9%) reported using substances in the prior year, most frequently marijuana, methamphetamine, and crack/cocaine. Those with unmet gender-affirming health care needs, lack of insurance, or a history of experiencing racial violence, transphobic violence, adult housing instability, or extreme poverty had higher odds of substance use. Sex work and condomless anal sex were also independently associated with substance use. CONCLUSIONS: Among this sample of trans women, substance use and substance use concurrent with sex were highly prevalent, and associated with a number of socioeconomic and health care needs. These findings corroborate the need for holistic and intersectional efforts to reduce substance use and HIV risk.

A global cautionary tale: discrimination and violence against trans women worsen despite investments in public resources and improvements in health insurance access and utilization of health care.

BACKGROUND: To determine if improvements in social determinants of health for trans women and decreases in transphobic discrimination and violence occurred over three study periods during which extensive local programs were implemented to specifically address longstanding inequities suffered by the transgender community. METHODS: Interviewer-administered surveys from repeated cross-sectional Transwomen Empowered to Advance Community Health (TEACH) studies in 2010, 2013 and 2016-2017 in San Francisco collected experiences with transphobia violence and discrimination. Respondent-driven sampling was used to obtain a sample of participants who identified as a trans woman. RESULTS: Violence due to gender identity was prevalent; in each study period, verbal abuse or harassment was reported by over 83% of participants, and physical abuse or harassment was reported by over 56%. Adverse social determinants of health including homelessness, living below the poverty limit, methamphetamine use, depression, PTSD, and anxiety all significantly increased from 2010 to 2016. When testing for trends, housing discrimination and physical violence were both more likely in 2016-2017 compared to the two earlier study periods. Housing discrimination (aOR 1.41, 95% CI 1.00-1.98) and physical violence due to gender identity/presentation (aOR 1.39, 95% CI 1.00-1.92) both significantly increased from 2010 to 2016. CONCLUSION: Our findings are particularly alarming during a period when significant public health resources and community-based initiatives specifically for trans women were implemented and could have reasonably led us to expect improvements. Despite these efforts, physical violence and housing discrimination among trans women worsened during the study periods. To ensure future improvements, research and interventions need to shift the focus and burden from trans people to cisgender people who are the perpetuators of anti-trans sentiment, stigma, discrimination and victimization.

Financial impacts and community resources utilization of children with feeding difficulties.

BACKGROUND: To examine the extent to which financial impacts and community resources utilization are associated with pediatric feeding difficulties. We hypothesize that children with feeding difficulties will have more financial impacts and community resources utilization than children without feeding difficulties. METHODS: We conducted a secondary analysis of cross-sectional data from the 2017-2018 National Survey of Children's Health (NSCH) regarding 14,960 children 0-5 years. NSCH utilized random sampling of families across the United States to collect nationally representative data. Outcomes included out-of-pocket costs, caregivers leaving a job due to the child's health, food insufficiency, receival of food or cash assistance, and receival of special education and/or developmental services. We used a multivariable logistic regression controlling for sociodemographic factors to examine the associations of feeding difficulties with financial impacts and community resources utilization outcomes. RESULTS: Out of 14,690 respondents, children were a mean (SD) age of 2.53(0.03) years and 1.7% reported feeding difficulties. These children had higher odds of having out-of-pocket costs of ≥$1000 (OR: 3.01; 95% CI: 1.61, 5.62), having a caregiver that left a job due to their child's health (OR: 3.16; 95% CI: 2.01, 4.98), experiencing food insufficiency (OR: 1.67; 95% CI: 1.03, 2.71), and receiving special education and/or developmental services (OR 3.98; 95% CI: 2.46, 6.45) than children without feeding difficulties. CONCLUSIONS: Children with feeding difficulties are more likely to have financial impacts and community resources utilization than children without feeding difficulties. This information can be used to tailor interventions to improve family-centered care and outcomes for children.

"Lost trust in the system": system barriers to publicly available mental health and substance use services for transgender women in San Francisco.

BACKGROUND: Little is known about the barriers to mental health and substance use services for trans women living with HIV. We conducted a qualitative study with trans women living with HIV and providers to explore barriers to mental health and substance use services in San Francisco. METHODS: We conducted focus group discussions and key informant interviews with a total of 15 medical, mental health, substance use, and social service providers and trans women living with HIV. We identified, analyzed, and reported themes using thematic analysis and derived themes directly from the data. RESULTS: Our study participants identified two main themes and three subthemes. One main theme is that trans women and providers have lost trust in the system due to (a) lack of a linkage system between referrals and services, (b) structural barriers such as service location, language capacity, clinic hours, and (c) constant changes in services available. Another main theme is anti-trans and mental health stigma. CONCLUSIONS: Interventions to coordinate linkage from medical to mental health and substance use (MHSU) services are urgently needed to facilitate the utilization of MHSU services. Other interventions to improve quality monitoring and system improvement, and to address multiple stigmas broadly in society are needed to improve unmet MHSU service needs among trans women living with HIV in San Francisco.

EQUIP emergency: can interventions to reduce racism, discrimination and stigma in EDs improve outcomes?

BACKGROUND: Despite a publicly funded system, health care in Canada has been shown to be deeply inequitable, particularly toward Indigenous people. Based on research identifying key dimensions of equity-oriented health care as being cultural safety, harm reduction and trauma- and violence-informed care, an intervention to promote equity at the organizational level was tested in primary health care, refined and adapted, and tested in Emergency Departments (EDs). METHODS: In partnership with clinical, community and Indigenous leaders in three diverse EDs in one Canadian province, we supported direct care staff to tailor and implement the intervention. Intervention activities varied in type and intensity at each site. Survey data were collected pre- and post-intervention from every consecutive patient over age 18 presenting to the EDs (n = 4771) with 3315 completing post-visit questions in 4 waves at two sites and 3 waves (due to pandemic constraints) at the third. Administrative data were collected for 12 months pre- and 12 months post-intervention. RESULTS: Throughout the study period, the participating EDs were dealing with a worsening epidemic of overdoses and deaths related to a toxic drug supply, and the COVID 19 pandemic curtailed both intervention activities and data collection. Despite these constraints, staff at two of the EDs mounted equity-oriented intervention strategies; the other site was experiencing continued, significant staff shortages and leadership changeover. Longitudinal analysis using multiple regression showed non-significant but encouraging trends in patient perceptions of quality of care and patient experiences of discrimination in the ED. Subgroup analysis showed that specific groups of patients experienced care in significantly different ways at each site. An interrupted time series of administrative data showed no significant change in staff sick time, but showed a significant decrease in the percentage of patients who left without care being completed at the site with the most robust intervention activities. CONCLUSIONS: The trends in patient perceptions and the significant decrease in the percentage of patients who left without care being completed suggest potential for impact. Realization of this potential will depend on readiness, commitment and resources at the organizational and systems levels. TRIAL REGISTRATION: Clinical Trials.gov #NCT03369678 (registration date November 18, 2017).

The Dose Response Effects of Digital HIV Care Navigation on Mental Health and Viral Suppression Among Young People Living With HIV: Single-Arm, Prospective Study With a Pre-Post Design.

BACKGROUND: The HIV epidemic has revealed considerable disparities in health among sexual and gender minorities of color within the Unites States, disproportionately affecting cisgender men who have sex with men (MSM) and trans women. Social inequities further disadvantage those with intersectional identities through homophobia, antitrans discrimination, and racism, shaping not only those at risk for HIV infection but also HIV prevention and care outcomes. Digital interventions have great potential to address barriers and improve HIV care among cisgender MSM and trans women; however, efficacy of digital HIV care interventions vary and need further examination. OBJECTIVE: This study assessed the 12-month efficacy of a 6-month digital HIV care navigation intervention among young people living with HIV in San Francisco, California. We examined dose-response relationships among intervention exposure (eg, text messaging), viral suppression, and mental health. Health electronic navigation (eNav) is a 6-month, text message-based, digital HIV care navigation intervention, in which young people living with HIV are connected to their own HIV care navigator through text messaging to improve engagement in HIV primary care. METHODS: This study had a single-arm, prospective, pre-post design. Eligibility criteria for the study included the following: identifying as cisgender MSM or trans women, being between the ages of 18 and 34 years, being newly diagnosed with HIV, or not being engaged or retained in HIV care or having a detectable viral load. We assessed and analyzed sociodemographics, intervention exposure, and HIV care and mental health outcome data for participants who completed the 6-month Health eNav intervention. We assessed all outcomes using generalized estimating equations to account for within-subjects correlation, and marginal effects of texting engagement on all outcomes were calculated over the entire 12-month study period. Finally, we specified an interaction between texting engagement and time to evaluate the effects of texting engagement on outcomes. RESULTS: Over the entire 12-month period, this study shows that every one-text increase in engagement was associated with an increased odds of undetectable viral load (adjusted odds ratio 1.01, 95% CI 1.00-1.02; P=.03). Mean negative mental health experiences decreased significantly at 12 months compared to baseline for every one-text increase in engagement (coefficient on interaction term 0.97, 95% CI 0.96-0.99; P<.01). CONCLUSIONS: Digital care navigation interventions including Health eNav may be a critical component in the health delivery service system as the digital safety net for those whose social vulnerability is exacerbated in times of crisis, disasters, or global pandemics owing to multiple social inequities. We found that increased engagement in a digital HIV care navigation intervention helped improve viral suppression and mental health-intersecting comorbid conditions-6 months after the intervention concluded. Digital care navigation may be a promising, effective, sustainable, and scalable intervention. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/16406.

Five-year trends in induction of labour in a large Australian metropolitan maternity service.

BACKGROUND: The World Health Organisation recommends that induction of labour (IOL) be performed only with a clear medical indication. Australian rates of IOL appear to be rising, with more than one-third of women having labour induced. This may reflect changing clinician and consumer perceptions of the benefits and potential harms of term IOL. AIMS: To understand recent trends in the rates and indications for IOL. MATERIALS AND METHODS: A retrospective cohort study was undertaken in a Level 6 maternity facility, in metropolitan South-East Queensland, Australia. Routinely collected data were gathered between 2015 and 2020. Exclusion criteria were multiple pregnancies, stillbirth and pre-labour rupture of membranes. Pre-labour rupture of membranes was excluded due to inability to assess if IOL for this indication was a true induction or augmentation of labour. Indications for induction were grouped into maternal, fetal, elective indications, 'post-dates' and decreased fetal movements (DFM). Rates of IOL and frequency of the various indications were compared over time. RESULTS: About 46 530 livebirths occurred during the study period, with labour induced in 31.7%. The proportion of women undergoing IOL increased from 29.8% in 2015 to 33.4% in 2019 (P < 0.001). The proportion of inductions for DFM and elective indications increased over time, with a substantial decrease in 'post-dates' IOL. CONCLUSIONS: This large contemporary analysis of IOL trends in Australia has demonstrated rising rates and changing indications for IOL. There remain large knowledge gaps in areas such as care of women with DFM, definitions and management of 'post-term pregnancy', and the economic and service impacts of rising trends in the rate of IOL.

Delayed cord clamping: Impact on fetal cord blood gas analysis.

Both delayed cord clamping (DCC) and cord blood gas (CBG) analysis are recommended practices for preterm births. However, the compliance rates remain lower than expected, with a DCC rate of only 48.9% and CBG sampling of 66.6% in the preterm cohort. DCC was associated with a significant reduction in success rate of paired CBG analysis in both the term and preterm cohort of 8.3% and 7.7% respectively. Our study highlights the difficulty in achieving both recommendations.

Hepatitis C Care Cascades for 3 Populations at High Risk: Low-income Trans Women, Young People Who Inject Drugs, and Men Who Have Sex With Men and Inject Drugs.

BACKGROUND: To achieve elimination of hepatitis C virus (HCV) infection, limited resources can be best allocated through estimation of "care cascades" among groups disproportionately affected. In San Francisco and elsewhere, these groups include young (age ≤ 30 years) people who inject drugs (YPWID), men who have sex with men who inject drugs (MSM-IDU), and low-income trans women. METHODS: We developed cross-sectional HCV care cascades for YPWID, MSM-IDU, and trans women using diverse data sources. Population sizes were estimated using an inverse variance-weighted average of estimates from the peer-reviewed literature between 2013 and 2019. Proportions of past/current HCV infection, diagnosed infection, treatment initiation, and evidence of cure (sustained virologic response at 12 weeks posttreatment) were estimated from the literature using data from 7 programs and studies in San Francisco between 2015 and 2020. RESULTS: The estimated number of YPWID in San Francisco was 3748; 58.4% had past/current HCV infection, of whom 66.4% were diagnosed with current infection, 9.1% had initiated treatment, and 50% had confirmed cure. The corresponding figures for the 8135 estimated MSM-IDU were: 29.4% with past/current HCV infection, 70.3% diagnosed with current infection, 28.4% initiated treatment, and 38.9% with confirmed cure. For the estimated 951 low-income trans women, 24.8% had past/current HCV infection, 68.9% were diagnosed with current infection, 56.5% initiated treatment, and 75.5% had confirmed cure. CONCLUSIONS: In all 3 populations, diagnosis rates were relatively high; however, attention is needed to urgently increase treatment initiation in all groups, with a particular unmet need among YPWID.