High prevalence of hepatitis B virus among MSM living with HIV in India.

People living with HIV (PWH) have been shown to bear a higher burden of hepatitis B virus (HBV) due to shared routes and risk factors for transmission. Populations such as men who have sex with men (MSM) are at an increased risk of both being infected with HBV and HIV, that places them at higher risk of hepatocellular carcinoma. Using weighted and adjusted multilevel logistic regression, we characterized the prevalence and correlates of hepatitis B surface antigen (HBsAg) among MSM living with HIV across 12 Indian cities from 2012 to 2013. Overall, the prevalence of HBsAg was 8% (range across cities: 0.5%-19%). Being between the ages of 25-34, and 35-44 increased the odds of having chronic HBV infection compared to MSM 24 years or younger. Daily or seasonal employment and being unemployed increased the odds of HBsAg prevalence compared to those with monthly or weekly wages. Sexual risk behaviours such as having had sex with both men and women in the prior 6 months and history of sex work increased the odds of having HBV. Ever having insertive sex with a man or hijra (assigned male at birth, currently identifies as female/nonbinary) was negatively associated with HBV. Despite the existence of efficacious vaccines, HBV continues to have high prevalence among PWHs. Programmes to increase early screening, vaccinations and HBV literacy are urgently needed. Integrating HBV and HIV programmes for MSM populations could be critical in addressing this dual burden and improving outcomes for both infections.

Patterns of Polysubstance Use in Young Black and Latinx Sexual Minority Men and Transgender Women and Its Association with Sexual Partnership Factors: The PUSH Study.

Background: Adult studies have demonstrated that polysubstance use increases HIV acquisition risk through increased sexual behaviors, however, few studies have examined polysubstance in young Black and Latinx sexual minority men (SMM) and transgender women (TW). Methods: We used cross-sectional data from 466 young Black and Latinx SMM and TW living in four high HIV-burden US cities enrolled in the PUSH Study, a status-neutral randomized control trial to increase HIV prevention and treatment adherence. We examined data for patterns of polysubstance use comparing age differences of use and explored associations between substance use and sexual partnership factors - inconsistent condom use, pressure to have condomless anal sex, and older partner, using bivariate and multivariate analyses. Results: Most participants described prior substance use with alcohol and cannabis being most common (76% each) and 23% described other illicit drug use, including stimulants, cocaine, hallucinogens, sedatives, opioids, and inhalants. Polysubstance use was common with nearly half (47%) of participants reporting alcohol and cannabis use, 20% reporting alcohol, cannabis, and one other illicit drug use, and 19% reporting alcohol or cannabis use plus one other illicit drug use. Polysubstance use was associated with greater adjusted odds of pressure to have condomless anal sex, older partner (>5 years older), and inconsistent condom use. Conclusions: Associations of polysubstance use with sexual practices and sexual partnerships that are known predictors of HIV acquisition or transmission among Black and Latinx SMM and TW underscore the need for combination interventions that include substance use treatment alongside antiretroviral-based and partner-based HIV prevention and treatment interventions.Trial Registration: ClinicalTrials.gov Identifier: NCT03194477.

Changes in HIV care continuum indicators among community-based samples of HIV-infected people who inject drugs and men who have sex with men across 21 cities in India.

Monitoring key populations' progress towards UNAIDS 90-90-90 targets is essential to achieving HIV/AIDS epidemic control. Using serial cross-sectional data, we evaluated changes in HIV care continuum among people who inject drugs(PWID) and men who have sex with men(MSM) in India. Cross-sectional baseline (2012/2013) and follow-up (2016/2017) samples were recruited using respondent-driven sampling across 21 cities. All participants were tested for HIV and RNA measured in HIV-positive participants. Linear regression was used to model temporal site-level changes in continuum indicators in MSM versus PWID. At baseline, we recruited 2,544 HIV-infected PWID and 1,086 HIV-infected MSM. At follow-up, we recruited 2,517 HIV-infected PWID and 1,763 HIV-infected MSM. At baseline, there were no significant differences in continuum indicators between MSM and PWID. At follow-up, compared to PWID, the proportion of MSM reaching each care continuum indicator-awareness of status, receipt of care, ART use, viral suppression-increased by 15-33 percentage points: 78% of MSM versus 49% of PWID were aware of their status (p < 0.01); 56% of MSM versus 32% of PWID were virologically suppressed (p = 0.05). MSM showed marked improvements across the care continuum, whereas PWID lagged and may require additional intervention. Differential improvement in HIV engagement may necessitate population-specific interventions and routine surveillance to facilitate HIV elimination.

Deep learning-based atherosclerotic coronary plaque segmentation on coronary CT angiography.

OBJECTIVES: Volumetric evaluation of coronary artery disease (CAD) allows better prediction of cardiac events. However, CAD segmentation is labor intensive. Our objective was to create an open-source deep learning (DL) model to segment coronary plaques on coronary CT angiography (CCTA). METHODS: Three hundred eight individuals' 894 CCTA scans with 3035 manually segmented plaques by an expert reader (considered as ground truth) were used to train (186/308, 60%), validate (tune, 61/308, 20%), and test (61/308, 20%) a 3D U-net model. We also evaluated the model on an external test set of 50 individuals with vulnerable plaques acquired at a different site. Furthermore, we applied transfer learning on 77 individuals' data and re-evaluated the model's performance using intra-class correlation coefficient (ICC). RESULTS: On the test set, DL outperformed the currently used minimum cost approach method to quantify total: ICC: 0.88 [CI: 0.85-0.91] vs. 0.63 [CI: 0.42-0.76], noncalcified: 0.84 [CI: 0.80-0.88] vs. 0.45 [CI: 0.26-0.59], calcified: 0.99 [CI: 0.98-0.99] vs. 0.96 [CI: 0.94-0.97], and low attenuation noncalcified: 0.25 [CI: 0.13-0.37] vs. -0.01 [CI: -0.13 to 0.11] plaque volumes. On the external dataset, substantial improvement was observed in DL model performance after transfer learning, total: 0.62 [CI: 0.01-0.84] vs. 0.94 [CI: 0.87-0.97], noncalcified: 0.54 [CI: -0.04 to 0.80] vs. 0.93 [CI: 0.86-0.96], calcified: 0.91 [CI:0.85-0.95] vs. 0.95 [CI: 0.91-0.97], and low attenuation noncalcified 0.48 [CI: 0.18-0.69] vs. 0.86 [CI: 0.76-0.92]. CONCLUSIONS: Our open-source DL algorithm achieved excellent agreement with expert CAD segmentations. However, transfer learning may be required to achieve accurate segmentations in the case of different plaque characteristics or machinery. KEY POINTS: • Deep learning 3D U-net model for coronary segmentation achieves comparable results with expert readers' volumetric plaque quantification. • Transfer learning may be needed to achieve similar results for other scanner and plaque characteristics. • The developed deep learning algorithm is open-source and may be implemented in any CT analysis software.

Temporal assessment of lesion morphology on radiological images beyond lesion volumes-a proof-of-principle study.

OBJECTIVES: To develop a general framework to assess temporal changes in lesion morphology on radiological images beyond volumetric changes and to test whether cocaine abstinence changes coronary plaque structure on serial coronary CT angiography (CTA). METHODS: Chronic cocaine users with human immunodeficiency virus (HIV) infection were prospectively enrolled to undergo cash-based contingency management to achieve cocaine abstinence. Participants underwent coronary CTA at baseline and 6 and 12 months following recruitment. We segmented all coronary plaques and extracted 1103 radiomic features. We implemented weighted correlation network analysis to derive consensus eigen radiomic features (named as different colors) and used linear mixed models and mediation analysis to assess whether cocaine abstinence affects plaque morphology correcting for clinical variables and plaque volumes and whether serum biomarkers causally mediate these changes. Furthermore, we used Bayesian hidden Markov network changepoint analysis to assess the potential rewiring of the radiomic network. RESULTS: Sixty-nine PLWH (median age 55 IQR: 52-59 years, 19% female) completed the study, of whom 26 achieved total abstinence. Twenty consensus eigen radiomic features were derived. Cocaine abstinence significantly affected the pink and cyan eigen features (-0.04 CI: [-0.06; -0.02], p = 0.0009; 0.03 CI: [0.001; 0.04], p = 0.0017, respectively). These effects were mediated through changes in endothelin-1 levels. In abstinent individuals, we observed significant rewiring of the latent radiomic signature network. CONCLUSIONS: Using our proposed framework, we found 1 year of cocaine abstinence to significantly change specific latent coronary plaque morphological features and rewire the latent morphologic network above and beyond changes in plaque volumes and clinical characteristics. KEY POINTS: • We propose a general methodology to decompose the latent morphology of lesions on radiological images using a radiomics-based systems biology approach. • As a proof-of-principle, we show that 1 year of cocaine abstinence results in significant changes in specific latent coronary plaque morphologic features and rewiring of the latent morphologic network above and beyond changes in plaque volumes and clinical characteristics. • We found endothelin-1 levels to mediate these structural changes providing potential pathological pathways warranting further investigation.

Assessing the Relationship Between HIV Quality of Care and Treatment Literacy on ART Adherence and Viral Suppression Among Female Sex Workers Living in the Dominican Republic.

This study assessed the relationship between the quality of HIV care and treatment literacy on antiretroviral therapy (ART) adherence and viral suppression among female sex workers (FSWs) living with HIV (n = 211) in Santo Domingo, Dominican Republic. Multivariable logistic regression results indicate better patient-provider communication (AOR 1.04; 95% CI 1.01-1.07) and respectful treatment (AOR 2.17; 95% CI 1.09-4.32) increase the odds of viral suppression, while higher costs reduce both the odds of ART adherence (AOR 0.57, 95% CI 0.34- 0.95) and being virally suppressed (AOR 0.59, 95% CI 0.41-0.85). Greater treatment literacy was associated with an increased odds of ART adherence (AOR 4.15 for understanding of viral load; 95% CI 1.50-11.52) and viral suppression (AOR 2.75 for understanding of CD4 count; 95% CI 1.31-5.80). Findings support investments in treatment education, effective and respectful patient-provider communication, dignified care, and cost-support for associated HIV care costs to facilitate FSWs' pathway towards viral suppression.

RESUMEN: Este estudio evaluó la relación entre la calidad de la atención para el VIH y la alfabetización relacionada al tratamiento sobre la adherencia a la terapia antirretroviral (TAR) y la supresión viral entre las trabajadoras sexuales (TRSX) que viven con el VIH (n = 211) en Santo Domingo, República Dominicana. Los resultados de la regresión logística multivariable indican una mejor comunicación entre el paciente y el proveedor (RMa: 1.04; IC del 95%: 1.01­1.07) y un tratamiento respetuoso (RMa: 2.17; IC del 95%: 1.09­4.32) aumenta la probabilidad de supresión viral, mientras que los costos elevados reducen tanto las probabilidades de adherencia al TAR (RMa: 0.57; IC del 95%: 0.34­0.95) como la supresión viral (RMa: 0.59, IC del 95%: 0.41­0.85). Una mayor alfabetización relacionada al tratamiento se asoció con una mayor probabilidad de adherencia al TAR (RMa: 4.15 para la comprensión de la carga viral; IC del 95%: 1.50­11.52) y la supresión viral (RMa: 2.75 para la comprensión del conteo de CD4; IC del 95%: 1.31­5.80). Los hallazgos respaldan inversiones en educación sobre el tratamiento, la comunicación efectiva y respetuosa entre el paciente y el proveedor, la atención digna y el apoyo económico para los costos asociados con la atención del VIH para facilitar el camino de las TRSX hacia la supresión viral.

Characterizing the PrEP Continuum for Black and Latinx Sexual and Gender Minority Youth.

Pre-exposure prophylaxis (PrEP) rollout efforts thus far have inadequately reached young people from underrepresented backgrounds. This study explores PrEP engagement among young Black and Latinx men who have sex with men, transgender women, and gender diverse individuals in three U.S. cities using an adapted PrEP continuum measure. We analyze data from the recruitment phase of an ongoing PrEP engagement intervention (n = 319) using partial proportional odds logistic regression. Participants reported high willingness and intention to use PrEP, yet most (82%) were not currently taking PrEP. Being insured (aOR = 2.95, 95%-CI = 1.60-5.49), having one or more PrEP users in one's sexual network (aOR = 4.19, 95%-CI = 2.61-6.79), and higher individual HIV risk scores (aOR = 1.62, 95%-CI = 1.34-1.97) were each associated with being further along the PrEP continuum. Strategies are needed to address barriers to healthcare access and leverage connections within social and sexual networks in order to bolster PrEP engagement among marginalized young people from diverse backgrounds.

RESUMEN: Los esfuerzos de dar a conocer la profilaxis prexposición (PrEP) hasta el momento han llegado de forma inadecuada a los jóvenes de entornos desfavorecidos. Este estudio explora en tres ciudades de los EE. UU. el compromiso con la PrEP entre los jóvenes de raza negra y latino quienes son minorías sexuales o de género, utilizando una medida de seguimiento de la PrEP adaptada. Analizamos los datos de la fase de reclutamiento de una participación en la PrEP en curso (n = 319) utilizando una regresión logística parcial de probabilidades proporcionales. Los participantes manifestaron una alta disposición e intención de utilizar la PrEP, aunque la mayoría (82%) no tomaba actualmente la PrEP. Estar asegurado (aOR = 2,95, 95%-CI = 1,60­5,49), tener uno o más usuarios de la PrEP en su red sexual (aOR = 4,19, 95%-CI = 2,61­6,79), y mayores puntuaciones individuales de riesgo de VIH (aOR = 1,62, 95%-CI = 1,34­1,97) se asociaron con el hecho de llevar un seguimiento estrecho con la PrEP. Se necesitan estrategias para abordar las barreras de acceso a la atención médica y aprovechar las conexiones entre las redes sociales y las de carácter sexual, con el fin de reforzar el compromiso con la PrEP entre los jóvenes marginados de diversas procedencias.

Substance use is associated with condomless anal intercourse among men who have sex with men in India: a partner-level analysis.

BACKGROUND: Men who have sex with men (MSM) bear a disproportionately high burden of new HIV infections while lagging behind other populations with respect to engagement across the HIV care continuum. General risk factors for condomless anal intercourse (CAI) among MSM are well studied but there is a paucity of partner-level data, where emerging evidence suggests that much of the variation in condom use occurs. METHODS: MSM were recruited across 10 cities in India using respondent-driven sampling (RDS) from 2016-17. Among the individuals who reported sexual intercourse in the prior 6 months, condom use and partner characteristics of the last 4 partners were captured. Correlates of CAI at the individual and partner level were determined using Poisson regression models using generalized estimating equations and incorporating RDS-II weights, which weights estimates for the participant's network size. RESULTS: Among the 8,086 individuals, 21,723 sexual partnerships were analyzed. The prevalence of CAI was 46.9% and most partners were casual or one-time (70.7%) with partner HIV status reported as unknown in 42.6% of the sexual encounters. In multivariable analyses, partner-level characteristics associated with higher likelihood of CAI included unknown partner HIV status (aPR vs. known HIV negative partner: 1.34; 95% confidence interval (CI): 1.27-1.43) and use of alcohol/ drugs prior to intercourse either sometimes (aPR 1.42; 95% CI: 1.33-1.51) or always (aPR 1.31; 95% CI: 1.23-1.41). At an individual level, any HIV treatment literacy was associated with a lower likelihood of CAI (aPR 0.80; 95% CI: 0.74-0.86). CONCLUSIONS: To reduce HIV transmission among this population of MSM across India, combination interventions are likely needed. Interventions targeting substance use and education as well as initiatives to increase self-testing are urgently needed among MSM in India and have the potential to reduce HIV transmission in this high-risk population. Trial registration ClinicalTrials.gov Identifier: NCT01686750. Date of Registration: September 18, 2012.

Exploring peer navigation and support in the quality of HIV care experiences of female sex workers in the Dominican Republic.

BACKGROUND: Despite evidence on peer navigation's association with positive HIV outcomes, such as engagement in HIV care and antiretroviral therapy (ART) initiation, the mechanisms through which peer navigation may influence these outcomes have been less explored. The purpose of this study is to describe the role of peer navigation and support on enhancing the quality of HIV treatment and care services experienced by female sex workers (FSWs). METHODS: Survey data was derived from a quantitative cohort (n = 211) of FSWs living with HIV in the Dominican Republic and complemented with data from two rounds of in-depth interviews (IDIs) from a qualitative subsample (n = 20 per round). Descriptive statistics and multivariable logistic regressions were used to explore the association between peer navigation and relational aspects of care and overall satisfaction of the quality of HIV treatment and care. Thematic analysis was employed to code and synthesize textual data from IDIs. RESULTS: 41.2% of the participants reported having had contact with a peer navigator in the last 6 months. Qualitative data revealed that peer navigation and support was instrumental in assisting FSWs linkage to HIV care after diagnosis, elevating FSWs' ability to access more comprehensive clinical care facilities, and promoting agency by improving FSWs' skills to more strategically and effectively engage with the clinic environment and health care providers. Peer navigation was positively associated with experiencing more respectful treatment by clinic staff (AOR: 6.65, 95% CI: 2.32-19.02), and greater satisfaction with overall HIV care services (AOR: 2.57, 95% CI: 1.77-3.74). CONCLUSION: Promoting the full integration of peer navigation into healthcare structures is a strategic approach to enhance the quality of HIV care experienced by FSWs and improve their HIV-related outcomes.

Cardiovascular risk factors and illicit drug use may have a more profound effect on coronary atherosclerosis progression in people living with HIV.

OBJECTIVES: To assess whether HIV infection directly or indirectly promotes coronary artery disease (CAD) volume progression in a longitudinal study of African Americans. METHODS: We randomly selected 300 individuals with subclinical CAD (210 male; age: 48.0 ± 7.2 years; 226 HIV infected, 174 cocaine users) from 1429 cardiovascularly asymptomatic participants of a prospective epidemiological study between May 2004 and August 2015. Individuals underwent coronary CT angiography at two time points (mean follow-up: 4.0 ± 2.3 years). We quantified noncalcified (NCP: -100-350HU), low-attenuation noncalcified (LA-NCP: -100-30HU), and calcified (CP: ≥ 351 HU) plaque volumes. Linear mixed models were used to assess the effects of HIV infection, atherosclerotic cardiovascular disease (ASCVD) risk, and years of cocaine use on plaque volumes. RESULTS: There was no significant difference in annual progression rates between HIV-infected and HIV-uninfected regarding NCP (8.7 [IQR: 3.0-19.4] mm3/year vs. 4.9 [IQR: 1.5-18.3] mm3/year, p = 0.14), LA-NCP (0.2 [IQR: 0.0-1.6] mm3/year vs. 0.2 [IQR: 0.0-0.9] mm3/year, p = 0.07) or CP volumes (0.3 [IQR: 0.0-3.4] mm3/year vs. 0.1 [IQR: 0.0-3.2] mm3/year, p = 0.30). Multivariately, HIV infection was not associated with NCP (-6.9mm3, CI: [-32.8-19.0], p = 0.60), LA-NCP (-0.1mm3, CI: [-2.6-2.4], p = 0.92), or CP volumes (-0.3mm3, CI: [-9.3-8.6], p = 0.96). However, each percentage of ASCVD and each year of cocaine use significantly increased total, NCP, and CP volumes among HIV-infected individuals, but not among HIV-uninfected. Importantly, none of the HIV-associated medications had any effect on plaque volumes (p > 0.05 for all). CONCLUSIONS: The more profound adverse effect of risk factors in HIV-infected individuals may explain the accelerated progression of CAD in these people, as HIV infection was not independently associated with any coronary plaque volume. KEY POINTS: • Human immunodeficiency virus-infected individuals may have similar subclinical coronary artery disease, as the infection is not independently associated with coronary plaque volumes. • However, cardiovascular risk factors and illicit drug use may have a more profound effect on atherosclerosis progression in those with human immunodeficiency virus infection, which may explain the accelerated progression of CAD in these people. • Nevertheless, through rigorous prevention and abstinence from illicit drugs, these individuals may experience similar cardiovascular outcomes as -uninfected individuals.

Depressive symptoms among Peruvian adult residents amidst a National Lockdown during the COVID-19 pandemic.

BACKGROUND: Population health and well-being in Latin America, the current epicenter of the COVID-19 pandemic, has been severely affected during the past semester. Despite the growing evidence about the link between the pandemic, its control measures, and mental health worldwide, there is still no regional evidence of the potential mental health impact. We describe the prevalence and distribution of depressive symptoms across demographic and socioeconomic risk factors in the Peruvian population amidst a national lockdown during the COVID-19 pandemic. METHODS: Cross-sectional study conducted during the community transmission phase and national lockdown in Peru (May 4th-16th, 2020). We recorded 64,493 responses from adult Peruvian residents through an opt-in online questionnaire. All analyses were weighted using raking based on proportions of sociodemographic variables from the last Peruvian census in 2017. The prevalence of depressive symptoms was calculated using the Patient Health Questionnaire (PHQ-9) score of 10 or more. We identified associated demographic and socioeconomic factors by prior mental health diagnosis. Sensitivity analysis considered an alternative cut-off point for depressive symptoms of PHQ-9 ≥ 14. RESULTS: A total of 57,446 participants were included in the analytical sample. A third of the participants (n = 23,526, unweighted) showed depressive symptoms in the 2 weeks prior to the study. Participants who reported a previous mental health diagnosis doubled the sample prevalence of depressive symptoms (59, 95%CI 56.7, 61.4%) of those without a prior diagnosis. Psychosocial and functioning reactions were largely more prevalent among females and young adults. A dose-response relationship was found between household income and depressive symptoms across previous mental health diagnosis strata, being as low as 32% less in the wealthiest than the most impoverished group (PR: 0.68, 95%CI 0.58,0.79). Other critical factors associated with a higher burden of depressive symptoms were lower education level, single, unemployed, and chronic comorbidity. CONCLUSIONS: An increased burden of depressive symptoms and psychosocial reactions has emerged during the COVID-19 pandemic in Peru compared to previous years. The mental health burden disproportionately affects women, the younger population, and those with low income and education. As the country eases the social distancing measures, it is crucial to use local evidence to adjust public health policies and mental health services to the renewed population needs.

Prevalence and Phylogenetic Characterization of Hepatitis C Virus Among Indian Men Who Have Sex With Men: Limited Evidence for Sexual Transmission.

BACKGROUND: Data from high-income countries suggest increasing hepatitis C virus (HCV) prevalence/incidence among human immunodeficiency virus (HIV)-infected men who have sex with men (MSM), but limited data derive from low-and-middle-income countries. METHODS: We recruited 4994 MSM from 5 states across India using respondent-driven sampling. Logistic regression incorporating respondent-driven sampling weights and machine learning feature selection were used to identify correlates of prevalent HCV, and Bayesian phylogenetic analysis was used to examine genetic clustering. RESULTS: The median age was 25 years, the HIV prevalence was 7.2%, and 49.3% of participants reported recent unprotected anal intercourse. The HCV prevalence was 1.3% (95% confidence interval, 1.0%-1.6%; site range, 0.2%-3.4%) and was 3.1% in HIV-positive versus 1.1% among HIV-negative men. HCV infection was significantly associated with injection drug use (odds ratio, 177.1; 95% confidence interval, 72.7-431.5) and HIV infection (4.34; 1.88-10.05). Machine learning did not uncover any additional epidemiologic signal. Phylogenetic analysis revealed 3 clusters suggestive of linked transmission; each contained ≥1 individual reporting injection drug use. CONCLUSIONS: We observed a low HCV prevalence in this large sample of MSM despite a high prevalence of known risk factors, reflecting either the need for a threshold of HCV for sexual transmission and/or variability in sexual practices across settings.

Gaps in science and evidence-based interventions to respond to Intimate Partner Violence among Black gay and bisexual men in the U.S.: A Call for An Intersectional Social Justice Approach.

Intimate Partner Violence (IPV) is a prevalent, but underrecognized issue among sexual minorities (SM) broadly, but especially among Black Gay and Bisexual Men (BGBM). Over the last several years, acts of IPV among BGBM made national news, drawing attention to the unique ways that IPV plays out within this particular population. Yet, little research has examined the intersections between race and sexuality among BGBM, the lack of culturally responsive IPV services, their support needs, or the barriers that BGBM face when seeking IPV related services. When examined closely, the field of IPV has traditionally focused on cisgender heterosexual white woman as victims and cisgender white men as perpetrators, which has historically impacted the availability and quality of IPV services for other populations. This narrative critique of the IPV movement calls for an intersectional social justice and health equity approach to address the unique and intersectional needs of BGBM who experience IPV. By centering the intersectional needs of BGBM and the role that racism, homophobia, and heteronormative has played in shaping IPV-related services, this article challenges the IPV field to advance a social justice orientation in order to address the unmet needs of BGBM who experience IPV.

Psychosocial Barriers to Viral Suppression in a Community-based Sample of Human Immunodeficiency Virus-infected Men Who Have Sex With Men and People Who Inject Drugs in India.

BACKGROUND: Little is known about the impact of psychosocial factors and substance use on viral suppression among human immunodeficiency virus (HIV)-infected key populations in resource-limited settings. Accordingly, we examined the association and interactions between depression, alcohol use, and recreational drug use on viral suppression among men who have sex with men (MSM) and people who inject drugs (PWID) in India. METHODS: MSM and PWID were recruited across India using respondent-driven sampling (RDS). Correlates of viral suppression were determined using Poisson regression models incorporating RDS-II weights. Two-way multiplicative interactions were assessed with separate models of all combinations of the 3 variables of interest using interaction terms; 3-way interactions were evaluated by stratifying 2-way interactions by the third variable. RESULTS: Among 1454 treatment-eligible HIV-infected MSM and 1939 PWID, older age (adjusted prevalence ratio [aPR], 1.14 for MSM; 1.41 for PWID) and higher HIV treatment literacy (aPR, 1.58 for MSM; 3.04 for PWID) were positively associated with viral suppression. Among MSM, there was evidence of a synergistic negative association between severe depression and recreational drug use (aPR, 0.37 [95% confidence interval {CI}, .16-.84]), alcohol dependence and recreational drug use (aPR, 0.45 [95% CI, .20-.99]), and severe depression, alcohol dependence, and recreational drug use (aPR, 0.23 [95% CI, .09-.57]). Among PWID, daily injection (aPR, 0.51 [95% CI, .31-.82]) was the primary barrier to suppression. CONCLUSIONS: Incorporating psychosocial and harm-reduction services into differentiated care models targeting MSM and PWID in low-resource settings is critical to achieving the 90-90-90 HIV/AIDS targets.

Perspectives on the Future of Epidemiology: A Framework for Training.

Over the past century, the field of epidemiology has evolved and adapted to changing public health needs. Challenges include newly emerging public health concerns across broad and diverse content areas, new methods, and vast data sources. We recognize the need to engage and educate the next generation of epidemiologists and prepare them to tackle these issues of the 21st century. In this commentary, we suggest a skeleton framework upon which departments of epidemiology should build their curriculum. We propose domains that include applied epidemiology, biological and social determinants of health, communication, creativity and ability to collaborate and lead, statistical methods, and study design. We believe all students should gain skills across these domains to tackle the challenges posed to us. The aim is to train smart thinkers, not technicians, to embrace challenges and move the expanding field of epidemiology forward.

Integrating HCV testing with HIV programs improves hepatitis C outcomes in people who inject drugs: A cluster-randomized trial.

BACKGROUND & AIMS: There have been calls to integrate HCV testing into existing services, including harm reduction and HIV prevention and treatment, but there are few empirical trials to date. We evaluated the impact of integrating HCV testing/education into integrated care centers (ICCs) delivering HIV services to people who inject drugs (PWID) across India, using a cluster-randomized trial. METHODS: We compared ICCs with usual care in the PWID stratum (12 sites) of a 22-site cluster-randomized trial. In 6 sites, ICCs delivering HIV testing, harm reduction, other preventive services and linkage to HIV treatment were scaled from opioid agonist therapy centers and operated for 2 years. On-site rapid HCV antibody testing was integrated after 1 year. To assess impact, we conducted baseline and evaluation surveys using respondent-driven sampling (RDS) across the 12 sites (n = 11,993 recruited at baseline; n = 11,721 recruited at evaluation). The primary outcome was population-level self-reported HCV testing history. RESULTS: At evaluation, HCV antibody prevalence ranged from 7.2-76.6%. Across 6 ICCs, 5,263 ICC clients underwent HCV testing, of whom 2,278 were newly diagnosed. At evaluation, PWID in ICC clusters were 4-fold more likely to report being tested for HCV than in usual care clusters, adjusting for baseline testing (adjusted prevalence ratio [aPR] 3.69; 95% CI 1.34-10.2). PWID in ICC clusters were also 7-fold more likely to be aware of their HCV status (aPR 7.11; 95% CI 1.14-44.3) and significantly more likely to initiate treatment (aPR 9.86; 95% CI 1.52-63.8). CONCLUSIONS: We provide among the first empirical data supporting the integration of HCV testing into HIV/harm reduction services. To achieve elimination targets, programs will need to scale-up such venues to deliver comprehensive HCV services. CLINICALTRIALS. GOV IDENTIFIER: NCT01686750. LAY SUMMARY: Delivering hepatitis C virus (HCV) testing to people who inject drugs (PWID) in places where they also have access to HIV prevention and treatment services is an effective way to improve uptake of HCV testing among communities of PWID. To achieve the World Health Organization's ambitious elimination targets, integrated programs will need to be scaled up to deliver comprehensive HCV services.

Depression, sexual behavior, and HIV treatment outcomes among transgender women, cisgender women and men who have sex with men living with HIV in Brazil and Thailand: a short report.

One in five transgender women (TW) are living with HIV, yet little has been published about their health outcomes. We analyzed data from TW (n = 37), cisgender women (CW, n = 165), and cisgender men who have sex with men (MSM, n = 151) in Thailand and Brazil. We hypothesized: (1) TW will have higher odds of depressive symptoms, lower odds of condom use and greater odds of a detectable viral load compared to MSM and CW; and (2) TW will have lower odds of condom use and higher odds of detectable viral load. We found that TW had higher odds of depression (OR 2.2, 95%CI: 1.0, 4.8, p = 0.04) and were less likely than MSM (22% v. 42%, p = 0.01) to use condoms with partners of unknown serostatus. In multivariable models, TW had lower odds than MSM of using condoms with partners with unknown serostatus (OR 0.38, 95%CI: 0.15, 0.90) and CW had lower odds than MSM of using condoms with HIV-negative partners (0.60 [0.38, 0.95], p = 0.029). We found no significant differences in detectable viral load. Disaggregating data by gender is important to understand factors that contribute to viral suppression and HIV transmission risk among people living with HIV.

The Centennial of the Department of Epidemiology at Johns Hopkins Bloomberg School of Public Health: A Century of Epidemiologic Discovery and Education.

The Department of Epidemiology at Johns Hopkins School of Hygiene and Public Health was founded in 1919, with Wade Hampton Frost as inaugural chair. In our Centennial Year, we review how our research and educational programs have changed. Early years focused on doctoral education in epidemiology and some limited undergraduate training for practice. Foundational work on concepts and methods linked to the infectious diseases of the day made major contributions to study designs and analytical methodologies, largely still in use. With the epidemiologic transition from infectious to chronic disease, new methods were developed. The Department of Chronic Diseases merged with the Department of Epidemiology in 1970, under the leadership of Abraham Lilienfeld. Leon Gordis became chair in 1975, and multiple educational tracks were developed. Genetic epidemiology began in 1979, followed by advances in infectious disease epidemiology spurred by the human immunodeficiency virus/acquired immune deficiency syndrome epidemic. Collaborations with the Department of Medicine led to development of the Welch Center for Prevention, Epidemiology, and Clinical Research in 1989. Between 1994 and 2008, the department experienced rapid growth in faculty and students. A new methods curriculum was instituted for upper-level epidemiologic training in 2006. Today's research projects are increasingly collaborative, taking advantage of new technologies and methods of data collection, responding to "big data" analysis challenges. In our second century, the department continues to address issues of disease etiology and epidemiologic practice.

Economic Insecurity and Deaths of Despair in US Counties.

Recent research has implicated economic insecurity in increasing midlife death rates and "deaths of despair," including suicide, chronic liver disease, and drug and alcohol poisoning. In this ecological longitudinal study, we evaluated the association between changes in economic insecurity and increases in deaths of despair and midlife all-cause mortality in US counties during 2000-2015. We extended a previously developed measure of economic insecurity using indicators from the Census and Federal Reserve Bank in US counties for the years 2000 and 2010. Linear regression models were used to estimate the association of change in economic insecurity with change in death rates through 2015. Counties experiencing elevated economic insecurity in either 2000 or 2010 had higher rates of deaths of despair and all-cause midlife mortality at baseline but similar rates of increase in deaths of despair from 2001 to 2015 compared with counties with stable low economic insecurity. Counties in the highest tertile of economic insecurity in 2000 and 2010 had 41% (95% confidence interval: 1.36, 1.47) higher midlife mortality rates at baseline and a rate of increase of 2% more per 5-year period (95% confidence interval: 1.00, 1.03) than counties with stable low economic insecurity. Economic insecurity may represent a population-level driver of US death trends.

Durable HIV Suppression Among People Who Inject Drugs From a Community-Based Cohort Study in Baltimore, Maryland, 1997-2017.

People who inject drugs (PWID) face disparities in human immunodeficiency virus (HIV) treatment outcomes and may be less likely to achieve durable viral suppression. We characterized transitions into and out of viral suppression from 1997 to 2017 in a long-standing community-based cohort study of PWID, the AIDS Link to Intravenous Experience (ALIVE) Study, analyzing HIV-positive participants who had made a study visit in or after 1997. We defined the probabilities of transitioning between 4 states: 1) suppressed, 2) detectable, 3) lost to follow-up, and 4) deceased. We used multinomial logistic regression analysis to examine factors associated with transition probabilities, with a focus on transitions from suppression to other states. Among 1,061 participants, the median age was 44 years, 32% were female, 93% were African-American, 59% had recently injected drugs, and 28% were virologically suppressed at baseline. Significant improvements in durable viral suppression were observed over time; however, death rates remained relatively stable. In adjusted analysis, injection drug use and homelessness were associated with increased virological rebound in earlier time periods, while only age and race were associated with virological rebound in 2012-2017. Opioid use was associated with an increased risk of death following suppression in 2012-2017. Despite significant improvements in durable viral suppression, subgroups of PWID may need additional efforts to maintain viral suppression and prevent premature mortality.