Myocarditis Attributable to Monkeypox Virus Infection in 2 Patients, United States, 2022.

We report 2 immunocompetent and otherwise healthy adults in the United States who had monkeypox and required hospitalization for viral myocarditis. Both patients were unvaccinated against orthopoxviruses. They had shortness of breath or chest pain and elevated cardiac biomarkers. No immediate complications were observed. They were discharged home after symptoms resolved.

Patient Demographics and the Utilization of a Novel 3-Anatomic-Site Testing Panel Including Rectal Self-Collection as Compared With Usual Care Testing.

BACKGROUND: At Kaiser Permanente Mid-Atlantic States, we designed a 3-anatomic-site panel (urine, oropharynx, and rectum) with a self-collect feature for rectal sites. We compared the proportion tested at each anatomic site, demographic factors, and HIV status between those who received the 3-site panel versus usual care. METHODS: Patients entered our laboratories without a prior appointment and underwent urine (usual care [patient collected]), oropharynx (laboratory technician collected), and rectal site (patient collected) testing. Providers recommended the panel to their patients. Patients then had the choice to accept or to reject the panel. Multivariate and logistic regressions were conducted to explore the relationship of age, sex, race, and HIV status with Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) test results as well as the type of testing (3-site panel vs. usual care testing) received. RESULTS: A total of 145,854 patients received usual care testing as compared with 9227 who received the panel. For those who underwent usual care testing, 4.0% tested positive for CT and 0.85% for GC. For those who received the panel, 9.1% tested positive for CT and 6.4% for GC. Those who received the 3-site panel were more likely to test positive for CT (odds ratio [OR], 2.70; confidence interval [CI], 2.46-2.97) and GC (OR, 4.00; CI, 3.59-4.64). White patients were the most likely to receive the panel compared with Black patients (OR, 3.14; CI, 2.96-3.33). Patients with HIV had greater odds of undergoing the panel (OR, 15.62; CI, 14.67-16.64) and of testing positive for CT (OR, 1.27; CI, 1.07-1.51) and GC (OR, 1.39; CI, 1.14-1.68). CONCLUSIONS: Patients who received the panel had higher odds of testing positive for CT and GC compared with patients with usual testing. Physician training may address the racial and sex differences observed in the panel enrollment and increase utilization. Self-collection for rectal sites should lead to higher detection of CT and GC.

Beyond the HIV Care Continuum and Viral Suppression: Broadening the Scope of Quality Metrics for Total HIV Patient Care.

Assessing quality care for people with HIV (PWH) should not be limited to reporting on HIV Care Continuum benchmarks, particularly viral suppression rates. At Kaiser Permanente Mid-Atlantic States (KPMAS), an integrated health system providing HIV care in the District of Columbia, Maryland, and Virginia, we created a comprehensive measure of HIV quality care, including both preventative measures and clinical outcomes. We included PWH ≥18 years old with ≥6 months KPMAS membership between 2015 and 2018. Process quality metrics (QMs) include: pneumococcal vaccination and influenza vaccination; primary care physician (PCP) and/or HIV/infectious disease (HIV/ID) visits with additional HIV/ID visit; antiretroviral treatment medication fills; and syphilis and gonorrhea/chlamydia screenings. Outcome QMs include HIV RNA <200/mL and other measurements within normal range [blood pressure, body mass index (BMI), hemoglobin, blood sugar, alanine transaminase, low-density lipoproteins, estimated glomerular filtration rate]; no hospitalization/emergency department visit; no new depression diagnosis; remaining or becoming a nonsmoker. Logistic models estimated odds of achieving QMs associated with sex, age, race/ethnicity, insurance type, and HIV risk. A total of 4996 observations were analyzed. 45.6% met all process QMs, while 19.6% met all outcome QMs. Least frequently met process QM was PCP or HIV/ID visit (74.5%); least met outcome QM was BMI (60.2%). Significantly lower odds of achieving all QMs among women {odds ratio (OR) = 0.63 [95% confidence interval (CI): 0.49-0.81]} and those with Medicaid and Medicare [vs. commercial; OR = 0.48 (95% CI: 0.30-0.76) and 0.47 (95% CI: 0.31-0.71)]. Broadening the scope of HIV patient care QMs beyond viral suppression helps identify opportunities for improvement. Successful process metrics do not necessarily coincide with greater outcome metrics.

Impact of Alternative Encounter Types on HIV Viral Suppression Rates in an Integrated Health System.

Kaiser Permanente Mid-Atlantic States (KPMAS) members are increasingly utilizing electronic encounter types, such as telephone appointments and secure messaging for healthcare purposes, although their impact on health outcomes is unknown. We evaluated whether use of alternative encounters by adult human immunodeficiency virus (HIV)-infected patients affected the likelihood of achieving viral suppression (VS). Our study population of 3114 patients contributed 6520 patient-years between 2014 and 2016. We compared VS (HIV RNA <200 copies/mL) by number of in-person visits (1 or ≥2), with further stratification for additional phone and/or e-mail encounters (none, phone only, e-mail only, and both phone and e-mail). Rate ratios (RRs) for VS by number of in-person visits and encounter types were obtained from Poisson modeling, adjusting for age, sex, race/ethnicity, and HIV risk. Compared to those with ≥2 visits, patients with one in-person visit alone were significantly less likely to achieve VS (RR = 0.93; 95% confidence interval, CI: [0.87-1.00]), as were those with one in-person visit plus a telephone encounter (0.93; [0.90-0.97]). We did not find significant differences in VS comparing patients with one in-person visit plus e-mail only (RR = 1.00; 95% CI: [0.97-1.02]) or plus e-mail and telephone (0.99; [0.97-1.01]) to those with ≥2 in-person visits. If supplemented by e-mail communications (with or without telephone contact), patients with one in-person visit per year had similar estimated rates of VS compared with ≥2 in-person visits. More research is needed to know if these findings apply to other care systems.

The HIV Care Cascade Measured Over Time and by Age, Sex, and Race in a Large National Integrated Care System.

HIV care cascades can evaluate programmatic success over time. However, methodologies for estimating cascade stages vary, and few have evaluated differences by demographic subgroups. We examined cascade performance over time and by age, sex, and race/ethnicity in Kaiser Permanente, providing HIV care in eight US states and Washington, DC. We created cascades for HIV+ members' age ≥13 for 2010-2012. We measured "linkage" (a visit/CD4 within 90 days of being diagnosed for new patients; ≥1 medical visit/year if established); "retention" (≥2 medical visits ≥60 days apart); filled ART (filled ≥3 months of combination ART); and viral suppression (HIV RNA <200 copies/mL last measured in year). The cascades were stratified by calendar year, sex, age, and race/ethnicity. We found men had statistically (p < 0.05) higher percent linkage, filled ART, and viral suppression for 2010 and 2011 but not for 2012. Women had significantly greater retention for all years. Annually, older age was associated (p < 0.05) with retention, filled ART, and viral suppression but not linkage. Latinos had greater (p < 0.05) retention than whites or blacks in all years, with similar retention comparing blacks and whites. Filled ART and viral suppression was increased (p < 0.05) for whites compared with all racial/ethnic groups in all years. Cascade methodology requiring success at upstream stages before measuring success at later stages (i.e., "dependent" methodology) underreported performance by up to 20% compared with evaluating each stage separately ("independent"). Thus, care results improved over time, but significant differences exist by patient demographics. Specifically, retention efforts should be targeted toward younger patients and blacks; women, blacks, and Latinos require greater ART prescribing.

HIV quality performance measures in a large integrated health care system.

HIV quality performance measurements are critical to evaluating a care program's success in areas of testing, access to and retention in care, care processes and outcomes. Kaiser Permanente (KP) provides care to over 8 million Americans and over 19,000 HIV-infected adults. We undertook a quality performance measurement program to assess the care and outcomes for our HIV-positive patient population. We also examined HIV testing practices among our HIV-uninfected patients presenting with a sexually transmitted infection. Our metrics were extracted electronically (encompassing two time periods: July 1, 2005 through June 30, 2006 and the entire calendar year 2007) and did not require any manual data extraction, which was a primary objective of our strategy. For most individual care measures, improvement over time was noted, with 85% or more performance seen on some measures (accessing care and initiating antiretroviral therapy). Opportunities for improvement were identified on other measures, such as diagnosing HIV at an earlier stage of infection, and more consistent Pneumocystis jiroveci pneumonia prophylaxis. Over 90% of our patients on antiretroviral therapy had maximal viral control, along with high median antiretroviral medication adherence. Our results compare favorably to those of other organizations, with a KP HIV mortality rate less than 50% of the overall U.S. rate. These results have implications for improving our care process going forward, as well as for the new U.S. domestic HIV/AIDS Strategy.

Epidemiologic characteristics and natural history of HIV-1 natural viral suppressors.

OBJECTIVE: The objective of this study was to detail the epidemiologic characteristics and natural history of HIV-1 natural viral suppressors (NVSs), a cohort of HIV-1-infected individuals who are able to suppress viral replication to undetectable levels in the absence of therapy. DESIGN AND METHODS: HIV-1 patients who met the NVS criteria were enrolled into a prospective study. The incidence and prevalence of NVS were calculated by performing a chart review on all patients seen in 1 clinic in a 10-year period. Cumulative probability of progression-free survival was calculated by Kaplan-Meier product limit method. RESULTS: Forty individuals enrolled in the study. The median year of diagnosis was 1994, and individuals demonstrated a median 6.7 years of HIV-1 viral suppression and CD4 count of 795 cells per microliter. NVS had an incidence of 1.1% [95% confidence interval (CI), 0.0 to 2.1] and prevalence of 1.5% (95% CI, 0.8 to 2.1). Only 1 patient (2.5%) has progressed. Within the first 10 years for follow-up having met the definition of NVS, 95.1% (95% CI 86.5% to 100%) of the NVS continued to control their viral loads to undetectable levels. CONCLUSIONS: The NVS cohort has demonstrated remarkable stability and a low rate of progression over many years. Detailed evaluations of viral-host immune regulatory factors associated with persistent HIV-1 natural viral suppression, and loss of such suppression, has the potential to provide important new insight in HIV pathogenesis and future immune regulatory targeted preventive and therapeutic research.