CDC-Funded HIV Testing Services Outcomes and Social Determinants of Health in Ending the HIV Epidemic in the U.S. Jurisdictions.

We performed an ecological analysis to examine associations between CDC-funded HIV testing services outcomes and social determinants of health (SDOH) among Ending the HIV Epidemic in the U.S. jurisdictions. Using National HIV Prevention Program Monitoring & Evaluation (2020) and American Community Survey (2016-2020) data, we ran robust Poisson models (adjusted for race/ethnicity). In healthcare settings, a 10% absolute increase in percentage without health insurance was associated with a 40% lower prevalence of newly diagnosed positivity (aPR = 0.60, 95% CI: 0.43-0.83); a $5,000 increase in median household income (aPR = 1.04, 95% CI: 1.03-1.06) and a 10% absolute increase in percentage unemployed (aPR = 1.80, 95% CI: 1.31-2.46) were associated with 4% and 80%, respectively, higher prevalence of percentage linked to HIV medical care within 30 days of diagnosis (i.e., linkage). In non-healthcare settings, a 10% absolute increase in percentage with less than high school diploma (aPR = 0.53, 95% CI: 0.29-0.96) was associated with a 47% lower prevalence of newly diagnosed positivity, whereas a 10% absolute increase in percentage without health insurance (aPR = 1.92, 95% CI: 1.29-2.88) was associated with a 92% higher prevalence of newly diagnosed positivity; a 10% absolute increase in percentage with less than high school diploma was associated with a 35% lower prevalence of linkage (aPR = 0.65, 95% CI: 0.43-0.97). Addressing SDOH in HIV prevention programs will play an important role in ending the HIV epidemic.

Prioritization of Evidence-Based and Evidence-Informed Interventions for Retention in Medical Care for Persons with HIV.

Up to 50% of those diagnosed with HIV in the U.S. are not retained in medical care. Care retention provides opportunity to monitor benefits of HIV therapy and enable viral suppression. To increase retention, there is a need to prioritize best practices appropriate for translation and dissemination for real-world implementation. Eighteen interventions from CDC's Compendium of Evidence-Based Interventions were scored using the RE-AIM framework to determine those most suitable for dissemination. A CDC Division of HIV Prevention workgroup developed a RE-AIM scale with emphasis on the Implementation and Maintenance dimensions and less emphasis on the Efficacy dimension since all 18 interventions were already identified as evidence-based or evidence-informed. Raters referenced primary efficacy publications and scores were averaged for a ranked RE-AIM score for interventions. Of 18 interventions, four included care linkage and 7 included viral suppression outcomes. Interventions received between 20.6 and 35.3 points (45 maximum). Scores were converted into a percentage of the total possible with ranges between 45.8 and 78.4%. Top four interventions were ARTAS (78.4%); Routine Screening for HIV (RUSH) (73.2%); Optn4Life (67.4%) and Virology Fast Track (65.9%). All four scored high on Implementation and Maintenance dimensions. Select items within the scale were applicable to health equity, covering topics such as reaching under-served focus populations and acceptability to that population. Navigation-enhanced Case Management (NAV) scored highest on the health equity subscale. RE-AIM prioritization scores will inform dissemination and translation efforts, help clinical staff select feasible interventions for implementation, and support sustainability for those interventions.

RESUMEN: Hasta el 50% de las personas diagnosticadas con VIH en USA no son retenidos en cuidados médicos impactando su monitoreo y supresión viral. Dieciocho intervenciones de retención fueron evaluadas utilizando el marco RE-AIM para determinar su adecuación para la difusión. Evaluadores promediaron las intervenciones. Cuatro intervenciones incluyeron enlace de atención y 7 supresión viral. Las cuatro intervenciones principales fueron ARTAS, detección de rutina para el VIH, Optn4Life y Vía rápida de virología. Elementos del marco fueron usados para evaluar equidad en salud y cubrieron temas de cómo llegar a las poblaciones desatendidas y la aceptabilidad de esa población. La intervención gestión de casos para mejorar con navegación (NAV) obtuvo la puntuación más alta en la subescala de equidad. RE-AIM y los puntajes de priorización de equidad informarán los esfuerzos de difusión y traducción, ayudarán al personal clínico a seleccionar las intervenciones para la implementación y apoyarán la sostenibilidad.

Survey of case study users during pandemic shift to remote instruction.

Before COVID-19, the use of case studies to learn science was well established in high school and postsecondary classrooms. Once the pandemic ensued, many faculty continued to use the method as a way to infuse elements of active learning remotely. The results of a survey taken by 600 faculty reveal how they accomplished this feat. Respondents to the survey found that the case method readily transferred to online learning. Most used a mixture of synchronous and asynchronous classrooms. Serious challenges were encountered, primarily due to the difficulty instructors had in keeping track of learner participation. Many obstacles were overcome by creative strategies such as using Google Forms. Some semblance of a normal classroom was achieved by using online conferencing tools and using small groups in synchronous breakout rooms. Cases were commonly broken into chunks and spread over several days. This worked especially well with cases that were already structured this way, including interrupted cases and problem-based learning exercises. Assessment of student performance largely followed the traditional path of exams, projects, and essays, although a third of the faculty attempted to evaluate participation. Classes conducted via an asynchronous approach were largely lecture based, with cases given to learners to complete as homework either individually or as groups. The greatest challenge in this setting was that answers to case questions were often readily available to learners on the internet. This was avoided by faculty modifying questions or creating their own.

Cocaine Use May be Associated with Increased Depression in Persons Infected with HIV.

HIV infection, depression, and cocaine use are independently associated with increased inflammatory signal production. There is increasing evidence about the role of inflammation in depression. In HIV disease, cocaine use may increase disease progression as well as alter T cell functioning resulting in cytokine activation and thereby increasing susceptibility to depression. We examined the association between cocaine use and depression among 447 African American persons infected with HIV who were frequent cocaine users or non-users, enrolled in an observational study in Baltimore, Maryland, between August 2003 and December 2012. The overall prevalence of depression was 40.9 % (183 of 447) participants. Among persons who were depressed, the prevalence of cocaine use was 81.4 % (149 of 183), compared to 69.3 % among persons who were not depressed (183 of 264), P = 0.004. Cocaine use was associated with nearly twofold increased odds of depression, unadjusted odds ratio (OR) 1.94, (95 % CI 1.23, 3.06); P = 0.004, compared to never using cocaine, and OR 1.02, (95 % CI 1.10, 1.05); P = 0.04 in adjusted analysis. A dose-response relationship between increasing duration of cocaine use and depression was observed. Frequency and duration of cocaine use may be associated with depression. We speculate that depression among cocaine users with HIV may involve an inflammatory component that needs further examination.

Asian People Reached by the Centers for Disease Control and Prevention HIV Testing Program in the United States: HIV Testing, Linkage to HIV Medical Care, and Interview for Partner Services 2014-2020.

The purpose of this analysis is to describe HIV tests and associated outcomes for Asian people reached by the Centers for Disease Control and Prevention (CDC) HIV testing program. We analyzed CDC-funded HIV tests among Asian individuals in the United States, Puerto Rico, and the U.S. Virgin Islands (2014-2020). Of the 415,560 tests, the positivity of new diagnoses was higher among males (0.49%, aPR = 7.64) than females (0.06%), and in the West (0.42%, aPR = 1.15) than in the South (0.25%). In non-health care settings, positivity was highest among men who have sex with men (MSM; 0.87%) and transgender people (0.46%). Linkage to HIV medical care among Asian people was 87.5%, and 70.7% were interviewed for partner services. Our findings suggest that improvements are crucial, particularly for Asian MSM, in linkage to care and interview for partner services.

CDC-Funded HIV Testing and Undiagnosed HIV Infection in Ending the HIV Epidemic in the U.S. Jurisdictions.

BACKGROUND: Approximately 13% of persons with HIV (PWH) are unaware of their status. To help end HIV, it is important to understand the relationship between the rates of HIV testing and undiagnosed HIV infection. SETTING: Ending the HIV in the U.S. (EHE) jurisdictions. METHODS: Using 2021 data from the National HIV Surveillance System and the National HIV Prevention Program Monitoring and Evaluation system, we calculated estimated rates of undiagnosed HIV infections per 100,000 population and rates of CDC-funded HIV tests per 1,000 population. We assessed the association between the two rates using Spearman's rank correlation. We also calculated a rank difference between the two rates for each EHE jurisdiction to help identify jurisdictions with greater unfilled needs for HIV testing. RESULTS: Overall, CDC-funded HIV tests per 1,000 population were positively associated with estimated rate of undiagnosed HIV infection per 100,000 population (rho=0.55, p<0.001). EHE jurisdictions with the greatest magnitude of negative rank differences (i.e., higher undiagnosed HIV infection per 100,000 population and lower CDC-funded HIV tests per 1,000 population) were Prince George's County, MD; Mecklenburg County, NC; Hudson County, NJ; Bronx County, NY, and Hamilton County, OH. CONCLUSIONS: In general, CDC-funded HIV testing is being conducted in jurisdictions with the greatest needs. However, we also found large discrepancies between CDC-funded HIV testing and undiagnosed HIV infection rates for some jurisdictions. These jurisdictions may want to identify barriers to their HIV testing services and expand their programs to ensure that all PWH in their jurisdictions are diagnosed.

HIV Testing Services Outcomes in CDC-Funded Health Departments During COVID-19.

BACKGROUND: Organizations offering HIV prevention services have reported interruptions during the COVID-19 pandemic. The national extent of these interruptions and their public health impact remain largely unexplored. METHODS: Using data from 60 state and local health departments, we compared HIV testing services outcomes in calendar years 2019 and 2020, including the number of Centers for Disease Control and Prevention (CDC)-funded HIV tests conducted, the percentage of persons with newly diagnosed HIV infection (ie, HIV positivity), and the percentage linked to HIV medical care within 30 days after new diagnoses (ie, linkage to care) using χ2 and robust Poisson models. We also assessed the independent associations between the pandemic period (ie, March-December 2020) and the number of COVID-19 cases with monthly HIV testing services outcomes using multivariable robust Poisson models. RESULTS: There was a 46.0% (P < 0.001) reduction in the number of CDC-funded HIV tests conducted in 2020 (n = 1,255,895) compared with 2019 (n = 2,324,421). Although there were fewer persons with newly diagnosed HIV in 2020 (n = 5581 vs. n = 7739 in 2019), HIV positivity was greater in 2020 (0.4% vs. 0.3% in 2019; adjusted prevalence ratio [aPR] = 1.33, 95% confidence interval [CI]: 1.05 to 1.69). When adjusting for the monthly number of COVID-19 cases, the pandemic period was associated with a 56% reduction in the number of monthly CDC-funded HIV tests (adjusted rate ratio = 0.44, 95% CI: 0.37 to 0.52) but 28% higher monthly HIV positivity (aPR = 1.28 95% CI: 1.16 to 1.41) and 10% higher linkage to care (aPR = 1.10, 95% CI: 1.02 to 1.18). DISCUSSION: Despite increased HIV positivity, a drastic reduction in the number of CDC-funded HIV tests was observed in 2020, affecting the ability to identify persons with newly diagnosed HIV. CDC and health departments will need to expand testing strategies to cover tests not conducted in 2020 while adapting to the continuing pandemic.A visual abstract is available for this article at: http://links.lww.com/QAI/B941.

Role of real-time reverse transcription polymerase chain reaction for detection of respiratory viruses in critically ill children with respiratory disease: Is it time for a change in algorithm?

OBJECTIVES: To identify the respiratory viral pathogens associated with acute lower respiratory tract infection in critically ill pediatric patients by using real-time reverse transcription-polymerase chain reaction, and compare results with those of direct fluorescence antibody assay testing. DESIGN: Observational cohort study. SETTING: Pediatric intensive care unit at a tertiary care academic hospital. PATIENTS: Pediatric patients admitted to the pediatric intensive care unit with severe respiratory symptoms consistent with viral lower respiratory tract infection. INTERVENTIONS: None. MEASUREMENTS: Respiratory samples of pediatric patients admitted to the pediatric intensive care unit with severe respiratory symptoms between January 2008 and July 2009 were tested with direct fluorescence antibody assay and real-time reverse transcription-polymerase chain reaction. MAIN RESULTS: At least one viral agent was detected in 70.5% of specimens by real-time reverse transcription-polymerase chain reaction and in 16.5% by direct fluorescence antibody assay (p < .001). Real-time reverse transcription-polymerase chain reaction increased the total viral yield five-fold compared to direct fluorescence antibody assay. Rhinovirus was the most commonly identified virus (41.6%). For viruses included in the direct fluorescence antibody assay panel, direct fluorescence antibody assay had a sensitivity of 0.42 (95% confidence interval 0.25-0.61) and a specificity of 1 (95% confidence interval 0.86-1.00) compared with real-time reverse transcription-polymerase chain reaction. Coinfections were not uncommon, in particular with rhinovirus, and these patients tended to have higher mortality. CONCLUSIONS: Direct fluorescence antibody assay testing is a suboptimal method for the detection of respiratory viruses in critically ill children with lower respiratory tract infection. Given the importance of a prompt and accurate viral diagnosis for this group of patients, we suggest that real-time reverse transcription-polymerase chain reaction becomes part of the routine diagnostic algorithm in critically ill children when a viral etiology is suspected, even if conventional tests yield a negative result.

Prevalence of Acanthamoeba spp. and other free-living amoebae in household water, Ohio, USA--1990-1992.

Knowledge of the prevalence of free-living amoebae (FLA) in US household water can provide a focus for prevention of amoeba-associated illnesses. Household water samples from two Ohio counties, collected and examined for amoebae during 1990-1992, were used to describe the prevalence of Acanthamoeba and other FLA in a household setting. Amoebae were isolated and identified by morphologic features. A total of 2,454 samples from 467 households were examined. Amoebae were found in water samples of 371 (79%) households. Sites most likely to contain amoeba were shower heads (52%) and kitchen sprayers (50%). Species of Hartmannella, Acanthamoeba, or Vahlkampfia were most common. Detection was higher in biofilm swab samples than in water samples. Detection of FLA and Acanthamoeba, at 79% and 51%, respectively, exceed estimates that have been published in previous surveys of household sources. We believe FLA are commonplace inhabitants of household water in this sample as they are in the environment.

Response to a Large HIV Outbreak, Cabell County, West Virginia, 2018-2019.

INTRODUCTION: In January 2019, the West Virginia Bureau for Public Health detected increased HIV diagnoses among people who inject drugs in Cabell County. Responding to HIV clusters and outbreaks is 1 of the 4 pillars of the Ending the HIV Epidemic in the U.S. initiative and requires activities from the Diagnose, Treat, and Prevent pillars. This article describes the design and implementation of a comprehensive response, featuring interventions from all pillars. METHODS: This study used West Virginia Bureau for Public Health data to identify HIV diagnoses during January 1, 2018-October 9, 2019 among (1) people who inject drugs linked to Cabell County, (2) their sex or injecting partners, or (3) others with an HIV sequence linked to Cabell County people who inject drugs. Surveillance data, including HIV-1 polymerase sequences, were analyzed to estimate the transmission rate and timing of infections using molecular clock phylogenetic analysis. Federal, state, and local partners designed and implemented a comprehensive response during January 2019-October 2019. RESULTS: Of 82 people identified in the outbreak, most were male (60%), were White (91%), and reported unstable housing (80%). In a large molecular cluster containing 56 of 60 (93%) available sequences, 93% of inferred transmissions occurred after January 1, 2018. HIV testing, HIV pre-exposure prophylaxis, and syringe services were rapidly expanded, leading to improved linkage to HIV care and viral suppression. CONCLUSIONS: Evidence of rapid transmission in this outbreak galvanized robust collaboration among federal, state, and local partners, leading to critical improvements in HIV prevention and care services. HIV outbreak response requires increased coordination and creativity to improve service delivery to people affected by rapid HIV transmission.

Characteristics of Intracranial Group A Streptococcal Infections in US Children, 1997-2014.

BACKGROUND: Few data on intracranial group A Streptococcus (GAS) infection in children are available. Here, we describe the demographic, clinical, and diagnostic characteristics of 91 children with intracranial GAS infection. METHODS: Cases of intracranial GAS infection in persons ≤18 years of age reported between 1997 and 2014 were identified by the Centers for Disease Control and Prevention's population- and laboratory-based Active Bacterial Core surveillance (ABCs) system. Medical charts were abstracted using a active, standardized case report form. All available isolates were emm typed. US census data were used to calculate rates. RESULTS: ABCs identified 2596 children with invasive GAS infection over an 18-year period; 91 (3.5%) had an intracranial infection. Intracranial infections were most frequent during the winter months and among children aged <1 year. The average annual incidence was 0.07 cases per 100000 children. For 83 patients for whom information for further classification was available, the principal clinical presentations included meningitis (35 [42%]), intracranial infection after otitis media, mastoiditis, or sinusitis (34 [41%]), and ventriculoperitoneal shunt infection (14 [17%]). Seven (8%) of these infections progressed to streptococcal toxic shock syndrome. The overall case fatality rate was 15%. GAS emm types 1 (31% of available isolates) and 12 (13% of available isolates) were most common. CONCLUSIONS: Pediatric intracranial (GAS) infections are uncommon but often severe. Risk factors for intracranial GAS infection include the presence of a ventriculoperitoneal shunt and contiguous infections in the middle ear or sinuses.

Utility of DNA microarrays for detection of viruses in acute respiratory tract infections in children.

OBJECTIVE: To assess the utility of a panviral DNA microarray platform (Virochip) in the detection of viruses associated with pediatric respiratory tract infections (RTIs). STUDY DESIGN: The Virochip was compared with conventional direct fluorescent antibody (DFA)- and polymerase chain reaction (PCR)-based testing for the detection of respiratory viruses in 278 consecutive nasopharyngeal aspirate samples from 222 children. RESULTS: The Virochip was superior in performance to DFA, showing a 19% increase in the detection of 7 respiratory viruses included in standard DFA panels, and was similar to virus-specific PCR (sensitivity, 85% to 90%; specificity, >/=99%; positive predictive value, 94% to 96%; negative predictive value, 97% to 98%) in the detection of respiratory syncytial virus, influenza A, and rhinoviruses/enteroviruses. The Virochip also detected viruses not routinely tested for or missed by DFA and PCR, as well as double infections and infections in critically ill patients that DFA failed to detect. CONCLUSIONS: Given its favorable sensitivity and specificity profile and expanded spectrum for detection, microarray-based viral testing holds promise for clinical diagnosis of pediatric RTIs.

An Evaluation of Mpowerment on Individual-Level HIV Risk Behavior, Testing, and Psychosocial Factors Among Young MSM of Color: The Monitoring and Evaluation of MP (MEM) Project.

Young men who have sex with men (MSM) of color are at increased risk for HIV infection. Mpowerment (MP) is an intervention designed to reduce risky sexual behavior and increase HIV testing among young MSM ages 18-29. From 2009 to 2012, three community-based organizations with support from the U.S. Centers for Disease Control and Prevention evaluated MP among N = 298 participants. Following a repeated measures design, data from 3- and 6-month follow-ups were compared to baseline. HIV testing and self-efficacy for safer sex increased at both follow-up time points; self-acceptance as an MSM was higher at follow-up 2. Condomless anal/vaginal sex was lower at follow-up 1 only. Frequency of exchange of safer sex messages among gay/bisexual/transgender friends was lower at follow-up 1, but similar to baseline at follow-up 2. Exposure to MP was associated with improved perceived positive social norms about safer sex and safer sex messages among gay/bisexual/transgender friends.

Development and clinical evaluation of a novel fully automated qualitative PCR assay for the diagnosis of anogenital herpes simplex virus infection.

Molecular detection of viral infections has the potential to improve microbial diagnostics, particularly with the emergence of rapid automated systems. We describe the design of the IDbox fully automated cassette-based system for nucleic acid extraction and real-time PCR amplification and perform a clinical evaluation for the diagnosis of genital herpes simplex infections. At optimal cutoff values determined by receiver-operator curves, the IDbox showed sensitivities of 94.9% (95% confidence interval [CI] 84.9-98.7%) and 97.0% (95% CI 88.5-99.5%) and specificities of 96.7% (95% CI 91.2-98.9%) and 97.3% (95% CI 91.9-99.3%) relative to herpes simplex virus culture and PCR, respectively. We discuss relevant design characteristics and approaches used for each step of the analytical process to enhance assay sensitivity and provide accurate results in the presence of potential cross-reactive organisms and interfering substances.

Analytical and clinical performance characteristics of the Simplexa BK virus quantitative PCR assay for the diagnosis of polyomavirus-associated nephropathy in renal transplant recipients using plasma and urine specimens.

BACKGROUND: Polyomavirus-associated nephropathy is a significant cause of kidney rejection in renal transplant recipients. Quantification of BK viral load in plasma and urine can predict the development of polyomavirus-associated nephropathy, though each assay requires careful evaluation of analytical and clinical performance characteristics for optimal use. OBJECTIVES: This study evaluated the analytical and clinical performance characteristics of the Simplexa BK virus quantitative PCR assay. STUDY DESIGN: Analytical validation was performed using commercial standards, BK virus stock culture, and patient specimens. Clinical performance was evaluated using biopsy-proven BK nephropathy as the gold standard. RESULTS: The Simplexa BK virus quantitative PCR assay was linear over a range of 2.7-10.4 log(10) copies/mL. Limit of detection was 2.7-2.8 log(10) copies/mL in plasma and urine samples. Sensitivities were 100% and 100% and specificities were 84% and 86% for plasma and urine samples, respectively, when compared to a reference BK assay. Clinical cutoff values of 4.0 log(10) copies/mL (plasma) and 7.5 log(10) copies/mL (urine) yielded 100% sensitivity and specificities of 87.5% and 85%, respectively, for biopsy-proven polyomavirus nephropathy. CONCLUSIONS: The Simplexa BK virus quantitative PCR assay has high sensitivity and acceptable analytical characteristics for clinical use. The clinical cutoff values presented here provide a rational approach to the monitoring and treatment of renal transplant recipients for polyomavirus-associated nephropathy.

Comparison of QIAGEN automated nucleic acid extraction methods for CMV quantitative PCR testing.

We examined the effect of nucleic acid extraction methods on the analytic characteristics of a quantitative polymerase chain reaction (PCR) assay for cytomegalovirus (CMV). Human serum samples were extracted with 2 automated instruments (BioRobot EZ1 and QIAsymphony SP, QIAGEN, Valencia, CA) and CMV PCR results compared with those of pp65 antigenemia testing. Both extraction methods yielded results that were comparably linear and precise, whereas the QIAsymphony SP had a slightly lower limit of detection (1.92 log(10) copies/mL vs 2.26 log(10) copies/mL). In both cases, PCR was more sensitive than CMV antigen detection, detecting CMV viremia in 12% (EZ1) and 21% (QIAsymphony) of antigen-negative specimens. This study demonstrates the feasibility of using 2 different extraction techniques to yield results within 0.5 log(10) copies/mL of the mean value, a level that would allow for clinical comparison between different laboratory assays.

Risk factors for pediatric invasive group A streptococcal disease.

Invasive group A Streptococcus (GAS) infections can be fatal and can occur in healthy children. A case-control study identified factors associated with pediatric disease. Case-patients were identified when Streptococcus pyogenes was isolated from a normally sterile site, and matched controls (>or=2) were identified by using sequential-digit dialing. All participants were noninstitutionalized surveillance-area residents <18 years of age. Conditional regression identified factors associated with invasive disease: other children living in the home (odds ratio [OR]=16.85, p=0.0002) and new use of nonsteroidal antiinflammatory drugs (OR=10.64, p=0.005) were associated with increased risk. More rooms in the home (OR=0.67, p=0.03) and household member(s) with runny nose (OR=0.09, p=0.002) were associated with decreased risk. Among children, household-level characteristics that influence exposure to GAS most affect development of invasive disease.

Cardiac surgery 2002: staged repair of hypoplastic left heart syndrome.

Congenital heart surgery is an evolving field. As techniques improve and procedures are modified, enhanced patient outcomes are evident. Technological advancements, pharmacologic interventions, and hemodynamic support provide better patient outcomes. Hypoplastic left heart syndrome (HLHS) is one of many complex, poorly understood congenital heart defects presenting in the first weeks of life. It causes 25% of infant deaths. This article presents a staged approach for intervention in neonates with HLHS.