HIV Care Outcomes in Relation to Racial Redlining and Structural Factors Affecting Medical Care Access Among Black and White Persons with Diagnosed HIV-United States, 2017.

Black/African American (Black) versus White persons are unequally burdened by human immunodeficiency virus (HIV) in the United States. Structural factors can influence social determinants of health, key components in reducing HIV-related health inequality by race. This analysis examined HIV care outcomes among Black and White persons with diagnosed HIV (PWDH) in relation to three structural factors: racial redlining, Medicaid expansion, and Ryan White HIV/AIDS Program (RWHAP) use. Using National HIV Surveillance System, U.S. Census, and Home Mortgage Disclosure Act data, we examined linkage to HIV care and viral suppression (i.e., viral load < 200 copies/mL) in relation to the structural factors among 12,996 Black and White PWDH with HIV diagnosed in 2017/alive at year-end 2018, aged ≥ 18 years, and residing in 38 U.S. jurisdictions with complete laboratory data, geocoding, and census tract-level redlining indexes. Compared to White PWDH, a lower proportion of Black PWDH were linked to HIV care within 1 month after diagnosis and were virally suppressed in 2018. Redlining was not associated with the HIV care outcomes. A higher prevalence of PWDH residing (v. not residing) in states with Medicaid expansion were linked to HIV care ≤ 1 month after diagnosis. A higher prevalence of those residing (v. not residing) in states with > 50% of PWDH in RWHAP had viral suppression. Direct exposure to redlining was not associated with poor HIV care outcomes. Structural factors that reduce the financial burden of HIV care and improve care access like Medicaid expansion and RWHAP might improve HIV care outcomes of PWDH.

Binge Drinking, Non-injection Drug Use, and Sexual Risk Behaviors among Adolescent Sexual Minority Males, 3 US Cities, 2015.

In 2016, more than 90% of HIV diagnoses among young men aged 13-19 years were attributed to male-male sexual contact. Little is known about how binge drinking and non-injection drug use may be associated with risky sexual behavior among adolescent sexual minority males (ASMM). Using data from the National HIV Behavioral Surveillance, we examined how binge drinking and non-injection drug use may be associated with sexual risk among ASMM. ASMM were recruited for interviews in 3 cities: Chicago, New York City, and Philadelphia. Among 16-18-year-olds (N = 488), we evaluated the association between binge drinking (≥ 5 drinks in one sitting in the past 30 days), non-injection drug use (past 12-month use of methamphetamines, powder cocaine, downers, painkillers, ecstasy, poppers, and "other"), and two past 12-month sexual risk outcomes: condomless anal intercourse with a casual partner and having multiple sex partners. We used log-linked Poisson regression models with robust standard errors to estimate prevalence ratios (PR) and 95% confidence intervals (CI). Overall, 26% of 16-18-year-old ASMM binge drank, and 21% reported non-injection drug use. Among ASMM who binge drank, 34% reported condomless anal intercourse with a casual partner compared with 22% of those who did not (PR: 1.53, 95% CI: 1.04-2.26). Similarly, 84% of ASMM who binge drank reported having multiple partners compared with 61% of those who did not (PR: 1.38, 95% CI: 1.09-1.76). Among ASMM who used non-injection drugs, 37% reported condomless anal intercourse compared with 22% of those who did not (PR: 1.70, 95% CI 1.09-2.50), while 86% of those who used non-injection drugs had multiple partners compared with 62% of those who did not (PR: 1.40, 95% CI: 1.06-1.80). Our findings suggest that the prevalence of substance misuse is high among sexual minority youth and is associated with sexual risk in this population. Our findings highlight the need for high-quality HIV prevention programs for ASMM especially as HIV prevention programs for this population are scarce.

Mental health, social support, and HIV-related sexual risk behaviors among HIV-negative adolescent sexual minority males: three U.S. cities, 2015.

We examined the association between mental health issues, social support, and HIV among adolescent sexual minority males (SMM), who are disproportionally affected by HIV. National HIV Behavioral Surveillance among Young Men Who Have Sex with Men (NHBS-YMSM) data among SMM aged 13-18 years were collected in three cities (Chicago, New York City, and Philadelphia). Separate log-linked Poisson regression models were used to estimate associations between mental health issues and social support (general and family), and 3 HIV-related sexual risk behavior outcomes: past-year condomless anal intercourse (CAI) with a male partner, past-year sex with ≥ 4 partners, and first vaginal or anal sex before age 13. Of 547 adolescent SMM, 22% reported ever attempting suicide and 10% reported past-month suicidal ideation. The majority (52%) reported depression and anxiety. Thirty-nine percent reported CAI, 29% reported ≥ 4 sex partners and 22% reported first sex before age 13. Ever attempting suicide, suicidal ideation, and depression and anxiety were associated with CAI. Separately, ever attempting suicide and lack of family support were associated with ≥ 4 sex partners. None of the mental health or support measures were associated with having sex before age 13. General social support was not associated with any sexual risk behaviors. Mental health issues are common among adolescent SMM and associated with sexual risk behaviors. Including mental health support in comprehensive HIV prevention for adolescent SMM could potentially reduce HIV risk in this population.

High Human Immunodeficiency Virus Incidence and Prevalence and Associated Factors Among Adolescent Sexual Minority Males-3 Cities, 2015.

Background: Much has been written about the impact of human immunodeficiency virus (HIV) among young (13-24) sexual minority men (SMM). Evidence for concern is substantial for emerging adult (18-24 years) SMM. Data documenting the burden and associated risk factors of HIV among adolescent SMM (<18 years) remain limited. Methods: Adolescent SMM aged 13-18 years were recruited in 3 cities (Chicago, New York City, and Philadelphia) for interview and HIV testing. We used χ2 tests for percentages of binary variables and 1-way analysis of variance for means of continuous variables to assess differences by race/ethnicity in behaviors. We calculated estimated annual HIV incidence density (number of HIV infections per 100 person-years [PY] at risk). We computed Fisher's exact tests to determine differences in HIV prevalence by selected characteristics. Results: Of 415 sexually active adolescent SMM with a valid HIV test result, 25 (6%) had a positive test. Estimated annual HIV incidence density was 3.4/100 PY; incidence density was highest for blacks, followed by Hispanics, then whites (4.1, 3.2, and 1.1/100 PY, respectively). Factors associated with higher HIV prevalence included black race; ≥4 male partners, condomless anal sex, and exchange sex in the past 12 months; and a recent partner who was older, black, HIV-infected, or had ever been in jail or prison (P < .05). Conclusions: HIV-related risk behaviors, prevalence, and estimated incidence density for adolescent SMM were high, especially for minority SMM. Our findings suggest that initiating intervention efforts early may be helpful in combating these trends.

Age-Associated Trends in Diagnosis and Prevalence of Infection with HIV Among Men Who Have Sex with Men - United States, 2008-2016.

In 2016, two thirds of diagnosed human immunodeficiency virus (HIV) infections in the United States were attributed to male-to-male sexual contact (1). The risk for sexual acquisition and transmission of HIV changes through the lifespan (2); to better guide prevention efforts for gay, bisexual, and other men who have sex with men (MSM*), CDC analyzed National HIV Surveillance System† (NHSS) data for MSM aged ≥13 years by age group (13-29, 30-49, and ≥50 years) in 50 states and the District of Columbia (DC). During 2008-2016, the annual number of diagnoses of HIV infection increased 3% per year among MSM aged 13-29 years, decreased 4% per year among those aged 30-49 years and was stable for MSM aged ≥50 years. The number of HIV diagnoses among MSM aged 13-29 years was four times that of MSM aged ≥50 years. During 2008-2015, the number of MSM aged ≥50 years living with diagnosed HIV infection (prevalence of HIV infection) increased an average of 11% per year and at year-end 2015 was three times that of MSM aged 13-29 years. Racial/ethnic disparities in HIV infection persisted, particularly among younger black/African American MSM who accounted for 49% of all diagnoses among MSM aged 13-29 years during 2008-2016. To avert the most infections and improve health outcomes (3), sexually active MSM at risk for HIV infection should be tested at least once a year, and, if positive, linked to and retained in HIV medical care to achieve viral suppression (4). Those testing negative should be provided HIV prevention services, including preexposure prophylaxis (PrEP) (5).

Sexual Risk Behavior Differences Among Sexual Minority High School Students - United States, 2015 and 2017.

Sexual minority youths (i.e., those identifying as gay, lesbian, bisexual, or another nonheterosexual identity or reporting same-sex attraction or sexual partners) are at higher risk than youths who are not sexual minority youth (nonsexual minority youth) for negative health behaviors and outcomes, including human immunodeficiency virus (HIV) infection, other sexually transmitted diseases (STDs), pregnancy (1),* and related sexual risk behaviors (2). Less is known about sexual risk behavior differences between sexual minority youth subgroups. This is the first analysis of subgroup differences among sexual minority youths using nationally representative Youth Risk Behavior Survey (YRBS) data. CDC analyzed pooled data from the 2015 and 2017 cycles of the national YRBS, a cross-sectional, school-based survey assessing health behaviors among U.S. students in grades 9-12. Analyses examined differences in eight sexual risk behaviors between subgroups of sexual minority youths and nonsexual minority youths, as well as within sexual minority youths. Logistic regression models controlling for race/ethnicity and grade found that bisexual females and "not sure" males reported higher prevalences for many behaviors than did heterosexual students. For behavior-based subgroups, the largest number of differences were seen between students who had sexual contact with both sexes compared with students with only opposite-sex sexual contact. Findings highlight subgroup differences within sexual minority youths that could inform interventions to promote healthy behavior.

Association Between Enacted Stigma and HIV-Related Risk Behavior Among MSM, National HIV Behavioral Surveillance System, 2011.

MSM bear a disproportionate burden of the HIV epidemic. Enacted stigma (overt negative actions) against sexual minorities may play an important role in increasing HIV risk among this population. Using data from the 2011 National HIV Behavioral Surveillance system, MSM cycle, we examined the independent associations between three measures of enacted stigma (verbal harassment, discrimination, physical assault) and engagement in each of four HIV-related risk behaviors as outcomes: condomless anal intercourse (CAI) at last sex with a male partner of HIV discordant or unknown status and, in the past 12 months, CAI with a male partner, ≥4 male sex partners, and exchange sex. Of 9819 MSM, 32% experienced verbal harassment in the past 12 months, 23% experienced discrimination, and 8% experienced physical assault. Discordant CAI at last sex with a male partner was associated with previous discrimination and physical assault. Past 12 month CAI with a male partner, ≥4 male sex partners, and exchange sex were each associated with verbal harassment, discrimination, and physical assault. These findings indicate that a sizable proportion of MSM report occurrences of past 12 month enacted stigma and suggest that these experiences may be associated with HIV-related risk behavior. Addressing stigma towards sexual minorities must involve an integrated, multi-faceted approach, including interventions at the individual, community, and societal level.

Association between parent-adolescent communication about sex-related topics and HIV testing, United States. 2006-2013.

Adolescents need information about sex-related topics in order to reduce risk behavior and engage in healthy sexual decision-making. Parents have the potential to be an important source of this information. Using the 2006-2010 and 2011-2013 National Survey of Family Growth, we examined associations between parent-adolescent communication before age 18 about sex-related topics and HIV testing among respondents aged 18-24 that ever had sexual intercourse (women = 3893; men = 3359). Analyses showed that for both men and women, discussing how to prevent HIV/AIDS and how to use a condom with a parent before age 18 were positively associated with HIV testing. Among women only, discussions about methods of birth control, where to get birth control, and STDs were positively associated with HIV testing. Developing strategies and interventions to facilitate parent-adolescent communication about sex-related topics, particularly HIV prevention and condom use, may be important to increase HIV testing among young women and men.

Age-Specific Race and Ethnicity Disparities in HIV Infection and Awareness Among Men Who Have Sex With Men--20 US Cities, 2008-2014.

BACKGROUND: Over half of human immunodeficiency virus (HIV) infections in the United States occur among men who have sex with men (MSM). Among MSM, 16% of estimated new infections in 2010 occurred among black MSM <25 years old. METHODOLOGY: We analyzed National HIV Behavioral Surveillance data on MSM from 20 cities. Poisson models were used to test racial disparities, by age, in HIV prevalence, HIV awareness, and sex behaviors among MSM in 2014. Data from 2008, 2011, and 2014 were used to examine how racial/ethnic disparities changed across time. RESULTS: While black MSM did not report greater sexual risk than other MSM, they were most likely to be infected with HIV and least likely to know it. Among black MSM aged 18-24 years tested in 2014, 26% were HIV positive. Among white MSM aged 18-24 years tested in 2014, 3% were HIV positive. The disparity in HIV prevalence between black and white MSM increased from 2008 to 2014, especially among young MSM. CONCLUSIONS: Disparities in HIV prevalence between black and white MSM continue to increase. Black MSM may be infected with HIV at younger ages than other MSM and may benefit from prevention efforts that address the needs of younger men.

Uptake of Testing for HIV and Syphilis Among Men Who Have Sex with Men in Baltimore, Maryland: 2004-2011.

Men who have sex with men (MSM) in Baltimore are at disproportionately high risk for HIV and syphilis infection. Testing and diagnosis are important first steps in receiving treatment and reducing transmission. We analyzed cross-sectional data collected in 2004-2005, 2008, and 2011 among MSM not reporting a previous positive HIV test (n = 1268) in Baltimore, Maryland as part of the National HIV Behavioral Surveillance System to determine the proportion of men tested for HIV and/or syphilis within the previous 12 months and examine the extent to which opportunities for testing were being missed in health care settings. Within the previous 12 months, 54 % of men had received an HIV test; 31 % had received a syphilis test; and only 23 % of men had received testing for both. Among 979 men who did not receive both tests, 72 % had seen a health care provider in the past year, suggesting missed testing opportunities.

A multisite study of the prevalence of HIV with rapid testing in mental health settings.

OBJECTIVES: We estimated HIV prevalence and risk factors among persons receiving mental health treatment in Philadelphia, Pennsylvania, and Baltimore, Maryland, January 2009 to August 2011. METHODS: We used a multisite, cross-sectional design stratified by clinical setting. We tested 1061 individuals for HIV in university-based inpatient psychiatric units (n = 287), intensive case-management programs (n = 273), and community mental health centers (n = 501). RESULTS: Fifty-one individuals (4.8%) were HIV-infected. Confirmed positive HIV tests were 5.9% (95% confidence interval [CI] = 3.7%, 9.4%) for inpatient units, 5.1% (95% CI = 3.1%, 8.5%) for intensive case-management programs, and 4.0% (95% CI = 2.6%, 6.1%) for community mental health centers. Characteristics associated with HIV included Black race, homosexual or bisexual identity, and HCV infection. CONCLUSIONS: HIV prevalence for individuals receiving mental health services was about 4 times as high as in the general population. We found a positive association between psychiatric symptom severity and HIV infection, indicating that engaging persons with mental illness in appropriate mental health treatment may be important to HIV prevention. These findings reinforce recommendations for routine HIV testing in all clinical settings to ensure that HIV-infected persons receiving mental health services are identified and referred to timely infectious disease care.

Trends in HIV prevalence and HIV testing among young MSM: five United States cities, 1994-2011.

We examined trends in cross-sectional HIV prevalence (a surrogate for incidence) and past 12 month testing behavior among young men who have sex with men (MSM). The Young Men's Survey and the National HIV Behavioral Surveillance System conducted interviews and HIV testing among MSM recruited by venue-based sampling during 1994-2011. Using data from five cities, we determined whether interview year was associated with HIV prevalence and recent testing for MSM ages 18-22 and 23-29 years, after adjusting for city, race/ethnicity, and education. Multivariable analysis demonstrated an overall increase in prevalence among MSM ages 23-29 years, driven by an increase in Baltimore. There was no change in HIV prevalence among MSM ages 18-22 years overall, although prevalence increased in Baltimore. HIV testing increased significantly for both age groups. Gains in HIV testing are encouraging, but increasing prevalence among young MSM in Baltimore suggests increasing incidence and the need for additional efforts for this population.

Enhancements to the National HIV Surveillance System, United States, 2013-2023.

HIV infection is monitored through the National HIV Surveillance System (NHSS) to help improve the health of people with HIV and reduce transmission. NHSS data are routinely used at federal, state, and local levels to monitor the distribution and transmission of HIV, plan and evaluate prevention and care programs, allocate resources, inform policy development, and identify and respond to rapid transmission in the United States. We describe the expanded use of HIV surveillance data since the 2013 NHSS status update, during which time the Centers for Disease Control and Prevention (CDC) coordinated to revise the HIV surveillance case definition to support the detection of early infection and reporting of laboratory data, expanded data collection to include information on sexual orientation and gender identity, enhanced data deduplication processes to improve quality, and expanded reporting to include social determinants of health and health equity measures. CDC maximized the effects of federal funding by integrating funding for HIV prevention and surveillance into a single program; the integration of program funding has expanded the use of HIV surveillance data and strengthened surveillance, resulting in enhanced cluster response capacity and intensified data-to-care activities to ensure sustained viral suppression. NHSS data serve as the primary source for monitoring HIV trends and progress toward achieving national initiatives, including the US Department of Health and Human Services' Ending the HIV Epidemic in the United States initiative, the White House's National HIV/AIDS Strategy (2022-2025), and Healthy People 2030. The NHSS will continue to modernize, adapt, and broaden its scope as the need for high-quality HIV surveillance data remains.

Assessing concordance of HIV risk behaviors collected by different surveillance systems.

OBJECTIVES: Assess concordance of assigned transmission category between National HIV Surveillance System (NHSS) and Medical Monitoring Project (MMP); assess persistence of behaviors by comparing transmission category to current behavior. DESIGN: Retrospective analysis of HIV surveillance data. METHODS: For 4034 participants in the 2016 MMP cycle, transmission category was assigned in NHSS and MMP by applying a hierarchy to acquisition risk behaviors and selecting the most likely risk behavior that led to HIV acquisition. We assessed concordance of transmission category between systems, the number of persons with an updated transmission category in NHSS after incorporating MMP data, and concordance of transmission category and current behavior. RESULTS: Concordance of transmission category between NHSS and MMP was 87% for men with evidence of male-to-male sexual contact and ranged from 27% to 62% in persons with other transmission categories. Transmission category in NHSS was updated for 9% of persons after incorporating MMP data, mostly affecting those with no identified risk in NHSS. Current behavior aligned with updated NHSS transmission category in 56% of men with a transmission category of male-to-male sexual contact. However, only 8% of men and 5% of women with a transmission category of injection drug use had recently injected drugs. CONCLUSION: HIV surveillance systems can better inform prevention efforts with more complete risk information. Sexual behaviors are more persistent over time than injection drug use. In addition to promoting viral suppression, routinely assessing risk and tailoring prevention activities accordingly can improve health outcomes.

Opportunistic Illnesses in Children With HIV Infection in the United States, 1997-2016.

BACKGROUND: Among children with HIV infection, opportunistic illness (OI) rates decreased after introduction of highly active antiretroviral therapy (ART) in 1997. We evaluated whether such decreases have continued. METHODS: Data from the Centers for Disease Control and Prevention's National HIV Surveillance System for children with HIV living in the US during 1997-2016 was used to enumerate infants experiencing the first OI by birth year and OIs among all children <13 years of age (stratified by natality). We calculated the time to first OI among infants using Kaplan-Meier methods. RESULTS: Among infants born during 1997-2016, 711 first OIs were diagnosed. The percentage of the first OIs diagnosed in successive 5-year birth periods was: 60.0% (1997-2001), 24.6% (2002-2006), 11.3% (2007-2011), and 3.4% (2012-2016). For every OI, the number of first cases decreased nearly annually. Time to first OI increased in successive birth periods. Among children <13 years of age, 2083 OI were diagnosed, including Pneumocystis jiroveci pneumonia, candidiasis, recurrent bacterial infection, wasting syndrome, cytomegalovirus, lymphocytic interstitial pneumonitis, tuberculosis, nontuberculous mycobacteriosis and herpes simplex virus. The rate (#/1000 person-years) decreased overall (60-7.2) and for all individual OIs. Earlier during 1997-2016, rates for all OIs were higher among foreign-born than US-born children but later became similar for all OIs except tuberculosis. CONCLUSIONS: Among children with HIV in the US, numbers and rates of all OIs decreased during 1997-2016. Earlier, OI rates were highest among non-US-born children but were later comparable with those among US-born children for all OIs except tuberculosis.

Family Factors and HIV-Related Risk Behaviors Among Adolescent Sexual Minority Males in Three United States Cities, 2015.

Purpose: We examined the relationship between family factors and HIV-related sexual risk behaviors among adolescent sexual minority males (ASMM) who are affected disproportionately by HIV. Methods: We analyzed results from the National HIV Behavioral Surveillance among Young Men Who Have Sex with Men. Adolescent males ages 13-18 who identified as gay or bisexual, or who reported attraction to or sex with males were interviewed in 2015 in Chicago, New York City, and Philadelphia. Separate log-linked Poisson regression models were used to estimate associations between family factors and sexual risk behaviors. Results: Of the 569 ASMM, 41% had condomless anal intercourse in the past 12 months, 38% had ≥4 male sex partners in the past 12 months, and 23% had vaginal or anal sex before age 13. ASMM who had ever been kicked out of their house or run away, those who were out to their mother, and those who were out to their father, were more likely to engage in sexual risk behaviors. ASMM who were currently living with parents or guardians and those who received a positive reaction to their outness by their mother were less likely to engage in sexual risk behaviors. Conclusion: Our findings highlight the important role of family factors in HIV risk reduction among ASMM. A better understanding of the complex dynamics of these families will help in developing family-based interventions.

Estimating the probability of diagnosis within 1 year of HIV acquisition.

BACKGROUND: Early diagnosis of HIV is important for the prevention of ongoing transmission and development of HIV-related illness. The purpose of this study is to develop an outcome indicator to monitor the progress in early HIV diagnosis. METHODS: Persons diagnosed with HIV in New York City and their first CD4 test results were used to estimate the distribution of HIV diagnosis delay, based on a CD4 count depletion model. The distribution was then used to estimate the probability of diagnosis within 1 year of HIV acquisition, which is the number of cases diagnosed in a given calendar year for which diagnosis occurred within 1 year of acquisition divided by the number of incident cases in that calendar year. RESULTS: In 2012-2016, the estimated annual probability of diagnosis within 1 year of HIV acquisition in New York City was 43.0% [95% confidence interval (CI): 37.9-48.2%), 42.5% (95% CI: 36.8--48.3%), 42.8% (95% CI: 36.3--49.2%), 42.9% (95% CI: 35.4--50.3%), and 42.2% (95% CI: 33.1--51.2%), respectively. CONCLUSION: National and local health jurisdictions should consider using this new outcome indicator, the probability of diagnosis within 1 year of HIV acquisition, to monitor their progress in early HIV diagnosis.

Self-Directed Violence After Medical Emergency Department Visits Among Youth.

INTRODUCTION: Identifying medical encounters that precede self-directed violence may allow for important prevention opportunities. This study examined the risk of self-directed violence after visiting the emergency department for a range of physical health conditions among youth. METHODS: This retrospective cohort study used 2012-2013 statewide emergency department data from six states. Among patients aged 15-29 years, the exposure group included 2,192,322 emergency department visits for 16 selected conditions, coded by whether visits for those conditions were the first, second, or third or later visit for that condition. Emergency department visits for a minor infection served as the reference group (n=149,163). A Cox proportional hazard model was used to assess the risk of a self-directed violence event within 6 months for each condition. Analyses were conducted in 2017. RESULTS: Overall, 8,489 (0.4%) of all patients visited the emergency department for self-directed violence over a 6-month period. Initial visits for epilepsy or seizures conveyed a markedly elevated hazard ratio for subsequent self-directed violence at 6.0 and 5.7, respectively (p<0.001). Initial visits for other conditions showed moderately elevated risk with hazard ratios primarily <2. Second visits for various pain symptoms, syncope, vomiting, or non-self-directed violence injury also had a 3- to 5-fold increase in hazard ratios for subsequent self-directed violence. Hazard ratios for third or later visit increased to 8.8 for back pain, 6.9 for headache, about 5 for abdominal pain, dental complaints, and non-self-directed violence injury (p<0.001). CONCLUSIONS: Young people presenting to the emergency department for certain medical conditions are at an increased risk of subsequent self-directed violence. An awareness of these patterns may help guide screening efforts for suicide prevention in clinical settings.

Bloodstream infections in patients given treatment with intravenous prostanoids.

OBJECTIVE: In September 2006, the Centers for Disease Control and Prevention was notified of cases of gram-negative bloodstream infection (BSI) occurring among outpatients who received an intravenous formulation of the prostanoid treprostinil. An investigation was conducted to determine rates of prostanoid-associated BSI in this patient population and possible risk factors for infection. METHODS: We performed a retrospective cohort study of patients who had received intravenous formulations of at least 1 of the 2 approved prostanoids (epoprostenol and treprostinil) from January 1, 2004, through late 2006. Chart reviews were conducted at 2 large centers for pulmonary arterial hypertension, and a survey of infection control practices was conducted at 1 center. RESULTS: A total of 224 patients were given intravenous prostanoid treatment, corresponding to 146,093 treatment-days during the study period. Overall, there were 0.55 cases of BSI and 0.18 cases of BSI due to gram-negative organisms per 1,000 treatment-days. BSI rates were higher for patients who received intravenous treprostinil than for patients who received intravenous epoprostenol (1.13 vs. 0.42 BSIs per 1,000 treatment-days; P < .001), as were rates of BSI due to gram-negative organisms (0.81 vs. 0.04 BSIs per 1,000 treatment-days; P < .001). Adjusted hazard ratios for all BSIs and for BSIs due to gram-negative organisms were higher among patients given treatment with intravenous treprostinil. The survey identified no significant differences in medication-related infection control practices. CONCLUSION: At 2 centers, BSI due to gram-negative pathogens was more common than previously reported and was more frequent among patients given treatment with intravenous treprostinil than among patients given treatment with intravenous epoprostenol. Whether similar results would be found at other centers for pulmonary arterial hypertension warrants further investigation. This investigation underscores the importance of surveillance and evaluation of healthcare-related adverse events in patients given treatment primarily as outpatients.

Social support networks and maternal mental health and well-being.

The link between social networks and mental health has increasingly been recognized by public health as an important topic of interest. In this paper, we explore this association among a specific group: mothers. Specifically, we discuss how maternal mental health can be understood in the context of social networks, the influence of specific social relationships, and how the type and quality of support can mediate maternal mental health outcomes. We review interventions that foster social networks to address maternal mental health as well as other related health outcomes. Findings suggest that interventions that combine multiple treatment approaches may be more effective in addressing mental health. Also, traditional measures of social networks may not be appropriate for vulnerable populations, with qualitative, rather than quantitative, indicators of social networks being more predictive of maternal health and well-being. The implications of these findings and future research directions are discussed.