Geographic variation in HCV treatment penetration among people who inject drugs in Baltimore, MD.

We evaluated geographic heterogeneity in hepatitis C virus (HCV) treatment penetration among people who inject drug (PWID) across Baltimore, MD since the advent of direct-acting antivirals (DAAs) using space-time clusters of HCV viraemia. Using data from a community-based cohort of PWID, the AIDS Linked to the IntraVenous Experience (ALIVE) study, we identified space-time clusters with higher-than-expected rates of HCV viraemia between 2015 and 2019 using scan statistics. We used Poisson regression to identify covariates associated with HCV viraemia and used the regression-fitted values to detect adjusted space-time clusters of HCV viraemia in Baltimore city. Overall, in the cohort, HCV viraemia fell from 77% in 2015 to 64%, 49%, 39% and 36% from 2016 to 2019. In Baltimore city, the percentage of census tracts where prevalence of HCV viraemia was ≥85% dropped from 57% to 34%, 25%, 22% and 10% from 2015 to 2019. We identified two clusters of higher-than-expected HCV viraemia in the unadjusted analysis that lasted from 2015 to 2017 in East and West Baltimore and one adjusted cluster of HCV viraemia in West Baltimore from 2015 to 2016. Neither differences in age, sex, race, HIV status, nor neighbourhood deprivation were able to explain the significant space-time clusters. However, residing in a cluster with higher-than-expected viraemia was associated with age, sex, educational attainment and higher levels of neighbourhood deprivation. Nearly 4 years after DAAs became available, HCV treatment has penetrated all PWID communities across Baltimore city. While nearly all census tracts experienced improvements, change was more gradual in areas with higher levels of poverty.

The Relationship Between Intersectional Drug Use and HIV Stigma and HIV Care Engagement Among Women Living with HIV in Ukraine.

This study used an intersectional approach to explore the association between enacted and internalized drug use and HIV stigma on HIV care outcomes among HIV-positive women who inject drugs in Ukraine. Surveys were conducted in Kyiv in 2019-2020. Among the 306 respondents, 55% were engaged in HIV care. More than half (52%) of participants not engaged in care reported internalized stigma related to both drug use and HIV status (i.e., intersectional stigma), compared to only 35% of those who were engaged in HIV care. Among those engaged in care, 36% reported intersectional enacted stigma compared to 44% of those not engaged in care; however, this difference was not statistically significant in the univariable analysis (p = 0.06). In the univariable analysis, participants who reported intersectional internalized stigma had 62% lower odds of being engaged in HIV care (OR 0.38, 95% CI 0.22, 0.65, p < 0.001). In the adjusted model, reported intersectional internalized stigma (aOR 0.52, 95% CI 0.30, 0.92, p = 0.026), reported intersectional enacted stigma (aOR 0.47, 95% CI 0.23, 0.95, p = 0.036), and knowing their HIV status for more than 5-years (aOR 2.29, 95% CI 1.35, 3.87, p = 0.002) were significant predictors of HIV care engagement. These findings indicate that interventions to improve HIV care engagement must address women's experiences of both HIV and drug use stigma and the different mechanisms through which stigma operates.

Temporal trends in HCV treatment uptake and success among people who inject drugs in Baltimore, MD since the introduction of direct acting antivirals.

Background: Although hepatitis C virus (HCV) can be cured by direct acting antivirals (DAA), uptake is not well characterized for people who inject drugs (PWID). Methods: Among 1,130 participants of a community-based cohort of PWID with chronic HCV, we longitudinally characterized HCV treatment uptake and cure early (2014-2016) and later (2017-2020). Results: Cumulative HCV treatment uptake increased from 4% in 2014 to 68% in 2020 and the percent with HCV viremia declined from nearly 100% to 33%. Predictors of treatment uptake varied across periods. Age (incidence rate ratio [IRR] per 5-year increase: 1.28; 95% confidence interval [CI]: 1.15, 1.42), educational attainment (IRR for ≥ high school diploma: 1.31; 95% CI: 1.04, 1.66), HIV coinfection with suppressed viral load (IRR vs. HIV negative: 2.08; 95% CI: 1.63, 2.66) and alcohol dependence (IRR vs. no alcohol use: 0.63; 95% CI: 0.43, 0.91) were associated with treatment uptake in the early period, but not later. HIV coinfection with a detectable viral load (IRR vs. HIV negative: 0.46; 95% CI: 0.23, 0.95) and daily injecting (IRR: 0.46 vs. no injection; 95% CI: 0.27, 0.79) were significantly associated with lower treatment uptake later. Homelessness was associated with significantly reduced likelihood of viral clearance in the late DAA era (IRR: 0.51; 95% CI: 0.30, 0.88). Conclusion: Treatment uptake improved substantially in this cohort of PWID in the first five years of DAA availability with commensurate declines in viremia. Additional efforts are needed to treat those actively injecting and unstably housed in order to realize elimination goals.

The association between climate change attitudes and COVID-19 attitudes: The link is more than political ideology✰,✰✰,☠.

The COVID-19 pandemic and climate change are two current global threats. This study examined the relationship between climate change attitudes and COVID-19 behaviors and risk perceptions. Drivers of climate change attitudes and COVID-19 behaviors were also assessed. Study participants were an online sample of 520 respondents from a longitudinal study of COVID-19 and well-being in the US. Logistic regression models were used to examine the outcomes of climate change opinions and COVID-19 perceptions and prevention behaviors (perceived COVID-19 risk, mask wearing, social distancing, and vaccine intentions). Covariates included political ideology, conspiracy beliefs, and trust in scientific information about COVID-19. In the multivariable models of COVID-19 perceptions and prevention behaviors, climate change opinions were also included as a covariate. In these models, climate change attitudes were significantly associated with perceived risk of COVID-19, always wearing masks, decreased time spent with others due to COVID-19, and intention to get a COVID-19 vaccine. In adjusted models, the odds of wearing a mask increased 41% (CI: 1.11-1.78) for every 1-point increase on the climate attitude scale and decreased 13% (CI: 0.79-0.96) if the participant distrusted COVID-19 information. Those who reported distrust of COVID-19 information (aOR: 1.61, CI: 1.40-1.85), politically conservative ideology (aOR: 1.24, CI: 1.04-1.47), lower concern about climate change (aOR: 0.71, CI: 0.53-0.97), female sex (aOR: 2.39 CI: 1.38-4.13), and lower disbelief in conspiracy theories (aOR: 0.63, CI: 0.51-0.80) had higher odds of not intending to be vaccinated. These findings suggest that climate change attitudes are linked to COVID-19 behaviors and perceptions, which are not completely driven by political ideology or trust in scientific information.

The Relationship between Social Norms, Avoidance, Future Orientation, and Willingness to Engage in Climate Change Advocacy Communications.

This study examined factors associated with willingness to engage in communication behaviors related to climate change advocacy. Data were collected as part of an online, longitudinal US study beginning in March 2020. Outcomes included willingness to post materials online, contact state legislators, and talk with peers about climate change. Covariates included climate change-related social norms, avoidance of climate change information, and perceptions of the future impact of climate change. A minority of the 586 respondents (23%) reported regular conversations about climate change, while approximately half of the respondents reported willingness to discuss climate change with peers (58%), post materials online (47%), and contact state legislators (46%). Strong predictors of willingness to engage in each climate change communications behaviors included climate change social norms, not avoiding climate change information, and believing that climate change will have a negative impact on the future. Findings indicate the importance of designing programs to foster increased climate change communications in order to promote community-level climate change advocacy norms.

The Hepatitis C Virus Care Continuum: Linkage to Hepatitis C Virus Care and Treatment Among Patients at an Urban Health Network, Philadelphia, PA.

Improving care and treatment for persons infected with hepatitis C virus (HCV) can reduce HCV-related morbidity and mortality. Our primary objective was to examine the HCV care continuum among patients receiving care at five federally qualified health centers (FQHCs) in Philadelphia, PA, where a testing and linkage to care program had been established. Among the five FQHCs, one served a homeless population, two served public housing residents, one served a majority Hispanic population, and the last, a "test and treat" site, also provided HCV treatment to patients. We analyzed data from electronic health records of patients tested for HCV antibody from 2012 to 2016 and calculated the percentage of patients across nine steps of the HCV care continuum ranging from diagnosis to cure. We further explored factors associated with successful patient navigation through two steps of the continuum using multivariable logistic regression. Of 885 chronically infected patients, 92.2% received their RNA-positive result, 82.7% were referred to an HCV provider, 69.4% were medically evaluated by the provider, 55.3% underwent liver disease staging, 15.0% initiated treatment, 12.0% completed treatment, 8.7% were assessed for sustained virologic response (SVR), and 8.0% achieved SVR. Regression results revealed that test and treat site patients were significantly more likely to be medically evaluated (adjusted odds ratio [aOR], 2.76; 95% confidence interval [CI], 1.82-4.17) and to undergo liver disease staging (aOR, 1.92; 95% CI, 1.02-2.86) than patients at the other FQHCs combined. Conclusion: In this US urban setting, over two thirds of HCV-infected patients were linked to care; although treatment uptake was low overall, it was highest at the test and treat site; scaling up treatment services in HCV testing settings will be vital to improve the HCV care continuum.

Integrating Routine HCV Testing in Primary Care: Lessons Learned from Five Federally Qualified Health Centers in Philadelphia, Pennsylvania, 2012-2014.

OBJECTIVE: An estimated 2.7-3.9 million Americans are infected with hepatitis C virus (HCV). Despite being the most common blood-borne virus in the United States, routine HCV testing is not commonly practiced. To address this gap, we measured the impact of integrated routine HCV testing on patient care. METHODS: As part of CDC's Hepatitis Testing and Linkage to Care initiative, which promoted viral hepatitis B and hepatitis C screening, posttest counseling, and linkage to care at 34 U.S. sites, National Nursing Centers Consortium integrated a routine opt-out HCV testing and linkage-to-care model at five federally qualified health centers in Philadelphia, Pennsylvania, from October 1, 2012, to June 30, 2014. The model included medical assistant-initiated testing, reflex laboratory-based HCV tests, and electronic health record modifications to prompt, track, and facilitate reimbursement for tests performed on uninsured patients. RESULTS: During the study period, 4,207 unique patients received HCV antibody (anti-HCV) testing, of whom 488 (11.6%) tested anti-HCV positive. Of those testing positive, 433 (88.7%) received a confirmatory HCV RNA test; of these 433 recipients, 313 (72.3%) were diagnosed with current infection (overall prevalence = 7.4%), of which 243 (77.6%) received their HCV RNA-positive results, 184 (58.8%) were referred to an HCV care provider, and 121 (38.7%) were linked to care. The highest rates of current infection were among non-Hispanic white patients (18.1%, 90/496); patients from the Public Health Management Corporation Care Clinic, which treats HIV and HCV patients on-site (14.3%, 200/1,394); and patients aged 50-69 years (10.7%, 189/1,767). CONCLUSION: Our model successfully integrated HCV testing and linkage to care into routine primary care. This study also identified potential successes and barriers that may be experienced by other primary care health centers that are integrating HCV testing.

Attitudes Toward HIV Pre-Exposure Prophylaxis in a United States Urban Clinic Population.

A majority of US studies on attitudes toward PrEP focus on men who have sex with men with little representation of African Americans. This cross-sectional study seeks to determine openness to PrEP, and examine motivations for openness among Philadelphia residents. Patients undergoing HIV rapid testing between May 2012 and December 2014 in a public setting were administered a survey. Questions included openness to PrEP and reasons for openness to PrEP. Multivariate logistic regression models were used to investigate associations between openness and potential predictors. Analyses were conducted using R version 3.2.4 and the epitools and car packages. Of 5606 respondents, over 90 % were African American. Men were more likely to express openness (61.4 % of men, 54.8 % of women, p < 0.0001). Predictors of openness were younger age, black race, higher perceived risk for HIV by patient or as assessed by Tester, intermittent /no condom use, greater number of partners in 12 months and previous HIV testing. The main reason for openness was fear of HIV, and for disinterest was lack of recognition of risk. Understanding openness to PrEP, and reasons for openness to or disinterest in PrEP are critical to determining the best approaches to facilitate engagement in PrEP care by communities and persons at elevated risk for HIV acquisition. Further study is needed on how best to manage disinterest in PrEP by those at high risk for HIV, and how openness to PrEP translates into concrete steps to take PrEP.

Dual-Routine HCV/HIV Testing: Seroprevalence and Linkage to Care in Four Community Health Centers in Philadelphia, Pennsylvania.

OBJECTIVE: Despite common risk factors, screening for hepatitis C virus (HCV) and HIV at the same time as part of routine medical care (dual-routine HCV/HIV testing) is not commonly implemented in the United States. This study examined improvements in feasibility of implementation, screening increase, and linkage to care when a dual-routine HCV/HIV testing model was integrated into routine primary care. METHODS: National Nursing Centers Consortium implemented a dual-routine HCV/HIV testing model at four community health centers in Philadelphia, Pennsylvania, on September 1, 2013. Routine HCV and opt-out HIV testing replaced the routine HCV and opt-in HIV testing model through medical assistant-led, laboratory-based testing and electronic medical record modification to prompt, track, report, and facilitate reimbursement for tests performed on uninsured individuals. This study examined testing, seropositivity, and linkage-to-care comparison data for the nine months before (December 1, 2012-August 31, 2013) and after (September 1, 2013-May 31, 2014) implementation of the dual-routine HCV/HIV testing model. RESULTS: A total of 1,526 HCV and 1,731 HIV tests were performed before, and 1,888 HCV and 3,890 HIV tests were performed after dual-routine testing implementation, resulting in a 23.7% increase in HCV tests and a 124.7% increase in HIV tests. A total of 70 currently HCV-infected and four new HIV-seropositive patients vs. 101 HCV-infected and 13 new HIV-seropositive patients were identified during these two periods, representing increases of 44.3% for HCV antibody-positive and RNA-positive tests and 225.0% for HIV-positive tests. Linkage to care increased from 27 currently infected HCV--positive and one HIV-positive patient pre-dual-routine testing to 39 HCV--positive and nine HIV-positive patients post-dual-routine testing. CONCLUSION: The dual-routine HCV/HIV testing model shows that integrating dual-routine testing in a primary care setting is possible and leads to increased HCV and HIV screening, enhanced seropositivity diagnosis, and improved linkage to care.

Identification and Linkage to Care of HCV-Infected Persons in Five Health Centers - Philadelphia, Pennsylvania, 2012-2014.

Approximately three million persons in the United States are infected with hepatitis C virus (HCV), a blood-borne pathogen that is an increasing cause of liver disease and mortality in the United States. Treatments for HCV are curative, of short duration, and have few associated side effects, increasing the importance of identifying HCV-infected persons. Many persons with HCV infection were infected decades ago, before implementation of prevention measures and most are unaware of their infection, regardless of when it occurred. Most newly diagnosed cases are associated with injection drug use. Persons born during 1945-1965 have a fivefold higher risk of HCV infection than other adults and the highest risk for HCV-related morbidity and mortality. CDC recommends testing for this group, for persons who inject drugs, and others at risk for HCV infection. From October 2012 through July 2014, the National Nursing Centers Consortium (NNCC) carried out a project to integrate routine HCV testing and linkage-to-care in five federally qualified health centers in Philadelphia, PA, that primarily serve homeless persons and public housing residents. During the project period, 4,514 patients across the five centers were tested for HCV. Of these, 595 (13.2%) were HCV-antibody positive and 550 (92.4%) had a confirmatory HCV-RNA test performed. Of those who had a confirmatory HCV-RNA test performed, 390 (70.9%) were identified as having current (i.e., chronic) HCV infection (overall prevalence = 8.6%). Of those currently infected with HCV, 90% were informed of their status, 78% were referred to an HCV care specialist, and 62% went to the referred specialist for care. Replicable system modifications that improved HCV testing and care included enhancements to electronic medical records (EMRs), simplification of HCV testing protocols, and addition of a linkage-to-care coordinator. Findings from this project highlight the need for innovative strategies for HCV testing, care, and treatment, as well as the important role of community health centers in expanding access for patient populations disproportionately affected by HCV infection.

Revision total knee arthroplasty using metaphyseal sleeves at short-term follow-up.

The treatment of bone loss in revision total knee arthroplasty (TKA) has involved using revision implants in association with cement, augments, particulate, and structural allograft. Newer metaphyseal augments were introduced to allow for metaphyseal fixation of the prosthesis while managing significant bone loss. The purpose of the current study was to evaluate the outcome of revision TKA using metaphyseal sleeves. The authors prospectively followed 96 knees that underwent revision TKA with metaphyseal sleeves. Eighty-three knees met the minimum 2-year criteria for follow-up. Thirty-six sleeves were used in femoral revisions and 83 sleeves were used in tibial revisions. The defects were classified according to the Anderson Orthopaedic Research Institute classification. Femoral defects were classified as type I in 4 knees, type IIb in 25 knees, and type III in 7 knees. Tibial defects were classified as type I in 9 knees, type IIa in 1 knee, type IIb in 68 knees, and type III in 5 knees. The patients were followed for an average of 2.4 years (range, 2.0-3.7 years). Mean Knee Society function score improved from 47.9 to 61.1 points. Mean Short Form 36 physical score improved from 43.3 to 56.3 points. Mean Western Ontario and McMaster Universities Arthritis Index improved from 55.3 to 25.9 points. None of the implants demonstrated progressive radiolucent lines around the metaphyseal sleeves. At final follow-up, only 2 (2.7%) tibial components required revision for aseptic loosening. At short-term follow-up, revision TKA with metaphyseal sleeves provided reliable fixation. This is especially encouraging given the severe nature of bone loss in the majority of patients in whom a metaphyseal sleeve was used. Long-term follow-up is needed to demonstrate the true effectiveness of these devices.

Revision hip arthroplasty: infection is the most common cause of failure.

BACKGROUND: Revision total hip arthroplasty (THA), although relieving pain and restoring function, fails in some patients. In contrast to failures in primary THA, the frequency of the causes of failure in revision THA has been less well established. QUESTIONS/PURPOSES: We therefore determined the rate of each failure mode and the survivorship of revision THAs. METHODS: We retrospectively reviewed the charts of 1366 revision THAs performed between 2000 and 2007. There were 609 (44.5%) men and 757 (55.5%) women with a mean age of 66 years. The indications for the revision surgery were mainly aseptic loosening (51%), instability (15%), wear (14%), and infection (8%). The minimum followup was 1 day (mean, 5.5 years; range, 1 day to 9 years). RESULTS: Two hundred fifty-six of the revisions (18.7%) failed with an average time to failure of 16.6 months (range, 1 day to 7.5 years). Among 256 failed hips, infection was the most common cause of failure (30.2%) followed by instability (25.1%) and aseptic loosening (19.4%). At 5 years, the survivorships of septic and aseptic groups were 67% and 84.8%, respectively. Revision for infection or instability appears to have a considerably lower survivorship when compared to revision for aseptic causes. CONCLUSIONS: The lower survivorship of revision for infection or instability highlights the importance of implementing better preventative methods that can minimize the impact of these two major causes of failure. LEVEL OF EVIDENCE: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Do tantalum and titanium cups show similar results in revision hip arthroplasty?

UNLABELLED: Porous surfaces are intended to enhance osteointegration of cementless implants. Tantalum has been introduced in an effort to enhance osseointegration potential of uncemented components. We therefore compared the clinical outcome of acetabular components with two different porous surfaces. We retrospectively reviewed 283 patients (295 hips) who underwent cementless revision hip arthroplasty with either an HA-coated titanium cup (207 patients, 214 hips) or porous tantalum cup (79 patients, 81 hips). The minimum followup was 24 months in both groups (titanium: average 51.8 months, range, 24-98 months; tantalum: average, 35.4 months, range, 24-63 months). The titanium and tantalum groups had a mechanical failure rate (clinical plus radiographic) of 8% and 6%, respectively. In hips with minor bone deficiency (type 1, 2A, 2B using the classification of Paprosky et al.), 6% of titanium cups and 4% of tantalum cups failed. In hips with major bone deficiency (type 2C, 3), 24% of titanium cups and 12% of tantalum cups developed failure. In the major bone deficiency group, the tantalum cups had fewer numbers of lucent zones around the cup. Eighty-two percent of titanium cups that failed did so at 6 months postoperatively or later, whereas 80% of tantalum cups that failed did so in less than 6 months. Radiographically in the major group, tantalum cups yielded better fixation. LEVEL OF EVIDENCE: Level III, retrospective comparative study. See the Guidelines for Authors for a complete description of levels of evidence.