Vision Problems As a Contributor to Lower Engagement in Care Among Aging Men Living with HIV.

PURPOSE: To investigate vision impairment as a barrier to engagement in medical care among aging persons living with HIV (PLWH) who experience multimorbidity and complex care needs. SETTING: Multicenter AIDS Cohort Study (MACS), a prospective observational cohort of aging PLWH men. METHODS: We examined relationships of self-reported vision difficulty with indicators of care engagement: 1) adherence to HIV antiretroviral therapy (ART; defined as taking ≥95% of medications); 2) self-reported avoidance of medical care; 3) self-reported tendency to ask a doctor questions about care (>2 questions at a medical visit), as well as with quality of life. A modified version of the National Eye Institute Vision Function Questionnaire was administered at three semi-annual visits (from October 2017 to March 2019) to assess difficulty performing vision-dependent tasks. RESULTS: We included 1063 PLWH (median age 57 years, 31% Black). Data on care engagement outcomes were analyzed using repeated measures logistic regression with generalized estimating equations adjusted for race, and at visit values for age, education level, depressive symptoms, alcohol use, and smoking status. Compared to no vision difficulty, those reporting moderate to extreme vision difficulty on at least one task had 2.2 times higher odds (95% CI: 1.4, 3.4) of having less than optimal ART adherence, 1.9 times higher odds (95% CI: 1.1, 3.4) of avoiding necessary medical care and median quality of life scores 8 points lower. CONCLUSION: These findings suggest vision impairment decreases medical care engagement including HIV care and quality of life among aging PLWH.

Longitudinal Analysis of Overlapping Psychosocial Factors Predicting Incident Hospitalization Among Mixed HIV Serostatus Men who have Sex with Men in the Multicenter AIDS Cohort Study.

Men who have sex with men (MSM) are at increased risk for certain types of chronic diseases and mental health problems. Despite having extended survival in the highly active antiretroviral therapy (HAART) era, MSM living with HIV contend with aging-related diseases and complications with treatment. Consequent hospitalizations incur high costs, fear, low quality of life, and frailty. Unlike heterosexual men, MSM experience more structural violence and "syndemics" of psychosocial factors that not only accelerate HIV acquisition and transmission risk but also may increase morbidity, leading to greater rates of hospitalization. We aim to examine the impact of "syndemic" psychosocial factors on the incidence of hospitalization among geographically diverse MSM in the US. Participants were 1760 MSM from the Multicenter AIDS Cohort Study (MACS) between 2004 and 2019. We examined the relationship between six psychosocial factors (depression, stimulant use, smoking, heroin use, childhood sexual abuse, and intimate partner violence) and incident hospitalization (admission to a hospital for treatment). We found a positive dose-response relationship between the number of syndemic factors and hospitalization. MSM reporting five or more syndemic factors had over twice the risk of hospitalization compared to MSM without syndemic factors [aRR = 2.14 (95% CI = 1.56, 2.94)]. Psychosocial factors synergistically increased hospitalizations over time. The positive dose-response relationship between the number of syndemic factors and hospitalization and the synergistic effects of these factors underscore the need for interventions that disentangle the syndemics to reduce hospitalization and related costs and improve the quality of life among MSM.

The Relationship Between Posttraumatic Stress Disorder and Alcohol Misuse and Smoking Among Aging Men Who Have Sex With Men: No Evidence of Exercise or Volunteering Impact.

OBJECTIVES: To determine if the association between posttraumatic stress disorder (PTSD) and substance use (alcohol misuse or smoking tobacco) is mediated/moderated by exercise or volunteering among aging (≥40 years) men who have sex with men (MSM), and if this mediation/moderation differs by HIV serostatus. METHODS: Multicenter AIDS Cohort Study data were used. Three datasets with PTSD measured during different time periods (10/1/2017-3/31/2018, 898 men; 4/1/2018-9/30/2018, 890 men; 10/1/2018-3/31/2019, 895 men) were analyzed. Longitudinal mediation analyses estimated the mediation effect of exercise and volunteering on the outcomes. RESULTS: Nine percent of MSM had evidence of PTSD. There was no statistically significant mediation effect of exercise or volunteering regardless of substance use outcome. The odds of smoking at a future visit among MSM with PTSD were approximately double those of MSM without PTSD. Results did not differ by HIV serostatus. DISCUSSION: There is a particular need for effective smoking cessation interventions for aging MSM with PTSD.

Relationship among serum levels of IL-6, sIL-6R, s gp130 and CD126 on T-cell in HIV-1 infected and uninfected men participating in the Los Angeles Multi-Center AIDS Cohort Study.

INTRODUCTION: Interleukin 6 (IL-6) activates cells through its unique heterodimeric signaling complex of IL-6 receptor (IL6R) subunit and interleukin 6 signal transducer ß-subunit glycoprotein 130 (gp130). The objective of this study was to investigate associations among serum levels of IL-6, sIL-6R, sgp130 and relative fluorescence intensity (RFI) of the α-subunit of the IL-6 receptor (CD126) on T-cells of HIV-1 infected and uninfected men. METHODS: Blood samples were obtained from 69 HIV-1-infected men on Highly Active Antiretroviral Therapy (HAART) with mean age of 49.1 and 52 HIV-1-uninfected with mean age of 54.3 years -. All men were participating in the Los Angeles Multi-Center AIDS Cohort Study (MACS). Serum levels of IL-6, sIL-6R, sgp130 were measured by enzyme-linked immunoassays and T-cell phenotypic analysis and RFI of CD126 on CD4+ and CD8+ by flow cytometry. RESULTS: Mean serum levels of IL-6, sIL6R, sgp130 and of CD126 RFI on CD4+ were 4.34 pg/mL, 39.3 ng/mL, 349 ng/mL and 526 RFI respectively for HIV-1-infected men and 2.74 pg/mL, 41.9 ng/mL, 318 ng/mL and 561 RFI respectively for HIV-1-uninfected men. The mean serum concentrations of IL-6, sIL-6R in HIV-1-infected and uninfected men were not significantly different (p>0.05). There was a positive correlation between plasma HIV-1 RNA and the levels of IL-6 (p<0.001), sIL6R (p = 0.002) but no correlation with sgp130 (p = 0.339). In addition, there was a negative correlation between serum levels of IL-6 with RFI of CD126 on CD4+ (p = 0.037) and a positive correlation between serum levels of sgp130 (p = 0.021) and sIL-6R in HIV-1-infected men. CONCLUSION: Knowledge of biological variation, differences in the blood levels of biomarkers among healthy individuals and individuals experiencing illness, are very important for selection of appropriate tests for stage and progression of disease. Our data suggest no correlation among IL-6, and sIL-R6, in the treated phase of HIV-1 infection. The action and blood level of IL-6 and its receptors may be different at each stage of a disease progression.

Extracellular vesicles as biomarkers for AIDS-associated non-Hodgkin lymphoma risk.

Introduction: Extracellular vesicles are membrane-bound structures secreted into the extracellular milieu by cells and can carry bioactive molecules. There is emerging evidence suggesting that EVs play a role in the diagnosis, treatment, and prognosis of certain cancers. In this study, we investigate the association of EVs bearing PD-L1 and molecules important in B-cell activation and differentiation with AIDS-NHL risk. Methods: EVs were isolated from archived serum collected prior to the diagnosis of AIDS-NHL in cases (N = 51) and matched HIV+ controls (N = 52) who were men enrolled in the Los Angeles site of the MACS/WIHS Combined Cohort Study (MWCCS). Serum specimens of AIDS-NHL cases were collected at a mean time of 1.25 years (range of 2 to 36 months) prior to an AIDS-NHL diagnosis. The expression of PD-L1 and other molecules on EVs (CD40, CD40L, TNF-RII, IL-6Rα, B7-H3, ICAM-1, and FasL) were quantified by Luminex multiplex assay. Results and discussion: We observed significantly higher levels of EVs bearing PD-L1, CD40, TNF-RII and/or IL-6Rα in AIDS-NHL cases compared with controls. Using multivariate conditional logistic regression models adjusted for age and CD4+ T-cell count, we found that EVs bearing PD-L1 (OR = 1.93; 95% CI: 1.10 - 3.38), CD40 (OR = 1.97, 95% CI: 1.09 - 3.58), TNF-RII (OR = 5.06; 95% CI: 1.99 - 12.85) and/or IL-6Rα (OR = 4.67; 95% CI: 1.40 - 15.53) were significantly and positively associated with AIDS-NHL risk. In addition, EVs bearing these molecules were significantly and positively associated with non-CNS lymphoma: PD-L1 (OR = 1.94; 95% CI: 1.01 - 3.72); CD40 (OR = 2.66; 95% CI: 1.12 - 6.35); TNF-RII (OR = 9.64; 95% CI: 2.52 - 36.86); IL-6Rα (OR = 8.34; 95% CI: 1.73 - 40.15). These findings suggest that EVs bearing PD-L1, CD40, TNF-RII and/or IL-6Rα could serve as biomarkers for the early detection of NHL in PLWH.

Factors associated with lifetime HIV testing among women in four Southeast Asian countries: Evidence from the demographic and health surveys.

BACKGROUND: Southeast Asian countries have been trying to increase HIV testing coverage of women since awareness of HIV status is essential to eliminate mother-to-child transmission of HIV. This study determined factors related to lifetime HIV testing uptake among women aged 15-49 years in four Southeast Asian countries: Myanmar, Cambodia, the Philippines and Timor-Leste. METHODS: This study used cross-sectional data from the 2015-16 Myanmar Demographic and Health Survey (DHS), the 2014 Cambodia DHS, the 2017 Philippines National DHS and the 2016 Timor-Leste DHS. We conducted multivariable logistic regression analyses to identify factors associated with lifetime HIV testing among women aged 15-49 years who completed the surveys in each country and ran a fixed effects logistic regression model using pooled data. RESULTS: The proportions of lifetime HIV testing uptake among women aged 15-49 years were 42.1% in Cambodia, 19.5% in Myanmar, 4.6% in the Philippines, and 3.7% in Timor-Leste. Marital status, age, education, and wealth were significantly associated with lifetime HIV testing uptake among women in all four countries. Other factors (e.g., comprehensive knowledge of HIV, rural/urban residence, positive attitudes towards negotiation for safer sex) were also significant determinants of HIV testing uptake among women in some of these countries. CONCLUSIONS: A multi-sectoral collaboration of related sectors and organizations is necessary to increase access to HIV testing and HIV knowledge of women to overcome the barriers to HIV testing. It is critical to make HIV testing services available and accessible to women, especially in rural areas.

Longitudinal associations of relationship support and strain and internalized homophobia with mental health among middle-aged and older gay and bisexual men.

Objectives: Mental health concerns (e.g. depression, anxiety) that negatively impact gay, bisexual, and other men who have sex with men (GBMSM) persist over the life course and into old age, but less is known about potential contributors to GBMSM's mental health. Close relationships can be a source of risk or resilience from stress, exerting direct relationships on mental health, and may mediate well-established associations between minority stress and mental health. This study examined whether primary partner relationship support and strain were uniquely associated with, and mediated the association between internalized homophobia, and mental health among older GBMSM.Methods: GBMSM (N = 517, M age = 60) from the Multicenter AIDS Cohort Study, who were in primary relationships with men, provided self-report data at four timepoints. We used multilevel modeling to examine longitudinal associations among relationship support and strain and internalized homophobia with depression and anxiety.Results: Relationship strain, but not support, was positively associated with mental health concerns longitudinally. There was a significant, positive indirect effect of internalized homophobia on depression and anxiety through strain, but no support. Internalized homophobia was positively associated with relationship strain, which was positively associated with mental health symptoms longitudinally.Conclusions: Relationship strain was associated with depression and anxiety longitudinally among middle-aged and older GBMSM and mediated associations of internalized homophobia with mental health. The role of partner support warrants further investigation. Mental health interventions are critically needed for older GBMSM and, for partnered GBMSM, should include strategies for reducing relationship strain to foster well-being.

Self-Reported Combination HIV Prevention Strategies Enacted by a Prospective Cohort of Midlife and Older Men Who Have Sex with Men in the United States: A Latent Class Analysis.

Insights into combination HIV prevention (CHP) strategies to reduce HIV incidence among midlife and older adult men who have sex with men (MSM) are limited. The current study is a secondary data analysis evaluating CHP in a sample of sexually active midlife and older adult MSM (N = 566) from the Multicenter AIDS Cohort Study Healthy Aging Substudy. Stratified by HIV serostatus, we used latent class analyses to identify CHP classes based on self-reported sociobehavioral and biobehavioral prevention strategies that participants and their male partners used in the prior 6 months. We identified three CHP classes among men living without HIV (MLWOH), including the following: high CHP overall (43.0%), high anal sex abstention (15.0%), and low prevention overall (42.0%). Among men living with HIV (MLWH), we identified four CHP classes, including the following: high CHP overall (20.9%), high CHP/low condom use (27.1%), high condom reliance (22.3%), and low prevention overall (29.7%). There were small differences by sociodemographic characteristics and sexual behavior practices between the classes; however, poppers use was often linked to being in high CHP groups. Our findings support that CHP is not one-size-fits-all for midlife and older adult MSM. There remains a need to scale up clinical providers' sexual health communication practices to assist midlife and older MSM incorporate prevention strategies, particularly biobehavioral prevention strategies that align with their patients' lived experiences.

Effects of Erectile Dysfunction Drugs Use on T-cells and Immune Markers on Men Who Have Sex with Men.

Objective: Examine prospective relationships between erectile dysfunction (ED) drugs EDand CD4 and CD8 T-cells, and immune markers among men who have sex with men (MSM). Methods: Data from Multicenter AIDS Cohort Study, an observational prospective cohort study, with semi-annual follow-ups conducted in four U.S. centers from 1998 onwards was used. Marginal structural models using g-computation was fitted to estimate the mean differences for the effects of self-reported ED drug use on CD4 and CD8 T-cell outcomes and immune biomarkers. Results: Total of 1,391 men with HIV (MWH) and 307 men without HIV (MWOH) was included. Baseline mean CD4 cell count among MWH and MWOH was 499.9 cells/µL and 966.7 cells/µL, respectively. At baseline, 41.8% of MWH were virally suppressed. ED drug users reported a mean of 44.4 months of exposure to ED drugs. ED drug use was associated with increased CD4 cell outcomes among MWH but not MWOH. Mean differences in CD4 cell counts after 1 year of ED drug use was 57.6 cells/µL and increased to 117.7 after 10 years among MWH. CD8 counts were higher in ED drug users among MWH over 10 years than non-users; no consistent differences were found among MWOH. ED drug use appeared to reduce immune marker levels, such as IL-6 and increase markers, such as IL-10. We observed similar effects of ED drug use on biomarker levels among MWOH. Conclusion: Long-term use of ED drugs do not adversely affect immune function among MWH or MWOH. Future studies on the relationships between different types of ED drugs and effects on T-cell subtypes are warranted.

Long-term intra- and inter-individual biological variation of serum lipid of HIV-infected and uninfected men participating in the Los Angeles Multi-Center AIDS Cohort Study (MACS).

BACKGROUND: To assess the long-term biological coefficient of variation within individuals (CVI) and between individuals (CVG), effect of aging and cholesterol lowering drugs on blood levels of lipids in HIV-1-infected and -uninfected men. METHODS: Bloods were analyzed every six months over 17 years for total cholesterol (TC), triglycerides (TGs), high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C) in 140 HIV-uninfected (38-66 years old) and 90 HIV-treated infected (48-64 years old) white Caucasian men to examine CVI, CVG, and the effect of cholesterol lowering drugs (CLDs) on lipid levels, and estimated changes per year of biomarkers. RESULTS: With exception of HDL-C, the long term CVI compared with CVG were higher for serum levels of TC, TGs, and LDL-C in both HIV-1 infected and uninfected men not taking CLDs. Excluding results of TGs in HIV positive men, the CVI compared with CVG were lower for serum levels of TC, HDL-C, and LDL-C in both groups not taking CLDs. There were significant (p < 0.05) differences in the median serum values of lipid biomarkers among 77 HIV negative men taking and 63 not taking CLDs. Also, with exception of HDL, there were significant (p < 0.05) differences in the median values of TC, TGs and LDL-C among 28 HIV positive men taking or not taking CLDs. CONCLUSION: Long term CVI and CVG of biomarkers will be useful for monitoring antiviral therapy side effects on lipid profiles in HIV-infected men. CVI of HIV-infected men for TC, TGs, HDL, LDL were higher significantly than CVI of HIV-uninfected men. Interestingly the long term CVI were higher than CVG for the men, who were on CLDs compared to men not on CLDs. The long-term pattern of CVI and CVG of lipid markers in both HIV-infected and uninfected men on CLDs differed from their short-term pattern.

Does Social Support Predict Depressive Symptoms? A Longitudinal Study of Midlife and Older Men Who Have Sex with Men from the Multicenter AIDS Cohort Study.

The present study was designed to identify social support classes across time among midlife (40-64 years) and older (65+ years) gay, bisexual, and other men who have sex with men (MSM), and whether social support protects against depressive symptoms in this population. This study applied longitudinal latent class analysis across five visits on 1,329 individuals age 40 or older at baseline using data from the Multicenter AIDS Cohort Study (MACS) Healthy Aging substudy collected from April 2016 to October 2018. We identified four classes of social support across time: Partner-centered, that is, high levels of support from one's primary partner(s) and moderate support from friends and family; Friend-centered, that is, high levels of support from friends and chosen family; Low, that is, low levels of support from all sources; and Robust, that is, high levels of support from all sources. We found differences in class membership by age, race/ethnicity, employment status, sexual identity, education, relationship status, and HIV status. Finally, compared to MSM in the low support class, men in the other classes had lower odds of depressive symptoms at the final visit. The most common type of social support was partner-centered, while the least common type was robust. These findings suggest that the presence of any social support, regardless of the source, protects against depressive symptoms.

Characteristics and Longitudinal Patterns of Erectile Dysfunction Drug Use Among Men Who Have Sex with Men in the U.S.

We investigated the longitudinal relationship between erectile dysfunction (ED) drug use with behavioral factors, including substance use and sexual activities in men who have sex with men from the Multicenter AIDS Cohort Study during 1998-2016 (n = 1636). We used a bivariate random-intercept model to evaluate ED drug use along with other behavioral factors to assess relationships between the two outcomes over time on a population level and also at the individual level. Average ED drug use among men who have sex with men (MSM) with HIV was positively correlated with average use of marijuana (r = .19), poppers (r = .27), and stimulants (r = .25). In this group, testosterone use (r = .32), multiple partners (r = .41), insertive anal intercourse with condom (r = .40), and insertive anal intercourse without condom (r = .43) all showed moderate correlations over time with average ED use (p < .001). Associations among MSM without HIV were similar, with average marijuana use (r = .19) and stimulant use (r = .22) being positively correlated with average ED drug use, and were also correlated with having multiple partners (r = .36), insertive anal intercourse with condom (r = .22), and insertive anal intercourse without condom (r = .18) over time. Positive within-individual associations between ED drug use and multiple partners and insertive anal intercourse with and without condom were observed regardless of HIV serostatus. This study showed that MSM who reported use of ED drugs were also, on average, more likely to use recreational drugs and engage in sexual activities, such as having multiple partners and insertive anal intercourse. Within individuals, average ED drug use was also positively correlated with sexual behaviors.

Characteristics of the MACS/WIHS Combined Cohort Study: Opportunities for Research on Aging With HIV in the Longest US Observational Study of HIV.

In 2019, the National Institutes of Health combined the Multicenter AIDS Cohort Study (MACS) and the Women's Interagency HIV Study (WIHS) into the MACS/WIHS Combined Cohort Study (MWCCS). In this paper, participants who made a study visit during October 2018-September 2019 (targeted for MWCCS enrollment) are described by human immunodeficiency virus (HIV) serostatus and compared with people living with HIV (PLWH) in the United States. Participants include 2,115 women and 1,901 men with a median age of 56 years (interquartile range, 48-63); 62% are PLWH. Study sites encompass the South (18%), the Mid-Atlantic/Northeast (45%), the West Coast (22%), and the Midwest (15%). Participant race/ethnicity approximates that of PLWH throughout the United States. Longitudinal data and specimens collected for 35 years (men) and 25 years (women) were combined. Differences in data collection and coding were reviewed, and key risk factor and comorbidity data were harmonized. For example, recent use of alcohol (62%) and tobacco (28%) are common, as are dyslipidemia (64%), hypertension (56%), obesity (42%), mildly or severely impaired daily activities (31%), depressive symptoms (28%), and diabetes (22%). The MWCCS repository includes serum, plasma, peripheral blood mononuclear cells, cell pellets, urine, cervicovaginal lavage samples, oral samples, B-cell lines, stool, and semen specimens. Demographic differences between the MACS and WIHS can confound analyses by sex. The merged MWCCS is both an ongoing observational cohort study and a valuable resource for harmonized longitudinal data and specimens for HIV-related research.

Social-environmental resiliencies protect against loneliness among HIV-Positive and HIV- negative older men who have sex with men: Results from the Multicenter AIDS Cohort Study (MACS).

RATIONALE: Loneliness is associated with negative health outcomes, such as cardiovascular disease, cognitive impairment, dementia, physical functional decline, depression, and increased mortality risk, among HIV- positive and HIV-negative older men who have sex with men (MSM). Given these negative health outcomes, it is imperative to identify factors that minimize loneliness in these vulnerable groups. OBJECTIVE: We sought to examine whether social-environmental resiliencies-defined as an individual's level of support, social bonding, and psychological sense of community among gay men-buffer against symptoms of loneliness. METHOD: We analyzed longitudinal data from 1,255 older MSM with and without HIV infection, all of whom were enrolled in the Multicenter AIDS Cohort Study (MACS). Using longitudinal latent class analysis (LLCA), we identified three underlying classes (Social Connectors, Non-community Connectors, and Social Isolates) in the social environment of the sample. We assessed the prevalence of loneliness by these latent classes. By lagging social environmental factors over time, we were able to examine the temporal relationships between latent classes and subsequent loneliness. RESULTS: Consistent with our hypothesis, multivariate associations revealed that compared to Social Connectors with high levels of social support and social bonding and a strong perceived sense of community among gay men, Social Isolates (Prevalence Ratio (PR): 1.42; 95% CI: 1.08-1.88; p = 0.0120) and Non-community Connectors (PR: 1.34; 95% CI: 1.03-1.75; p = 0.0322) were more likely to experience loneliness after adjustment for covariates and baseline loneliness. There were no differences by HIV status. CONCLUSIONS: These longitudinal data allowed us to make causal inferences related to the social environmental resiliencies lowering the odds of loneliness among HIV-positive and HIV-negative older MSM. Developing individual- and community-level tailored interventions for these populations by leveraging social environmental resiliencies is key to reducing loneliness and promoting health.

Antiretroviral therapy (ART) coverage at public and private ART facilities in Myanmar.

Myanmar's continuum of HIV care was surveyed to assess the National AIDS Control Programme's progress; according to its reports, ART coverage was 38% in 2014, 47% in 2015, and 56% in 2016. To evaluate ART coverage and gaps in care, a serial cross-sectional study used the national programme data reported between January 2014 and December 2016, including 228 public and 62 private ART facilities. ART coverage among PLHIV under 15 years old was 89% in 2014, 93% in 2015, and 88% in 2016. Retention in ART care among women was higher than among men, although women were more likely to discontinue care. PLHIV who were enrolled in ART facilities initiated ART at the rates of 60% in 2014, 68% in 2015, and 74% in 2016. Over the 3-year study period, these facilities reported that 2.5-3.7% of PLHIV taking ART had died, and that 3.3-4.8% were lost to follow-up. PLHIV who were tested for viral load were low (2.5-3%). The continuum of HIV care at ART facilities has improved, but more information about attrition and viral suppression are still needed. The reporting system for newly diagnosed PLHIV and facilities for viral load testing need to be strengthened.

NIH Workshop on HIV-Associated Comorbidities, Coinfections, and Complications: Summary and Recommendation for Future Research.

BACKGROUND: With potent antiretroviral therapy and simplified regimens, people living with HIV (PWH) are achieving near-normal lifespans but not necessarily a normal health span or healthy aging. PWH have a higher than expected risk of developing a number of non-AIDS comorbidities, coinfections, and complications (CCC), often against a background of stigma, poverty, and isolation. SETTING: To gain a better understanding of research needs for HIV-associated CCC, the NIH convened a 2-day workshop (HIV-associated CCC, or HIV ACTION). METHODS: A cross-institute NIH planning committee identified 6 key research areas: epidemiology and population research, pathogenesis and basic science research, clinical research, implementation science research, syndemics research and international research in low and middle income countries. Investigators were selected to lead working groups (WGs) to assess the state-of-the-art and identify 3-5 priority areas in each field before the workshop. A 2-day program at the NIH was developed which included presentations by invited experts and WG members. RESULTS: Over 400 participants attended the workshop. After general and individual WG discussions, the most pressing gaps, questions, or proposed action items were identified. Priority lists of pressing research issues were presented by cochairs of each WG. A detailed report is posted at the NHLBI website. This article reports the streamlined priority list and a summary of WG discussions to inform investigators of current priorities in the field. CONCLUSION: Collaborative efforts of many disciplines are needed to improve the health and wellbeing of PWH. Several common themes emerged across WG representing potential priorities for investigators and recommendations for the NIH.

The Enigma of the Human Immunodeficiency Virus (HIV) Epidemic in China.

Nearly 17 years ago China launched its National HIV/AIDS Response Program, yet the epidemic still is not slowing. New cases and new deaths increase every year-in 2005, 40 711 people living with human immunodeficiency virus (HIV; PLWH) were diagnosed and 5729 died, whereas in 2019, 148 598 PLWH were diagnosed and 31 522 died. Moreover, the estimated PLWH population in China has risen to >1.25 million. However, epidemic data are worryingly complex and difficult to interpret, presenting challenges to the redirection and refocusing of efforts toward achievement of control. Here we present three "windows" into China's epidemic data. From these viewpoints, it appears we still do not know how much infection exists, how much transmission is occurring, and in what contexts transmission happens. The enigma that is China's HIV epidemic must be better understood. A new research agenda must be developed and executed if we are to change the future of HIV in China.

COVID-19 symptoms and SARS-CoV-2 infection among people living with HIV in the US: the MACS/WIHS combined cohort study.

BACKGROUND: SARS-CoV-2 infection among People Living With HIV (PLWH) is not well-described. OBJECTIVE: To study COVID-19 symptoms and SARS-CoV-2 PCR-based swab testing among participants of the Multicenter AIDS Cohort Study (MACS) and Women's Interagency HIV Study (WIHS). METHODS: A telephone survey was collected April-June 30, 2020. Symptom and testing prevalence were explored. Multivariable logistic regression was used to examine the factors associated with SARS-CoV-2 positivity. RESULTS: The survey was completed by 3411 participants, including 2078 (61%) PLWH and 1333 HIV-seronegative (SN) participants from across the US. Thirteen percent (n = 441) were tested for SARS-CoV-2 infection (13.4% of PLWH vs 12.2% of SN). Among those tested, positivity was higher in PLWH than SN (11.2% vs 6.1%, p = 0.08). Reasons for not being tested included testing not being available (30% of participants) and not knowing where to get tested (16% of participants). Most symptoms reported since January 2020 were similar in PLWH and SN, including headache (23% vs. 24%), myalgias (19% vs 18%), shortness of breath (14% vs 13%), chills (12% vs 10%), fever (6% vs 6%) and loss of taste or smell (6% vs 7%). Among PLWH who tested positive for SARS-CoV-2 DNA, the most common symptoms were headache (71%), myalgia (68%), cough (68%) and chills (65%). In multivariable analysis among those tested, the odds of SARS-CoV-2 positivity were higher among PLWH than SN (aOR = 2.22 95%CI = 01.01-4.85, p = 0.046) and among those living with others versus living alone (aOR = 2.95 95%CI = 1.18-7.40). CONCLUSION: Prevalence and type of COVID-19 symptoms were similar in PLWH and SN. SARS-CoV-2 infection may be elevated among PLWH.

Spatial distribution of tuberculosis incidence in Los Angeles County.

BACKGROUND: In Los Angeles County, the tuberculosis (TB) disease incidence rate is seven times higher among non-U.S.-born persons than U.S.-born persons and varies by country of birth. But translating these findings into public health action requires more granular information, especially considering that Los Angeles County is more than 4000 mile2. Local public health authorities may benefit from data on which areas of the county are most affected, yet these data remain largely unreported in part because of limitations of sparse data. We aimed to describe the spatial distribution of TB disease incidence in Los Angeles County while addressing challenges arising from sparse data and accounting for known cofactors. METHODS: Data on 5447 TB cases from Los Angeles County were combined with stratified population estimates available from the 2005-2011 Public Use Microdata Survey. TB disease incidence rates stratified by country of birth and Public Use Microdata Area were calculated and spatial smoothing was applied using a conditional autoregressive model. We used Bayesian Poisson models to investigate spatial patterns adjusting for age, sex, country of birth and years since initial arrival in the U.S. RESULTS: There were notable differences in the crude and spatially-smoothed maps of TB disease rates for high-risk subgroups, namely persons born in Mexico, Vietnam or the Philippines. Spatially-smoothed maps showed areas of high incidence in downtown Los Angeles and surrounding areas for persons born in the Philippines or Vietnam. Areas of high incidence were more dispersed for persons born in Mexico. Adjusted models suggested that the spatial distribution of TB disease could not be fully explained using age, sex, country of birth and years since initial arrival. CONCLUSIONS: This study highlights areas of high TB incidence within Los Angeles County both for U.S.-born cases and for cases born in Mexico, Vietnam or the Philippines. It also highlights areas that had high incidence rates even when accounting for non-spatial error and country of birth, age, sex, and years since initial arrival in the U.S. Information on spatial distribution provided here complements other descriptions of local disease burden and may help focus ongoing efforts to scale up testing for TB infection and treatment among high-risk subgroups.

Marijuana use and pneumonia risk in a cohort of HIV-infected and HIV-uninfected men.

BACKGROUND: The prevalence of marijuana use is increasing in the United States. Marijuana smoking has been shown to impair the microbicidal activity of alveolar macrophages and decrease the number of ciliated epithelial cells in the bronchi with a parallel increase in the number of mucus-secreting surface epithelial cells, which may increase the risk of pneumonia. However, it remains unclear whether there is an association between smoking marijuana and pneumonia. METHODS: Using data from the Multicenter AIDS Cohort Study (MACS), a long-term observational cohort study of men who have sex with men in the United States, we used Cox proportional hazards models to estimate the risk of pneumonia among HIV-infected (n = 2784) and HIV-uninfected (n = 2665) men from 1984 to 2013, adjusted for time-varying and fixed baseline covariates. RESULTS: Weekly or daily marijuana use was not significantly associated with increased risk of pneumonia among HIV-uninfected men (adjusted hazard ratio; 95% confidence limits: 0.83, 0.56-1.23). In the disaggregated dose-response analysis, daily use (0.68, 0.34-1.35) was associated with a lower point estimate than weekly use [0.99, 0.79-1.25]. CONCLUSION: Marijuana smoking was not associated with a significant increase in risk of pneumonia among HIV-infected or HIV-uninfected men.