A Multicenter Retrospective Cohort Study to Characterize Patients Hospitalized With Multisystem Inflammatory Syndrome in Adults and Coronavirus Disease 2019 in the United States, 2020-2021.

BACKGROUND: The diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-associated multisystem inflammatory syndrome in adults (MIS-A) requires distinguishing it from acute coronavirus disease 2019 (COVID-19) and may affect clinical management. METHODS: In this retrospective cohort study, we applied the US Centers for Disease Control and Prevention case definition to identify adults hospitalized with MIS-A at 6 academic medical centers from 1 March 2020 to 31 December 2021. Patients MIS-A were matched by age group, sex, site, and admission date at a 1:2 ratio to patients hospitalized with acute symptomatic COVID-19. Conditional logistic regression was used to compare demographic characteristics, presenting symptoms, laboratory and imaging results, treatments administered, and outcomes between cohorts. RESULTS: Through medical record review of 10 223 patients hospitalized with SARS-CoV-2-associated illness, we identified 53 MIS-A cases. Compared with 106 matched patients with COVID-19, those with MIS-A were more likely to be non-Hispanic black and less likely to be non-Hispanic white. They more likely had laboratory-confirmed COVID-19 ≥14 days before hospitalization, more likely had positive in-hospital SARS-CoV-2 serologic testing, and more often presented with gastrointestinal symptoms and chest pain. They were less likely to have underlying medical conditions and to present with cough and dyspnea. On admission, patients with MIS-A had higher neutrophil-to-lymphocyte ratio and higher levels of C-reactive protein, ferritin, procalcitonin, and D-dimer than patients with COVID-19. They also had longer hospitalization and more likely required intensive care admission, invasive mechanical ventilation, and vasopressors. The mortality rate was 6% in both cohorts. CONCLUSIONS: Compared with patients with acute symptomatic COVID-19, adults with MIS-A more often manifest certain symptoms and laboratory findings early during hospitalization. These features may facilitate diagnosis and management.

Clinical presentation of Monkeypox among people living with HIV in South Florida: a case series.

Introduction: Monkeypox, historically a zoonotic disease caused by monkeypox virus, is a new global health emergency. Since May 2022, dozens of non-endemic countries have seen new cases with rapid spread. Generally a self-limited disease, there are vulnerable populations, in which severe or deadly illness can occur. There is limited data on immunocompromised patients in this outbreak, particularly on people living with HIV, who are disproportionately affected. Methods: We reported seven cases of monkeypox in people living with HIV in South Florida, USA. Relevant demographic, epidemiologic and clinical data were described. Results: All the patients were men, identified as gay or bisexual, and were on combination antiretroviral therapy (cART) for HIV. Six of the seven had CD4 counts more than 200 cells/mm3 (one unknown level), and one of the seven had detectable HIV viral load. Six had sexual or intimate contact with asymptomatic partners prior to development of symptoms. Two were hospitalized, one for proctitis and one for an increasing number of lesions. Six had disseminated lesions and one had localized perianal lesions and all had 5-25 total number of lesions. Five received tecovirimat with resolution of lesions in 2-14 days and all were doing well at the time of the present report. Close contacts received the Jynneos vaccine which was well tolerated. Conclusions: Our case series described monkeypox in people living with HIV and have noted atypical symptoms (lack of fever and more notable anogenital lesions) and relatively mild course as described in HIV seronegative patients. We stress the importance of early detection and isolation as well as vaccination to contacts, which has been well tolerated. In our case series, we are unable to estimate the effectiveness of tecovirimat given the limited number of patients, but all our patients had lesions that resolved within two weeks of rash onset and had no side effects reported.

A Longitudinal Analysis of SARS-CoV-2 Antibody Responses Among People With HIV.

Background: The concentration and duration of antibodies (Ab) to SARS-CoV-2 infection predicts the severity of the disease and the clinical outcomes. Older people and those with HIV have impaired immune responses, worse outcomes after SARS-CoV-2 infection, and lower antibody responses after viral infection and vaccination. This study evaluated an Ab response to SARS-CoV-2 in people with HIV (PWH) and without HIV (HIV-) and its association with age. Methods: A total of 23 COVID+PWH and 21 COVID+HIV- participants were followed longitudinally for 6 months post-mild COVID-19. Immunoglobin G (IgG) and immunoglobin M (IgM) Ab responses were measured by an in-house developed ELISA. Time points and HIV status interaction were analyzed using Poisson generalized estimating equations, and correlations were analyzed using non-parametric tests. Results: Median age in PWH was 55 years with 28.6% women, while in the HIV- group was 36 years with 60.9% women. The mean time from COVID-19 diagnosis to study enrollment was 16 days for PWH and 11 days for HIV-. The mean CD4+ T-cell count/µl for PWH was 772.10 (±365.21). SARS-CoV-2 IgM and IgG were detected at all time points and Ab response levels did not differ by HIV status (p > 0.05). At entry, age showed a weak direct association with IgG responses (ρ = 0.44, p < 0.05) in HIV- but did not show any association in PWH. Similar associations between age, IgG, and HIV status emerged at day 14 (T1; ρ = 0.50, p < 0.05), 3 months (T3; ρ = 0.50, p < 0.05), and 6 months visit (T4; ρ = 0.78, p < 0.05) in the HIV- group. Conclusion: The Ab responses in the 6-month post-SARS-CoV-2 infection did not differ by HIV status, though a positive association was found between age and Ab response in older PWH. Results suggest that immune protection and vaccine responses are similar for PWH than for those without HIV infection.

Recovery does not always signal the end of the battle: A case of post SARS-CoV-2 multisystem inflammatory syndrome in an adult.

We describe a case of SARS-CoV-2 post-infectious inflammatory syndrome in an adult who presented with multiorgan failure two months following his initial diagnosis of SARS-CoV-2 infection. This case highlights clinician's early recognition of this devastating sequela and challenges in appropriate management of this patient.

Sex Differences in the Association Between Stress, Loneliness, and COVID-19 Burden Among People with HIV in the United States.

Little is known about the psychological implications of the coronavirus disease 2019 (COVID-19) pandemic on people with HIV. The purpose of this study was to assess the impact of COVID-19 among men and women with HIV in Miami, Florida. We hypothesized that the burden of the COVID-19 pandemic will be higher for women, and psychological factors will increase COVID-19 burden among them. People with (n = 231) and without HIV (n = 42) residing in Miami, Florida completed a survey assessing psychological outcomes such as loneliness, depression, and stress, as well as the burden of COVID-19, on their daily lives. t-Tests and chi-square analyses were used to assess sex differences in study variables. Logistic regression was used to compare the interaction effects predicting stress and loneliness by COVID-19 burden and sex. A total of 273 completed the survey; the outcomes of the study, loneliness, and stress did not differ by HIV status (p = .458 and p = .922). Overall, men and women reported similar prevalence of COVID-19 burden. However, a greater proportion of women reported losing childcare than men (18% vs. 9%, p = .029, respectively), as well as losing mental health care (15% vs. 7%, p = .049, respectively). There was a significant interaction between COVID-19 burden and sex for loneliness and stress such that the association between COVID-19 burden and loneliness was greater for women (p < .001) than for men (p = .353) and the association between COVID-19 burden and stress was greater for women (p = .013) than men (p = .628). Both men and women with HIV are impacted by the COVID-19 pandemic, but women may experience higher levels of stress and loneliness than men. Sex differences may require tailored interventions to more effectively mitigate the impact of the pandemic on mental health.

Case Series of Multisystem Inflammatory Syndrome in Adults Associated with SARS-CoV-2 Infection - United Kingdom and United States, March-August 2020.

During the course of the coronavirus disease 2019 (COVID-19) pandemic, reports of a new multisystem inflammatory syndrome in children (MIS-C) have been increasing in Europe and the United States (1-3). Clinical features in children have varied but predominantly include shock, cardiac dysfunction, abdominal pain, and elevated inflammatory markers, including C-reactive protein (CRP), ferritin, D-dimer, and interleukin-6 (1). Since June 2020, several case reports have described a similar syndrome in adults; this review describes in detail nine patients reported to CDC, seven from published case reports, and summarizes the findings in 11 patients described in three case series in peer-reviewed journals (4-6). These 27 patients had cardiovascular, gastrointestinal, dermatologic, and neurologic symptoms without severe respiratory illness and concurrently received positive test results for SARS-CoV-2, the virus that causes COVID-19, by polymerase chain reaction (PCR) or antibody assays indicating recent infection. Reports of these patients highlight the recognition of an illness referred to here as multisystem inflammatory syndrome in adults (MIS-A), the heterogeneity of clinical signs and symptoms, and the role for antibody testing in identifying similar cases among adults. Clinicians and health departments should consider MIS-A in adults with compatible signs and symptoms. These patients might not have positive SARS-CoV-2 PCR or antigen test results, and antibody testing might be needed to confirm previous SARS-CoV-2 infection. Because of the temporal association between MIS-A and SARS-CoV-2 infections, interventions that prevent COVID-19 might prevent MIS-A. Further research is needed to understand the pathogenesis and long-term effects of this newly described condition.

A Pharmacist-Led, Same-Day, HIV Pre-Exposure Prophylaxis Initiation Program to Increase PrEP Uptake and Decrease Time to PrEP Initiation.

Mississippi has one of the highest rates of HIV in the United States, but has low pre-exposure prophylaxis (PrEP) uptake, particularly among black men who have sex with men (MSM) and women. From November 2018 to May 2019, patients at high risk of HIV who tested negative for HIV at a nonclinical testing center in Jackson, Mississippi, were referred to an on-site clinical pharmacist for same-day PrEP initiation. The pharmacist evaluated patients for medical contraindications to PrEP, but no baseline labs were obtained. The pharmacist provided a PrEP prescription and scheduled a clinical appointment for patients within 6 weeks, at which time they were evaluated by a clinician and completed baseline labs. The pharmacist evaluated 69 patients for PrEP; 57% were MSM, 77% were black, and 65% were uninsured. All patients received a PrEP prescription; 83% received the prescription the same day and 97% received it within 5 days. Fifty-three (77%) of 69 clients filled the prescription; 87% of whom filled it within 1 week. Only 23 (43%) of 53 clients who filled their prescription attended their initial clinical appointment within 6 weeks of obtaining PrEP. There were no differences in PrEP initiation or retention by patient sex/gender. This pilot program suggests that an on-site pharmacist working in a nonclinical testing center in the southern United States can successfully initiate PrEP among predominately low-income black MSM. Future efforts should seek to better integrate laboratory testing into this demedicalized model of PrEP and to improve retention in care.

"We don't treat your kind": Assessing HIV health needs holistically among transgender people in Jackson, Mississippi.

HIV disproportionately impacts transgender communities and the majority of new infections occur in the Southern United States. Yet, limited data exists on contextual realities of HIV vulnerability and healthcare needs among transgender individuals in the Deep South. Addressing this gap in the literature, we assess the health needs, including barriers and facilitators to accessing healthcare, including and beyond HIV, from the perspective of transgender men and women in Mississippi. Between June-August 2014, in-depth, semi-structured qualitative interviews (n = 14) were conducted with adult transgender persons at an LGBT healthcare setting in Jackson, Mississippi. In-depth interviews lasted between 60-90 minutes and followed semi-structured format (themes probed: HIV vulnerability, healthcare needs, and availability of gender-affirming medical care). Audio files were transcribed verbatim and analyzed using Dedoose (v.6.1.18). Among participants (mean age = 23.3 years, standard deviation = 4.98), 43% identified as a transgender man or on a transmasculine spectrum, 43% as Black, and 21% self-reported living with HIV. HIV-related services were frequently described as the primary gateway to accessing healthcare needs. Nonetheless, participants' primary health concerns were: gender affirmation processes (hormones, silicone, binding/packing); mental health; and drug/alcohol use. Stigma and discrimination were commonly reported in healthcare settings and health-related information was primarily attained through social networks and online resources. Results highlight gender identity alongside race and pervasive marginalization as key social determinants of transgender health in Mississippi. As Mississippi is one of several states actively debating transgender access to public accommodations, findings underscore the need to treat transgender health as a holistic and multidimensional construct, including, but moving beyond, HIV prevention and care.

Single-dose versus 7-day-dose metronidazole for the treatment of trichomoniasis in women: an open-label, randomised controlled trial.

BACKGROUND: Among women, trichomoniasis is the most common non-viral sexually transmitted infection worldwide, and is associated with serious reproductive morbidity, poor birth outcomes, and amplified HIV transmission. Single-dose metronidazole is the first-line treatment for trichomoniasis. However, bacterial vaginosis can alter treatment efficacy in HIV-infected women, and single-dose metronidazole treatment might not always clear infection. We compared single-dose metronidazole with a 7-day dose for the treatment of trichomoniasis among HIV-uninfected, non-pregnant women and tested whether efficacy was modified by bacterial vaginosis. METHODS: In this multicentre, open-label, randomised controlled trial, participants were recruited at three sexual health clinics in the USA. We included women positive for Trichomonas vaginalis infection according to clinical screening. Participants were randomly assigned (1:1) to receive either a single dose of 2 g of metronidazole (single-dose group) or 500 mg of metronidazole twice daily for 7 days (7-day-dose group). The randomisation was done by blocks of four or six for each site. Patients and investigators were aware of treatment assignment. The primary outcome was T vaginalis infection by intention to treat, at test-of-cure 4 weeks after completion of treatment. The analysis of the primary outcome per nucleic acid amplification test or culture was also stratified by bacterial vaginosis status. This trial is registered with ClinicalTrials.gov, number NCT01018095, and with the US Food and Drug Administration, number IND118276, and is closed to accrual. FINDINGS: Participants were recruited from Oct 6, 2014, to April 26, 2017. Of the 1028 patients assessed for eligibility, 623 women were randomly assigned to treatment groups (311 women in the single-dose group and 312 women in the 7-day-dose group; intention-to-treat population). Although planned enrolment had been 1664 women, the study was stopped early because of funding limitations. Patients in the 7-day-dose group were less likely to be T vaginalis positive at test-of-cure than those in the single-dose group (34 [11%] of 312 vs 58 [19%] of 311, relative risk 0·55, 95% CI 0·34-0·70; p<0·0001). Bacterial vaginosis status had no significant effect on relative risk (p=0·17). Self-reported adherence was 96% in the 7-day-dose group and 99% in the single-dose group. Side-effects were similar by group; the most common side-effect was nausea (124 [23%]), followed by headache (38 [7%]) and vomiting (19 [4%]). INTERPRETATION: The 7-day-dose metronidazole should be the preferred treatment for trichomoniasis among women. FUNDING: National Institutes of Health.

Women's willingness to experiment with condoms and lubricants: A study of women residing in a high HIV seroprevalence area.

The objective of this study was to investigate women's willingness to experiment with new condoms and lubricants, in order to inform condom promotion in a city with high rates of poverty and HIV. One hundred and seventy-three women (85.9% Black) sexually transmitted infection clinic attendees in Jackson, Mississippi, United States completed a questionnaire assessing willingness to experiment with condoms and lubricants and sexual pleasure and lubrication in relation to last condom use. Most women were willing to: (1) experiment with new types of condoms and lubricants to increase their sexual pleasure, (2) touch/handle these products in the absence of a partner, and (3) suggest experimenting with new condoms and lubricants to a sex partner. Previous positive sexual experiences with lubricant during condom use predicted willingness. The role women may play in male condom use should not be underestimated. Clinicians may benefit women by encouraging them to try new types of condoms and lubricants to find products consistent with sexual pleasure.

Social, structural, behavioral and clinical factors influencing retention in Pre-Exposure Prophylaxis (PrEP) care in Mississippi.

Pre-exposure prophylaxis (PrEP) is a biomedical intervention that can reduce rates of HIV transmission when taken once daily by HIV-negative individuals. Little is understood about PrEP uptake and retention in care among the populations most heavily impacted by the HIV epidemic, particularly among young men who have sex with men (YMSM) in the Deep South. Therefore, this study explored the structural, social, behavioral, and clinical factors that affect PrEP use and retention in care among YMSM in Jackson, Mississippi. Thirty MSM who were prescribed PrEP at an outpatient primary care clinic were interviewed and included 23 men who had been retained in PrEP care and seven who had not been retained. The mean age of participants was 26.6 years. Most (23) participants were African American. Major factors affecting PrEP use and retention in PrEP care included 1) structural factors such as cost and access to financial assistance for medications and clinical services; 2) social factors such as stigma and relationship status; 3) behavioral factors including sexual risk behaviors; and 4) clinical factors such as perceived and actual side effects. Many participants also discussed the positive spillover effects of PrEP use and reported that PrEP had a positive impact on their health. Four of the seven individuals who had not been retained re-enrolled in PrEP care after completing their interviews, suggesting that case management and ongoing outreach can enhance retention in PrEP care. Interventions to enhance retention in PrEP care among MSM in the Deep South will be most effective if they address the complex structural, social, clinical, and behavioral factors that influence PrEP uptake and retention in PrEP care.

Implementation of Preexposure Prophylaxis for Human Immunodeficiency Virus Prevention Among Men Who Have Sex With Men at a New England Sexually Transmitted Diseases Clinic.

BACKGROUND: Preexposure prophylaxis (PrEP) is efficacious in preventing human immunodeficiency virus (HIV) among men who have sex with men (MSM). We assessed PrEP uptake among MSM presenting for services at a sexually transmitted diseases (STD) clinic. METHODS: Men who have sex with men presenting to the Rhode Island STD Clinic between October 2013 and November 2014 were educated about, and offered, PrEP. We categorized PrEP engagement using an implementation cascade to describe gaps in uptake which described MSM who: (1) were educated about PrEP, (2) indicated interest, (3) successfully received follow-up contact, (4) scheduled an appointment, (5) attended an appointment, and (6) initiated PrEP (ie, received a prescription). Bivariate and multivariable logistic regression models were used to examine predictors of PrEP initiation. RESULTS: A total of 234 MSM were educated about PrEP; of these, 56% expressed interest. Common reasons for lack of interest were low HIV risk perception (37%), wanting more time to consider (10%), concern about side effects (7%), and financial barriers (3%). Among those interested, 53% followed up. Of those, 51% scheduled an appointment. The most common reason patients did not schedule an appointment was low HIV risk perception (38%). Seventy-seven percent of those with an appointment attended the appointment; of those, 93% initiated PrEP. Patients with higher HIV-risk perception (adjusted odds ratios, 2.17; 95% confidence interval, 1.29-3.64) and a history of sex with an HIV-positive partner (adjusted odds ratios, 7.08; 95% confidence interval, 2.35-21.34) had significantly higher odds of initiating PrEP. CONCLUSIONS: Low HIV-risk perception was the most significant barrier to PrEP uptake among MSM attending a public STD clinic.

Retention in care outcomes for HIV pre-exposure prophylaxis implementation programmes among men who have sex with men in three US cities.

INTRODUCTION: Despite the efficacy of pre-exposure prophylaxis (PrEP) in preventing HIV transmission, few studies have evaluated PrEP use and retention in care outcomes in real-world settings outside of clinical trials. METHODS: Data were collected from PrEP clinical care programmes in three mid-size US cities: Providence, Rhode Island (RI); Jackson, Mississippi (MS); and St. Louis, Missouri (MO). We assessed the demographic and social characteristics of patients prescribed PrEP and documented their insurance and copayment experiences. We assessed retention in PrEP care at three and six months. Multivariate analyses were used to predict retention in care among men who have sex with men (MSM). HIV acquisition among the cohort was also assessed. RESULTS: A total of 267 (RI: 117; MS: 88; MO: 62) patients were prescribed PrEP; 81% filled prescriptions (RI: 73%; MS: 82%; MO: 94%; p<0.001). Patients in MS and MO were more commonly African American than in RI (72% and 26% vs. 7%, respectively), but less frequently Latino (2% and 3% vs. 24%, respectively). More patients reported living below the federal poverty line in MS (52%) compared to MO (23%) and RI (26%). Most patients were MSM (RI: 92%; MS: 88%; MO: 84%). The majority of MSM reported recent condomless anal sex (RI: 70%; MS: 65%; MO: 75%). Among 171 patients prescribed PrEP at least six months beforehand, 72% were retained in care at three months (RI: 68%; MS: 70%; MO: 87%; p=0.12) and 57% were retained in PrEP care at six months (RI: 53%: MS: 61%; MO: 63%; p=0.51). Insurance status and medication costs were not found to be significant barriers for obtaining PrEP. Three patients became infected with HIV during the six-month period after being prescribed PrEP (1.1%; 3/267), including one in RI (suspected acute HIV infection), one in MO (confirmed poor adherence) and one in MS (seroconverted just prior to initiation). CONCLUSIONS: PrEP initiation and retention in care differed across these distinct settings. In contrast, retention in PrEP care was consistently suboptimal across sites. Further research is needed to identify the individual, social and structural factors that may impede or enhance retention in PrEP care.