Mind the gap: observation windows to define periods of event ascertainment as a quality control method for longitudinal electronic health record data.

PURPOSE: Use of electronic health records (EHRs) in health research may lead to the false assumption of complete event ascertainment. We estimated "observation windows" (OWs), defined as periods within which the assumption of complete ascertainment of events is more likely to hold, as a quality control approach to reducing the likelihood of this false assumption. We demonstrated the impact of OWs on estimating the rates of type II diabetes mellitus (diabetes) from HIV clinical cohorts. METHODS: Data contributed by 16 HIV clinical cohorts to the NA-ACCORD were used to identify and evaluate OWs for an operationalized definition of diabetes occurrence as a case study. Procedures included (1) gathering cohort-level data; (2) visualizing and summarizing gaps in observations; (3) systematically establishing start and stop dates during which the assumption of complete ascertainment of diabetes events was reasonable; and (4) visualizing the diabetes OWs relative to the cohort open and close dates to identify immortal person-time. We estimated diabetes occurrence event rates and 95% confidence intervals in the most recent decade that data were available (January 1, 2007, to December 31, 2016). RESULTS: The number of diabetes events decreased by 17% with the use of the diabetes OWs; immortal person-time was removed decreasing total person-years by 23%. Consequently, the diabetes rate increased from 1.23 (95% confidence interval [1.20, 1.25]) per 100 person-years to 1.32 [1.29, 1.35] per 100 person-years with the use of diabetes OWs. CONCLUSIONS: As the use of EHR-curated data for event-driven health research continues to expand, OWs have utility as a quality control approach to complete event ascertainment, helping to improve accuracy of estimates by removing immortal person-time when ascertainment is incomplete.

Contributions of traditional and HIV-related risk factors on non-AIDS-defining cancer, myocardial infarction, and end-stage liver and renal diseases in adults with HIV in the USA and Canada: a collaboration of cohort studies.

BACKGROUND: Adults with HIV have an increased burden of non-AIDS-defining cancers, myocardial infarction, end-stage liver disease, and end-stage renal disease. The objective of this study was to estimate the population attributable fractions (PAFs) of preventable or modifiable HIV-related and traditional risk factors for non-AIDS-defining cancers, myocardial infarction, end-stage liver disease, and end-stage renal disease outcomes. METHODS: We included participants receiving care in academic and community-based outpatient HIV clinical cohorts in the USA and Canada from Jan 1, 2000, to Dec 31, 2014, who contributed to the North American AIDS Cohort Collaboration on Research and Design and who had validated non-AIDS-defining cancers, myocardial infarction, end-stage liver disease, or end-stage renal disease outcomes. Traditional risk factors were tobacco smoking, hypertension, elevated total cholesterol, type 2 diabetes, renal impairment (stage 4 chronic kidney disease), and hepatitis C virus and hepatitis B virus infections. HIV-related risk factors were low CD4 count (<200 cells per µL), detectable plasma HIV RNA (>400 copies per mL), and history of a clinical AIDS diagnosis. PAFs and 95% CIs were estimated to quantify the proportion of outcomes that could be avoided if the risk factor was prevented. FINDINGS: In each of the study populations for the four outcomes (1405 of 61 500 had non-AIDS-defining cancer, 347 of 29 515 had myocardial infarctions, 387 of 35 044 had end-stage liver disease events, and 255 of 35 620 had end-stage renal disease events), about 17% were older than 50 years at study entry, about 50% were non-white, and about 80% were men. Preventing smoking would avoid 24% (95% CI 13-35) of these cancers and 37% (7-66) of the myocardial infarctions. Preventing elevated total cholesterol and hypertension would avoid the greatest proportion of myocardial infarctions: 44% (30-58) for cholesterol and 42% (28-56) for hypertension. For liver disease, the PAF was greatest for hepatitis C infection (33%; 95% CI 17-48). For renal disease, the PAF was greatest for hypertension (39%; 26-51) followed by elevated total cholesterol (22%; 13-31), detectable HIV RNA (19; 9-31), and low CD4 cell count (13%; 4-21). INTERPRETATION: The substantial proportion of non-AIDS-defining cancers, myocardial infarction, end-stage liver disease, and end-stage renal disease outcomes that could be prevented with interventions on traditional risk factors elevates the importance of screening for these risk factors, improving the effectiveness of prevention (or modification) of these risk factors, and creating sustainable care models to implement such interventions during the decades of life of adults living with HIV who are receiving care. FUNDING: National Institutes of Health, US Centers for Disease Control and Prevention, the US Agency for Healthcare Research and Quality, the US Health Resources and Services Administration, the Canadian Institutes of Health Research, the Ontario Ministry of Health and Long Term Care, and the Government of Alberta.

One Size Fits (n)One: The Influence of Sex, Age, and Sexual Human Immunodeficiency Virus (HIV) Acquisition Risk on Racial/Ethnic Disparities in the HIV Care Continuum in the United States.

BACKGROUND: The United States National HIV/AIDS Strategy established goals to reduce disparities in retention in human immunodeficiency virus (HIV) care, antiretroviral therapy (ART) use, and viral suppression. The impact of sex, age, and sexual HIV acquisition risk (ie, heterosexual vs same-sex contact) on the magnitude of HIV-related racial/ethnic disparities is not well understood. METHODS: We estimated age-stratified racial/ethnic differences in the 5-year restricted mean percentage of person-time spent in care, on ART, and virally suppressed among 19 521 women (21.4%), men who have sex with men (MSM; 59.0%), and men who have sex with women (MSW; 19.6%) entering HIV care in the North American AIDS Cohort Collaboration on Research and Design between 2004 and 2014. RESULTS: Among women aged 18-29 years, whites spent 12.0% (95% confidence interval [CI], 1.1%-20.2%), 9.2% (95% CI, .4%-20.4%), and 13.5% (95% CI, 2.7%-22.5%) less person-time in care, on ART, and virally suppressed, respectively, than Hispanics. Black MSM aged ≥50 years spent 6.3% (95% CI, 1.3%-11.7%), 11.0% (95% CI, 4.6%-18.1%), and 9.7% (95% CI, 3.6%-16.8%) less person-time in these stages, respectively, than white MSM ≥50 years of age. Among MSM aged 40-49 years, blacks spent 9.8% (95% CI, 2.4%-16.5%) and 11.9% (95% CI, 3.8%-19.3%) less person-time on ART and virally suppressed, respectively, than whites. CONCLUSIONS: Racial/ethnic differences in HIV care persist in specific populations defined by sex, age, and sexual HIV acquisition risk. Clinical and public health interventions that jointly target these demographic factors are needed.

Reduced Cancer Survival Among Adults With HIV and AIDS-Defining Illnesses Despite No Difference in Cancer Stage at Diagnosis.

BACKGROUND: It is not known whether immune dysfunction is associated with increased risk of death after cancer diagnosis in persons with HIV (PWH). AIDS-defining illness (ADI) can signal significant immunosuppression. Our objective was to determine differences in cancer stage and mortality rates in PWH with and without history of ADI. METHODS: PWH with anal, oropharynx, cervical, lung cancers, or Hodgkin lymphoma diagnoses from January 2000 to December 2009 in the North American AIDS Cohort Collaboration on Research and Design were included. RESULTS: Among 81,865 PWH, 814 had diagnoses included in the study; 341 (39%) had a history of ADI at time of cancer diagnosis. For each cancer type, stage at diagnosis did not differ by ADI (P > 0.05). Mortality and survival estimates for cervical cancer were limited by n = 5 diagnoses. Adjusted mortality rate ratios showed a 30%-70% increase in mortality among those with ADI for all cancer diagnoses, although only lung cancer was statistically significant. Survival after lung cancer diagnosis was poorer in PWH with ADI vs. without (P = 0.0001); the probability of survival was also poorer in those with ADI at, or before other cancers although not statistically significant. CONCLUSIONS: PWH with a history of ADI at lung cancer diagnosis had higher mortality and poorer survival after diagnosis compared to those without. Although not statistically significant, the findings of increased mortality and decreased survival among those with ADI (vs. without) were consistent for all other cancers, suggesting the need for further investigations into the role of HIV-related immune suppression and cancer outcomes.

Survey of partner notification practices for sexually transmissible infections in the United States.

UNLABELLED: Background Partner notification (PN) for sexually transmissible infections (STIs) is a vital STI control method. The most recent evaluation of PN practices in the United States, conducted in 1999, indicated that few STI patients were offered PN services. The objectives of this study were to obtain a preliminary understanding of the current provision of PN services in HIV/STI testing sites throughout the US and to determine the types of PN services available. METHODS: A convenience sample of 300 randomly selected testing sites was contacted to administer a phone survey about PN practices. These sites were from a large database maintained by the Centers for Disease Control and Prevention. Sites were eligible to participate if they provided testing services for chlamydia, gonorrhoea, HIV or syphilis and were not hospitals or Planned Parenthood locations. RESULTS: Of the 300 eligible sites called, 79 sites were successfully reached, of which 74 agreed to participate, yielding a response rate of 24.7% and a cooperation rate of 93.7%. Most surveyed testing sites provided some form of PN service (anonymous or non-anonymous) on site or through an affiliate for chlamydia (100%), gonorrhoea (97%), HIV (91%) and syphilis (96%) infection. Anonymous PN services were available at 67-69% of sites. Only 6-9% of sites offered Internet-based PN services. CONCLUSIONS: Most surveyed testing sites currently offer some type of PN service for chlamydia, gonorrhoea, HIV or syphilis infection. However, approximately one-third of surveyed sites do not offer anonymous services. Novel, Internet-based methods may be warranted to increase the availability of anonymous services.

Qualitative assessment of HIV prevention challenges and opportunities among Latino immigrant men in a new receiving city.

Changing demographics in new receiving communities contributes to a lag time between the arrival of new immigrants and the development of appropriate services. This scarcity of services can exacerbate existing disparities in health conditions such as HIV, which disproportionately affects Latinos. Focus groups were conducted in Baltimore with 59 Latino men who had immigrated to the U.S. within the past 10 years to explore the challenges and opportunities to accessing HIV testing and preventative services. Transcripts were analyzed through a modified thematic constant comparison approach. Four thematic categories emerged: information about HIV, HIV fear and stigma, barriers to accessing healthcare, and opportunities for intervention approaches. Information and communication technology provides an opportunity to improve access to HIV testing and prevention services. Individualized interventions, though, must be disseminated in collaboration with community-, structural-, and policy-level interventions that address HIV risk, HIV/AIDS stigma, and healthcare access among Latino immigrants.

Predictors of male partner treatment for sexually transmitted infection.

BACKGROUND: Patient-initiated notification is a commonly used practice for notifying sex partners of possible exposure to a sexually transmitted infection (STI); however, 46% to 75% of partners are never treated. The Contraceptive CHOICE Project (CHOICE) is a longitudinal cohort study of women that provides no-cost contraception, STI testing, treatment to participants, and free partner treatment. Our objective was to evaluate characteristics of women who tested positive for chlamydia, gonorrhea, or trichomoniasis, and their association with successful partner treatment. METHODS: We analyzed baseline survey and STI testing, notification, and treatment data from the first 5087 participants enrolled in CHOICE. We considered "treated partners" to be men who received antibiotic treatment at the study clinic or by a prescription through the study. Independent predictors of successful partner treatment were identified using univariate analysis and multivariable analysis using Poisson regression with robust error variance. RESULTS: Forty-four percent of male partners were successfully treated. Women whose partners were less likely to obtain treatment were black (adjusted Relative Risk (RR adj) RR adj = 0.6; 95% confidence interval [CI]: 0.5-0.8) or reported some concern about future STI with the partner (RR adj = 0.6; 95% CI: 0.4, 0.8). Women whose partners were more likely to receive treatment were living with their partner (RR adj = 1.4; 95% CI: 1.1-1.8) or reported recent inconsistent condom use (RR adj = 1.5; 95% CI: 1.1-2.1). CONCLUSIONS: The male partner treatment rate resulting from female patient-initiated partner notification in our study was low. Our findings highlight the need to develop novel notification interventions that yield higher partner treatment rates and consider patient-specific factors, such as race and relationship status.