RESUMO
Importance: Clinicians are a key component of preexposure prophylaxis (PrEP) care. Yet, no prior studies have quantitatively investigated how PrEP adherence differs by clinician specialty. Objective: To understand the association between prescribing clinician specialty and patients not picking up (reversal/abandonment) their initial PrEP prescription. Design, Setting, and Participants: This cross-sectional study of patients who were 18 years or older used pharmacy claims data from 2015 to 2019 on new insurer-approved PrEP prescriptions that were matched with clinician data from the US National Plan and Provider Enumeration System. Data were analyzed from January to May 2022. Main Outcomes and Measures: Clinician specialties included primary care practitioners (PCPs), infectious disease (ID), or other specialties. Reversal was defined as a patient not picking up their insurer-approved initial PrEP prescription. Abandonment was defined as a patient who reversed and still did not pick their prescription within 365 days. Results: Of the 37â¯003 patients, 4439 (12%) were female and 32â¯564 (88%) were male, and 77% were aged 25 to 54 years. A total of 24â¯604 (67%) received prescriptions from PCPs, 3571 (10%) from ID specialists, and 8828 (24%) from other specialty clinicians. The prevalence of reversals for patients of PCPs, ID specialists, and other specialty clinicians was 18%, 18%, and 25%, respectively, and for abandonments was 12%, 12%, and 20%, respectively. After adjusting for confounding, logistic regression models showed that, compared with patients who were prescribed PrEP by a PCP, patients prescribed PrEP by ID specialists had 10% lower odds of reversals (odds ratio [OR], 0.90; 95% CI, 0.81-0.99) and 12% lower odds of abandonment (OR, 0.88; 95% CI, 0.78-0.98), while patients prescribed by other clinicians had 33% higher odds of reversals (OR, 1.33; 95% CI, 1.25-1.41) and 54% higher odds of abandonment (OR, 1.54; 95% CI, 1.44-1.65). Conclusion: The results of this cross-sectional study suggest that PCPs do most of the new PrEP prescribing and are a critical entry point for patients. PrEP adherence differs by clinician specialties, likely due to the populations served by them. Future studies to test interventions that provide adherence support and education are needed.
RESUMO
Background: Little is known about how best to reach people with social marketing messages promoting use of clinical HIV and sexually transmitted infection (STI) services. Objective: We evaluated a multiplatform, digital social marketing campaign intended to increase use of HIV/STI testing, treatment, and prevention services among gay, bisexual, and other men who have sex with men (MSM) at an LGBTQ+ (lesbian, gay, bisexual, transgender, queer, and/or questioning) community health center. Methods: We evaluated engagement with a social marketing campaign launched by Open Door Health, the only LGBTQ+ community health center in Rhode Island, during the first 8 months of implementation (April to November 2021). Three types of advertisements encouraging use of HIV/STI services were developed and implemented on Google Search, Google Display, Grindr, and Facebook. Platforms tracked the number of times that an advertisement was displayed to a user (impressions), that a user clicked through to a landing page that facilitated scheduling (clicks), and that a user requested a call to schedule an appointment from the landing page (conversions). We calculated the click-through rate (clicks per impression), conversion rate (conversions per click), and the dollar amount spent per 1000 impressions and per click and conversion. Results: Overall, Google Search yielded the highest click-through rate (7.1%) and conversion rate (7.0%) compared to Google Display, Grindr, and Facebook (click-through rates=0.4%-3.3%; conversion rates=0%-0.03%). Although the spend per 1000 impressions and per click was higher for Google Search compared to other platforms, the spend per conversion-which measures the number of people intending to attend the clinic for services-was substantially lower for Google Search (US $48.19 vs US $3120.42-US $3436.03). Conclusions: Campaigns using the Google Search platform may yield the greatest return on investment for engaging MSM in HIV/STI services at community health clinics. Future studies are needed to measure clinical outcomes among those who present to the clinic for services after viewing campaign advertisements and to compare the return on investment with use of social marketing campaigns relative to other approaches.
Assuntos
Homossexualidade Masculina , Marketing Social , Humanos , Masculino , Homossexualidade Masculina/estatística & dados numéricos , Homossexualidade Masculina/psicologia , Adulto , Minorias Sexuais e de Gênero/estatística & dados numéricos , Minorias Sexuais e de Gênero/psicologia , Promoção da Saúde/métodos , Saúde Sexual/estatística & dados numéricos , Pessoa de Meia-Idade , Estudos de Casos Organizacionais , Infecções Sexualmente Transmissíveis/prevenção & controle , Infecções por HIV/prevenção & controleRESUMO
BACKGROUND: Delays in hospital presentation limit access to acute stroke treatments. While prior research has focused on patient-level factors, broader ecological and social determinants have not been well studied. We aimed to create a geospatial map of prehospital delay and examine the role of community-level social vulnerability. METHODS: We studied patients with ischemic stroke who arrived by emergency medical services in 2015 to 2017 from the American Heart Association Get With The Guidelines-Stroke registry. The primary outcome was time to hospital arrival after stroke (in minutes), beginning at last known well in most cases. Using Geographic Information System mapping, we displayed the geography of delay. We then used Cox proportional hazard models to study the relationship between community-level factors and arrival time (adjusted hazard ratios [aHR] <1.0 indicate delay). The primary exposure was the social vulnerability index (SVI), a metric of social vulnerability for every ZIP Code Tabulation Area ranging from 0.0 to 1.0. RESULTS: Of 750â 336 patients, 149â 145 met inclusion criteria. The mean age was 73 years, and 51% were female. The median time to hospital arrival was 140 minutes (Q1: 60 minutes, Q3: 458 minutes). The geospatial map revealed that many zones of delay overlapped with socially vulnerable areas (https://harvard-cga.maps.arcgis.com/apps/webappviewer/index.html?id=08f6e885c71b457f83cefc71013bcaa7). Cox models (aHR, 95% CI) confirmed that higher SVI, including quartiles 3 (aHR, 0.96 [95% CI, 0.93-0.98]) and 4 (aHR, 0.93 [95% CI, 0.91-0.95]), was associated with delay. Patients from SVI quartile 4 neighborhoods arrived 15.6 minutes [15-16.2] slower than patients from SVI quartile 1. Specific SVI themes associated with delay were a community's socioeconomic status (aHR, 0.80 [95% CI, 0.74-0.85]) and housing type and transportation (aHR, 0.89 [95% CI, 0.84-0.94]). CONCLUSIONS: This map of acute stroke presentation times shows areas with a high incidence of delay. Increased social vulnerability characterizes these areas. Such places should be systematically targeted to improve population-level stroke presentation times.
Assuntos
Hospitalização , AVC Isquêmico , Sistema de Registros , Tempo para o Tratamento , Tempo para o Tratamento/estatística & dados numéricos , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Lacunas de Evidências , AVC Isquêmico/epidemiologia , AVC Isquêmico/terapia , Hospitalização/estatística & dados numéricos , Estados Unidos/epidemiologia , Análise Espaço-Temporal , Mapeamento Geográfico , Modelos de Riscos Proporcionais , Serviços Médicos de Emergência/estatística & dados numéricosRESUMO
As the field of public health rises to the demands of real-time surveillance and rapid data-sharing needs in a postpandemic world, it is time to examine our approaches to the dissemination and accessibility of such data. Distinct challenges exist when working to develop a shared public health language and narratives based on data. It requires that we assess our understanding of public health data literacy, revisit our approach to communication and engagement, and continuously evaluate our impact and relevance. Key stakeholders and cocreators are critical to this process and include people with lived experience, community organizations, governmental partners, and research institutions. In this viewpoint paper, we offer an instructive approach to the tools we used, assessed, and adapted across 3 unique overdose data dashboard projects in Rhode Island, United States. We are calling this model the "Rhode Island Approach to Public Health Data Literacy, Partnerships, and Action." This approach reflects the iterative lessons learned about the improvement of data dashboards through collaboration and strong partnerships across community members, state agencies, and an academic research team. We will highlight key tools and approaches that are accessible and engaging and allow developers and stakeholders to self-assess their goals for their data dashboards and evaluate engagement with these tools by their desired audiences and users.
Assuntos
Overdose de Drogas , Alfabetização , Humanos , Estados Unidos , Rhode Island/epidemiologia , Saúde Pública , Sistemas de Painéis , Overdose de Drogas/prevenção & controleRESUMO
Black sexually minoritized men (SMM) and transgender women (TW) are subgroups with lower rates of substance use and comparable rates of condom use relative to White SMM and TW yet experience heightened vulnerability to HIV. This study sought to explore associations of substance use, including sex-drug use (i.e., drug or alcohol use during sex to enhance sex), and condomless sex among Black SMM and TW. Data were collected from Black SMM and TW living in Chicago, Illinois, enrolled in the Neighborhoods and Networks (N2) cohort study, from November 2018 to April 2019. We used bivariate analyses followed by a multilevel egocentric network analysis to identify factors associated with condomless sex. We conducted Spearman correlation coefficients to examine correlations between pairs of sex-drugs to enhance sex. We used a bipartite network analysis to identify correlates of sex-drug use and condomless sex. A total of 352 Black SMM and TW (egos) provided information about 933 sexual partners (alters). Of respondents, 45% reported condomless sex and 61% reported sex-drug use. In unadjusted analyses, marijuana (34%) and cocaine/crack (5%) sex-drug use were associated with condomless sex (p < 0.05). Condomless sex was positively associated with sex-polydrug use, or the use of 2+ drugs or 1 drug and alcohol (OR = 1.48; 95% CI: 1.02-2.14; p = 0.039), and negatively associated with sharing an HIV-negative serostatus with a sexual partner (OR = 0.57; 95% CI: 0.33-0.98; p = 0.041), having a different HIV serostatus with a sexual partner (OR = 0.37; 95% CI: 0.21-0.64; p < 0.001) or not knowing the HIV serostatus of a sexual partner (OR = 0.47; 95% CI: 0.26-0.84; p = 0.011). The following pairs of sex-polydrug use had Spearman correlation coefficients higher than 0.3: marijuana and alcohol, ecstasy and alcohol, cocaine/crack and ecstasy, and methamphetamine and poppers (p < 0.05). HIV prevention interventions for Black SMM and TW designed to reduce HIV transmission through egocentric sexual networks could address sex-drug use through sex-positive and pleasure-centered harm reduction strategies and provide and promote biomedical prevention and care options at supraoptimal levels.
Assuntos
Transtornos Relacionados ao Uso de Substâncias , Pessoas Transgênero , Humanos , Masculino , Feminino , Chicago , Estudos de Coortes , Adulto , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Negro ou Afro-Americano , Adulto Jovem , Comportamento Sexual , Adolescente , Infecções por HIV/prevenção & controleRESUMO
OBJECTIVE: Examine differences in neighborhood characteristics and services between overdose hotspot and non-hotspot neighborhoods and identify neighborhood-level population factors associated with increased overdose incidence. METHODS: We conducted a population-based retrospective analysis of Rhode Island, USA residents who had a fatal or non-fatal overdose from 2016 to 2020 using an environmental scan and data from Rhode Island emergency medical services, State Unintentional Drug Overdose Reporting System, and the American Community Survey. We conducted a spatial scan via SaTScan to identify non-fatal and fatal overdose hotspots and compared the characteristics of hotspot and non-hotspot neighborhoods. We identified associations between census block group-level characteristics using a Besag-York-Mollié model specification with a conditional autoregressive spatial random effect. RESULTS: We identified 7 non-fatal and 3 fatal overdose hotspots in Rhode Island during the study period. Hotspot neighborhoods had higher proportions of Black and Latino/a residents, renter-occupied housing, vacant housing, unemployment, and cost-burdened households. A higher proportion of hotspot neighborhoods had a religious organization, a health center, or a police station. Non-fatal overdose risk increased in a dose responsive manner with increasing proportions of residents living in poverty. There was increased relative risk of non-fatal and fatal overdoses in neighborhoods with crowded housing above the mean (RR 1.19 [95 % CI 1.05, 1.34]; RR 1.21 [95 % CI 1.18, 1.38], respectively). CONCLUSION: Neighborhoods with increased prevalence of housing instability and poverty are at highest risk of overdose. The high availability of social services in overdose hotspots presents an opportunity to work with established organizations to prevent overdose deaths.
Assuntos
Overdose de Drogas , Overdose de Opiáceos , Humanos , Overdose de Opiáceos/epidemiologia , Overdose de Opiáceos/prevenção & controle , Overdose de Opiáceos/tratamento farmacológico , Estudos Retrospectivos , Rhode Island/epidemiologia , Overdose de Drogas/epidemiologia , Overdose de Drogas/prevenção & controle , Overdose de Drogas/tratamento farmacológico , Análise Espacial , Analgésicos OpioidesRESUMO
BACKGROUND: Drug overdose persists as a leading cause of death in the United States, but resources to address it remain limited. As a result, health authorities must consider where to allocate scarce resources within their jurisdictions. Machine learning offers a strategy to identify areas with increased future overdose risk to proactively allocate overdose prevention resources. This modeling study is embedded in a randomized trial to measure the effect of proactive resource allocation on statewide overdose rates in Rhode Island (RI). METHODS: We used statewide data from RI from 2016 to 2020 to develop an ensemble machine learning model predicting neighborhood-level fatal overdose risk. Our ensemble model integrated gradient boosting machine and super learner base models in a moving window framework to make predictions in 6-month intervals. Our performance target, developed a priori with the RI Department of Health, was to identify the 20% of RI neighborhoods containing at least 40% of statewide overdose deaths, including at least one neighborhood per municipality. The model was validated after trial launch. RESULTS: Our model selected priority neighborhoods capturing 40.2% of statewide overdose deaths during the test periods and 44.1% of statewide overdose deaths during validation periods. Our ensemble outperformed the base models during the test periods and performed comparably to the best-performing base model during the validation periods. CONCLUSIONS: We demonstrated the capacity for machine learning models to predict neighborhood-level fatal overdose risk to a degree of accuracy suitable for practitioners. Jurisdictions may consider predictive modeling as a tool to guide allocation of scarce resources.
Assuntos
Overdose de Drogas , Humanos , Estados Unidos , Rhode Island/epidemiologia , Overdose de Drogas/epidemiologia , Aprendizado de Máquina , Características de Residência , Escolaridade , Analgésicos OpioidesRESUMO
Oral HIV pre-exposure prophylaxis (PrEP) is highly effective for preventing HIV. Several different developments in the US either threaten to increase or promise to decrease PrEP out-of-pocket costs and access in the coming years. In a sample of 58,529 people with a new insurer-approved PrEP prescription, we estimated risk-adjusted percentages of patients who abandoned (did not fill) their initial prescription across six out-of-pocket cost categories. We then simulated the percentage of patients who would abandon PrEP under hypothetical changes to out-of-pocket costs, ranging from $0 to more than $500. PrEP abandonment rates of 5.5 percent at $0 rose to 42.6 percent at more than $500; even a small increase from $0 to $10 doubled the rate of abandonment. Conversely, abandonment rates that were 48.0 percent with out-of-pocket costs of more than $500 dropped to 7.3 percent when those costs were cut to $0. HIV diagnoses were two to three times higher among patients who abandoned PrEP prescriptions than among those who filled them. These results imply that recent legal challenges to the provision of PrEP with no cost sharing could substantially increase PrEP abandonment and HIV rates, upending progress on the HIV/AIDS epidemic.
Assuntos
Síndrome da Imunodeficiência Adquirida , Epidemias , Profilaxia Pré-Exposição , Humanos , Gastos em Saúde , Custo Compartilhado de SeguroRESUMO
Uptake and retention in clinical care for pre-exposure prophylaxis (PrEP) is suboptimal, particularly among young African American men who have sex with men (MSM) in the Deep South. We conducted a two-phase study to develop and implement an intervention to increase PrEP persistence. In Phase I, we conducted focus groups with 27 young African American MSM taking PrEP at a community health center in Jackson, Mississippi to elicit recommendations for the PrEP persistence intervention. We developed an intervention based on recommendations in Phase I, and in Phase II, ten participants were enrolled in an open pilot. Eight participants completed Phase II study activities, including a single intervention session, phone call check-ins, and four assessments (Months 0, 1, 3, and 6). Exit interviews demonstrated a high level of acceptability and satisfaction with the intervention. These formative data demonstrate the initial promise of a novel intervention to improve PrEP persistence among young African American MSM.
Assuntos
Fármacos Anti-HIV , Infecções por HIV , Profilaxia Pré-Exposição , Minorias Sexuais e de Gênero , Masculino , Humanos , Homossexualidade Masculina , Negro ou Afro-Americano , Infecções por HIV/prevenção & controle , Infecções por HIV/tratamento farmacológico , Projetos Piloto , Fármacos Anti-HIV/uso terapêuticoRESUMO
OBJECTIVE: In the United States, one in five newly insurer-approved pre-exposure prophylaxis (PrEP) prescriptions are reversed with over 70% of those reversed, being abandoned. Given the Ending the HIV Epidemic (EHE) initiative's goals, we assessed geographic variations of PrEP reversal and abandonment across EHE and non-EHE counties in the United States. DESIGN: This was a cross-sectional analysis of secondary data. METHODS: Data were collected from Symphony Analytics for adults 18 years and older, with a newly prescribed PrEP claim. Using the proportion of PrEP prescriptions by county, hotspot analysis was conducted utilizing Getis Ord Gi∗ statistics stratified by EHE and non EHE counties. Multivariable logistic regression was used to identify factors associated with residing in hotspots of PrEP reversal or PrEP abandonments. RESULTS: Across 516 counties representing 36,204 patients, the overall PrEP reversal rate was 19.4%, whereas the PrEP abandonment rate was 13.7%. Reversals and abandonments were higher for non-EHE (22.7 and 17.1%) than EHE (15.6 and 10.5%) counties. In both EHE and non-EHE counties, younger age, less education, females, and an out-of-pocket cost of greater than $100, were significantly associated with greater likelihood of residing in hotspots of PrEP reversal or abandonment, while Hispanics, Medicaid recipients, and an out-of-pocket cost of $10 or less had lower likelihood of residing in hotspots of reversal and abandonment. CONCLUSION: Findings indicate the need for implementation of focused interventions to address disparities observed in PrEP reversal and abandonment. Moreover, to improve primary PrEP adherence, national PrEP access programs should streamline and improve PrEP accessibility across different geographic jurisdictions.
Assuntos
Fármacos Anti-HIV , Infecções por HIV , Profilaxia Pré-Exposição , Adulto , Feminino , Humanos , Estados Unidos , Infecções por HIV/prevenção & controle , Infecções por HIV/epidemiologia , Estudos Transversais , Medicaid , Prescrições , Fármacos Anti-HIV/uso terapêuticoRESUMO
Background: The US Ending the HIV Epidemic (EHE) initiative aims to reduce national HIV incidence 90% by 2030 and to address the disproportionate burden of HIV among different racial/ethnic populations. Florida's state-wide 2022-2026 Integrated HIV Prevention and Care Plan outlines objectives for reaching EHE goals. In Miami-Dade County, we determined the epidemiological impact of achieving the integrated plan's objectives individually and jointly. Methods: We adapted an HIV transmission model calibrated to Miami-Dade County adjusting access to HIV testing, pre-exposure prophylaxis (PrEP) and antiretroviral treatment to model the effects of each objective between 2022 and 2030. We compared two service scale-up approaches: (a) scale-up proportionally to existing racial/ethnic group access levels, and (b) scale-up according to new diagnoses across racial/ethnic groups (equity-oriented). We estimated reductions in new HIV infections by each objective and approach, compared to the EHE's incidence reduction target. Findings: The single most influential strategy was reducing new HIV diagnoses in Hispanic/Latinx men who have sex with men through increased PrEP uptake, resulting in 907/2444 (37.1%) fewer annual new HIV infections in 2030. Achieving all objectives jointly would result in 1537/2444 (62.9%) and 1553/2444 (63.5%) fewer annual new HIV infections with the proportional and equity-oriented approaches, respectively. Interpretation: Achieving the goals of Florida's integrated care plan would significantly reduce HIV incidence in Miami-Dade County; however, further efforts are required to achieve EHE targets. Structural changes in service delivery and a focus on effective implementation of available interventions to address racial/ethnic disparities will be crucial to ending the HIV epidemic. Funding: This work was supported by the National Institutes of Health/National Institute on Drug Abuse grant no. R01-DA041747.
RESUMO
Prior applications of machine learning to population health have relied on conventional model assessment criteria, limiting the utility of models as decision support tools for public health practitioners. To facilitate practitioners' use of machine learning as a decision support tool for area-level intervention, we developed and applied 4 practice-based predictive model evaluation criteria (implementation capacity, preventive potential, health equity, and jurisdictional practicalities). We used a case study of overdose prevention in Rhode Island to illustrate how these criteria could inform public health practice and health equity promotion. We used Rhode Island overdose mortality records from January 2016-June 2020 (n = 1,408) and neighborhood-level US Census data. We employed 2 disparate machine learning models, Gaussian process and random forest, to illustrate the comparative utility of our criteria to guide interventions. Our models predicted 7.5%-36.4% of overdose deaths during the test period, illustrating the preventive potential of overdose interventions assuming 5%-20% statewide implementation capacities for neighborhood-level resource deployment. We describe the health equity implications of use of predictive modeling to guide interventions along the lines of urbanicity, racial/ethnic composition, and poverty. We then discuss considerations to complement predictive model evaluation criteria and inform the prevention and mitigation of spatially dynamic public health problems across the breadth of practice. This article is part of a Special Collection on Mental Health.
Assuntos
Overdose de Drogas , Humanos , Rhode Island/epidemiologia , Overdose de Drogas/prevenção & controle , Promoção da Saúde , Saúde Pública , Prática de Saúde Pública , Analgésicos OpioidesRESUMO
The association between recent release from incarceration and dramatically increased risk of fatal overdose is well-established at the individual level. Fatal overdose and. arrest/release are spatially clustered, suggesting that this association may persist at the neighborhood level. We analyzed multicomponent data from Rhode Island, 2016-2020, and observed a modest association at the census tract level between rates of release per 1000 population and fatal overdose per 100,000 person-years, adjusting for spatial autocorrelation in both the exposure and outcome. Our results suggest that for each additional person released to a given census tract per 1000 population, there is a corresponding increase in the rate of fatal overdose by 2 per 100,000 person years. This association is more pronounced in suburban tracts, where each additional release awaiting trial is associated with an increase in the rate of fatal overdose of 4 per 100,000 person-years and 6 per 100,000 person-years for each additional release following sentence expiration. This association is not modified by the presence or absence of a licensed medication for opioid use disorder (MOUD) treatment provider in the same or surrounding tracts. Our results suggest that neighborhood-level release rates are moderately informative as to tract-level rates of fatal overdose and underscore the importance of expanding pre-release MOUD access in correctional settings. Future research should explore risk and resource environments particularly in suburban and rural areas and their impacts on overdose risk among individuals returning to the community.
Assuntos
Overdose de Drogas , Transtornos Relacionados ao Uso de Opioides , Humanos , Analgésicos Opioides/uso terapêutico , Overdose de Drogas/epidemiologia , Overdose de Drogas/tratamento farmacológico , Acessibilidade aos Serviços de Saúde , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Rhode Island/epidemiologia , PrisioneirosRESUMO
Individual-level behavior can be influenced by injunctive and descriptive social network norms surrounding that behavior. There is a need to understand how the influence of social norms within an individual's social networks may influence individual-level sexual behavior. We aimed to typologize the network-level norms of sexual behaviors within the social networks of Black sexual and gender minoritized groups (SGM) assigned male at birth. Survey data were collected in Chicago, Illinois, USA, between 2018 and 2019 from Black SGM. A total of 371 participants provided individual-level information about sociodemographic characteristics and HIV vulnerability from sex (i.e., condomless sex, group sex, use of alcohol/drugs to enhance sex) and completed an egocentric network inventory assessing perceptions of their social network members' (alters') injunctive and descriptive norms surrounding sexual behaviors with increased HIV vulnerability. We used Latent Profile Analysis (LPA) to identify network-level norms based on the proportion of alters' approval of the participant engaging in condomless sex, group sex, and use of drugs to enhance sex (i.e., injunctive norms) and alters' engagement in these behaviors (i.e., descriptive norms). We then used binomial regression analyses to examine associations between network-level norm profiles and individual-level HIV vulnerability from sex. The results of our LPA indicated that our sample experienced five distinct latent profiles of network-level norms: (1) low HIV vulnerability network norm, (2) moderately high HIV vulnerability network norm, (3) high HIV vulnerability network norm, (4) condomless sex dominant network norm, and (5) approval of drug use during sex dominant network norm. Condomless anal sex, group sex, and using drugs to enhance sex were positively and significantly associated with higher HIV vulnerability social network norm profiles, relative to low HIV vulnerability norm profiles. To mitigate Black SGM's HIV vulnerability, future HIV risk reduction strategies can consider using network-level intervention approaches such as opinion leaders, segmentation, induction, or alteration, through an intersectionality framework.
Assuntos
Infecções por HIV , Comportamento Sexual , Recém-Nascido , Humanos , Masculino , Chicago/epidemiologia , Estudos de Coortes , Sexo sem Proteção , Infecções por HIV/epidemiologiaRESUMO
Black sexual minority men (SMM) in the Deep South are heavily impacted by HIV; yet studies fail to consider discordance across aspects of sexual orientation (i.e., identity, attraction, behavior) or how a lack of concordance enhances vulnerability to HIV. We sought to explore the overlap across aspects of sexual orientation and examine associations between each aspect and the number of sexual partners who engaged in HIV vulnerability-enhancing behaviors, and HIV prevention and care outcomes. A total of 204 Black SMM completed surveys, reporting their sexual identity, attraction, and behavior (i.e., sex with men only vs. sex with men and women), number of condomless sex or transactional sex (e.g., buyers vs. sellers) partners in the past 6 months, and adherence to pre-exposure prophylaxis (PrEP) or antiretroviral therapy (ART) among users. Less than one in four participants (22.5%) reported overlap in same-sex sexual orientations, while 17.1% of bisexual men reported overlap across aspects. In multivariable models, differences were found in how aspects of sexual orientation were associated with the number of partners who bought or sold sex; as well as how often participants tested for HIV in the past 12 months. Results suggest different aspects of sexual orientation have implications for addressing HIV among Black SMM in the Deep South.
RESUMEN: Los hombres negros de minorías sexuales (SMM) en el Sur Profundo de los Estados Unidos se ven gravemente afectados por el VIH; sin embargo, los estudios no suelen considerar la discrepancia entre los diferentes aspectos de la orientación sexual (es decir, identidad, atracción, comportamiento) o cómo la falta de concordancia aumenta la vulnerabilidad al VIH. Buscamos explorar el grado de concordancia entre los aspectos de la orientación sexual y examinar las asociaciones entre cada aspecto y la cantidad de parejas sexuales que se involucraron en comportamientos que incrementan la vulnerabilidad al VIH y los resultados de la prevención y atención del VIH. Un total de 204 hombres negros de SMM completaron encuestas sobre su identidad sexual, atracción y comportamiento (es decir, sexo solo con hombres frente a hombres y mujeres), número de parejas sexuales sin condón o sexo transaccional (p. ej., compradores frente a vendedores) en los últimos seis meses, y la adherencia a la profilaxis previa a la exposición (PrEP) o la terapia antirretroviral (TAR) entre los que utilizan estas tecnologías médicas. Menos de uno de cada cuatro participantes (22.5%) reportaron concordancia entre los distintos aspectos de la orientación sexual, mientras que el 17.1% de los hombres bisexuales reportaron concordancia en todos los aspectos. Utilizando modelos multivariables, se encontraron diferencias en el grado de asociación entre los diferentes aspectos de la orientación sexual y el número de parejas que compraron o vendieron sexo, así como entre los distintos aspectos de la orientación sexual y la frecuencia con la que los participantes se hicieron la prueba del VIH en los últimos 12 meses. Los resultados sugieren que diferentes aspectos de la orientación sexual tienen implicaciones para abordar el VIH entre los SMM negros en el Sur Profundo.
Assuntos
Infecções por HIV , Profilaxia Pré-Exposição , Minorias Sexuais e de Gênero , Feminino , Humanos , Masculino , Homossexualidade Masculina , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Estudos de Coortes , Comportamento Sexual , Profilaxia Pré-Exposição/métodosRESUMO
We developed an agent-based model using a trial emulation approach to quantify effect measure modification of spillover effects of pre-exposure prophylaxis (PrEP) for HIV among men who have sex with men (MSM) in the Atlanta-Sandy Springs-Roswell metropolitan area, Georgia. PrEP may impact not only the individual prescribed, but also their partners and beyond, known as spillover. We simulated a two-stage randomised trial with eligible components (≥3 agents with ≥1 HIV+ agent) first randomised to intervention or control (no PrEP). Within intervention components, agents were randomised to PrEP with coverage of 70%, providing insight into a high PrEP coverage strategy. We evaluated effect modification by component-level characteristics and estimated spillover effects on HIV incidence using an extension of randomisation-based estimators. We observed an attenuation of the spillover effect when agents were in components with a higher prevalence of either drug use or bridging potential (if an agent acts as a mediator between ≥2 connected groups of agents). The estimated spillover effects were larger in magnitude among components with either higher HIV prevalence or greater density (number of existing partnerships compared to all possible partnerships). Consideration of effect modification is important when evaluating the spillover of PrEP among MSM.
Assuntos
Infecções por HIV , Profilaxia Pré-Exposição , Minorias Sexuais e de Gênero , Masculino , Humanos , Homossexualidade Masculina , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Infecções por HIV/tratamento farmacológico , Georgia/epidemiologiaRESUMO
BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic continues to put strain on health systems in the United States, leading to significant shifts in the delivery of routine clinical services, including those offering HIV pre-exposure prophylaxis (PrEP). We aimed to assess whether individuals discontinued PrEP use at higher rates during the COVID-19 pandemic and the extent to which disruptions to usual clinical care were mitigated through telehealth. METHODS: Using data from an ongoing prospective cohort of men who have sex with men (MSM) newly initiating PrEP in 3 mid-sized cities (n = 195), we calculated the rate of first-time discontinuation of PrEP use in the period before the COVID-19 pandemic and during the COVID-19 pandemic and compared these rates using incidence rate ratios (IRRs). Furthermore, we compared the characteristics of patients who discontinued PrEP use during these periods with those who continued to use PrEP during both periods. RESULTS: Rates of PrEP discontinuation before the COVID pandemic and during the COVID-19 pandemic were comparable [4.29 vs. 5.20 discontinuations per 100 person-months; IRR: 1.95; 95% confidence interval (CI): 0.83 to 1.77]. Although no significant differences in the PrEP discontinuation rate were observed in the overall population, the rate of PrEP discontinuation increased by almost 3-fold among participants aged 18-24 year old (IRR: 2.78; 95% CI: 1.48 to 5.23) and by 29% among participants covered by public insurance plans at enrollment (IRR: 1.29; 95% CI: 1.03 to 5.09). Those who continued to use PrEP were more likely to have had a follow-up clinical visit by telehealth in the early months of the pandemic (45% vs. 17%). CONCLUSIONS: In this study, rates of PrEP discontinuation were largely unchanged with the onset of the COVID-19 pandemic. The use of telehealth likely helped retain patients in PrEP care and should continue to be offered in the future.
Assuntos
Fármacos Anti-HIV , COVID-19 , Infecções por HIV , Profilaxia Pré-Exposição , Minorias Sexuais e de Gênero , Adolescente , Adulto , Fármacos Anti-HIV/uso terapêutico , COVID-19/epidemiologia , COVID-19/prevenção & controle , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Homossexualidade Masculina , Humanos , Masculino , Pandemias/prevenção & controle , Estudos Prospectivos , Estados Unidos/epidemiologia , Adulto JovemRESUMO
We conducted a cross-sectional web-based study to assess attitudes and experiences with HIV pre-exposure prophylaxis (PrEP) amongst a multiracial cohort of gay, bisexual, and other men who have sex with men (MSM) and transgender women in Long Island, New York. Participants were recruited through clinical providers and community-based organizations. The survey assessed knowledge and attitudes toward PrEP and factors that facilitate willingness to take it. Of the 189 respondents, most participants were Latinx/Hispanic (57.1%; n = 105), gay-identifying (81.2%; n = 151), and cisgender men (88.7%; n = 165). One in five participants completed high school or lower (19.4%; n = 36). Among those who had never used PrEP (53.4%; n = 101), nearly all participants were willing to use it if it were free or covered as part of their insurance (89.4%; n = 84). The most common barriers to not using PrEP was not knowing where to obtain it (68.3%; n = 69), concerns about side effects (42.1%; n = 35), and concerns about affordability (38.5%; n = 25). This study discusses specific nuances to the suburbs, including cultural norms and structural barriers that should be incorporated in health promotion initiatives in addressing these factors.
Assuntos
Infecções por HIV , Profilaxia Pré-Exposição , Minorias Sexuais e de Gênero , Pessoas Transgênero , Estudos Transversais , Feminino , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Conhecimentos, Atitudes e Prática em Saúde , Homossexualidade Masculina , Humanos , MasculinoRESUMO
BACKGROUND: Despite recent HIV outbreaks among people who inject drugs (PWID) in nonurban US settings, syringe service programs (SSP) are often inaccessible in these communities. Furthermore, pre-exposure prophylaxis (PrEP) awareness and coverage for PWID is limited. We aimed to model the impact of PrEP on HIV transmission among PWID in a rural setting. SETTING: Using a calibrated agent-based model, we simulated HIV transmission in an adult population (n = 14,573 agents) in Scott County, Indiana between 2015 and 2024. METHODS: We modeled PrEP eligibility according to CDC guidelines for PWID. PrEP coverage increased by 15% points in the range 10%-70%. Two counterfactual scenarios were modeled: Unrestricted access for PWID and PrEP for SSP attendees . We calculated the number of new HIV infections and number of person-years on PrEP per averted infection. RESULTS: In the status quo scenario, 153 (95% Simulation Interval: 85, 259) new HIV infections occurred among PWID over 10 years. Compared with the status quo, 40% PrEP coverage resulted in 25% fewer HIV infections in the Unrestricted access for PWID scenario and 10% fewer HIV infections in the PrEP for SSP attendees scenario. The PYPAI was 21 and 43 in the Unrestricted access for PWID and PrEP for SSP attendees scenarios, respectively. CONCLUSION: Our modeling suggests that PrEP provides substantial benefit to PWID in rural US communities, with fewer restrictions on access providing the greatest effect. Control of HIV outbreaks will require expansion of public health interventions that meet the needs of all individuals.
Assuntos
Fármacos Anti-HIV , Usuários de Drogas , Infecções por HIV , Profilaxia Pré-Exposição , Abuso de Substâncias por Via Intravenosa , Adulto , Estados Unidos/epidemiologia , Humanos , Profilaxia Pré-Exposição/métodos , Abuso de Substâncias por Via Intravenosa/complicações , Abuso de Substâncias por Via Intravenosa/epidemiologia , Abuso de Substâncias por Via Intravenosa/tratamento farmacológico , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Infecções por HIV/tratamento farmacológico , Indiana/epidemiologia , Fármacos Anti-HIV/uso terapêuticoRESUMO
OBJECTIVES: To compare the characteristics of individual overdose decedents in Rhode Island, 2016-2020 to the neighborhoods where fatal overdoses occurred over the same time period. METHODS: We conducted a retrospective analysis of fatal overdoses occurring between January 1, 2016 and June 30, 2020. Using individual- and neighborhood-level data, we conducted descriptive analyses to explore the characteristics of individuals and neighborhoods most affected by overdose. RESULTS: Most overdose decedents during the study period were non-Hispanic White. Across increasingly more White and non-Hispanic neighborhoods, rates of fatal overdose per 100,000 person-years decreased. An opposite pattern was observed across quintiles of average neighborhood poverty. CONCLUSIONS: Rates of fatal overdose were higher in less White, more Hispanic, and poorer neighborhoods, suggesting modest divergence between the characteristics of individuals and the neighborhoods most severely affected. These impacts may not be uniform across space and may accrue differentially to more disadvantaged and racially/ethnically diverse neighborhoods.