Realizing the promise of long-acting antiretroviral treatment strategies for individuals with HIV and adherence challenges: an illustrative case series.

BACKGROUND: Adherence to antiretroviral treatment (ART) remains the cornerstone of optimal HIV outcomes, including viral suppression (VS), immune recovery, and decreased transmission risk. For many people with HIV (PWH), particularly those with early-acquired HIV, structural, behavioral, and cognitive barriers to adherence and competing priorities related to life events may be difficult to overcome, resulting in nonadherence. Long-acting injectable antiretroviral therapies (LAI-ART) may be a useful strategy to overcome some of these barriers. However, to date, the approved LAI-ART strategies (e.g., cabotegravir and rilpivirine (CAB/RPV)) have targeted those who have already attained viral suppression, precluding their use in the 40% of adolescents and young adults (AYA) that VS has eluded. CASE PRESENTATION: Ms. X is a 30-year-old woman with perinatally-acquired HIV and barriers to adherence. Despite many interventions, she remained persistently viremic, with resultant immune suppression and multiple comorbid opportunistic conditions, and viral load (VL) > 10,000,000 copies/ml. Given her longstanding history of poor adherence to an oral regimen, a switch to monthly intramuscular (IM) injections and biweekly infusions of ibalizumab were initiated leading to decreased viral load to 8,110 copies/ml within two weeks. Ms. H is a 33-year-old woman with cognitive limitations due to childhood lead poisoning. Her viral load trajectory took a downward turn, precipitated by various life events, remaining elevated despite intensive case management. Initiation of LAI-ART (CAB/RPV) in this patient led to an undetectable VL (< 20 copies/ml) within two months of treatment initiation. Miss Y. is a 37-year-old woman with perinatally-acquired HIV and chronic challenges with nonadherence and longstanding immunosuppression with CD4 < 200 cells/mm3 for > 5 years. She received a 1-month oral lead-in (OLI) of cabotegravir/rilpivirine, followed by the injectable loading dose. She has since adhered to all her monthly dosing appointments, sustained VS, and transitioned to a bi-monthly injection schedule. CONCLUSION: These three individuals with HIV (perinatally and non-perinatally acquired) with longstanding nonadherence and persistent viremia were successfully initiated on LAI-ART through the process of care coordination and the collective efforts of the care team, highlighting the barriers, challenges, and the multidisciplinary coordination needed to assure successful implementation of this strategy for the most vulnerable of patients.

Using Innovation to Address Adolescent and Young Adult Health Disparities in Pelvic Inflammatory Disease: Design of the Technology Enhanced Community Health Precision Nursing (TECH-PN) Trial.

New approaches to pelvic inflammatory disease (PID) care among adolescents and young adults (AYAs) that optimize self-care and personalize treatment are warranted to address age and racial-ethnic PID-related health disparities. Here we describe the 13-month preliminary feasibility and acceptability outcomes of recruitment, retention, and intervention delivery for Technology Enhanced Community Health Precision Nursing (TECH-PN) randomized controlled trial. Urban AYAs 13-25 years assigned female sex at birth with acute mild-moderate PID provided baseline and follow-up interview data and vaginal specimens for sexually transmitted infection (STI), cytokine, and microbiota assessment. All participants received medications and text-messaging support. Participants were block randomized to either control or intervention. Control participants received 1 community nursing visit with self-management for interim care per national guidelines. Intervention participants received unlimited precision care services driven by interim STI and macrolide resistance testing results by an advanced practice provider. In the first 13 months, 75.2% patients were eligible, and 76.1% of eligible patients enrolled. Of the participants, 94% completed the intervention and 96%, 91%, and 89%, respectively, completed their 14-, 30-, and 90-day visits. Baseline laboratory results revealed infection rates that were highest for Mycoplasma genitalium (45%) followed by Chlamydia trachomatis (31%). Preliminary enrollment, STI, intervention delivery, and retention data demonstrate the feasibility and acceptability of the TECH-PN intervention and support rationale for precision care for PID among urban AYAs. ClinicalTrials.gov Identifier. NCT03828994.

Clearance of Mycoplasma genitalium and Trichomonas vaginalis Among Adolescents and Young Adults With Pelvic Inflammatory Disease: Results From the Tech-N Study.

Current pelvic inflammatory disease (PID) treatment effectively treats Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT). However, coverage may be inadequate for Mycoplasma genitalium (MG)/Trichomonas vaginalis (TV) infections. We compared the longitudinal MG and TV outcomes with NG/CT outcomes for women enrolled in a longitudinal randomized controlled trial to optimize outcomes after PID. The prevalences of CT and NG were lower at 30- and 90-day follow-up compared with the prevalence at the time of diagnosis. No significant difference was observed for MG (odds ratio, 0.95; 0.86-1.04; P = 0.265) and TV (odds ratio, 0.89; 0.75-1.04; P = 0.146) over time for both treatment groups, showing that persistence and/or reinfection with MG and TV occurs more frequently than with CT or NG after treatment of PID using current national treatment guidelines.

Longitudinal impact of screening colonoscopy on greenhouse gas emissions.

BACKGROUND AND AIM: Colonoscopy is the gold-standard screening test for colorectal cancer. However, it has come under scrutiny for its carbon footprint and contribution to greenhouse gas (GHG) emissions compared to other medical procedures. Notwithstanding, screening colonoscopies may have a positive effect on GHG emissions that is unknown. This study estimated the carbon emissions prevented by screening colonoscopies in the U.S. METHODS: Using the reported number of screening colonoscopies performed annually in the U.S. and the absolute risk reduction (ARR) reported in the NorDICC trial, we calculated the expected minimum number of cancer treatment and surveillance visits prevented through screening based on the cancer stage. The average carbon emission averted per mile traveled was computed using the Environmental Protection Agency's (EPA) GHG equivalencies calculator. The final estimate of carbon emissions averted over a decade by screening colonoscopies performed in one year was determined. RESULT: 6.3 million screening colonoscopies performed in one year prevent 1,134,000 colorectal cancers over a ten-year period. Of these, 38∙3% (434,254) are localized, 38∙8% (440,281) are regional, and 22∙9% (259,465) are metastatic disease. The minimum number of post-diagnosis visits prevented is 11 for stage I, ≥ 21 for stage II, ≥25 for stage III, and ≥ 20 for stage IV disease, comprised of diagnostic, surgical evaluation, chemotherapy, and surveillance visits. The total number of visits prevented by screening is 2,388,397 for stage I, 5,254,421 for stage II, 13,120,369 for stage III, and 9,210,972 for stage IV disease. Approximately 395 million miles of travel and 158,263 metric tons of CO2, equivalent to 177 million pounds of coal burned, 19 billion smartphones charged, or 18 million gallons of gasoline consumed, were saved over ten years through screening. CONCLUSION: Colorectal cancer screening decreases cancer-related GHG emissions and minimizes the environmental impact of cancer treatment.

Accuracy of Provider Predictions of Viral Suppression Among Adolescents and Young Adults With HIV in an HIV Clinical Program.

BACKGROUND: Providers caring for adolescents and young adults with HIV (AYA-HIV) mostly base their adherence counseling during clinical encounters on clinical judgment and expectations of patients' medication adherence. There is currently no data on provider predictions of viral suppression for AYA-HIV. We aimed to assess the accuracy of provider predictions of patients' viral suppression status compared to viral load results. METHODS: Providers caring for AYA-HIV were asked to predict the likelihood of viral suppression of patients before a clinical encounter and give reasons for their predictions. Provider predictions were compared to actual viral load measurements of patients. Patient data were abstracted from electronic health records. The final analysis included 9 providers, 28 patients, and 34 observations of paired provider predictions and viral load results. RESULTS: Provider prediction accuracy of viral suppression was low (59%, Cohen's Kappa = 0.16). Provider predictions of lack of viral suppression were based on nonadherence to medications, new patient status, or structural vulnerabilities (e.g., unstable housing). Anticipated viral suppression was based on medication adherence, history of viral suppression, and the presence of family or other social forms of support. CONCLUSIONS: Providers have difficulty accurately predicting viral suppression among AYA-HIV and may base their counseling on incorrect assumptions. Rapid point-of-care viral load testing may provide opportunities to improve counseling provided during the clinical encounter.

Accuracy of Provider Predictions of Viral Suppression among Adolescents and Young Adults with HIV in an HIV Clinical ProgramProviders caring for adolescents and young adults with HIV (AYA-HIV) mostly base their adherence counseling during clinical encounters on clinical judgment and expectations of patients' medication adherence. Currently, no data exist on provider predictions of viral suppression for AYA-HIV. We aimed to assess the accuracy of provider predictions of patients' viral suppression compared to viral load results. Providers caring for AYA-HIV were asked to predict the likelihood of viral suppression of patients before a clinical encounter with reasons for their predictions. Provider predictions were compared to actual viral load measurements of patients. Patient data were abstracted from electronic health records. The final analysis included nine providers, 28 patients, and 34 observations of paired provider predictions and viral load results. Provider prediction accuracy of viral suppression was low (59%, Cohen's Kappa=0.16). Provider predictions of lack of viral suppression were based on non-adherence to medications, new patient status, or structural vulnerabilities (e.g., unstable housing). Anticipated viral suppression was based on medication adherence, history of viral suppression, and presence of family or other social forms of support. Providers have difficulty predicting viral suppression among AYA-HIV and may base counseling on incorrect assumptions. Rapid point-of-care viral load testing may provide opportunities to improve counseling.

Preparing the Frontlines: Delivering Special Pathogen Training to Maryland Hospital Staff.

Healthcare workers (HCWs) at community hospitals, also known as frontline hospitals (FLHs), may encounter patients with possible infectious diseases, including those caused by high-consequence pathogens such as Zaire ebolavirus. We created and piloted a 1-day, in-person, didactic and skills training program to determine the feasibility and acceptability of implementing an educational program to enhance the knowledge and skills needed to respond when a patient with a potential high-consequence pathogen presents to an FLH. The Maryland Department of Health queried all 104 state FLHs to identify their interest in participating in the pilot training program. HCWs from 12 (75%) of the 16 interested FLHs participated in the program before it was interrupted by the COVID-19 pandemic. In addition to pathogen-specific training based on the Identify, Isolate, and Inform framework, we provided skills training in the proper use of personal protective equipment, spill cleanup, and removal of an incapacitated HCW from an isolation area. We conducted a paired pretraining and posttraining knowledge assessment and measured a significant learning gain among 135 participants (2-tailed t test, P<.05). Over 95% of the participants reported that the training was relevant to their daily work and the clinical simulations and reference material were useful and appropriate for their learning level. Findings from this pilot program demonstrated the feasibility and acceptability of a 1-day combined didactic and skills training program focused on high-consequence pathogens. We plan to reengage the original FLHs and add regional FLHs in an updated training effort based on our findings.

Management of Pelvic Inflammatory Disease in Clinical Practice.

Pelvic inflammatory disease (PID) is a common reproductive health disorder among women of reproductive age. The treatment of PID has slowly evolved, reflecting changing antibiotic susceptibility and advancements in therapeutics and research; however, it has been largely unchanged over the last several decades. The most recent treatment recommendations consider the severity of infection, clinical presentation, and the polymicrobial nature of the disease. In addition, the role of novel organisms like Mycoplasma genitalium in PID is of emerging significance. PID treatment guidance offers oral and parenteral treatment options based on the patient's clinical status; however, deviations from the published guidelines are a general concern. Point of care (POC) testing for precision care, provision of adherence support, optimizing self-management and prevention strategies, and other alternative or synergistic approaches that maximize treatment outcomes will be instrumental for addressing the current challenges in PID diagnosis and management.

The Future of Sexually Transmitted Infection Research: Understanding Adolescent Perspectives for Implementation of a Chlamydia Vaccine.

PURPOSE: Despite advancements in developing a vaccine for Chlamydia trachomatis (CT), vaccine hesitancy has historically limited the adoption of sexually transmitted infection immunization. This report investigates adolescent perspectives toward a potential CT vaccine and vaccine research. METHODS: As part of the Technology Enhanced Community Health Nursing (TECH-N) study, conducted from 2012-2017, we surveyed 112 adolescents and young adults aged 13-25 years who presented with pelvic inflammatory disease regarding their perspectives on a CT vaccine and willingness to participate in vaccine research. Descriptive statistical analyses were conducted. RESULTS: Most participants were African American (95%), on Medicaid (89%), and sexually experienced (100%). Most respondents would accept a vaccine (95%) and preferred a provider's recommendation (86%) over parents, partners, or friends. A majority (70%) would not be embarrassed to participate in research. DISCUSSION: Respondents showed favorable attitudes toward CT vaccination and research in this high-risk study population.

Understanding Perceived Risks and Sexual Behavior Among Adolescents and Young Adults During the COVID-19 Pandemic.

PURPOSE: We sought to describe the relationship between COVID-19 risk perception and sexual behaviors among urban adolescents and young adults (AYA). METHODS: Data were collected from 159 urban AYAs on COVID-19 risk perception, COVID-19 infections and deaths, romantic relationships, and sexual behavior during the stay-at-home order using a telephone survey. RESULTS: Seventy-nine percent of the study participants engaged in sexual intercourse during the stay-at-home order. Only 38% of these used condoms during their last sexual encounter. Experiencing COVID-19 positivity within their social circle was not related to COVID-19 testing. Concern for COVID-19 infection or experiencing a COVID-19 diagnosis or death in one's social circles was not associated with sexual intercourse or condom use. DISCUSSION: Urban AYA remained at risk for sexually transmitted infections, and COVID-19, given high baseline community rates of sexually transmitted infections and COVID-19, low condom use, and low COVID-19 risk perception at the time of the survey.

Preventing and diagnosing HIV-related comorbidities in adolescents.

Adolescents with HIV are growing into adulthood and are at risk for comorbidities. Comorbidities in adolescents often go unrecognized, increasing morbidity and mortality, and contributing to poorer outcomes for youth with HIV. Youth with perinatally and nonperinatally acquired HIV are at risk of developing HIV-associated and non-HIV comorbidities, including cardiovascular diseases, diabetes, mental health disorders, renal diseases, and bone disorders. Youth with HIV are also at risk for altered fat distribution and weight gain associated with certain classes of antiretroviral therapy. Sexually transmitted infections from inconsistent condom use pose a sexual health challenge for youth with HIV. Prompt interventions through comprehensive history taking, physical exams, regular screening, and prevention and treatment of clinically evident comorbid conditions are needed to prevent progression and complications.

Can Automated Text Messaging Successfully Monitor Antibiotic Adherence for Urban Adolescents and Young Women Managed for Pelvic Inflammatory Disease in the Outpatient Setting.

Objective: This study evaluates patient responsiveness to an automated text messaging system for pelvic inflammatory disease (PID) self-care support, and measures the reliability of text-reported adherence. Design: Patients aged 13-25-years with mild to moderate PID were recruited from urban, academic outpatient settings. Enrolled patients received antibiotics and were randomized into a standard of care or intervention group. During a 14-day treatment period, participants in the intervention arm received a community-based nursing visit and daily text message medication reminders with evening prompts to report the number of doses taken. Result: Of the 97 participants randomized into the intervention arm, 91 (94%) were eligible for analysis. Most were African American and low income, with a mean age of 18.3 (SD=2.2) years. Participants responded to ~53% (SD=34%) of all dosage inquiry messages. Responsiveness attenuated at approximately 2.2% per day over the treatment period. Ninety-three percent (n=85) of the analyzed intervention arm returned for the two-week follow-up. Despite overall adherence and general responsiveness, text-reported and self-reported medication adherence were not well correlated (r=0.37, p<0.001). Conclusion: Our findings show that text messaging is a feasible strategy for reaching urban adolescents being managed for complicated sexually transmitted infections in outpatient settings. However, patient responsiveness to self-care text messages do vary, limiting the adherence monitoring capacity of this technology. Given the number of unanswered text messages and incomplete text-reported adherence data, additional measures to assess adolescents' adherence to PID medications are needed in clinical trials.

The Impact of Racism on the Health and Wellbeing of Black Indigenous and Other Youth of Color (BIPOC Youth).

Black, Indigenous, and other Youth of Color (BIPOC youth) experience racism from a young age. These experiences have both immediate and long-term impacts on their health and wellbeing. Systemic racism contributes to the inequitable distribution of health resources and other social determinants of health, creating barriers to accessing care. Substance use disorders and sexual/nonsexual risk behaviors have been linked to experiences of racism in BIPOC youth. The legacy of generational racial trauma can frame behaviors and attitudes in the present, undermining health and survival in this group. BIPOC youth also face difficulties navigating spheres characterized as white spaces. Ethnic-racial socialization may promote resilience and help with coping in the context of racial stress. While many professional health organizations have embraced dismantling racism, a shift in the narrative on racial values will be critical for preventing adversity and achieving health equity for BIPOC youth.

Dyadic Intervention for Sexually Transmitted Infection Prevention in Urban Adolescents and Young Adults (The SEXPERIENCE Study): Protocol for a Randomized Controlled Trial.

BACKGROUND: Adolescents and young adults (AYA) aged younger than 25 years have the highest rates of sexually transmitted infections (STIs) in the United States. Current STI prevention strategies for AYA rely primarily on individual approaches, leaving sexual partners with significant unmet sexual and reproductive health care and health education needs. Dyadic interventions may hold promise for harnessing the power of communal coping within relationship dynamics to enhance sexual decision making, communication, and behavior changes that reduce the future risk of STIs. OBJECTIVE: This paper describes the protocol and research methods of a dyad-based behavioral intervention that augments individual evidence-based interventions with joint health education counseling for heterosexual AYA dyads within a primary care setting. The trial aims to improve partner communication and collaborative sexual decision making and promote the adoption of sexual behaviors such as consistent condom use. The primary objective of this study is to assess the feasibility, acceptability, and effectiveness of a dyadic intervention targeted at preventing STIs in heterosexual couples in an urban setting. METHODS: A total of 100 AYA (50 dyads) aged 16 to 25 years, engaged in heterosexual intercourse, who reside in the city and are willing to recruit their main sexual partner for the study will be recruited and randomized into 2 groups, an intervention arm and a control arm. Participants will be recruited from an AYA medicine clinic and by using social media (Facebook and Instagram). The index participant and partner will complete a single individual session separately (Sister to Sister or Focus on the Future) with a gender-matched health educator. Dyads will then be randomized to receive an additional joint debriefing session together to discuss relationship dynamics, condom negotiation, etc. Participants will separately complete a telephone interview 6 weeks postintervention to determine the feasibility, acceptability, and impact of the intervention on mutual sexual negotiation, consistency of condom use, and communal coping skills, etc. RESULTS: So far, 25.4% (44/173) of eligible participants have been enrolled and randomized. Participants are mostly female (20/22, 91%), with at least a high school diploma (19/22, 86%), and 9 average lifetime sexual partners. Acceptability is high, with 98% (43/44) of participants expressing satisfaction with their study experience; 100% of dyads recruited were still together at 6-week follow-up. CONCLUSIONS: Findings from this study will add to the current literature on the approaches to STI prevention, and its success will inform its application in risk reduction counseling for youth who are most at risk. TRIAL REGISTRATION: Clinical Trials.gov NCT03275168; https://www.clinicaltrials.gov/ct2/history/NCT03275168. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/29389.

Experience and Outcomes of Breastfed Infants of Women Living With HIV in the United States: Findings From a Single-Center Breastfeeding Support Initiative.

We assessed breastfeeding outcomes for a cohort of infants born to women living with HIV (WLHIV) at an urban health care center in the United States. Ten infants were exclusively breastfed for a mean duration of 4.4 (1.0-8.6) months. All had negative HIV RNA PCRs at a median age of 16 months.

Adolescents and young adults with early acquired HIV infection in the united states: unique challenges in treatment and secondary prevention.

INTRODUCTION: Worldwide, children who acquired human immunodeficiency virus (HIV) at an early age, either perinatally or through blood transfusion, are reaching adolescence and adulthood due to successful antiretroviral treatment (ART). While many are thriving, a significant proportion face unprecedented multilevel challenges that can affect their long-term outcomes. Specifically, longstanding and poorly controlled HIV resulting from inadequate early regimens and nonadherence, along with the toxicities of some ART agents, can predispose them to sequelae including HIV-associated complications and other comorbidities. AREAS COVERED: This paper reviews and summarizes the unique issues facing adolescents and young adults with early acquired HIV (AYA-EAHIV), including ART challenges, emerging comorbidities, and complications, including mental health comorbidities, secondary prevention, and transition from pediatric/adolescent to adult care. EXPERT OPINION: AYA-EAHIV are a special population that have lived their entire lives with the physical and psychological toll of HIV mandating targeted and purposeful approaches to optimize their management and outcomes. Multifaceted inclusive and context-specific approaches focusing on heightened research, risk reduction interventions, and 'outside the box' thinking will be required to optimize treatment and reduce morbidity and mortality.

Social Media Versus Traditional Clinic-Based Recruitment for a Dyadic Sexually Transmitted Infection Prevention Trial: Results From the Sexperience Study.

BACKGROUND: The enrollment of youth in clinical trials has generally been achieved through conventional in-person recruitment but is evolving with the surge in the use of social media and presents an alternative resource for research recruitment for sexually transmitted infection (STI) prevention trials. PURPOSE: To compare the direct costs and performance of social media recruitment versus clinic-based recruitment method for a dyadic behavioral intervention for STI among heterosexual couples. METHODS: In the clinic-based recruitment arm spanning 60 weeks, patients aged 16-25 years were recruited through an adolescent/young adult clinic. Social media adverts targeting college students within the city were also posted online over 23 weeks, using Facebook ad software. We compared the direct costs and performance of both recruitment methods to assess feasibility. RESULTS: Three hundred eighty-one individuals were approached, of which 21 completed the dyadic intervention (11 from social media-based recruitment and 10 from clinic-based recruitment). Clinic-based recruitment accounted for 91.0% of total recruitment cost and 9.9% of the total cost was spent on social media recruitment via Facebook ad. CONCLUSIONS: Recruitment of adolescents and young adults for a dyadic behavioral STI intervention trial using social media is feasible, has lower direct costs, and results in similar outcomes compared to clinic-based recruitment.

A Retrospective Analysis of the Impact of Bariatric Surgery on the Management of Chronic Migraine.

PURPOSE: To investigate the association of the two most common bariatric surgical procedures, vertical sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass (RYGB), with sustained remission from chronic migraine. MATERIALS AND METHODS: Using IBM MarketScan® research database to examine inpatient and pharmacy claims from 2010 through 2017. A cohort of bariatric patients with chronic migraine was created using inclusion and exclusion criteria. Remission was defined as no refill of first-line migraine medication for 180 days after a patients' medication was expected to run out, and recurrence as medication refill after at least 180 days of remission. RESULTS: Of 1680 patients in our cohort, 931 (55.4%) experienced remission of migraine. Of these, 462 (49.6%) had undergone VSG, while 469 (50.4%) had undergone RYGB. Patients who underwent RYGB had an 11% (RR = 1.11, 95% CI: 1.05, 1.17) increase in likelihood of remission of migraine and a 20% (RR = 0.80, 95% CI: 0.63, 1.04) decrease in likelihood of recurrence of migraine compared to patients who underwent VSG. Older age group, higher number of medications at time of surgery, and female sex were associated with a decreased likelihood of remission. CONCLUSION: Type of bariatric procedure, age, number of medications at surgery, and sex were the most important predictors of migraine remission after surgery.

The Global Health Security Index is not predictive of vaccine rollout responses among OECD countries.

OBJECTIVE: This study sought to evaluate the utility of the Global Health Security (GHS) index in predicting the launch of COVID-19 vaccine rollout by Organization for Economic Cooperation and Development (OECD) member countries. METHODS: Country-level data on the preparedness to respond to infectious disease threats through vaccination rollout were collected using the GHS index. OECD member countries were rank-ordered based on the percentage of their populations fully vaccinated against COVID-19. Rank-ordering was conducted from the lowest to the highest, with each country assigned a score ranging from 1 to 33. Spearman's rank correlation between the GHS index and the percentage of the population that is fully vaccinated was also performed. RESULTS: Israel, ranked 34th in the world on the GHS index for pandemic preparedness, had the highest percentage of the population that was fully vaccinated against COVID-19 within 2 months of the global vaccine rollout. The Spearman rank correlation coefficient between GHS index and the percentage of population fully vaccinated was -0.1378, with a p-value of 0.43. CONCLUSION: The findings suggest an absence of correlation between the GHS index rating and the COVID-19 vaccine rollout of OECD countries, indicating that the preparedness of OECD countries for infectious disease threats may not be accurately reflected by the GHS index.

Statins use and COVID-19 outcomes in hospitalized patients.

BACKGROUND: There is an urgent need for novel therapeutic strategies for reversing COVID-19-related lung inflammation. Recent evidence has demonstrated that the cholesterol-lowering agents, statins, are associated with reduced mortality in patients with various respiratory infections. We sought to investigate the relationship between statin use and COVID-19 disease severity in hospitalized patients. METHODS: A retrospective analysis of COVID-19 patients admitted to the Johns Hopkins Medical Institutions between March 1, 2020 and June 30, 2020 was performed. The outcomes of interest were mortality and severe COVID-19 infection, as defined by prolonged hospital stay (≥ 7 days) and/ or invasive mechanical ventilation. Logistic regression, Cox proportional hazards regression and propensity score matching were used to obtain both univariable and multivariable associations between covariates and outcomes in addition to the average treatment effect of statin use. RESULTS: Of the 4,447 patients who met our inclusion criteria, 594 (13.4%) patients were exposed to statins on admission, of which 340 (57.2%) were male. The mean age was higher in statin users compared to non-users [64.9 ± 13.4 vs. 45.5 ± 16.6 years, p <0.001]. The average treatment effect of statin use on COVID-19-related mortality was RR = 1.00 (95% CI: 0.99-1.01, p = 0.928), while its effect on severe COVID-19 infection was RR = 1.18 (95% CI: 1.11-1.27, p <0.001). CONCLUSION: Statin use was not associated with altered mortality, but with an 18% increased risk of severe COVID-19 infection.

HIV Preexposure Prophylaxis Among Adolescents in the US: A Review.

Importance: Many adolescents and young adults in the US are disproportionately affected by HIV. Several others who are uninfected are at risk and in need of effective preventive strategies. The uptake rate of preexposure prophylaxis (PrEP) for HIV prevention has remained low among US adolescents. This review assesses the current status of PrEP uptake among at-risk adolescents aged 13 to 19 years and recommendations for improving PrEP access, uptake, and future needed directions, including specific recommendations for health care professionals. Observations: Of the 37 377 new HIV diagnoses made in 2018, 7734 diagnoses (21%) occurred in adolescents and young adults aged 12 to 24 years; of these, 1707 diagnoses (22%) occurred in adolescents aged 13 to 19 years. The greatest burden of HIV is found among young African American men who have sex with men, accounting for two-thirds of all HIV infections in adolescents and young adults. Preexposure prophylaxis awareness and engagement are lowest in adolescents with the greatest risk for HIV. Adolescent primary care clinicians and specialists do not routinely offer HIV testing as recommended by the Centers for Disease Control and Prevention or routinely assess sexual risk exposures of patients through sexual history taking. Clinicians' decision to prescribe PrEP for adolescents is often guided by their perceptions of the patient's HIV risk and their knowledge and acceptance of PrEP guidelines. State laws on consent, confidentiality, and the rights of the adolescent to independently access PrEP outside of parental influence differ across jurisdictions, often limiting access and uptake. Conclusions and Relevance: Use of PrEP in adolescents at risk for HIV is an important component of HIV prevention. Optimizing uptake includes improving clinicians' knowledge about HIV risk and prevention strategies, enhancing sexual history taking and risk assessment through training and retraining, and improving PrEP knowledge and acceptance of prescribing among clinicians. Leveraging the ubiquity of social media, encouraging family support, and performing research aimed at finding lifestyle-congruent formulations can help mitigate HIV transmission in adolescents at greatest risk for HIV.