The Impact of the COVID-19 Pandemic on Sexual Behavior and HIV Prevention and Treatment Services Among U.S. Men Who Have Sex With Men in the Post-Lockdown Era.

Early in the COVID-19 pandemic, disruptions to sexual health services and changes to sexual behavior due to the first COVID-19 lockdowns were common among U.S. gay, bisexual, and other men who have sex with men (GBMSM). Less is known about the persistence of these changes after this initial lockdown period. These changes have long-term implications for HIV prevention for current and future pandemic periods. This study collected information on COVID-related impacts on sexual behavior and HIV-related health service disruptions from a cohort of U.S. GBMSM at three time points during the COVID-19 pandemic. We observed that COVID-related disruptions to sexual behavior continued from early lockdown periods through December 2020. Although early interruptions to pre-exposure prophylaxis (PrEP) access resolved in later 2020 and interruptions to antiretroviral therapy (ART) adherence were minimal, extended disruptions were observed in HIV testing, sexually transmitted infection (STI) testing, HIV care clinical visits, and HIV viral load testing. Although sexual behavior did not return to prepandemic levels in late 2020, the reduced access to HIV prevention, testing, and treatment services during this period could result in an overall increased HIV transmission rate, with long-term impacts to the trajectory of the U.S. HIV epidemic. Additional resources and programs are needed to address challenges created by the COVID-19 pandemic, as well as prepare for future potential pandemics and other disruptive events.

Impacts of COVID-19 on sexual behaviors, HIV prevention and care among men who have sex with men: A comparison of New York City and Metropolitan Atlanta.

The COVID-19 pandemic has disrupted HIV prevention, care, and transmission opportunities. This likely varies by geography, given differences in COVID-19 burden and mandates over time, and by age, given different likelihoods of severe COVID-19 consequences. We consider changes in sexual behavior, HIV testing, pre-exposure prophylaxis (PrEP) use and antiretroviral therapy (ART) use among men who have sex with men (MSM) over the first year of the COVID-19 epidemic, comparing the Atlanta metropolitan area and New York City (NYC). We use two continuous time-series datasets and one panel dataset, assessing changes over time within city and comparing across cities, and disaggregate major findings by age. For clinical results, ART use showed by far the smallest reductions, and testing the largest. Disruptions occurred concurrently between cities, despite the major wave of COVID-19, and government mandates, occurring later in Atlanta. Test positivity increased in NYC only. In both cities, younger MSM saw the greatest reductions in testing and PrEP use, but the smallest in sexual behavior. Reduced clinical service usage would be unconcerning if stemming solely from reductions in exposure; however, the patterns for young MSM suggest that the COVID-19 epidemic likely generated new conditions for increased HIV transmission, especially in this cohort.

Systematic Review of Syndrome of the Trephined and Reconstructive Implications.

Syndrome of the trephined (SoT) is a severe complication following decompressive craniectomy resulting in neurological decline which can progress to aphasia, catatonia, and even death. While cranioplasty can reverse neurological symptoms of SoT, awareness of SoT is poor outside of the neurosurgery community. The authors performed a systematic review of the literature on SoT with a focus on reconstructive implications. Search terms "syndrome of the trephined" and "sunken flap syndrome" were applied to PubMed to identify primary studies through October 2021. Full-text review yielded 11 articles discussing SoT and reconstructive techniques or implications with 56 patients undergoing cranial reconstruction. Average age of the patients was 41.8±9.5 years. Sixty-three percent of the patients were male. The most common indication for craniectomy was traumatic brain injury (43%), followed by tumor resection (23%), intracerebral hemorrhage (11%), and aneurysmal subarachnoid hemorrhage (2%). Patients most commonly suffered from motor deficits (52%), decreased wakefulness (30%), depression or anxiety (21%), speech deficits (16%), headache (16%), and cognitive difficulties (2%). Time until presentation of symptoms following decompression was 4.4±8.9 months. Patients typically underwent cranioplasty with polyetheretherketone (48%), titanium mesh (21%), split thickness calvarial bone (16%), full thickness calvarial bone (14%), or split thickness rib graft (4%). Eight percent of patients required free tissue transfer for soft tissue coverage. Traumatic Brain Injury (TBI) was a risk factor for development of SoT when adjusting for age and sex (odds ratio: 8.2, 95% confidence interval: 1.2-8.9). No difference significant difference was observed between length until initial improvement of neurological symptoms following autologous versus allograft reconstruction (P=0.47). SoT can be a neurologically devastating complication of decompressive craniectomy which can resolve following urgent cranioplasty. Familiarity with this syndrome and its reconstructive implications is critical for the plastic surgery provider, who may be called upon to assist with these urgent cases.

Correlations between community-level HIV preexposure prophylaxis coverage and individual-level sexual behaviors among United States MSM.

OBJECTIVE: To evaluate if community-level HIV PrEP coverage is correlated with individual sexual behaviors. DESIGN: We used demographic, behavioral, and sexual network data from ARTnet, a 2017-2019 study of United States MSM. METHODS: Multivariable regression models with a Bayesian modeling framework were used to estimate associations between area-level PrEP coverage and seven sexual behavior outcomes [number of total, main, and casual male partners (network degree); count of one-time partnerships; consistent condom use in one-time partnerships; and frequency of casual partnership anal sex (total and condomless)], controlling for individual PrEP use. RESULTS: PrEP coverage ranged from 10.3% (Philadelphia) to 38.9% (San Francisco). Total degree was highest in Miami (1.35) and lowest in Denver (0.78), while the count of one-time partners was highest in San Francisco (11.7/year) and lowest in Detroit (1.5/year). Adjusting for individual PrEP use and demographics, community PrEP coverage correlated with total degree [adjusted incidence rate ratio (aIRR) = 1.73; 95% credible interval (CrI), 0.92-3.44], casual degree (aIRR = 2.05; 95% CrI, 0.90-5.07), and count of one-time partnerships (aIRR = 1.90; 95% CrI, 0.46-8.54). Without adjustment for individual PrEP use, these associations strengthened. There were weaker or no associations with consistent condom use in one-time partnerships (aIRR = 1.68; 95% CrI, 0.86-3.35), main degree (aIRR = 1.21; 95% CrI, 0.48-3.20), and frequency of casual partnership condomless anal sex (aIRR = 0.23; 95% CrI, 0.01-3.60). CONCLUSION: Most correlations between community PrEP coverage and sexual behavior were explained by individual PrEP use. However, some residual associations remained after controlling for individual PrEP use, suggesting that PrEP coverage may partially drive community-level differences in sexual behaviors.

Epidemiology beyond its limits.

In 1995, journalist Gary Taubes published an article in Science titled "Epidemiology faces its limits," which questioned the utility of nonrandomized epidemiologic research and has since been cited more than 1000 times. He highlighted numerous examples of research topics he viewed as having questionable merit. Studies have since accumulated for these associations. We systematically evaluated current evidence of 53 example associations discussed in the article. Approximately one-quarter of those presented as doubtful are now widely viewed as causal based on current evaluations of the public health consensus. They include associations between alcohol consumption and breast cancer, residential radon exposure and lung cancer, and the use of tanning devices and melanoma. This history should inform current debates about the reproducibility of epidemiologic research results.

Seroadaptive Strategy Patterns of Young Black Gay, Bisexual, and Other Men Who Have Sex With Men in Atlanta, Georgia.

BACKGROUND: Young Black gay, bisexual, and other men who have sex with men (YBMSM) are disproportionally affected by HIV. Seroadaptive strategies-modification of sexual behavior based on an individual's perceived serostatus, the perceived status of the partner, and/or HIV transmission risk by the type of sex act-are often used to reduce the risk of HIV transmission or acquisition. METHODS: We used demographic, behavioral, and clinical data from Ele[MEN]t, a prospective cohort study of YBMSM aged 18-29 years in Atlanta, GA, conducted during 2015-2019. The prevalence of seroadaptive strategies at baseline was reported, and latent class analysis was used to identify the latent classes of strategies for both YBMSM known and not known to be living with HIV. Latent classes were compared by key behavioral and clinical characteristics to validate our findings. RESULTS: In a 4-class model, the most common latent class of YBMSM not known to be living with HIV (32.4%) was characterized by all individuals reporting only having sex with men not perceived to be living with HIV. The most common latent class of YBMSM known to be living with HIV (48.2%) was characterized by a combination of serosorting strategies, including using condoms for anal sex with partners not known to be living with HIV and avoiding sex with men not known to be living with HIV. CONCLUSIONS: YBMSM use various patterns of strategies to reduce their HIV transmission or acquisition risk. Our study highlights the need for targeted HIV prevention recommendations based on individual behaviors.

Projected HIV and Bacterial Sexually Transmitted Infection Incidence Following COVID-19-Related Sexual Distancing and Clinical Service Interruption.

BACKGROUND: The global COVID-19 pandemic has the potential to indirectly impact transmission dynamics and prevention of HIV and other sexually transmitted infections (STI). It is unknown what combined impact reductions in sexual activity and interruptions in HIV/STI services will have on HIV/STI epidemic trajectories. METHODS: We adapted a model of HIV, gonorrhea, and chlamydia for a population of approximately 103 000 men who have sex with men (MSM) in the Atlanta area. Model scenarios varied the timing, overlap, and relative extent of COVID-19-related sexual distancing and service interruption within 4 service categories (HIV screening, preexposure prophylaxis, antiretroviral therapy, and STI treatment). RESULTS: A 50% relative decrease in sexual partnerships and interruption of all clinical services, both lasting 18 months, would generally offset each other for HIV (total 5-year population impact for Atlanta MSM, -227 cases), but have net protective effect for STIs (-23 800 cases). If distancing lasted only 3 months but service interruption lasted 18 months, the total 5-year population impact would be an additional 890 HIV cases and 57 500 STI cases. CONCLUSIONS: Immediate action to limit the impact of service interruptions is needed to address the indirect effects of the global COVID-19 pandemic on the HIV/STI epidemic.

Projected HIV and Bacterial STI Incidence Following COVID-Related Sexual Distancing and Clinical Service Interruption.

BACKGROUND: The global COVID-19 pandemic has the potential to indirectly impact the transmission dynamics and prevention of HIV and other sexually transmitted infections (STI). Studies have already documented reductions in sexual activity ("sexual distancing") and interruptions in HIV/STI services, but it is unknown what combined impact these two forces will have on HIV/STI epidemic trajectories. METHODS: We adapted a network-based model of co-circulating HIV, gonorrhea, and chlamydia for a population of approximately 103,000 men who have sex with men (MSM) in the Atlanta area. Model scenarios varied the timing, overlap, and relative extent of COVID-related sexual distancing in casual and one-time partnership networks and service interruption within four service categories (HIV screening, HIV PrEP, HIV ART, and STI treatment). RESULTS: A 50% relative decrease in sexual partnerships and interruption of all clinical services, both lasting 18 months, would generally offset each other for HIV (total 5-year population impact for Atlanta MSM: -227 cases), but have net protective effect for STIs (-23,800 cases). Greater relative reductions and longer durations of service interruption would increase HIV and STI incidence, while greater relative reductions and longer durations of sexual distancing would decrease incidence of both. If distancing lasted only 3 months but service interruption lasted 18 months, the total 5-year population impact would be an additional 890 HIV cases and 57,500 STI cases. CONCLUSIONS: The counterbalancing impact of sexual distancing and clinical service interruption depends on the infection and the extent and durability of these COVID-related changes. If sexual behavior rebounds while service interruption persists, we project an excess of hundreds of HIV cases and thousands of STI cases just among Atlanta MSM over the next 5 years. Immediate action to limit the impact of service interruptions is needed to address the indirect effects of the global COVID pandemic on the HIV/STI epidemic.

Trends in Ectopic Pregnancy Diagnoses in United States Emergency Departments, 2006-2013.

OBJECTIVES: Ectopic pregnancy is an important adverse pregnancy outcome that is under-surveilled. Emergency department (ED) data can help provide insight on the trends of ectopic pregnancy incidence in the United States (US). METHODS: Data from the largest US all-payer ED database, the Healthcare Cost and Utilization Project Nationwide ED Sample, were used to identify trends in the annual ratio of ED ectopic pregnancy diagnoses to live births during 2006-2013, and the annual rate of diagnoses among all pregnancies during 2006-2010. Diagnoses were identified through International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedure codes and CPT codes. RESULTS: The overall ratio of weighted ED visits with an ectopic pregnancy diagnosis during 2006-2013 was 12.3 per 1000 live births. This ratio increased significantly from 2006 to 2013, from 11.0 to 13.7 ectopic pregnancies per 1000 live births, with no inflections in trend. The rate of ectopic pregnancy diagnoses per 1000 pregnancies increased during 2006-2010, from 7.0 to 8.3, with no inflections in trend. Females of all age groups experienced increases, though increases were less pronounced with increasing age. All geographic regions experienced increases, with increases being most pronounced in the Northeast. CONCLUSIONS: Our study suggests that ED ectopic pregnancy diagnoses may be increasing in the US, although the drivers of these increases are not clear. Our results highlight the need for national measures of total pregnancies, stratified by pertinent demographic variables, to evaluate trends in pregnancy-related conditions among key populations.

Trends in the Prevalence of Anogenital Warts Among Patients at Sexually Transmitted Disease Clinics-Sexually Transmitted Disease Surveillance Network, United States, 2010-2016.

BACKGROUND: Approximately 90% of genital warts are caused by human papillomavirus (HPV) types 6 and 11. In the United States, HPV vaccination has been recommended for girls and women aged ≤26 years, and since 2011, for boys and men aged ≤21 years and for gay, bisexual, and other men who have sex with men (MSM) aged ≤26 years. METHODS: Data were obtained from 27 clinics participating in the STD Surveillance Network. Trends in the annual prevalence of anogenital warts (AGW) from 2010-2016 were described by sex and by the sex of sex partners. RESULTS: During 2010-2016, significant declines in the prevalence of AGW were observed in women aged <40 years, men who have sex with women only (MSW) aged <40 years, and MSM of all age categories. An inflection in trend in 2012 was noted for MSW aged 20-24 or 25-29 years and for MSM aged 20-24 years. CONCLUSIONS: The observed declines in the prevalence of AGW suggest that HPV morbidity is declining among populations attending STD clinics, including MSW, MSM, and women. Declines in younger age groups are consistent with what would be expected following the implementation of HPV vaccination. However, declines were also observed in older age groups and are not likely to be the result of vaccination.

Susceptibility of Neisseria gonorrhoeae to Gentamicin-Gonococcal Isolate Surveillance Project, 2015-2016.

The gentamicin minimum inhibitory concentrations (MICs) of Neisseria gonorrhoeae isolates were determined. Seventy-three percent of isolates demonstrated an MIC range of 8 to 16 µg/mL, and 27% demonstrated an MIC of 4 µg/mL or less. Significant associations between gentamicin MIC and resistance or reduced susceptibility to other antimicrobials were found.