Case Series of People With HIV on the Long-Acting Combination of Lenacapavir and Cabotegravir: Call for a Trial.

Background: Injectable cabotegravir (CAB)/rilpivirine (RPV) is the only combination long-acting (LA) antiretroviral regimen approved for HIV. RPV may not be effective among individuals with non-nucleoside reverse transcriptase inhibitor (NNRTI) resistance, which has >10% prevalence in many countries. Lenacapavir (LEN) is an LA capsid inhibitor given every 6 months, but has not been studied in combination with other LA agents. Methods: We assembled a case series from 4 US academic medical centers where patients with adherence challenges were prescribed LEN subcutaneously every 26 weeks/CAB (+/- RPV) intramuscularly every 4 or 8 weeks. Descriptive statistics, including viral load (VL) outcomes, were summarized. Results: All patients (n = 34: 76% male; 24% cis/trans female; 41% Black; 38% Latino/a; median age [range], 47 [28-75] years; 29% and 71% on CAB every 4 or 8 weeks) reported challenges adhering to oral ART. The reasons for using LEN/CAB with or without RPV were documented or suspected NNRTI mutations (n = 21, 59%), integrase mutations (n = 5, 15%), high VL (n = 6, 18%), or continued viremia on CAB/RPV alone (n = 4, 12%). Injection site reactions on LA LEN were reported in 44% (32% grade I, 12% grade 2). All patients but 2 (32/34; 94%) were suppressed (VL <75 copies/mL) after starting LEN at a median (range) of 8 (4-16) weeks, with 16/34 (47%) suppressed at baseline. Conclusions: In this case series of 34 patients on LEN/CAB, high rates of virologic suppression (94%) were observed. Reasons for using LEN/CAB included adherence challenges and underlying resistance, mostly to NNRTIs. These data support a clinical trial of LEN/CAB among persons with NNRTI resistance.

Evaluation of an emergency department opt-out provider-driven HIV and syphilis screening and linkage-to-care program.

OBJECTIVE: While the effectiveness of emergency departments (ED) in screening for HIV and syphilis is understood, less is known about dual screening programs. We aim to evaluate the impact of an opt-out provider-initiated HIV and syphilis program on screening, diagnosis, and linkage to care outcomes. METHODS: We performed a retrospective review of patients screened pre (2014-2017) and post (2017-2021) program implementation. Primary outcomes include HIV and syphilis screening, incidence of positive tests, and proportion of patients linked to care. Secondary outcomes included pre-exposure prophylaxis (PrEP) referral and successful linkage rates for HIV-negative syphilis-positive patients. RESULTS: Pre-implementation, 882 HIV tests were performed, of which 22 (2.49%) were new cases and 18 (81.82%) were linked to care; 754 syphilis tests were performed, of which 33 (4.38%) were active infections and 30 (90.91%) were treated. No eligible patients received PrEP referral. Post-implementation, 12,999 HIV tests were performed, of which 73 (0.56%) were new cases and 55 (75.34%) were linked to care; 10,885 syphilis tests were performed, of which 216 (1.98%) were active infections and 188 (87.04%) were treated. 25 (9.09%) eligible patients were referred for PrEP, and four (16.0%) attended their appointment. CONCLUSIONS: Post-implementation, there was a 1373.81% and 1343.63% increase in screening, and a 231.82% and 554.55% increase in positive cases of HIV and syphilis, respectively. Dual screening programs can be successfully implemented within the existing ED framework to increase screening and early detection for HIV and syphilis.

Cancer burden in women with HIV on Medicaid: A nationwide analysis.

BACKGROUND: Cancer is the leading cause of death in people living with HIV. In the United States, nearly 1 in 4 people living with HIV are women, more than half of whom rely on Medicaid for healthcare coverage. OBJECTIVE: The objective of this study is to evaluate the cancer burden of women living with HIV on Medicaid. DESIGN: We conducted a cross-sectional study of women 18-64 years of age enrolled in Medicaid during 2012, using data from Medicaid Analytic eXtract files. METHODS: Using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes, we identified women living with HIV (n = 72,508) and women without HIV (n = 17,353,963), flagging the presence of 15 types of cancer and differentiating between AIDS-defining cancers and non-AIDS-defining cancers. We obtained adjusted prevalence ratios and 95% confidence intervals for each cancer and for all cancers combined, using multivariable log-binomial models, and additionally stratifying by age and race/ethnicity. RESULTS: The highest adjusted prevalence ratios were observed for Kaposi's sarcoma (81.79 (95% confidence interval: 57.11-117.22)) and non-Hodgkin's lymphoma (27.69 (21.67-35.39)). The adjusted prevalence ratios for anal and cervical cancer, both of which were human papillomavirus-associated cancers, were 19.31 (17.33-21.51) and 4.20 (3.90-4.52), respectively. Among women living with HIV, the adjusted prevalence ratio for all cancer types combined was about two-fold higher (1.99 (1.86-2.14)) in women 45-64 years of age than in women 18-44 years of age. For non-AIDS-defining cancers but not for AIDS-defining cancers, the adjusted prevalence ratios were higher in older than in younger women. There was no significant difference in the adjusted prevalence ratios for all cancer types combined in the race/ethnicity-stratified analyses of the women living with HIV cohort. However, in cancer type-specific sub-analyses, differences in adjusted prevalence ratios between Hispanic versus non-Hispanic women were observed. For example, the adjusted prevalence ratio for Hispanic women for non-Hodgkin's lymphoma was 2.00 (1.30-3.07) and 0.73 (0.58-0.92), respectively, for breast cancer. CONCLUSION: Compared to their counterparts without HIV, women living with HIV on Medicaid have excess prevalence of cervical and anal cancers, both of which are human papillomavirus related, as well as Kaposi's sarcoma and lymphoma. Older age is also associated with increased burden of non-AIDS-defining cancers in women living with HIV. Our findings emphasize the need for not only cancer screening among women living with HIV but also for efforts to increase human papillomavirus vaccination among all eligible individuals.

Heroin Use Is Associated With Vascular Inflammation in Human Immunodeficiency Virus.

BACKGROUND: Heroin use may work synergistically with human immunodeficiency virus (HIV) infection to cause greater immune dysregulation than either factor alone. Unraveling how this affects end-organ disease is key as it may play a role in the excess mortality seen in people with HIV (PWH) who use heroin despite access to care and antiretroviral therapy. METHODS: This is a prospectively enrolled, cross-sectional study of adults with and without HIV who use and do not use heroin using (18)F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) to compare tissue-specific inflammation including aortic (target-to-background ratio [TBR]), splenic, and bone marrow (standardized uptake value [SUV]). RESULTS: A total of 120 participants were enrolled. The unadjusted mean difference in aortic TBR was 0.43 between HIV-positive [HIV+] heroin+ and HIV+ heroin-negative [heroin-] (P = .02); however, among HIV-, aortic TBR was similar regardless of heroin-use status. Further, HIV-by-heroin-use status interaction was significant (P = .02), indicating that the relationship between heroin use and higher aortic TBR depended on HIV status. On the other hand, both HIV (1.54 vs 1.68; P = .04, unadjusted estimated means for HIV+ vs HIV-) and heroin use were associated with lower bone marrow SUV, although the effect of heroin depended on sex (heroin-use-by-sex interaction, P = .03). HIV-by-heroin-use interaction was not significant for splenic or bone marrow SUV. CONCLUSIONS: Aortic inflammation was greatest in PWH who use heroin, but paradoxically, bone marrow activity was the least in this group, suggesting complex and possibly divergent pathophysiology within these different end organs.

An artificial neural network classification method employing longitudinally monitored immune biomarkers to predict the clinical outcome of critically ill COVID-19 patients.

Background: The severe form of COVID-19 can cause a dysregulated host immune syndrome that might lead patients to death. To understand the underlying immune mechanisms that contribute to COVID-19 disease we have examined 28 different biomarkers in two cohorts of COVID-19 patients, aiming to systematically capture, quantify, and algorithmize how immune signals might be associated to the clinical outcome of COVID-19 patients. Methods: The longitudinal concentration of 28 biomarkers of 95 COVID-19 patients was measured. We performed a dimensionality reduction analysis to determine meaningful biomarkers for explaining the data variability. The biomarkers were used as input of artificial neural network, random forest, classification and regression trees, k-nearest neighbors and support vector machines. Two different clinical cohorts were used to grant validity to the findings. Results: We benchmarked the classification capacity of two COVID-19 clinicals studies with different models and found that artificial neural networks was the best classifier. From it, we could employ different sets of biomarkers to predict the clinical outcome of COVID-19 patients. First, all the biomarkers available yielded a satisfactory classification. Next, we assessed the prediction capacity of each protein separated. With a reduced set of biomarkers, our model presented 94% accuracy, 96.6% precision, 91.6% recall, and 95% of specificity upon the testing data. We used the same model to predict 83% and 87% (recovered and deceased) of unseen data, granting validity to the results obtained. Conclusions: In this work, using state-of-the-art computational techniques, we systematically identified an optimal set of biomarkers that are related to a prediction capacity of COVID-19 patients. The screening of such biomarkers might assist in understanding the underlying immune response towards inflammatory diseases.

Using the Positive Peers Mobile App to Improve Clinical Outcomes for Young People With HIV: Prospective Observational Cohort Comparison.

BACKGROUND: Disparities in HIV outcomes persist among racial, gender, and sexual minorities in the United States. Younger people face a greater risk of contracting HIV, often living without knowledge of their HIV status for long periods. The Positive Peers App (PPA) is a multifunctional HIV support tool designed to improve HIV-related clinical outcomes for young people with HIV. The app was designed according to the specifications of an in-care young adult HIV community in Northeast Ohio. Data provided in this study provide preliminary evidence of the usefulness of PPA as a relevant tool for engaging this clinical patient population in care and facilitating viral suppression. OBJECTIVE: In this study, we aimed to describe variations in PPA use and examine the associations between use and HIV clinical outcomes between self-selected user and nonuser cohorts in the same clinical population. METHODS: The PPA was offered free of charge to persons with HIV, aged 13 to 34 years of age, diagnosed with HIV within the last 12 months, out of care for 6 months during the last 24 months, or not virally suppressed (HIV viral load >200 copies/mL) in the prior 24 months. Baseline and 6- and 12-month surveys were administered via an audio computer-assisted self-interviewing system to all participants. The app's user activity was tracked natively by the app and stored in a secure server. Participant demographic and HIV care data were extracted from clinical records within 12 months before the start of the study and across the duration of the study period. HIV care outcomes of PPA users (n=114) were compared with those of nonusers (n=145) at the end of the study period (n=259). RESULTS: The analysis showed that younger PPA users (aged 13-24 years) were more likely to obtain HIV laboratories (adjusted odds ratio 2.85, 95% CI 1.03-7.90) and achieve sustained viral suppression than nonusers (adjusted odds ratio 4.2, 95% CI 1.2-13.9). CONCLUSIONS: The PPA appears to help younger users sustain HIV suppression. The app offers an important tool for addressing this critical population. The PPA remains in the field and is currently being adopted by other localities to facilitate their efforts to end the HIV epidemic. Although our reported observational results require additional validation and stringent ongoing surveillance, the results represent our best efforts in a pilot study to provide a measure of efficacy for the PPA. Next steps include a large-scale evaluation of the PPA acceptability and effectiveness. Given the building evidence of user reports and outcomes, the freely available PPA could be a helpful tool for achieving Ending the HIV Epidemic goals.

Excess cancer prevalence in men with HIV: A nationwide analysis of Medicaid data.

BACKGROUND: Cancer is one of the most common comorbidities in men living with HIV (MLWH). However, little is known about the MLWH subgroups with the highest cancer burden to which cancer prevention efforts should be targeted. Because Medicaid is the most important source of insurance for MLWH, we evaluated the excess cancer prevalence in MLWH on Medicaid relative to their non-HIV counterparts. METHODS: In this cross-sectional study using 2012 Medicaid Analytic eXtract data nationwide, we flagged the presence of HIV, 13 types of cancer, symptomatic HIV, and viral coinfections using codes from the International Classification of Diseases, Ninth Revision, Clinical Modification. The study population included individuals administratively noted to be of male sex (men), aged 18 to 64 years, with (n = 82,495) or without (n = 7,302,523) HIV. We developed log-binomial models with cancer as the outcome stratified by symptomatic status, age, and race/ethnicity. RESULTS: Cancer prevalence was higher in MLWH than in men without HIV (adjusted prevalence ratio [APR], 1.84; 95% confidence interval [CI], 1.78-1.90) and was higher among those with symptomatic HIV (APR, 2.74; 95% CI, 2.52-2.97) than among those with asymptomatic HIV (APR, 1.73; 95% CI, 1.67-1.79). The highest APRs were observed for anal cancer in younger men, both in the symptomatic and asymptomatic groups: APR, 312.97; 95% CI, 210.27-465.84, and APR, 482.26; 95% CI, 390.67-595.32, respectively. In race/ethnicity strata, the highest APRs were among Hispanic men for anal cancer (APR, 198.53; 95% CI, 144.54-272.68) and for lymphoma (APR, 9.10; 95% CI, 7.80-10.63). CONCLUSIONS: Given the Medicaid program's role in insuring MLWH, the current findings highlight the importance of the program's efforts to promote healthy behaviors and vaccination against human papillomavirus in all children and adolescents and to provide individualized cancer screening for MLWH.

Impact of Heroin and HIV on Gut Integrity and Immune Activation.

BACKGROUND: Altered gut integrity is central to HIV-related immune activation. Opioids may promote similar changes in gut permeability and/or increase systemic inflammation, potentially augmenting processes already occurring in people with HIV (PWH). SETTING: Urban hospital systems in Cleveland, Ohio, and surrounding communities. METHODS: This is a prospectively enrolled, cross-sectional study including people with and without HIV using heroin and people with and without HIV who have never used heroin, matched by age, sex, and CD4+ T-cell count (PWH only) to compare markers of gut integrity, microbial translocation, systemic inflammation, and immune activation. RESULTS: A total of 100 participants were enrolled. Active heroin use was associated with higher concentrations of lipopolysaccharide-binding protein (LBP), beta-D-glucan (BDG), high-sensitivity C-reactive protein (hsCRP), soluble tumor necrosis factor-α-receptors I and II, soluble CD163, inflammatory monocytes, and activated CD4+ lymphocytes in adjusted models. HIV status tended to modify the effect between heroin use and LBP, BDG, hsCRP, patrolling monocytes, and activated CD4+ lymphocytes (P < 0.15 for interactions); however, it was not as expected. The effect of heroin on these markers (except patrolling monocytes) was greatest among those without HIV rather than among those with HIV. CONCLUSIONS: Heroin use is associated with heightened microbial translocation, systemic inflammation, and immune activation. Concurrent HIV infection in virologically suppressed individuals does not seem to substantially worsen the effects heroin has on these markers.

An HIV Diagnostic Testing Algorithm Using the cobas HIV-1/HIV-2 Qualitative Assay for HIV Type Differentiation and Confirmation.

Human immunodeficiency virus types 1 and 2 (HIV-1 and HIV-2) diagnostic testing algorithms recommended by the Centers for Disease Control involve up to three tests and rely mostly on detection of viral antigen and host antibody responses. HIV-1 p24 antigen/HIV-1/HIV-2 antibody-reactive specimens are confirmed with an immunochromatographic HIV-1/HIV-2 antibody differentiation assay, and negative or indeterminate results from the differentiation assay are resolved by an HIV-1-specific nucleic acid amplification test (NAT). The performance of a proposed alternative algorithm using the cobas HIV-1/HIV-2 qualitative NAT as the differentiation assay was evaluated in subjects known to be infected with HIV-1 (n = 876) or HIV-2 (n = 139), at low (n = 6,017) or high (n = 1,020) risk of HIV-1 infection, or at high-risk for HIV-2 infection (n = 498) (study A). The performance of the cobas HIV-1/HIV-2 qualitative test was also evaluated by comparison to an HIV-1 or HIV-2 alternative NAT (study B). The HIV-1 and HIV-2 overall percent agreements (OPA) in study A ranged from 95% to 100% in all groups. The positive percent agreements (PPA) for HIV-1 and HIV-2 were 100% (876/876) and 99.4% (167/168), respectively, for known positive groups. The negative percent agreement in the HIV low-risk group was 100% for both HIV-1 and HIV-2. In study B, the HIV-1 and HIV-2 OPA ranged from 99% to 100% in all groups evaluated (n = 183 to 1,030), and the PPA for HIV-1 and HIV-2 were 100% and 99.5%, respectively, for known positive groups. The cobas HIV-1/HIV-2 qualitative assay can discriminate between HIV-1 and HIV-2 based on HIV RNA and can be included in an alternative diagnostic algorithm for HIV.

SARS-CoV-2 Infection among Serially Tested Emergency Medical Services Workers.

BACKGROUND: Emerging research has examined the prevalence of severe acute respiratory syndrome virus 2 (SARS-CoV-2) infections in numerous settings, but a critical gap in knowledge is an understanding of the rate of infection among first responders. METHODS: We conducted a prospective serial serologic survey by recruiting public first responders from Cleveland area emergency medical services agencies and fire departments. Volunteers submitted a nasopharyngeal swab for SARS-CoV-2 PCR testing and serum samples to detect the presence of antibodies to SARS-CoV-2 on two visits scheduled approximately 3 weeks apart. RESULTS: 296 respondents completed a first visit and 260 completed the second. While 71% of respondents reported exposure to SARS-CoV-2, only 5.4% (95% CI 3.1-8.6) had positive serologic testing. No subjects had a positive PCR. On the first visit, eight (50%) of the test-positive subjects had no symptoms and only one (6.2%) sought healthcare or missed school or work. None of the subjects that tested negative on the first visit were positive on their second. CONCLUSIONS: While our results show a relatively low rate of test positivity for SARS-CoV-2 amongst first responders, most were either asymptomatic or mildly symptomatic. The potential risk of asymptomatic transmission both between first responders and from first responders to vulnerable patients requires more study.

Levels of Soluble CD14 and Tumor Necrosis Factor Receptors 1 and 2 May Be Predictive of Death in Severe Coronavirus Disease 2019.

People infected with severe acute respiratory syndrome coronavirus 2 display a wide range of illness, from asymptomatic infection to severe respiratory distress resulting in death. We measured serum biomarkers in uninfected individuals and in individuals with mild, moderate, or critical coronavirus disease 2019 (COVID-19) disease. Levels of monocyte activation (soluble CD14 and fatty acid-binding protein 4) and inflammation (tumor necrosis factor receptors 1 and 2 [TNFR1 and TNFR2]) were increased in COVID-19 individuals, regardless of disease severity. Among patients with critical disease, individuals who recovered from COVID-19 had lower levels of TNFR1 and TNFR2 at hospital admission compared to these levels in patients with critical disease who ultimately died.

A Model for Syphilis Screening in the Emergency Department.

The incidence of syphilis infections is on the rise, particularly among African American men and men who have sex with men, and it is reaching epidemic levels in these communities throughout the United States. Although syphilis is relatively inexpensive to treat and cure and is a predictor for HIV incidence among men and transgender women who have sex with men, rates of co-screening for syphilis are low in the emergency department setting, with a dearth of literature on this topic since the 1990s and early 2000s. In this case study, we describe an operational model for routine syphilis screening implemented in June 2017 at the University Hospitals Cleveland Medical Center in Cleveland, Ohio. We describe the advantages of screening using a reverse testing algorithm rather than the traditional method and the necessity of partnering with the Cleveland Department of Public Health for both diagnostic and follow-up logistics.

Correlates of depression outcomes in collaborative care for HIV.

BACKGROUND: Collaborative care can treat depression in HIV but existing studies have been limited by excluding patients with acute or severe depression. The purpose of this analysis is to determine if real-world implementation of collaborative care in HIV is associated with improvement in depression, and to identify correlates of depression outcomes. METHODS: Collaborative care was implemented as part of a large practice transformation initiative. Change in depression, measured by PHQ-9 score, at baseline compared to 12 months post-enrollment was the outcome, which was operationalized as remission, response, and neither response nor remission. Bivariate and multivariate associations were assessed between several variables at baseline and the outcome. RESULTS: Out of 416, 99 (23.79%) patients remitted and 89 (21.39%) responded (without remission). In the bivariate analysis having a documented psychiatric comorbidity was associated with low remission [31 (16.58%)]; p = 0.008. Having generalized anxiety disorder was associated with low remission [18 (15.00%)] and response rates [26 (21.67%)]; p = 0.022. Having a substance use disorder (alcohol, cocaine, or amphetamine) - was associated with poor remission [29 (16.67%)] and response [33 (18.97%)]; p = 0.004. Social isolation was correlated with lower response and remission rates (p = 0.0022). In the multivariate analysis older age was associated with higher remission rates (OR: 1.10; 95% CI: 1.005-1.194) whereas being a Medicaid beneficiary (OR: 0.652; 95% CI: 1.123-2.797), having comorbid generalized anxiety disorder (OR: 0.267; 95% CI: 0.122-0.584) or a stimulant use disorder (cocaine [OR: 0.413; 95% CI: 0.222-0.926] or amphetamines [OR: 0.185; 95% CI: 0.037-0.766]), was associated with lower remission rates. CONCLUSION: We found that depression improved in our study subjects. We identified several modifiable correlates of depression outcomes.

Positive Peers Mobile Application Reduces Stigma Perception Among Young People Living With HIV.

Background. The burden of HIV-related stigma is associated with disparities in linkage to HIV care and viral suppression. The Positive Peers smartphone application aims to provide young people living with HIV with a supportive virtual community to counteract perceived stigma and better manage their illness. Method. A mixed-methods study that included a prospective survey and in-depth interviewing was conducted with young adults living with HIV, aged 13 to 34 years (n = 128). As part of a larger study, participants used the Positive Peers mobile application and reported demographic data, perceived stigma, and other psychosocial variables at enrollment, 6 months, and 12 months (n = 128). Select participants (n = 15) described their experiences in audio-recorded qualitative interviews. Verbatim transcripts were analyzed for potential themes and patterns. Results. A longitudinal multivariate model was developed to assess changes in stigma over the study period, overall, and with respect to participant characteristics. Baseline and 6-month stigma scores were higher for White and Other ethnicity persons relative to Black participants. At the 12-month time point, no statistical differences in stigma scores based on ethnicity were apparent. Interviews revealed Positive Peers as a nondiscriminatory community that offered a sense of belonging that appeared to have a restorative effect on negative self-image. Conclusions. Positive Peers provides a protected virtual space where young people living with HIV can converge in the common desire to support similar others. Mobile health applications that offer peer interaction may provide a persistent sense of belonging that neutralizes internalized stigmas in addition to benefits derived from application activity.

Adhering to antiretroviral therapy: A qualitative analysis of motivations for and obstacles to consistent use of antiretroviral therapy in people living with HIV.

OBJECTIVES: Based on the 2015 U.S. Centers for Disease Control and Prevention data, 40% of people living with HIV in the United States with an HIV diagnosis and 18.5% of people living with HIV in HIV care in the United States are not virally suppressed. Many HIV care clinics have implemented recommendations to improve the percentage of people living with HIV on antiretroviral therapy. To understand what more could be done, we examine patients' motivations and obstacles to maintaining adherence to antiretroviral therapy. METHODS: We conducted qualitative analysis using a qualitative description framework of in-depth interviews with people living with HIV receiving care at an urban HIV care clinic in the midwestern United States. RESULTS: We found that while many traditional barriers to care have been addressed by existing programs, there are key differences between those consistent with antiretroviral therapy and those inconsistent with antiretroviral therapy. In particular, self-motivation, diagnosis acceptance, treatment for depression, spiritual beliefs, perceived value of the HIV care team, and prior experience with health care distinguish these two groups. Most significantly, we found that people living with HIV consistent with antiretroviral therapy describe their main motivation as coming from themselves, whereas people living with HIV inconsistent with antiretroviral therapy more often describe their main motivation as coming from the HIV care team. CONCLUSION: Our results highlight the importance of the HIV care team's encouragement of maintaining antiretroviral adherence, as well as encouraging treatment for depression.

Associations Between Influencing Factors, Perceived Symptom Burden, and Perceived Overall Function Among Adults Living With HIV.

With adherence to combination antiretroviral therapy, HIV infection is now a chronic, but manageable, disease with associated symptoms and complications. However, there is limited evidence on how symptom burden affects perceived overall function among people living with HIV (PLWH). Furthermore, there is no consensus on the factors that affect symptom burden in PLWH. We examined relationships between factors that may influence symptom burden and perceived overall function, and the association between symptom burden and overall function in 179 adult PLWH. This study was a cross-sectional, secondary analysis using the Theory of Unpleasant Symptoms (Lenz, Pugh, Milligan, Gift, & Suppe, 1997). We found strong evidence that symptoms, especially pain, tiredness, and depression, are prevalent in PLWH, and that symptoms were predicted by perceived social support and the number of comorbidities. Increased symptom burden predicts reduced overall function. Interventions are needed to reduce symptoms and strengthen social support in PLWH. Initiating symptom assessment and management strategies early is paramount.

"Positive Peers": Function and Content Development of a Mobile App for Engaging and Retaining Young Adults in HIV Care.

BACKGROUND: Although treatment for HIV infection is widely available and well tolerated, less than 30% of adolescents and young adults living with HIV infection achieve stable viral suppression. Mobile technology affords increased opportunities for young people living with HIV to engage with information, health management tools, and social connections that can support adherence to treatment recommendations and medication. Although mobile apps are increasingly prevalent, few are informed by the target population. OBJECTIVE: The objective of this study was to describe the "Positive Peers" app, a mobile app currently being evaluated in a public hospital in the Midwestern United States. Formative development, key development strategies, user recruitment, and lessons learned are discussed in this paper. METHODS: "Positive Peers" was developed in collaboration with a community advisory board (CAB) comprising in-care young adults living with HIV and a multidisciplinary project team. Mobile app functions and features were developed over iterative collaborative sessions that were tailored to the CAB members. In turn, the CAB built rapport with the project team and revealed unique information that was used in app development. RESULTS: The study was funded on September 1, 2015; approved by the MetroHealth Institutional Review Board on August 31, 2016; and implemented from October 11, 2016, to May 31, 2019. The "Positive Peers" mobile app study has enrolled 128 users who reflect priority disparity population subgroups. The app administrator had frequent contact with users across app administration and study-related activities. Key lessons learned from the study include changing privacy concerns, data tracking reliability, and user barriers. Intermediate and outcome variable evaluation is expected in October 2019. CONCLUSIONS: Successful development of the "Positive Peers" mobile app was supported by multidisciplinary expertise, an enthusiastic CAB, and a multifaceted, proactive administrator.

Low Awareness of and Access to Pre-exposure Prophylaxis But High Interest Among Heterosexual Women in Cleveland, Ohio.

Women received <5% of all US pre-exposure prophylaxis (PrEP) prescriptions in 2016. Among 351 heterosexual women surveyed in Cleveland, Ohio, 14.5% were aware of PrEP, 20.5% knew where to access PrEP, 75.9% were willing to try PrEP, and 50.9% expressed interest in more information.

Doubling Hepatitis C Virus Screening in Primary Care Using Advanced Electronic Health Record Tools-A Non-Randomized Controlled Trial.

BACKGROUND: Hepatitis C virus (HCV) infection is a major public health burden, affecting over 4 million people. The Centers for Disease Control and Prevention and the US Preventive Services Task Force guidelines recommend screening everyone born between 1945 and 1965, but screening rates remain low. OBJECTIVE: To determine whether bulk ordering and electronic messaging to patients improves guideline-based HCV screening rates. DESIGN: A non-randomized controlled trial of 1024 adults from November 2016 to March 2017. PARTICIPANTS: Patients due for HCV screening with at least one primary care office visit in one of three primary care clinics and enrolled in the healthcare system's tethered personal health record (tPHR). INTERVENTIONS: Control patients received normal care for HCV screening, consisting of passive HCV reminders to providers during face-to-face visits and passive HCV screening notification through the patient's tPHR. Intervention patients received normal care and also had HCV antibody tests ordered for them and customized messages sent through their tPHR inviting them to go directly to the lab for HCV screening over a 12-week period. MAIN MEASURES: Percentage/number of patients receiving HCV antibody tests during the intervention period. Percentage/number of intervention group patients receiving HCV screening with other blood work. KEY RESULTS: In the intervention group, 33% (168 of 514) completed HCV testing, compared with 19% (97 of 510) of controls (OR 1.7, 95% CI 1.2-2.1). Bulk lab ordering appeared to have a large impact while bulk messaging appeared to have a less significant role. CONCLUSIONS: Leveraging population analytics and bulk ordering in an electronic health record with bulk messaging to a tPHR directly engages patients in blood screening tests and can significantly improve completion. This methodology has a broad range of applications including many recommended screening or disease-specific testing. This bulk ordering and direct-to-patient messaging approach improves patient screening while decreasing provider/staff work. TRIAL REGISTRATION: MetroHealth IRB16-00776 (ClinicalTrials.gov).