Correlates of Breakthrough SARS-CoV-2 Infections in People with HIV: Results from the CIHR CTN 328 Study.

COVID-19 breakthrough infection (BTI) can occur despite vaccination. Using a multi-centre, prospective, observational Canadian cohort of people with HIV (PWH) receiving ≥2 COVID-19 vaccines, we compared the SARS-CoV-2 spike (S) and receptor-binding domain (RBD)-specific IgG levels 3 and 6 months post second dose, as well as 1 month post third dose, in PWH with and without BTI. BTI was defined as positivity based on self-report measures (data up to last study visit) or IgG data (up to 1 month post dose 3). The self-report measures were based on their symptoms and either a positive PCR or rapid antigen test. The analysis was restricted to persons without previous COVID-19 infection. Persons without BTI remained COVID-19-naïve until ≥3 months following the third dose. Of 289 participants, 92 developed BTI (31.5 infections per 100 person-years). The median days between last vaccination and BTI was 128 (IQR 67, 176), with the most cases occurring between the third and fourth dose (n = 59), corresponding to the Omicron wave. In analyses adjusted for age, sex, race, multimorbidity, hypertension, chronic kidney disease, diabetes and obesity, a lower IgG S/RBD (log10 BAU/mL) at 1 month post dose 3 was significantly associated with BTI, suggesting that a lower IgG level at this time point may predict BTI in this cohort of PWH.

Positive childhood experiences serve as protective factors for mental health in pandemic-era youth with adverse childhood experiences.

BACKGROUND: While adverse childhood experiences (ACEs) predict poorer mental health across the life course, positive childhood experiences (PCEs) predict better mental health. It is unclear whether PCEs protect against poor mental health outcomes and promote mental well-being in pandemic-era adolescents with ACEs. METHODS: We examined the individual and joint contributions of ACEs and PCEs to mental health and well-being (MHW) in eleventh-grade British Columbian adolescents (N = 8864) during the fifth wave of COVID-19. We used a novel measure of ACEs that included community- and societal-level ACEs in addition to ACEs experienced at home to investigate the role of social and structural determinants of mental health in supporting the MHW of pandemic-era adolescents. A series of two-way ANCOVAs were conducted comparing MHW outcomes between adolescents with and without ACEs. Interaction effects were examined to investigate whether PCEs moderated the association between ACEs and MHW. RESULTS: Adolescents with no ACEs had significantly better MHW than those with one or more ACE. Having six or more PCEs was associated with better MHW in adolescents with and without ACEs. PCEs significantly moderated the association between ACEs and depression. Effect sizes were larger for PCEs than ACEs in relation to depression, mental well-being, and life satisfaction. CONCLUSIONS: PCEs may protect against depression among adolescents with ACEs and promote MHW among all pandemic-era adolescents. These findings emphasize the importance of addressing social determinants of mental health to mitigate the impact of ACEs and promote PCEs as part of a public health approach to MHW.

Gendered and racial experiences of moral distress: A scoping review.

AIM: To inform efforts to integrate gender and race into moral distress research, the review investigates if and how gender and racial analyses have been incorporated in such research. DESIGN: Scoping review. METHODS: The PRISMA (Preferred Reporting Items for Systematic and Meta-Analysis) Extension for Scoping Reviews was adopted. DATA SOURCES: Systematic literature search was conducted through PubMed, CINAHL and Web of Science databases. Boolean operators were used to identify moral distress literature which included gender and/or race data and published between 2012 and 2022. RESULTS: After screening and full-text review, 73 articles reporting on original moral distress research were included. Analysis was conducted on how gender and race were incorporated in research and interpretation of moral distress experiences among healthcare professionals. IMPACT: This study found that while there is an upward trend in including gender and race-disaggregated data in moral distress research, over half of such research did not conduct in-depth analysis of such data. Others only highlighted differential experiences such as moral distress levels of women vis-à-vis men. Only about 20% of publications interrogated how experiences of moral distress differed and/or explored factors behind their findings. CONCLUSION: There is a need to not only collect disaggregated data in moral distress research but also engage this data through gender and race-based analysis. Particularly, we highlight the need for intersectional analysis, which can elucidate how social identities and categories (such as gender and race) and structural inequalities (such as those sustained by sexism and racism) interact to influence moral experiences. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Moral distress as experienced by healthcare professionals is increasingly recognized as an important area of research with significant policy implications in the healthcare sector. This study offers insights for nuanced and targeted policy approaches. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

An Intersectional Analysis of Moral Distress and Intention to Leave Employment Among Long-Term Care Providers in British Columbia.

Objectives: In this study, we aimed to explore the relationship between intersectional inequities and moral distress among those working in Long-Term Care (LTC) in British Columbia, Canada. Methods: This was a cross-sectional and retrospective study. We assessed moral distress, of 1678 respondents, using a modified Moral Distress Scale, and an equivalent distress mitigation score, at the intersections of gender and racial/ethnic identity. Then, we explored which worker attributes were more predictive of intention to leave work. Results: We found notable difference in experiences of moral distress across intersecting identities, including high moral distress scores among Indigenous men and women, and white women. Significant differences in mitigation scores were also found by intersectional identities. Discussion: Moral distress was the most important predictor of intention to leave work. The differences across racial and gender identity groups suggest the need for tailored interventions to address moral distress among LTC providers.

Preventative behaviours and COVID-19 infection in a Canadian cohort of people living with HIV.

Few studies have examined preventative behaviour practices with respect to COVID-19 among people living with HIV (human immunodeficiency virus). Using a cross-sectional survey from a Canadian Institutes of Health Research Canadian HIV Trials Network study (CTN 328) of people living with HIV on vaccine immunogenicity, we examined the relationships between participant characteristics and behavioural practices intended to prevent COVID-19 infection. Participants living in four Canadian urban centers were enrolled between April 2021-January 2022, at which time they responded to a questionnaire on preventative behaviour practices. Questionnaire and clinical data were combined to explore relationships between preventive behaviours and (1) known COVID-19 infection pre-enrolment, (2) multimorbidity, (3) developing symptomatic COVID-19 infection, and (4) developing symptomatic COVID-19 infection during the Omicron wave. Among 375 participants, 49 had COVID-19 infection pre-enrolment and 88 post-enrolment. The proportion of participants reporting always engaging in preventative behaviours included 87% masking, 79% physical distancing, 70% limiting social gatherings, 65% limiting contact with at-risk individuals, 33% self-isolating due to symptoms, and 26% self-quarantining after possible exposure. Participants with known COVID-19 infection pre-enrolment were more likely to self-quarantine after possible exposure although asymptomatic (65.0% vs 23.4%, p < 0.001; Chi-square test). Participants with multiple comorbidities more likely endorsed physical distancing (85.7% vs 75.5%, p = 0.044; Chi-square test), although this was not significant in logistic regression analysis adjusted for age, sex, race, number of household members, number of bedrooms/bathrooms in the household per person, influenza immunization, and working in close physical proximity to others. Overall, participants reported frequent practice of preventative behaviours.

COVID-19 vaccine effectiveness by HIV status and history of injection drug use: a test-negative analysis.

INTRODUCTION: People living with HIV (PLWH) and/or who inject drugs may experience lower vaccine effectiveness (VE) against SARS-CoV-2 infection. METHODS: A validated algorithm was applied to population-based, linked administrative datasets in the British Columbia COVID-19 Cohort (BCC19C) to ascertain HIV status and create a population of PLWH and matched HIV-negative individuals. The study population was limited to individuals who received an RT-PCR laboratory test for SARS-CoV-2 between 15 December 2020 and 21 November 2021 in BC, Canada. Any history of injection drug use (IDU) was ascertained using a validated administrative algorithm. We used a test-negative study design (modified case-control analysis) and multivariable logistic regression to estimate adjusted VE by HIV status and history of IDU. RESULTS: Our analysis included 2700 PLWH and a matched population of 375,043 HIV-negative individuals, among whom there were 351 and 103,049 SARS-CoV-2 cases, respectively. The proportion of people with IDU history was much higher among PLWH compared to HIV-negative individuals (40.7% vs. 4.3%). Overall VE during the first 6 months after second dose was lower among PLWH with IDU history (65.8%, 95% CI = 43.5-79.3) than PLWH with no IDU history (80.3%, 95% CI = 62.7-89.6), and VE was particularly low at 4-6 months (42.4%, 95% CI = -17.8 to 71.8 with IDU history vs. 64.0%; 95% CI = 15.7-84.7 without), although confidence intervals were wide. In contrast, overall VE was 88.6% (95% CI = 88.2-89.0) in the matched HIV-negative population with no history of IDU and remained relatively high at 4-6 months after second dose (84.6%, 95% CI = 83.8-85.4). Despite different patterns of vaccine protection by HIV status and IDU history, peak estimates were similar (≥88%) across all populations. CONCLUSIONS: PLWH with a history of IDU may experience lower VE against COVID-19 infection, although findings were limited by a small sample size. The lower VE at 4-6 months may have implications for booster dose prioritization for PLWH and people who inject drugs. The immunocompromising effect of HIV, substance use and/or co-occurring comorbidities may partly explain these findings.

Antibody neutralization capacity after coronavirus disease 2019 vaccination in people with HIV in Canada.

OBJECTIVES: Many vaccines require higher/additional doses or adjuvants to provide adequate protection for people with HIV (PWH). Here, we compare coronavirus disease 2019 (COVID-19) vaccine-induced antibody neutralization capacity in PWH vs. HIV-negative individuals following two vaccine doses. DESIGN: In Canadian prospective observational cohorts, including a multicentre study of PWH receiving at least two COVID-19 vaccinations (mRNA or ChAdOx1-S), and a parallel study of HIV-negative controls (Stop the Spread Ottawa Cohort), we measured vaccine-induced neutralization capacity 3 months post dose 2 (±1 month). METHODS: COVID-19 neutralization efficiency was measured by calculating the half maximal inhibitory dilution (ID50) using a high-throughput protein-based neutralization assay for Ancestral (Wuhan), Delta and Omicron (BA.1) spike variants. Univariable and multivariable quantile regression were used to compare COVID-19-specific antibody neutralization capacity by HIV status. RESULTS: Neutralization assays were performed on 256 PWH and 256 controls based on specimen availability at the timepoint of interest, having received two vaccines and known date of vaccination. There was a significant interaction between HIV status and previous COVID-19 infection status in median ID50. There were no differences in median ID50 for HIV+ vs. HIV-negative persons without past COVID-19 infection. For participants with past COVID-19 infection, median ICD50 was significantly higher in controls than in PWH for ancestral SARS-CoV-2 and Omicron variants, with a trend for the Delta variant in the same direction. CONCLUSION: Vaccine-induced SARS-CoV-2 neutralization capacity was similar between PWH vs. HIV-negative persons without past COVID-19 infection, demonstrating favourable humoral-mediated immunogenicity. Both HIV+ and HIV-negative persons demonstrated hybrid immunity. TRIAL REGISTRATION: clinicaltrials.gov NCT04894448.

Development and validation of a youth climate anxiety scale for the Youth Development Instrument survey.

Emerging terms in the literature such as climate anxiety describe heightened concern, fear, and anxiety related to the climate crisis. Recent efforts have attempted to develop and validate scales to measure climate anxiety; however, extant research is largely focused on adults. Consequently, it is unclear whether developed measures are appropriate for adolescent populations, despite disproportionate impacts of the climate crisis experienced by this age group. The purpose of this study was two-fold; first, we aimed to assess levels of climate concern among Canadian adolescents using the Youth Development Instrument (YDI), a population-level youth well-being survey administered in schools with students (ages 15-18). Secondly, we collaborated with adolescents to adapt an existing climate anxiety scale to be included in the YDI survey. We used survey results to validate the adapted scale for use with adolescents and assessed levels of climate anxiety within our sample. In consultation with adolescents, the 13-item Climate Change Anxiety Scale (CCAS) was adapted to create the Climate Change Anxiety Scale - Short-form (CCAS-S) which consists of four-items adapted from the original CCAS. A total of 2306 respondents were included in analyses. Most adolescents reported feeling climate change concern (75.8%). A smaller proportion reported experiences of climate anxiety (48.7%). Confirmatory factor analysis supported a one-factor structure for the CCAS-S, with high internal consistency (Cronbach's alpha = 0.95) and good model fit with error co-variance. Findings from this study provide construct validity evidence and reliability for the use of the CCAS-S in adolescent populations.

Risk of COVID-19 hospitalization in people living with HIV and HIV-negative individuals and the role of COVID-19 vaccination: A retrospective cohort study.

OBJECTIVE: To examine the risk of hospitalization within 14 days of COVID-19 diagnosis among people living with HIV (PLWH) and HIV-negative individuals who had laboratory-confirmed SARS-CoV-2 infection. METHODS: We used Cox proportional hazard models to compare the relative risk of hospitalization in PLWH and HIV-negative individuals. Then, we used propensity score weighting to examine the influence of sociodemographic factors and comorbid conditions on risk of hospitalization. These models were further stratified by vaccination status and pandemic period (pre-Omicron: December 15, 2020, to November 21, 2021; Omicron: November 22, 2021, to October 31, 2022). RESULTS: The crude hazard ratio (HR) for risk of hospitalization in PLWH was 2.44 (95% confidence interval [CI]: 2.04-2.94). In propensity score-weighted models that included all covariates, the relative risk of hospitalization was substantially attenuated in the overall analyses (adjusted HR [aHR]: 1.03; 95% CI: 0.85-1.25), in vaccinated (aHR 1.00; 95% CI: 0.69-1.45), inadequately vaccinated (aHR: 1.04; 95% CI: 0.76-1.41) and unvaccinated individuals (aHR: 1.15; 95% CI: 0.84-1.56). CONCLUSION: PLWH had about two times the risk of COVID-19 hospitalization than HIV-negative individuals in crude analyses which attenuated in propensity score-weighted models. This suggests that the risk differential can be explained by sociodemographic factors and history of comorbidity, underscoring the need to address social and comorbid vulnerabilities (e.g., injecting drugs) that were more prominent among PLWH.

Evaluating the psychosocial status of BC children and youth during the COVID-19 pandemic: A MyHEARTSMAP cross-sectional study.

BACKGROUND: Understanding the psychosocial status of children and adolescents during the COVID-19 pandemic is vital to the appropriate and adequate allocation of social supports and mental health resources. This study evaluates the burden of mental health concerns and the impact of demographic factors while tracking mental health service recommendations to inform community service needs. METHODS: MyHEARTSMAP is a digital self-assessment mental health evaluation completed by children and their guardian throughout British Columbia between August 2020 to July 2021. Severity of mental health concerns was evaluated across psychiatric, social, functioning, and youth health domains. Proportional odds modelling evaluated the impact of demographic factors on severity. Recommendations for support services were provided based on the evaluation. RESULTS: We recruited 541 families who completed 424 psychosocial assessments on individual children. Some degree of difficulty across the psychiatric, social, or functional domains was reported for more than half of children and adolescents. Older youth and those not attending any formal school or education program were more likely to report greater psychiatric difficulty. Girls experienced greater social concerns, and children attending full-time school at-home were more likely to identify difficulty within the youth health domain but were not more likely to have psychiatric difficulties. Considerations to access community mental health service were triggered in the majority (74%) of cases. CONCLUSIONS: Psychosocial concerns are highly prevalent amongst children and adolescents during the COVID-19 pandemic. Based on identified needs of this cohort, additional community health supports are required, particularly for higher risk groups.

Mental health-related healthcare service utilisation and psychotropic drug dispensation trends in British Columbia during COVID-19 pandemic: a population-based study.

Background: The impact of the COVID-19 pandemic on the population's mental health is vital for informing public health policy and decision-making. However, information on mental health-related healthcare service utilisation trends beyond the first year of the pandemic is limited. Aims: We examined mental health-related healthcare service utilisation patterns and psychotropic drug dispensations in British Columbia, Canada, during the COVID-19 pandemic compared with the prepandemic period. Methods: We conducted a retrospective population-based secondary analysis using administrative health data to capture outpatient physician visits, emergency department visits, hospital admissions and psychotropic drug dispensations. We examined time trends of mental health-related healthcare service utilisation and psychotropic drug dispensations between January to December 2019 (prepandemic period) and January 2020 to December 2021 (pandemic period). In addition, we calculated age-standardised rates and rate ratios to compare mental health-related healthcare service utilisation before and during the first two years of the COVID-19 pandemic, stratified by year, sex, age and condition. Results: By late 2020, except for emergency department visits, utilisation of healthcare services recovered to prepandemic levels. Between 2019 and 2021, the monthly average rate for overall mental health-related outpatient physician visits, emergency department visits and psychotropic drug dispensations increased significantly by 24%, 5% and 8%, respectively. Notable and statistically significant increases were observed among 10-14 year-olds (44% in outpatient physician visits, 30% in emergency department visits, 55% in hospital admissions and 35% in psychotropic drug dispensations) and 15-19 year-olds (45% in outpatient physician visits, 14% in emergency department visits, 18% in hospital admissions and 34% in psychotropic drug dispensations). Additionally, these increases were more prominent among females than males, with some variation for specific mental health-related conditions. Conclusions: The increase in mental health-related healthcare service utilisation and psychotropic drug dispensations during the pandemic likely reflects significant societal consequences of both the pandemic and pandemic management measures. Recovery efforts in British Columbia should consider these findings, especially among the most affected subpopulations, such as adolescents.

Age-specific determinants of psychiatric outcomes after the first COVID-19 wave: baseline findings from a Canadian online cohort study.

BACKGROUND: Canadians endured unprecedented mental health (MH) and support access challenges during the first COVID-19 wave. Identifying groups of individuals who remain at risk beyond the acute pandemic phase is key to guiding systemic intervention efforts and policy. We hypothesized that determinants of three complementary, clinically actionable psychiatric outcomes would differ across Canadian age groups. METHODS: The Personal Impacts of COVID-19 Survey (PICS) was iteratively developed with stakeholder feedback, incorporating validated, age-appropriate measures. Baseline, cross-sectional online data collected between November 2020-July 2021 was used in analyses. Age group-specific determinants were sought for three key baseline MH outcomes: (1) current probable depression, generalized anxiety disorder, obsessive-compulsive disorder and/or suicide attempt during COVID-19, (2) increased severity of any lifetime psychiatric diagnosis, and (3) inadequate MH support access during COVID-19. Multivariable logistic regression models were constructed for children, youth (self- and parent-report), young adults (19-29 years) and adults over 29 years, using survey type as a covariate. Statistical significance was defined by 95% confidence interval excluding an odds ratio of one. RESULTS: Data from 3140 baseline surveys were analyzed. Late adolescence and early adulthood were identified as life phases with the worst MH outcomes. Poverty, limited education, home maker/caregiver roles, female and non-binary gender, LGBTQ2S + status and special educational, psychiatric and medical conditions were differentially identified as determinants across age groups. INTERPRETATION: Negative psychiatric impacts of COVID-19 on Canadians that include poor access to MH support clearly persisted beyond the first wave, widening pre-existing inequity gaps. This should guide policy makers and clinicians in current and future prioritization efforts.

Understanding COVID-19 Vaccine Confidence in People Living with HIV: A pan-Canadian Survey.

Understanding the roots of Covid-19 vaccine hesitancy in at-risk groups, such as persons living with HIV (PLWH), is of utmost importance. We developed a modified Vaccine Hesitancy Scale (VHS) questionnaire using items from the National Advisory Committee on Immunization Acceptability Matrix. To examine factors associated with receiving COVID-19 vaccine and the link between vaccine attitudes and beliefs with vaccine behavior, PLWH were recruited via social media and community-based organizations (February-May 2022). Descriptive statistics were used to summarize results. Total VHS score was generated by adding Likert scale scores and linear regression models used to compare results between participants who received or did not receive COVID-19 vaccines. Logistic regression models were used to identify factors associated with vaccine uptake. A total of 246 PLWH indicated whether they received a COVID-19 vaccine. 89% received ≥ 1 dose. Mean total VHS(SD) for persons having received ≥ 1 COVID-19 vaccine was 17.8(6.2) vs. 35.4(9.4) for participants not having received any COVID-19 vaccine. Persons who received ≥ 1 dose were significantly older than those who had not received any (48.4 ± 13.8 vs. 34.0 ± 7.7 years, p < 0.0001). The majority of participants considered COVID-19 vaccination important for their health(81.3%) and the health of others(84.4%). Multivariate logistic regression revealed the odds of taking ≥ 1dose were increased 2.4-fold [95% CI 1.6, 3.5] with each increase in age of 10 years (p < 0.0001). Sex and ethnicity were not different between groups. In conclusion, PLWH accept COVID-19 vaccines for both altruistic and individual reasons. With evolving recommendations and increasing numbers of booster vaccines, we must re-examine the needs of PLWH regularly.

Access to mental health support, unmet need and preferences among adolescents during the first year of the COVID-19 pandemic. / Accès à du soutien en santé mentale, besoins non comblés et préférences en la matière chez les adolescents au cours de la première année de la pandémie de COVID-19.

INTRODUCTION: The COVID-19 pandemic has had widespread effects on adolescent mental health. However, little is known about support-seeking, unmet need and preferences for mental health care among adolescents. METHODS: The Youth Development Instrument (YDI) is a school-administered survey of adolescents (N = 1928, mean age = 17.1, SD = 0.3) across British Columbia, Canada. In this cohort, we assessed the characteristics of accessed mental health supports, prevalence of unmet need and preferences for in-person versus internet-based services. RESULTS: Overall, 40% of adolescents obtained support for mental health, while 41% experienced unmet need. The most commonly accessed supports were family doctors or pediatricians (23.1%) and adults at school (20.6%). The most preferred mode of mental health care was in-person counselling (72.4%), followed by chat-based services (15.0%), phone call (8.1%) and video call (4.4%). The adjusted prevalence of accessing support was elevated among adolescents with anxiety (adjusted prevalence ratio [aPR] = 1.29, 95% CI: 1.10-1.51), those who used alcohol (1.14, 1.01-1.29), gender minorities (1.28, 1.03-1.58) and sexual minorities (1.28, 1.03-1.45). The adjusted prevalence of unmet need was elevated among adolescents with depression (1.90, 1.67-2.18), those with anxiety (1.78, 1.56-2.03), females (1.43, 1.31-1.58), gender minorities (1.45, 1.23-1.70) and sexual minorities (1.15, 1.07-1.23). CONCLUSION: Adolescents of gender or sexual minority status and those with anxiety were more likely than others to have discussed mental health concerns and also to have reported unmet need. The most common sources of support were primary health care providers and adults at school, while the most and least preferred modes of support were in-person and video call services, respectively.

Using novel methodology to estimate the prevalence of mental disorders in British Columbia, Canada.

PURPOSE: A needs-based model of health systems planning uses a systematic estimate of service needs for a given population. Our objective was to derive annual prevalence estimates of specific mental disorders in the adult population of British Columbia, Canada and use a novel triangulation approach encompassing multiple data sources and stratifying these estimates by age, sex, and severity to inform Ministry partners, who commissioned this work. METHODS: We performed systematic literature reviews and subsequent meta-analyses to derive an annual prevalence estimate for each mental disorder. We then generated age- and sex-specific estimates by triangulating published epidemiological studies, routinely collected province-wide health administrative data, and nationally representative health survey data sources. The age- and sex-specific estimates were further stratified by severity using the Global Burden of Disease severity distributions and published literature. RESULTS: Anxiety disorders had the highest annual prevalence estimates (6.93%), followed by depressive disorders (6.42%). All other mental disorders had an annual prevalence of less than 1%. Prevalence estimates were consistently higher in younger age groups. Depressive disorders, anxiety disorders, and eating disorders were higher in women, while estimates for bipolar disorders, schizophrenia, and ADHD were slightly higher in men in younger age groups. CONCLUSION: We generated robust annual prevalence estimates stratified by age, sex, and severity using a triangulation approach. Variation by age, sex, and severity implies that these factors need to be considered when planning for mental health services. Our approach is replicable and can be used as a model for needs-based planning in other jurisdictions.

Effectiveness of COVID-19 vaccines in people living with HIV in British Columbia and comparisons with a matched HIV-negative cohort: a test-negative design.

OBJECTIVES: We estimated the effectiveness of COVID-19 vaccines against laboratory-confirmed SARS-CoV-2 infection among people living with HIV (PLWH) and compared the estimates with a matched HIV-negative cohort. METHODS: We used the British Columbia COVID-19 Cohort, a population-based data platform, which integrates COVID-19 data on SARS-CoV-2 tests, laboratory-confirmed cases, and immunizations with provincial health services data. The vaccine effectiveness (VE) was estimated with a test-negative design using the multivariable logistic regression. RESULTS: The adjusted VE against SARS-CoV-2 infection was 71.1% (39.7, 86.1%) 7-59 days after two doses, rising to 89.3% (72.2, 95.9%) between 60 and 89 days. VE was preserved 4-6 months after the receipt of two doses, after which noticeable waning was observed (51.3% [4.8, 75.0%]). In the matched HIV-negative cohort (n = 375,043), VE peaked at 91.4% (90.9, 91.8%) 7-59 days after two doses and was sustained for up to 4 months, after which evidence of waning was observed, dropping to 84.2% (83.4, 85.0%) between 4 and 6 months. CONCLUSION: The receipt of two COVID-19 vaccine doses was effective against SARS-CoV-2 infection among PLWH pre-Omicron. VE estimates appeared to peak later in PLWH than in the matched HIV-negative cohort and the degree of waning was relatively quicker in PLWH; however, peak estimates were comparable in both populations.

Coronavirus disease 2019 vaccine effectiveness among a population-based cohort of people living with HIV.

OBJECTIVE: People with HIV were underrepresented in coronavirus disease 2019 (COVID-19) vaccine clinical trials. We estimated vaccine effectiveness (VE) against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection for the BNT162b2, mRNA-1273, and ChAdOx1 vaccines among a population-based cohort of people with HIV in Ontario, Canada. DESIGN: Test-negative design. METHODS: We identified people with HIV aged ≥19 years who were tested for SARS-CoV-2 by RT-PCR between December 14, 2020 (first availability of COVID-19 vaccines) and November 21, 2021 (pre-Omicron circulation). Outcomes included any infection, symptomatic infection, and COVID-19-related hospitalization/death. We compared the odds of vaccination between test-positive cases and test-negative controls using multivariable logistic regression with adjustment for age, sex, region, calendar time, SARS-CoV-2 test histories, influenza vaccination, comorbidities, and neighborhood-level socio-economic status. VE was derived as (1 - adjusted odds ratio) × 100%. RESULTS: Among 21 023 adults living with HIV, there were 801 (8.3%) test-positive cases and 8,879 (91.7%) test-negative controls. 20.1% cases and 47.8% of controls received ≥1 COVID-19 vaccine dose; among two-dose recipients, 93.4% received ≥1 mRNA dose. Two-dose VE ≥7 days before specimen collection was 82% (95% confidence interval [CI] = 74-87%) against any infection, 94% (95% CI = 82-98%) against symptomatic infection, and 97% (95% CI = 85-100%) against hospitalization/death. Against any infection, VE declined from 86% (95% CI = 77-92%) within 7-59 days after the second dose to 66% (95% CI = -15-90%) after ≥180 days; we did not observe evidence of waning protection for other outcomes. CONCLUSION: Two doses of COVID-19 vaccine offered substantial protection against symptomatic illness and hospitalization/death in people with HIV prior to the emergence of the Omicron variant. Our findings do not support a broad conclusion that COVID-19 VE is lower among people with HIV in populations that, for the most part, are attending HIV care, taking antiretroviral medication, and are virally suppressed.

The relationship between outpatient service use and emergency department visits among people treated for mental and substance use disorders: analysis of population-based administrative data in British Columbia, Canada.

BACKGROUND: Research findings on the association between outpatient service use and emergency department (ED) visits for mental and substance use disorders (MSUDs) are mixed and may differ by disorder type. METHODS: We used population-based linked administrative data in British Columbia, Canada to examine associations between outpatient primary care and psychiatry service use and ED visits among people ages 15 and older, comparing across people treated for three disorder categories: common mental disorders (MDs) (depressive, anxiety, and/or post-traumatic stress disorders), serious MDs (schizophrenia spectrum and/or bipolar disorders), and substance use disorders (SUDs) in 2016/7. We used hurdle models to examine the association between outpatient service use and odds of any ED visit for MSUDs as well count of ED visits for MSUDs, stratified by cohort in 2017/8. RESULTS: Having had one or more MSUD-related primary care visit was associated with lower odds of any ED visit among people treated for common MDs and SUDs but not people treated for serious MDs. Continuity of primary care was associated with slightly lower ED use in all cohorts. One or more outpatient psychiatrist visits was associated with lower odds of ED visits among people treated for serious MDs and SUDs, but not among people with common MDs. CONCLUSION: Findings highlight the importance of expanded access to outpatient specialist mental health services, particularly for people with serious MDs and SUDs, and collaborative models that can support primary care providers treating people with MSUDs.

Emergency department use for mental and substance use disorders: descriptive analysis of population-based, linked administrative data in British Columbia, Canada.

OBJECTIVES: Information on emergency department (ED) visits for mental and substance use disorders (MSUDs) is important for planning services but has not been explored in British Columbia (BC), Canada. We describe all MSUD ED visits for people ages 15 and older in the province of BC in 2017/2018 and document trends in MSUD ED visits between 2007/2008 and 2017/2018 by disorder group. DESIGN: Population-based linked administrative data comprised of ED records and physician billings capturing all MSUD ED visits in BC. SETTING: BC is Canada's westernmost province with a population of approximately 5 million. Permanent residents receive first-dollar coverage for all medically necessary services provided by licensed physicians or in hospitals, including ED services. POPULATION: All people age >15 with MSUD ED visits during the study period. MEASURES: All claims with a service location in the ED or corresponding to fee items billed only in the ED were examined alongside ED visits reported through a national reporting system. Patient characteristics (sex/gender, age, location of residence, income, treated disorders and comorbidities) and previous outpatient service use for all ED visits by visit diagnosis are also described. RESULTS: A total of 72 363 people made 134 063 visits to the ED in 2017/2018 for needs related to MSUD. MSUD ED visits have increased since 2010, particularly visits for substance use and anxiety disorders. People with more frequent visits were more likely to be male, on public prescription drug plans for income assistance, prescribed psychiatric medications, and living in lower-income neighbourhoods. They used more community-based primary care and psychiatry services and had lower continuity of primary care. CONCLUSIONS: MSUD ED visits are substantial and growing in BC. Findings underscore a need to strengthen and target community healthcare services and adequately resource and support EDs to manage growing patient populations.

Gay, bisexual, and other men who have sex with men accessing STI clinics: Optimizing HIV PrEP implementation.

BACKGROUND: Gay, bisexual and other men who have sex with men (gbMSM) who attend STI clinics represent an easily accessible population for promoting HIV prevention interventions. We examined characteristics of gbMSM STI clinic attendees to identify those who could most benefit from pre-exposure prophylaxis (PrEP). SETTING: GbMSM STI clinic attendees in British Columbia (BC), Canada. METHODS: A clinical electronic charting system of STI clinics in BC was used to identify gbMSM from 2004 to 2017. Incident HIV cases were defined as testers who had at least one HIV-negative test and a subsequent HIV-positive test. Seroconversion rates were calculated by risk factor variables and by year. Cox proportional hazards regression was used to identify independent predictors of HIV seroconversion. RESULTS: There were 9,038 gbMSM included, of whom 257 HIV seroconverted over the study period and 8,781 remained negative HIV testers, contributing 650.8 and 29,591.0 person-years to the analysis, respectively. The overall rate of seroconversion was 0.85 per 100 person-years (95% CI: 0.75-0.96). Incidence rates were higher among patients reporting >5 partners in the previous six months, inconsistent condom use, or having a partner living with HIV and who had a previous or concurrent diagnosis of rectal gonorrhea or rectal chlamydia. gbMSM presenting with two STIs such as rectal gonorrhea and syphilis (3.59/100 person-years [95%CI: 2.33-5.22]) or rectal chlamydia and syphilis (3.01/100 person-years [95%CI: 2.00-4.29]) had the highest incidence rates. CONCLUSION: gbMSM with preceding or concurrent rectal STI diagnoses or syphilis had higher rates of HIV seroconversion. The data support the inclusion of specific STI diagnoses as an indication for PrEP.