The Tenacious Treponema: A Retrospective Examination of Syphilis Treatment Disparities in Washington, DC.

BACKGROUND: Since 2000, there have been rising rates of syphilis infections nationally with higher incidence among minorities and persons living with human immunodeficiency virus (HIV) (PLWH). The purpose of this study was to determine syphilis treatment adequacy and factors associated with treatment delay. METHODS: This was a retrospective academic-public health collaboration with the District of Columbia Department of Public Health reviewing surveillance data of all primary, secondary, and early latent syphilis cases diagnosed between January 1, 2015, and December 31, 2019. Data were analyzed using multivariable logistic regression to identify factors associated with delayed treatment >14 days from diagnosis. RESULTS: Among 1852 individuals diagnosed with early syphilis, 93% (1730/1852) were male; 48% (893/1852) were coinfected with HIV; 43% (n = 796/1852) were African American/Black, 27% (n = 492/1852) were White, and race/ethnicity was unknown for 17% (n = 318/1852) of cases. Among 679 PLWH for whom viral load (VL) was known, 41% (278/679) had a VL < 20 copies/mL, and 18% (123/679) had VL >10,000 copies/mL. Treatment adequacy overall was 96.5%. Median time to syphilis treatment was 6 days (interquartile range = 4-7). Factors associated with delay of treatment included refused/unknown race (adjusted odds ratio [aOR], 1.95; 95% confidence interval [CI], 1.00-3.79), and HIV VL > 10,000 copies/mL (aOR, 1.97; 95% CI, 1.08-3.58). CONCLUSIONS: The factors we identified associated with delayed treatment may reflect systemic factors contributing to the increased rates of infection among key populations. This highlights the importance of targeted public health efforts with the goal of reducing transmission of both HIV and syphilis.

Longitudinal Assessment of the Enhanced Liver Fibrosis Score in the Era of Contemporary HIV and Hepatitis C Virus Treatment.

BACKGROUND: The trajectory of liver fibrosis is not well understood in the contemporary era of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) therapy. METHODS: We assessed the Enhanced Liver Fibrosis (ELF) score, aspartate transaminase-to-platelet ratio index (APRI) and Fibrosis-4 (FIB-4) in 116 women with HIV/HCV coinfection over a 4-year period. Random-effects linear regression models examined the rate of fibrosis change 1-2 years before starting HCV treatment, within 1 year before starting (peri-HCV treatment), within 1 year after and 1-2 years post-HCV treatment in unadjusted and adjusted models including age, race, and changes from pretreatment of factors that might affect fibrosis (eg, alcohol, integrase strand inhibitor [INSTI] use, waist circumference, CD4 count). RESULTS: INSTI use nearly doubled from pre- to peri-HCV treatment. In unadjusted analysis, there was a 3.3% rate of rise in ELF pre-HCV treatment, 2.2% and 3.6% rate of decline during the peri- and 1-year post-HCV treatment period, respectively, followed by a 0.3% rise. Similar findings were observed for APRI and FIB-4. There was little effect on the estimated fibrosis trajectories after adjustment. CONCLUSIONS: The apparent lack of decline in biomarkers of liver fibrosis beyond 1 year after HCV cure suggests that continued monitoring of liver fibrosis and interventions to mitigate progression in people with HIV after HCV cure remains essential.

A new smoking cessation 'cascade' among women with or at risk for HIV infection.

OBJECTIVES: The aim of this study was to define a smoking cessation 'cascade' among USA women with and without HIV and examine differences by sociodemographic characteristics. DESIGN: An observational cohort study using data from smokers participating in the Women's Interagency HIV Study between 2014 and 2019. METHODS: We followed 1165 women smokers with and without HIV from their first study visit in 2014 or 2015 until an attempt to quit smoking within approximately 3 years of follow-up, initial cessation (i.e. no restarting smoking within approximately 6 months of a quit attempt), and sustained cessation (i.e. no restarting smoking within approximately 12 months of a quit attempt). Using the Aalen-Johansen estimator, we estimated the cumulative probability of achieving each step, accounting for the competing risk of death. RESULTS: Forty-five percent of smokers attempted to quit, 27% achieved initial cessation, and 14% achieved sustained cessation with no differences by HIV status. Women with some post-high school education were more likely to achieve each step than those with less education. Outcomes did not differ by race. Thirty-six percent [95% confidence interval (95% CI): 31-42] of uninsured women attempted to quit compared with 47% (95% CI: 44-50) with Medicaid and 49% (95% CI: 41-59) with private insurance. CONCLUSION: To decrease smoking among USA women with and without HIV, targeted, multistage interventions, and increased insurance coverage are needed to address shortfalls along this cascade.

Health insurance and AIDS Drug Assistance Program (ADAP) increases retention in care among women living with HIV in the United States.

Our objective was to examine the association between healthcare payer type and missed HIV care visits among 1,366 US women living with HIV (WLWH) enrolled in the prospective Women's Interagency HIV Study (WIHS). We collected secondary patient-level data (October 1, 2017-September 30, 2018) from WLWH at nine WIHS sites. We used bivariate and multivariable binary logistic regression to examine the relationship between healthcare payer type (cross-classification of patients' ADAP and health insurance enrollment) and missed visits-based retention in care, defined as no-show appointments for which patients did not reschedule. Our sample included all WLWH who self-reported having received HIV care at least once during the two consecutive biannual WIHS visits a year prior to October 1, 2017-September 30, 2018. In the bivariate model, compared to uninsured WLWH without ADAP, WLWH with private insurance + ADAP were more likely to be retained in care, as were WLWH with Medicaid only and private insurance only. In the adjusted model, WLWH with private insurance only were more likely to be retained in care compared to uninsured WLWH without ADAP. Private health insurance and ADAP are associated with increased odds of retention in care among WLWH.

The Costs of Silencing the Self and Divided Self in the Context of Physical Abuse, Racial/Ethnic Identity, and Medication Adherence in Women Living with HIV.

Racial/ethnic minority status and physical abuse history are risk factors for higher mortality rates and lower adherence to antiretroviral therapy (ART) in women living with HIV (WLWH) in the United States. The current study tested the hypotheses that minority status and physical abuse history might lead women to silence the self (minimize and hide thoughts and feelings in order to avoid relational conflict, loss, and/or abuse) as measured by the Silencing the Self Scale (STSS), and that STSS might mediate and moderate relationships of physical abuse and racial/ethnic minority status with ART adherence. Divided Self (DS; acting in ways inconsistent with inner thoughts and feelings), an STSS subscale, was targeted for study along with the total STSS score. Participants were 513 women from the U.S. Women's Interagency HIV Study (M age = 46; 387, 75%, Black; 66, 13%, Hispanic; 60, 12%, White). Multiple logistic regressions indicated that across all racial/ethnic groups, physical abuse history related to higher DS and lower adherence. DS significantly mediated relationships between abuse and adherence. Compared to White women, Black women demonstrated worse ART adherence, but had lower total STSS. Racial/ethnic minority women and women with a physical abuse history who had higher DS had lower adherence than other groups. Results indicate that being a racial/ethnic minority or having a history of physical abuse may increase vulnerability to the deleterious effects of DS on ART adherence, findings that can help inform interventions to decrease health disparities in WLWH.

Rapid Deployment of a Free, Privacy-Assured COVID-19 Symptom Tracker for Public Safety During Reopening: System Development and Feasibility Study.

BACKGROUND: Since the emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the number of cases of coronavirus disease (COVID-19) in the United States has exponentially increased. Identifying and monitoring individuals with COVID-19 and individuals who have been exposed to the disease is critical to prevent transmission. Traditional contact tracing mechanisms are not structured on the scale needed to address this pandemic. As businesses reopen, institutions and agencies not traditionally engaged in disease prevention are being tasked with ensuring public safety. Systems to support organizations facing these new challenges are critically needed. Most currently available symptom trackers use a direct-to-consumer approach and use personal identifiers, which raises privacy concerns. OBJECTIVE: Our aim was to develop a monitoring and reporting system for COVID-19 to support institutions conducting monitoring activities without compromising privacy. METHODS: Our multidisciplinary team designed a symptom tracking system after consultation with experts. The system was designed in the Georgetown University AvesTerra knowledge management environment, which supports data integration and synthesis to identify actionable events and maintain privacy. We conducted a beta test for functionality among consenting Georgetown University medical students. RESULTS: The symptom tracker system was designed based on guiding principles developed during peer consultations. Institutions are provided access to the system through an efficient onboarding process that uses clickwrap technology to document agreement to limited terms of use to rapidly enable free access. Institutions provide their constituents with a unique identifier to enter data through a web-based user interface to collect vetted symptoms as well as clinical and epidemiologic data. The website also provides individuals with educational information through links to the COVID-19 prevention recommendations from the US Centers for Disease Control and Prevention. Safety features include instructions for people with new or worsening symptoms to seek care. No personal identifiers are collected in the system. The reporter mechanism safeguards data access so that institutions can only access their own data, and it provides institutions with on-demand access to the data entered by their constituents, organized in summary reports that highlight actionable data. Development of the system began on March 15, 2020, and it was launched on March 20, 2020. In the beta test, 48 Georgetown University School of Medicine students or their social contacts entered data into the system from March 31 to April 5, 2020. One of the 48 users (2%) reported active COVID-19 infection and had no symptoms by the end of the monitoring period. No other participants reported symptoms. Only data with the unique entity identifier for our beta test were generated in our summary reports. CONCLUSIONS: This system harnesses insights into privacy and data sharing to avoid regulatory and legal hurdles to rapid adaption by entities tasked with maintaining public safety. Our pilot study demonstrated feasibility and ease of use. Refinements based on feedback from early adapters included release of a Spanish language version. These systems provide technological advances to complement the traditional contact tracing and digital tracing applications being implemented to limit SARS-CoV-2 transmission during reopening.

Addressing Ethical Challenges in US-Based HIV Phylogenetic Research.

In recent years, phylogenetic analysis of HIV sequence data has been used in research studies to investigate transmission patterns between individuals and groups, including analysis of data from HIV prevention clinical trials, in molecular epidemiology, and in public health surveillance programs. Phylogenetic analysis can provide valuable information to inform HIV prevention efforts, but it also has risks, including stigma and marginalization of groups, or potential identification of HIV transmission between individuals. In response to these concerns, an interdisciplinary working group was assembled to address ethical challenges in US-based HIV phylogenetic research. The working group developed recommendations regarding (1) study design; (2) data security, access, and sharing; (3) legal issues; (4) community engagement; and (5) communication and dissemination. The working group also identified areas for future research and scholarship to promote ethical conduct of HIV phylogenetic research.

Neighborhood Poverty and Control of HIV, Hypertension, and Diabetes in the Women's Interagency HIV Study.

Neighborhoods with high poverty rates have limited resources to support residents' health. Using census data, we calculated the proportion of each Women's Interagency HIV Study participant's census tract (neighborhood) living below the poverty line. We assessed associations between neighborhood poverty and (1) unsuppressed viral load [VL] in HIV-seropositive women, (2) uncontrolled blood pressure among HIV-seropositive and HIV-seronegative hypertensive women, and (3) uncontrolled diabetes among HIV-seropositive and HIV-seronegative diabetic women using modified Poisson regression models. Neighborhood poverty was associated with unsuppressed VL in HIV-seropositive women (> 40% versus ≤ 20% poverty adjusted prevalence ratio (PR), 1.42; 95% confidence interval (CI) 1.04-1.92). In HIV-seronegative diabetic women, moderate neighborhood poverty was associated with uncontrolled diabetes (20-40% versus ≤ 20% poverty adjusted PR, 1.75; 95% CI 1.02-2.98). Neighborhood poverty was associated with neither uncontrolled diabetes among HIV-seropositive diabetic women, nor uncontrolled hypertension in hypertensive women, regardless of HIV status. Women living in areas with concentrated poverty may need additional resources to control health conditions effectively.

Longitudinal assessment of abnormal Papanicolaou test rates among women with HIV.

OBJECTIVE: To describe longitudinal changes in the prevalence of abnormal Papanicolau testing among women living with HIV. DESIGN: Prospective cohort study with sequential enrollment subcohorts. METHODS: Four waves of enrollment occurred in the Women's Interagency HIV Study, the US women's HIV cohort (1994-1995, 2001-2002, 2011-2012, 2013-2015). Pap testing was done at intake, with colposcopy prescribed for any abnormality. Rates of abnormal Pap test results (atypical squamous cells of uncertain significance or worse) and cervical intraepithelial neoplasia grade 2 (CIN2) or worse were calculated. Logistic regression models assessed changes in prevalence across cohorts after controlling for severity of HIV disease and other risk factors for abnormal Pap tests. RESULTS: The unadjusted prevalence of any Pap abnormality was 679/1769 (38%) in the original cohort, 195/684 (29%) in the 2001-2002 cohort, 46/231 (20%) in the 2011-2012 cohort, and 71/449 (16%) in the 2013-2015 cohort. In multivariable analysis, compared with risk in the 1994-1995 cohort, the adjusted risk in the 2001-2002 cohort was 0.79 (95% CI 0.59-1.05), in the 2011-2012 cohort was 0.67 (95% CI 0.43-1.04), and in the 2013-2015 cohort was 0.41 (95% CI 0.27-0.62) with P for trend less than 0.0001. CONCLUSION: Rates of abnormal cytology among women with HIV have fallen during the past two decades.

The Relationship Between Discrimination and Missed HIV Care Appointments Among Women Living with HIV.

Receiving regular HIV care is crucial for maintaining good health among persons with HIV. However, racial and gender disparities in HIV care receipt exist. Discrimination and its impact may vary by race/ethnicity and gender, contributing to disparities. Data from 1578 women in the Women's Interagency HIV Study ascertained from 10/1/2012 to 9/30/2016 were used to: (1) estimate the relationship between discrimination and missing any scheduled HIV care appointments and (2) assess whether this relationship is effect measure modified by race/ethnicity. Self-reported measures captured discrimination and the primary outcome of missing any HIV care appointments in the last 6 months. Log-binomial models accounting for measured sources of confounding and selection bias were fit. For the primary outcome analyses, women experiencing discrimination typically had a higher prevalence of missing an HIV care appointment. Moreover, there was no statistically significant evidence for effect measure modification by race/ethnicity. Interventions to minimize discrimination or its impact may improve HIV care engagement among women.

Improving HIV Surveillance Data by Using the ATra Black Box System to Assist Regional Deduplication Activities.

BACKGROUND: Focused attention on Data to Care underlines the importance of high-quality HIV surveillance data. This study identified the number of total duplicate and exact duplicate HIV case records in 9 separate Enhanced HIV/AIDS Reporting System (eHARS) databases reported by 8 jurisdictions and compared this approach to traditional Routine Interstate Duplicate Review resolution. METHODS: This study used the ATra Black Box System and 6 eHARS variables for matching case records across jurisdictions: last name, first name, date of birth, sex assigned at birth (birth sex), social security number, and race/ethnicity, plus 4 system-calculated values (first name Soundex, last name Soundex, partial date of birth, and partial social security number). RESULTS: In approximately 11 hours, this study matched 290,482 cases from 799,326 uploaded records, including 55,460 exact case pairs. Top case pair overlaps were between NYC and NYS (51%), DC and MD (10%), and FL and NYC (6%), followed closely by FL and NYS (4%), FL and NC (3%), DC and VA (3%), and MD and VA (3%). Jurisdictions estimated that they realized a combined 135 labor hours in time efficiency by using this approach compared with manual methods previously used for interstate duplication resolution. DISCUSSION: This approach discovered exact matches that were not previously identified. It also decreased time spent resolving duplicated case records across jurisdictions while improving accuracy and completeness of HIV surveillance data in support of public health program policies. Future uses of this approach should consider standardized protocols for postprocessing eHARS data.

Cumulative Burden of Depression and All-Cause Mortality in Women Living With Human Immunodeficiency Virus.

Background: Research linking depression to mortality among people living with human immunodeficiency virus (PLWH) has largely focused on binary "always vs never" characterizations of depression. However, depression is chronic and is likely to have cumulative effects on mortality over time. Quantifying depression as a cumulative exposure may provide a better indication of the clinical benefit of enhanced depression treatment protocols delivered in HIV care settings. Methods: Women living with HIV (WLWH), naive to antiretroviral therapy, from the Women's Interagency HIV Study were followed from their first visit in or after 1998 for up to 10 semiannual visits (5 years). Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression (CES-D) scale. An area-under-the-curve approach was used to translate CES-D scores into a time-updated measure of cumulative days with depression (CDWD). We estimated the effect of CDWD on all-cause mortality using marginal structural Cox proportional hazards models. Results: Overall, 818 women contributed 3292 woman-years over a median of 4.8 years of follow-up, during which the median (interquartile range) CDWD was 366 (97-853). Ninety-four women died during follow-up (2.9 deaths/100 woman-years). A dose-response relationship was observed between CDWD and mortality. Each additional 365 days spent with depression increased mortality risk by 72% (hazard ratio, 1.72; 95% confidence interval, 1.34-2.20). Conclusions: In this sample of WLWH, increased CDWD elevated mortality rates in a dose-response fashion. More frequent monitoring and enhanced depression treatment protocols designed to reduce CDWD may interrupt the accumulation of mortality risk among WLWH.

Stigma, Partners, Providers and Costs: Potential Barriers to PrEP Uptake among US Women.

BACKGROUND: Pre-Exposure Prophylaxis (PrEP) use has remained low among US women while significantly increasing among men who have sex with men. Besides lack of awareness, women face several social and structural barriers in gaining access to and using PrEP. METHODS: Four focus group discussions with 20 HIV-negative women who live in the Washington DC metropolitan area. RESULTS: The women expressed concerns about social and structural barriers to PrEP use. They were afraid that stigma related to using "HIV medicines" could affect PrEP use as well. They are worried that family and friends may question their reasons for taking anti-retrovirals and suspect that they were HIV-positive. They expected hostile reactions from male partners, including accusations of infidelity and introducing mistrust in their relationships. Communicating with health care providers about sexual matters in general and their need for PrEP in particular were identified as further barriers. Women reported that providers rarely ask about risk behaviors related to HIV acquisition; that short visits hinder establishing a trusting relationship to discuss sensitive matters. They were concerned that disclosure of risk behaviors may result in judgmental responses and harsh treatment from providers. Lastly, women were concerned that PrEP costs, including insurance coverage and copays, would keep PrEP out of their reach. While cognizant of the potential barriers, women were unwavering in their determination to find ways to circumvent challenges to PrEP access. CONCLUSION: Social and structural barriers may impede women's access to PrEP despite their own reported interest. Continued efforts to reduce HIV stigma, improve patient-provider relationships and ensure affordability of PrEP may increase the likelihood that women will use this important prevention modality.

Health Insurance Type and Control of Hypertension Among US Women Living With and Without HIV Infection in the Women's Interagency HIV Study.

BACKGROUND: Health care access is an important determinant of health. We assessed the effect of health insurance status and type on blood pressure control among US women living with (WLWH) and without HIV. METHODS: We used longitudinal cohort data from the Women's Interagency HIV Study (WIHS). WIHS participants were included at their first study visit since 2001 with incident uncontrolled blood pressure (BP) (i.e., BP ≥140/90 and at which BP at the prior visit was controlled (i.e., <135/85). We assessed time to regained BP control using inverse Kaplan-Meier curves and Cox proportional hazard models. Confounding and selection bias were accounted for using inverse probability-of-exposure-and-censoring weights. RESULTS: Most of the 1,130 WLWH and 422 HIV-uninfected WIHS participants who had an elevated systolic or diastolic measurement were insured via Medicaid, were African-American, and had a yearly income ≤$12,000. Among participants living with HIV, comparing the uninsured to those with Medicaid yielded an 18-month BP control risk difference of 0.16 (95% CI: 0.10, 0.23). This translates into a number-needed-to-treat (or insure) of 6; to reduce the caseload of WLWH with uncontrolled BP by one case, five individuals without insurance would need to be insured via Medicaid. Blood pressure control was similar among WLWH with private insurance and Medicaid. There were no differences observed by health insurance status on 18-month risk of BP control among the HIV-uninfected participants. CONCLUSIONS: These results underscore the importance of health insurance for hypertension control-especially for people living with HIV.

Impact of Health Insurance, ADAP, and Income on HIV Viral Suppression Among US Women in the Women's Interagency HIV Study, 2006-2009.

BACKGROUND: Implementation of the Affordable Care Act motivates assessment of health insurance and supplementary programs, such as the AIDS Drug Assistance Program (ADAP) on health outcomes of HIV-infected people in the United States. We assessed the effects of health insurance, ADAP, and income on HIV viral load suppression. METHODS: We used existing cohort data from the HIV-infected participants of the Women's Interagency HIV Study. Cox proportional hazards models were used to estimate the time from 2006 to unsuppressed HIV viral load (>200 copies/mL) among those with Medicaid, private, Medicare, or other public insurance, and no insurance, stratified by the use of ADAP. RESULTS: In 2006, 65% of women had Medicaid, 18% had private insurance, 3% had Medicare or other public insurance, and 14% reported no health insurance. ADAP coverage was reported by 284 women (20%); 56% of uninsured participants reported ADAP coverage. After accounting for study site, age, race, lowest observed CD4, and previous health insurance, the hazard ratio (HR) for unsuppressed viral load among those privately insured without ADAP, compared with those on Medicaid without ADAP (referent group), was 0.61 (95% CI: 0.48 to 0.77). Among the uninsured, those with ADAP had a lower relative hazard of unsuppressed viral load compared with the referent group (HR, 95% CI: 0.49, 0.28 to 0.85) than those without ADAP (HR, 95% CI: 1.00, 0.63 to 1.57). CONCLUSIONS: Although women with private insurance are most likely to be virally suppressed, ADAP also contributes to viral load suppression. Continued support of this program may be especially critical for states that have not expanded Medicaid.