Effect of the COVID-19 Lockdown on Mobile Payments for Maternal Health: Regression Discontinuity Analysis.

BACKGROUND: The COVID-19 pandemic resulted in the unprecedented popularity of digital financial services for contactless payments and government cash transfer programs to mitigate the economic effects of the pandemic. The effect of the pandemic on the use of digital financial services for health in low- and middle-income countries, however, is poorly understood. OBJECTIVE: This study aimed to assess the effect of the first COVID-19 lockdown on the use of a mobile maternal health wallet, with a particular focus on delineating the age-dependent differential effects, and draw conclusions on the effect of lockdown measures on the use of digital health services. METHODS: We analyzed 819,840 person-days of health wallet use data from 3416 women who used health care at 25 public sector primary care facilities and 4 hospitals in Antananarivo, Madagascar, between January 1 and August 27, 2020. We collected data on savings, payments, and voucher use at the point of care. To estimate the effects of the first COVID-19 lockdown in Madagascar, we used regression discontinuity analysis around the starting day of the first COVID-19 lockdown on March 23, 2020. We determined the bandwidth using a data-driven method for unbiased bandwidth selection and used modified Poisson regression for binary variables to estimate risk ratios as lockdown effect sizes. RESULTS: We recorded 3719 saving events, 1572 payment events, and 3144 use events of electronic vouchers. The first COVID-19 lockdown in Madagascar reduced mobile money savings by 58.5% (P<.001), payments by 45.8% (P<.001), and voucher use by 49.6% (P<.001). Voucher use recovered to the extrapolated prelockdown counterfactual after 214 days, while savings and payments did not cross the extrapolated prelockdown counterfactual. The recovery duration after the lockdown differed by age group. Women aged >30 years recovered substantially faster, returning to prelockdown rates after 34, 226, and 77 days for savings, payments, and voucher use, respectively. Younger women aged <25 years did not return to baseline values. The results remained robust in sensitivity analyses using ±20 days of the optimal bandwidth. CONCLUSIONS: The COVID-19 lockdown greatly reduced the use of mobile money in the health sector, affecting savings, payments, and voucher use. Savings were the most significantly reduced, implying that the lockdown affected women's expectations of future health care use. Declines in payments and voucher use indicated decreased actual health care use caused by the lockdown. These effects are crucial since many maternal and child health care services cannot be delayed, as the potential benefits will be lost or diminished. To mitigate the adverse impacts of lockdowns on maternal health service use, digital health services could be leveraged to provide access to telemedicine and enhance user communication with clear information on available health care access options and adherence to safety protocols.

Association of Medicaid expansion with health insurance, unmet need for medical care and substance use disorder treatment among people who inject drugs in 13 US states.

BACKGROUND AND AIMS: Impoverished people who inject drugs (PWID) are at the epicenter of US drug-related epidemics. Medicaid expansion is designed to reduce cost-related barriers to care by expanding Medicaid coverage to all US adults living at or below 138% of the federal poverty line. This study aimed to measure whether Medicaid expansion is (1) positively associated with the probability that participants are currently insured; (2) inversely related to the probability of reporting unmet need for medical care due to cost in the past year; and (3) positively associated with the probability that they report receiving substance use disorder (SUD) treatment in the past year, among PWID subsisting at ≤ 138% of the federal poverty line. DESIGN: A two-way fixed-effects model was used to analyze serial cross-sectional observational data. SETTING: Seventeen metro areas in 13 US states took part in the study. PARTICIPANTS: Participants were PWID who took part in any of the three waves (2012, 2015, 2018) of data gathered in the Center for Disease Control and Prevention's National HIV Behavioral Surveillance (NHBS), were aged ≤ 64 years and had incomes ≤ 138% of the federal poverty line. For SUD treatment analyses, the sample was further limited to PWID who used drugs daily, a proxy for SUD. MEASUREMENTS: State-level Medicaid expansion was measured using Kaiser Family Foundation data. Individual-level self-report measures were drawn from the NHBS surveys (e.g. health insurance coverage, unmet need for medical care because of its cost, SUD treatment program participation). FINDINGS: The sample for the insurance and unmet need analyses consisted of 19 946 impoverished PWID across 13 US states and 3 years. Approximately two-thirds were unhoused in the past year; 41.6% reported annual household incomes < $5000. In multivariable models, expansion was associated with a 19.0 [95% confidence interval (CI) = 9.0, 30.0] percentage-point increase in the probability of insurance coverage, and a 9.0 (95% CI = -15.0, -0.2) percentage-point reduction in the probability of unmet need. Expansion was unrelated to SUD treatment among PWID who used daily (n = 17 584). CONCLUSIONS: US Medicaid expansion may curb drug-related epidemics among impoverished people who inject drugs by increasing health insurance coverage and reducing unmet need for care. Persisting non-financial barriers may undermine expansion's impact upon substance use disorder treatment in this sample.

Drug use patterns and related factors among female sex workers in Iran in 2019-2020: results from Integrated Bio-Behavioral Surveillance-III (IBBS-III).

INTRODUCTION: Drug use is highly prevalent among female sex workers (FSWs). Some forms of drug use, such as injecting drug users (IDU), put them at greater risks for HIV and blood born disease (BBD). In this study, the pattern of drug use and its related factors among Iranian FSWs were investigated. MATERIALS AND METHODS: This cross-sectional study was performed based on the data of the integrated bio-behavioral surveillance-III (IBBS-III) on FSWs in 8 cities of Iran using the respondent-driven sampling (RDS) method conducting in 2019-2020. Of the 1515 FSWs participating in the IBBS-III study, 1,480 answered questions about drug use. To calculate the prevalence of drug use lifetime and in the past month, weighted analysis was used. Univariate and multivariate logistic regression was used to investigate the factors related to drug use. RESULTS: The prevalence of lifetime drug use and the prevalence of current drug use (single and poly drug use) among FSWs were estimated to be 29.3% and 18.86%, respectively. According to multivariate regression analysis, the odds ratio (odds) of lifetime drug use showed a statistically significant association with lower education (AOR = 1.18; 95% CI: 1.07-1.3), being a direct sex worker (AOR = 1.77; 95% CI: 1.21-2.61), working in team houses or hangouts (AOR = 1.51; 95% CI: 1.10-2.06), a history of intentional abortion (AOR = 1.41; 95% CI: 1.07-1.87), condom use in the last sex (AOR = 1.61; 95% CI: 1.19-2.17), a history of imprisonment (AOR = 3.05; 95% CI: 2.25-4.14), HIV positive tests (AOR = 8.24; 95% CI: 1.66-40.9), alcohol use (AOR = 1.69; 95% CI: 1.29-2.29), and finding sexual clients in places such as parties, shopping malls, streets, and hotels, or by friends (AOR = 1.46; 95% CI: 1.01-2.12). CONCLUSION: Given that drug use among FSWs is about 14 times higher than that of the Iranian general population, it is imperative that drug reduction programs be integrated into service packages. Specifically, prevention programs should be prioritized for occasional drug users within this population as they are at a greater risk of developing drug use issues compared to the general population.

Provider-Initiated HIV Testing in Puerto Rico from Data of the National HIV Behavioral Surveillance-Heterosexual Cycle (NHBS-HET) 2016: National Cross-sectional Survey.

BACKGROUND: According to the Centers for Disease Control and Prevention and World Health Organization guidelines, all individuals aged 13-64 years should get screened for HIV infection as part of their routine medical examinations. Individuals at high risk should get tested annually. OBJECTIVE: This study aimed to identify the sociodemographic, health care, and sexual behavioral characteristics of provider-initiated HIV testing using data from the Puerto Rico National HIV Behavioral Surveillance 2016 cycle, directed toward heterosexual individuals at increased risk of HIV infection. METHODS: A sample of 358 eligible participants were recruited through respondent-driven sampling, where sociodemographic characteristics, health care use, and HIV test referral were used to assess a description of the study sample. Pearson chi-square and Fisher tests were used to evaluate proportional differences. Multivariate logistic regression models were performed to determine the association between independent variables and HIV test referral. Adjusted prevalence ratios by sex and age with their 95% CIs were determined using a statistical significance level of .05. RESULTS: Despite 67.9% (243/358) of participants showing high-risk sexual behavioral practices and 67.4% (236/350) reporting a low perceived risk of HIV infection among those who visited a health care provider within the last 12 months, 80.7% (289/358) of the study sample did not receive an HIV test referral at a recent medical visit. Multivariate analysis showed that the estimated prevalence of the participants who received an HIV test referral among those who reported being engaged in high-risk sexual behaviors was 41% (adjusted prevalence ratio .59, 95% CI .39-.91; P=.02) lower than the estimated prevalence among those who did not engage in high-risk sexual behavior. CONCLUSIONS: This sample of Puerto Rican adults reported a significantly lower prevalence of receiving an HIV test referral among heterosexual individuals at increased risk of HIV infection who engaged in high-risk behaviors. This study further emphasizes the need for health care providers to follow recommended guidelines for HIV test referrals in health care settings. Promotion practices in the future should include enhancing referral and access to HIV tests and implementing preventive measures to counteract the HIV epidemic in Puerto Rico.

Behavioral-biological surveillance of emerging infectious diseases among a dynamic cohort in Thailand.

BACKGROUND: Interactions between humans and animals are the key elements of zoonotic spillover leading to zoonotic disease emergence. Research to understand the high-risk behaviors associated with disease transmission at the human-animal interface is limited, and few consider regional and local contexts. OBJECTIVE: This study employed an integrated behavioral-biological surveillance approach for the early detection of novel and known zoonotic viruses in potentially high-risk populations, in an effort to identify risk factors for spillover and to determine potential foci for risk-mitigation measures. METHOD: Participants were enrolled at two community-based sites (n = 472) in eastern and western Thailand and two hospital (clinical) sites (n = 206) in northeastern and central Thailand. A behavioral questionnaire was administered to understand participants' demographics, living conditions, health history, and animal-contact behaviors and attitudes. Biological specimens were tested for coronaviruses, filoviruses, flaviviruses, influenza viruses, and paramyxoviruses using pan (consensus) RNA Virus assays. RESULTS: Overall 61/678 (9%) of participants tested positive for the viral families screened which included influenza viruses (75%), paramyxoviruses (15%), human coronaviruses (3%), flaviviruses (3%), and enteroviruses (3%). The most salient predictors of reporting unusual symptoms (i.e., any illness or sickness that is not known or recognized in the community or diagnosed by medical providers) in the past year were having other household members who had unusual symptoms and being scratched or bitten by animals in the same year. Many participants reported raising and handling poultry (10.3% and 24.2%), swine (2%, 14.6%), and cattle (4.9%, 7.8%) and several participants also reported eating raw or undercooked meat of these animals (2.2%, 5.5%, 10.3% respectively). Twenty four participants (3.5%) reported handling bats or having bats in the house roof. Gender, age, and livelihood activities were shown to be significantly associated with participants' interactions with animals. Participants' knowledge of risks influenced their health-seeking behavior. CONCLUSION: The results suggest that there is a high level of interaction between humans, livestock, and wild animals in communities at sites we investigated in Thailand. This study highlights important differences among demographic and occupational risk factors as they relate to animal contact and zoonotic disease risk, which can be used by policymakers and local public health programs to build more effective surveillance strategies and behavior-focused interventions.

Prevalence of and racial/ethnic differences in sexuality disclosure among men who have sex with men in 23 U.S. cities-National HIV Behavioral Surveillance, 2017.

Sexuality disclosure among men who have sex with men (MSM) is key in access to HIV prevention services. We used weighted 2017 data from National HIV Behavioral Surveillance to investigate prevalence of, and racial/ethnic differences in, sexuality disclosure among MSM. Of 10,753 MSM, 89.4% (95% CI: 88.5-90.3%) had disclosed their sexuality to any non-lesbian, gay, or bisexual (LGB) friends, 85.9% (95% CI: 84.8-87.0%) had disclosed their sexuality to any family members, and 82.8% (95% CI: 81.6-83.9%) had disclosed their sexuality to any health care providers. Although most MSM had disclosed, 23.8% (95% CI: 22.4-25.1%) had not disclosed to at least one of the three groups. Black, Hispanic/Latino, or Asian MSM were less likely than White MSM to have disclosed their sexuality to any non-LGB friends, any family members, or any health care providers, after adjusting for age and region. We found high prevalence of sexuality disclosure among MSM, but racial/ethnic differences persist. Strategies and interventions to promote sexuality disclosure among MSM are needed.

Racial/Ethnic Inequities in Adverse Childhood Experiences and Selected Health-Related Behaviors and Problems Among Maryland Adolescents.

We examined racial/ethnic inequities in the prevalence of adverse childhood experiences (ACEs) and examined the association between ACEs and selected health-related behaviors and problems. Data for this cross-sectional study come from the 2018 Maryland Youth Risk Behavior Survey/Youth Tobacco Survey, a statewide survey of high school students (n = 40,188). ACEs included caregiver verbal abuse and household food insecurity, substance use or gambling, mental illness, and involvement with the criminal justice system. We estimated the prevalence of ACEs overall and by race/ethnicity, and then used multiple logistic regression to determine associations between ACEs and emotional/behavioral problems, adjusting for race/ethnicity. Outcome variables included emotional distress, poor school performance, suicidal ideation, fighting, alcohol use, and marijuana use. More than one fifth of students reported each individual ACE. Differences in the prevalence of ACEs by race/ethnicity were statistically significant (p < .001). More than one fourth (25.8%) reported one of the five ACEs, 15.1% reported two, and 15.4% reported three or more. For each ACE, reporting having experienced it (vs. not) was associated with a >30% higher prevalence for each of the outcome variables. Among students who reported three or more ACEs (relative to none), the odds of emotional distress and suicidal ideation were more than 8 times greater. Among Maryland adolescents, ACEs are common, are inequitably distributed by race/ethnicity, and are strongly linked to behavioral health. Findings suggest the need to monitor ACEs as a routine component of adolescent health surveillance and to refocus assessment and intervention toward "upstream" factors that shape adolescent health.

What Is the Willingness to Receive Vaccination Against COVID-19 Among the Elderly in Italy? Data From the PASSI d'Argento Surveillance System.

Introduction: Italy was one of the earliest countries to experience a severe COVID-19 epidemic and vaccinating the elderly, who constitute 23% of the population and have experienced the highest mortality rates, is a top priority. Estimating prevalences and understanding risk factors for COVID-19 vaccine hesitancy or refusal are important for development of targeted interventions. Methods: We used data from a specially developed COVID-19 module of PASSI D'Argento, an ongoing surveillance system of residents 65+ years of age to measure the prevalence and identify risk factors for hesitancy and refusal to receive the COVID-19 vaccine. We calculated multinomial regression relative risk ratios to examine the association between demographic characteristics, health status, COVID-19 attitudes and experiences and likely vaccine hesitancy and refusal. Results: Of the 1876 respondents, 55% reported they would accept vaccination and 16% would likely refuse; the remaining 29% were categorized as hesitant. Compared with the acceptance group, we identified several risk factors in common between the hesitancy group and the refusal group, including not having received vaccination against influenza during the previous flu season (hesitancy: RRR = 2.0; 95% CI 1.4-2.9; refusal: RRR = 12.1; 95%CI 7.6-19.4) and lower risk of having had a death from COVID-19 among family or friends (hesitancy: RRR = 4.8; 95%CI 2.0-11.4; refusal: RRR = 15.4; 95%CI 3.7-64.5). The hesitancy group was significantly more likely being worried and they did not know if consequences of the disease would be serious for them. Conclusion: Our findings show the importance of establishing and maintaining active contact between the preventive services, primary care providers and the population because trust is difficult to establish during an emergency like the COVID-19 pandemic. Italian public health is based on a capillary network of general practitioners and having them reach out to their patients who have not previously received influenza vaccine may be a useful strategy for targeting efforts to further encourage uptake of COVID-19 vaccination.

Is the severity of the Great Recession's aftershocks correlated with changes in access to the combined prevention environment among people who inject drugs?

BACKGROUND: The 2008 Recession was a global event that led to funding cuts for programs and services in the United States; though this recession officially ended in 2009, its aftershocks continued through 2012. We evaluated the relationship between the severity of the Great Recession's aftermath and spatial access to combined prevention services (i.e. HIV testing, syringe service programs, substance use disorder treatment program) for people who inject drugs (PWID) living in 19 metropolitan statistical areas (MSAs) in the United States. METHODS: The unit of analysis was the ZIP code; we sampled ZIP codes in these 19 MSAs where ≥1 PWID lived in 2009 and 2012, according to the CDC's National HIV Behavioral Surveillance. We used administrative data to describe the combined prevention environment (i.e., spatial access to HIV testing) for each ZIP code, and measured the severity of the recession's aftermath in each ZIP code, and in the counties and MSAs where these ZIP codes were located. Multilevel modeling estimated associations between changes in the aftermath of the Great Recession and ZIP code-level changes in spatial access to combined prevention services from 2009 to 2012. RESULTS: 675 ZIP codes located in 36 counties and 19 MSAs were included in this analysis. From 2009 to 2012, 21% of ZIP code areas lost access to combined prevention services and 14% gained access. ZIP codes with higher poverty rates relative to their respective MSAs were less likely to lose access (aOR: 0.91; 95% CI: 0.88, 0.95) and more likely to gain access (aOR: 1.05; 95% CI: 1.01, 1.09); there is some evidence to suggest the former association was attenuated for ZIP codes with higher percentages of non-Hispanic white residents. CONCLUSION: Combined prevention services for PWID living in these 675 ZIP codes demonstrated resilience in the aftermath of the Great Recession. Future research should explore whether community-based and federal HIV prevention initiatives contributed to this resilience, particularly in areas with higher concentrations of people of color.

Place-Based Correlates of Exchange Sex Among People Who Inject Drugs in 19 U.S. Metropolitan Areas, 2012.

This study examined overall and gender-specific associations between place-based characteristics and opposite-sex exchange sex among people who inject drugs (PWID) in the U.S. PWID were recruited from 19 metropolitan statistical areas (MSAs) for the Centers for Disease Control and Prevention's 2012 National HIV Behavioral Surveillance. Administrative data were used to describe the economic, social, and political features of the ZIP codes, MSAs, counties, and states where PWID lived. Multilevel modeling estimated associations of place characteristics and exchange sex. We found that 52% of women and 23% of men reported past-year opposite-sex exchange sex (N = 7599). Female PWID living in states with stronger policies supporting working caregivers had lower odds of exchange sex (aOR = 0.80; 95% CI 0.69, 0.94). PWID living in ZIP codes with greater economic deprivation had higher odds of exchange sex (aOR = 1.10; 95% CI 1.03, 1.17). We found that a high percentage of male PWID exchanged sex with women; determinants and risks of this group merit exploration. If future research establishes that the relationships identified here are causal, interventions to reduce exchange sex among PWID should include policies supporting working caregivers and reducing poverty rates.

Transgender Women's Internet Survey and Testing: Protocol and Key Indicators Report.

Purpose: There is a need for ongoing behavioral surveillance of human immunodeficiency virus (HIV)/sexually transmitted infection (STI) risk among transgender women, using assessments adapted to this population. We therefore developed and piloted the Transgender Women's Internet Survey and Testing (TWIST) study, a cross-sectional behavioral survey of transgender women in the United States coupled with remote biospecimen collection and testing. Methods: Participants age 15+ were recruited by using social media advertisements. Participants were eligible to take the survey if they reported male sex at birth, identified as female or as a transgender woman, resided in the United States, and reported ever having oral, vaginal, or anal sex. We examined a number of behavioral indicators by age, county population density, and medical gender affirmation treatment, using multivariable regression modeling. A sample of respondents was invited to receive a home biospecimen collection kit for HIV/STI testing. Results: The 401 participants were mainly non-Hispanic white and younger than 25 years. Self-reported HIV prevalence was 1.3% (5/401), and almost half (47.1%, 189/401) did not know their HIV status. Receiving medical gender affirmation was strongly associated with past-year HIV and STI testing, independent of general health care engagement. Of the 155 participants invited to receive home biospecimen collection kits, 48 (31.0%) consented and of those, 21 (43.8%) returned specimens for testing. Conclusion: This pilot study successfully reached its recruitment target and generated useful behavioral measures from an online sample of transgender women. We anticipate that online recruitment combined with self-collection of biospecimens will serve as an innovative and scalable strategy for ongoing monitoring of HIV/STI behavioral trends among U.S. transgender women.

Market characteristics and zoonotic disease risk perception in Cameroon bushmeat markets.

Behavioral practices are one of the key factors facilitating zoonotic disease transmission, especially in individuals who have frequent contact with wild animals, yet practices of those who work and live in high-risk animal-human interfaces, such as wild animal 'bushmeat' markets in the Congo Basin are not well documented in the social, health and medical sciences. This region, where hunting, butchering, and consumption of wild animal meat is frequent, represents a hotspot for disease emergence, and has experienced zoonotic disease spillover events, traced back to close human-animal contact with bats and non-human primates. Using a One Health approach, we conducted wildlife surveillance, human behavioral research, and concurrent human and animal biological sampling to identify and characterize factors associated with zoonotic disease emergence and transmission. Research was conducted through the USAID Emerging Pandemic Threats program between 2010 and 2019 including qualitative studies of bushmeat markets, with selected study sites prioritized based on proximity to bushmeat markets. Sites included two hospitals where we conducted surveillance of individuals with syndromes of acute febrile illness, community sites where we enrolled actors of the animal value chain (ie. hunters, middlemen, transporters), and bushmeat markets, where we enrolled bushmeat vendors, butchers, market managers, cleaners, and shoppers. Mixed methods research was undertaken at these sites and included investigation of bushmeat market dynamics through observational research, focus group discussions, quantitative questionnaires, and interviews. Participants were asked about their risk perception of zoonotic disease transmission and specific activities related to bushmeat trade, local market conditions, and regulations on bushmeat trade in Cameroon. Risks associated with blood contact and animal infection were not well understood by most market actors. As bushmeat markets are an important disease interface, as seen with CoVID19, risk mitigation measures in markets and bushmeat alternative strategies are discussed.

Distance matters: The association of proximity to syringe services programs with sharing of syringes and injecting equipment - 17 U.S. cities, 2015.

BACKGROUND: Syringe services programs (SSPs) have effectively limited the spread of HIV and hepatitis C (HCV) among people who inject drugs (PWID). Access to SSPs has been shown to reduce injection risk behaviors but the relationship between distance to an SSP and likelihood of sharing injection equipment is not well known. METHODS: We analyzed a sample of 8,392 PWID from 17 U.S. cities recruited through the National HIV Behavioral Surveillance (NHBS) system in 2015. Adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) were estimated from log-linked Poisson regression to explore associations between injecting equipment sharing in the past 12 months and distance to the nearest SSP. RESULTS: Regardless of SSP use, respondents who lived in zip codes further than the city-specific mean distance to nearest SSP were more likely to report sharing behavior. Among PWID who had not reported using an SSP in the previous 12 months, distributive sharing (aPR=1.13 95% CI=1.05, 1.21), receptive sharing (aPR=1.15, 95% CI=1.06, 1.24), and injection equipment sharing (aPR=1.08, 95% CI=1.03, 1.13) were more prevalent among residents who resided further than the average distance to the nearest SSP. CONCLUSIONS: Greater distance to an SSP was associated with increased sharing behaviors. Improved access to an SSP and subsequent decreases in sharing behaviors could reduce transmission of HIV and HCV among PWID. Accessibility should be taken into account when planning provision of SSPs.

Human immunodeficiency virus prevalence and high-risk behavior of home-based and nonhome-based female sex workers in three high-prevalent North-Eastern States of India.

BACKGROUND: Female sex workers (FSWs) have been identified as an important target group for human immunodeficiency virus (HIV)/sexually transmitted infections prevention. OBJECTIVES: This study aimed to describe sociodemographic and sex work characteristics and to identify the risk factors for HIV infection with special focus on the variations between home-based (HB) and non-HB (NHB) FSWs in three high-prevalent North-Eastern states of India: Manipur, Mizoram, and Nagaland. METHODS: Data from the National Integrated Bio-Behavioural Surveillance (IBBS) conducted in India during 2014-2015 were utilized in the study. IBBS is a quantitative survey conducted among identified high risk sub within India. Logistic regression analyses were performed using SAS 9.3.2 to determine the distribution and associations of sociodemographics and risk behaviors with HIV seropositivity of HB and NHB FSWs. RESULTS: HIV prevalence was found higher among NHB FSWs compared to HB FSW (7.3% vs. 4.6%). The proportions of FSW among HB (66.7%) were in sex work for longer duration are significantly higher than for NHB (60.2%) while risk of HIV infection due to injecting drug use was higher in NHB FSW (11.7% vs. 8.7%). Reference to FSW who were currently married, those who were widowed/divorced/separated had 2.73-fold risk of HIV. FSW who did not have any other income source were associated with 1.73 times more risk of HIV infection. Injecting drugs user among FSW respondents had four times higher likelihood to be HIV positive. CONCLUSION: A substantial proportion of NHB FSWs is mobile in nature. Targeted interventions are required urgently to minimize HIV risk among those FSWs especially the widowed/divorced/separated, sex work is only income source and who used injecting drugs for nonmedical purpose.

Factors associated with human immunodeficiency virus infection and self-assessed risk to human immunodeficiency virus among injecting drug users in Manipur, India.

BACKGROUND: The proximity of Northeast India to the Golden Triangle facilitates easy accessibility to illicit drugs, resulting in a higher proportion of injecting drug users (IDUs) in the states of Northeast India. The estimated human immunodeficiency virus (HIV) prevalence among IDU in Manipur which is 1.43% is higher than that of the national figure. OBJECTIVES: The objectives of the study were to find the factors associated with HIV infection and correlate the association between HIV status and self-assessed risk to HIV among IDUs in Manipur. METHODS: National Integrated Biological and Behavioral Surveillance (2014-2015) data were used for the study; all analyses done were weighted. In Manipur, information was collected from 1594 IDUs during the surveillance between 2014 and 2015 across four domains, namely Chandel (396), Imphal East (397), Thoubal (401), and Senapati (400). Chi-square test was performed to test the association between the independent and dependent variables. Multivariable logistic regression was performed to identify risk factors associated with HIV positivity. RESULTS: Higher age, unsafe injecting practice, low education status, and low-income status were significantly (P < 0.05) associated with HIV infection among IDUs in Manipur. Self-assessed risk of HIV infection by IDU was significantly associated with HIV positivity. CONCLUSION: Interventions among IDUs in Manipur should focus on emphasizing safe injecting practices along with creating awareness on HIV prevention and management.

Variation in injecting drug use behavior across different North-eastern States in India.

Prevalence of adult HIV infection in India is still high in certain North-eastern (NE) states, particularly among injecting drug users (IDUs). This study aims at exploring IDU behavior profile and their variation across the different states of NE region, India. Data were drawn from a population-based, cross-sectional survey of IDU in the integrated bio-behavioral surveillance from 2014 to 2015. A total of 4272 IDUs from four states (Manipur, Meghalaya, Mizoram, and Nagaland) aged ≥15 years were interviewed. Descriptive analysis was conducted to identify the variation in demographic and IDU behavior across four states. Youth predominance in Mizoram was evident by the mean age of initiation <18 years; 74% and 65% had the first exposure of any drug and injecting drug in <20 years. In Manipur and Nagaland, 60% and 49% of IDUs, respectively, were ≥30 years of age. These specific age groups may be targeted for IDU risk mitigation addressing the state-specific determinants.

Factors Associated with HIV Antiretroviral Therapy among Men Who Have Sex with Men in 20 US Cities, 2014.

Reducing HIV among men who have sex with men (MSM) is a national goal, and early diagnosis, timely linkage to HIV medical care, and ongoing care and treatment are critical for improving health outcomes for MSM with HIV and preventing transmission to others. We assessed demographic, social, and economic factors associated with HIV antiretroviral treatment among HIV-infected MSM. Data are from the National HIV Behavioral Surveillance (NHBS) collected in 2014 among MSM. We estimated prevalence ratios and 95% confidence intervals using average marginal predictions from logistic regression. Overall, 89% of HIV-positive MSM reported currently taking antiretroviral therapy (ART). After controlling for other variables, we found that higher perceived community stigma and not having health insurance were significant risk factors for not taking ART. We also found that high socioeconomic status (SES) was associated with taking ART. Race/ethnicity was not significantly associated with taking ART in either the unadjusted or adjusted analyses. Findings suggest that to increase ART use for MSM with HIV, we need to move beyond individual-level approaches and move towards the development, dissemination, and evaluation of structural and policy interventions that respond to these important social and economic factors.

Multimodal surveillance of healthcare associated infections in an intensive care unit of a large teaching hospital

BACKGROUND: Healthcare-associated infections (HAIs), or nosocomial infections, represent a significant burden in terms of mortality, morbidity, length of stay and costs for patients hospitalized in intensive care units (ICUs). Surveillance systems are recommended by national and international institutions to gather data on HAIs in order to develop and evaluate interventions that reduce the risk of HAIs. STUDY DESIGN: Here we describe the methodology and the results of the surveillance system implemented in the ICU of the Policlinico Umberto I, a large teaching hospital in Rome, from April 2016 to October 2018. METHODS: The multimodal infection surveillance system integrates four different approaches: i) active surveillance of inpatients; ii) environmental microbiological surveillance; iii) surveillance of isolated microorganisms; and iv) behavioral surveillance of healthcare personnel. Data were collected on catheter-related bloodstream infections, ventilation-associated pneumonia, catheter-associated urinary tract infections and primary bloodstream infections that developed in patients after 48 h in the ICU. For environmental surveillance 14 points were selected for sampling (i.e. bed edges, medication carts, PC keyboards, sink faucets). The system of active surveillance of HAIs also included surveillance of microorganisms, consisting of the molecular genotyping of bacterial isolates by pulsed-field gel electrophoresis (PFGE). From 1 November 2016, monitoring of compliance with guidelines for hand hygiene (HH) and proper glove or gown use by healthcare personnel was included in the surveillance system. After the first six months (baseline phase), a multimodal intervention to improve adherence to guidelines by healthcare personnel was conducted with the ICU staff. RESULTS: Overall, 773 patients were included in the active surveillance. The overall incidence rate of device-related HAIs was 14.1 (95% CI: 12.2-16.3) per 1000 patient-days. The monthly device-related HAI incident rate showed a decreasing trend over time, with peaks of incidence becoming progressively lower. The most common bacterial isolates were Klebsiella pneumoniae (20.7%), Acinetobacter baumannii (17.2%), Pseudomonas aeruginosa (13.4%) and Staphylococcus aureus (5.4%). Acinetobacter baumannii and Klebsiella pneumoniae showed the highest proportion of isolates with a multidrug-resistant profile. A total of 819 environmental samples were collected, from which 305 bacterial isolates were retrieved. The most frequent bacterial isolates were Acinetobacter baumannii (27.2%), Staphylococcus aureus (12.1%), Enterococcus faecalis (11.1%), Klebsiella pneumoniae (5.2%) and Pseudomonas aeruginosa (4.7%). All Acinetobacter baumannii, Pseudomonas aeruginosa and Klebsiella pneumoniae environmental isolates were at least multidrug-resistant. Genotyping showed a limited number of major PFGE patterns for both clinical and environmental isolates of Klebsiella pneumoniae and Acinetobacter baumannii. Behavioral compliance rates significantly improved from baseline to post-intervention phase. CONCLUSIONS: By integrating information gathered from active surveillance, environmental microbiological surveillance, surveillance of bacterial isolates and behavioral surveillance of healthcare personnel, the multimodal infection surveillance system returned a precise and detailed view of the infectious risk and microbial ecology of the ICU.

Network Properties Among Gay, Bisexual and Other Men Who Have Sex with Men Vary by Race.

The HIV burden among gay, bisexual, and other men who have sex with men (GBM) may be related to variations in network characteristics of the individual's social and sexual network. This study investigates variations in network properties among 188 Black and 295 White GBM recruited in New Orleans during the National HIV Behavioral Surveillance in 2014. Participants described up to five people who provided social support and five sex partners in the past 3 months. Network properties and network dissimilarity indicators were aggregated to the participant level as means or proportions and examined using PROC GLM. White participants reported larger networks (p = 0.0027), had known network members longer (p = 0.0033), and reported more substance use (p < 0.0001) within networks. Black participants reported networks with fewer men (p = 0.0056) and younger members (p = 0.0110) than those of White GBM. Network properties among GBM differ by race in New Orleans which may inform prevention interventions.

Identifying Which Place Characteristics are Associated with the Odds of Recent HIV Testing in a Large Sample of People Who Inject Drugs in 19 US Metropolitan Areas.

This exploratory analysis investigates relationships of place characteristics to HIV testing among people who inject drugs (PWID). We used CDC's 2012 National HIV Behavioral Surveillance (NHBS) data among PWID from 19 US metropolitan statistical areas (MSAs); we restricted the analytic sample to PWID self-reporting being HIV negative (N = 7477). Administrative data were analyzed to describe the 1. Sociodemographic Composition; 2. Economic disadvantage; 3. Healthcare Service/Law enforcement; and 4. HIV burden of the ZIP codes, counties, and MSAs where PWID lived. Multilevel models tested associations of place characteristics with HIV testing. Fifty-eight percent of PWID reported past-year testing. MSA-level per capita correctional expenditures were positively associated with recent HIV testing among black PWID, but not white PWID. Higher MSA-level household income and imbalanced sex ratios (more women than men) in the MSA were associated with higher odds of testing. HIV screening for PWID is suboptimal (58%) and needs improvement. Identifying place characteristics associated with testing among PWID can strengthen service allocation and interventions in areas of need to increase access to HIV testing.