Mpox Outbreak - Los Angeles County, California, May 4-August 17, 2023.

Since May 2022, approximately 2,500 mpox cases have been reported in Los Angeles County (LAC), California. Beginning in May 2023, the LAC Department of Public Health observed a consistent increase in mpox cases after a prolonged period of low incidence. A total of 56 cases were identified during May 4-August 17, 2023. A minority of mpox patients were fully vaccinated (29%). One patient was hospitalized; no deaths were reported. Two cases of reinfection occurred, both of which were associated with mild illness. The increasing number of cases during this period was significant, as few other health departments in the United States reported an increase in mpox cases during the same period. The outbreak spread similarly to the 2022 U.S. mpox outbreak, mainly through sexual contact among gay, bisexual, and other men who have sex with men. Vaccination against mpox became available in June 2022 and has been shown to be effective at preventing mpox disease. This outbreak was substantially smaller than the 2022 mpox outbreak in LAC (2,280 cases); possible explanations for the lower case count include increased immunity provided from vaccination against mpox and population immunity from previous infections. Nonetheless, mpox continues to spread within LAC, and preventive measures, such as receipt of JYNNEOS vaccination, are recommended for persons at risk of Monkeypox virus exposure.

Surveillance of Complicated Mpox Cases Unresponsive to Oral Tecovirimat in Los Angeles County, 2022.

The Los Angeles County Department of Public Health established a surveillance system to identify complicated (advanced human immunodeficiency virus [HIV] or hospitalized) mpox cases. From 1 August to 30 November 2022, we identified 1581 mpox cases, of which 134 (8.5%) were complicated. A subset of 8 cases did not recover after either initiating or completing a course of oral tecovirimat. All 8 patients were HIV positive and had advanced HIV (CD4 count <200 cells/µL). We identified 8 distinct mutations previously associated with tecovirimat resistance in specimens collected from 6 patients. Ongoing surveillance of viral evolution requires close coordination between health departments and frontline providers.

Countering Mpox Vaccination Disparities in Los Angeles County, California, May-December 2022.

Providing equitable access to vaccines for individuals at risk for mpox was critical for containing the 2022 mpox outbreak in Los Angeles County, California. Eligible non-Hispanic Black/African American and Latinx individuals had lower vaccine uptake than did non-Hispanic White individuals, despite having higher mpox case rates. Strategies to address disparities in vaccine uptake included using familiar messaging technology to reach individuals at risk for mpox, using partnerships with community-based organizations to raise mpox awareness, and bringing vaccines to locations convenient to at-risk individuals to improve access. (Am J Public Health. 2023;113(12):1258-1262. https://doi.org/10.2105/AJPH.2023.307409).

Projected Benefits of Long-Acting Antiretroviral Therapy in Nonsuppressed People With Human Immunodeficiency Virus Experiencing Adherence Barriers.

Background: In a demonstration project, long-acting, injectable cabotegravir-rilpivirine (CAB-RPV) achieved viral suppression in a high proportion of people with HIV (PWH) who were virologically nonsuppressed with adherence barriers. We projected the long-term impact of CAB-RPV for nonsuppressed PWH experiencing adherence barriers. Methods: Using the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) model, we compared 3 strategies: (1) standard of care oral integrase inhibitor-based ART (INSTI); (2) INSTI-based ART with supportive social services ("wraparound services" [WS]) (INSTI/WS); and (3) CAB-RPV with WS (CAB-RPV/WS). Model outcomes included viral suppression (%) and engagement in care (%) at 3 years, and life expectancy (life-years [LYs]). Base case cohort characteristics included mean age of 47y (standard deviation [SD], 10y), 90% male at birth, and baseline mean CD4 count 150/µL (SD, 75/µL). Viral suppression at 3 months was 13% (INSTI), 28% (INSTI/WS), and 60% (CAB-RPV/WS). Mean loss to follow-up was 28/100 person-years (PY) (SD, 2/100 PY) without WS and 16/100 PY (SD, 1/100 PY) with WS. Results: Projected viral suppression at 3 years would vary widely: 16% (INSTI), 38% (INSTI/WS), and 44% (CAB-RPV/WS). Life expectancy would be 7.4 LY (INSTI), 9.0 LY (INSTI/WS), and 9.4 LY (CAB-RPV/WS). Projected benefits over oral ART would be greater for PWH initiating CAB-RPV/WS at lower CD4 counts. Across plausible key parameter ranges, CAB-RPV/WS would improve viral suppression and life expectancy compared with oral INSTI strategies. Conclusions: These model-based results support that long-acting injectable CAB-RPV with extensive support services for nonsuppressed PWH experiencing adherence barriers is likely to increase viral suppression and improve survival. A prospective study to provide further evidence is needed.

Hemolysis during therapeutic plasma exchange: A rare phenomena.

Hemolysis is an uncommon complication in patients undergoing therapeutic plasma exchange (TPE) using cell separator machine based on continuous centrifugation method. However, it is frequently encountered in patients undergoing TPE using a membrane filtration technique. We report an interesting case where hemolysis was noted during TPE using a cell separator machine.

Cost-effectiveness of a Medical Care Coordination Program for People With HIV in Los Angeles County.

BACKGROUND: The Los Angeles County (LAC) Division of HIV and STD Programs implemented a medical care coordination (MCC) program to address the medical and psychosocial service needs of people with HIV (PWH) at risk for poor health outcomes. METHODS: Our objective was to evaluate the impact and cost-effectiveness of the MCC program. Using the CEPAC-US model populated with clinical characteristics and costs observed from the MCC program, we projected lifetime clinical and economic outcomes for a cohort of high-risk PWH under 2 strategies: (1) No MCC and (2) a 2-year MCC program. The cohort was stratified by acuity using social and clinical characteristics. Baseline viral suppression was 33% in both strategies; 2-year suppression was 33% with No MCC and 57% with MCC. The program cost $2700/person/year. Model outcomes included quality-adjusted life expectancy, lifetime medical costs, and cost-effectiveness. The cost-effectiveness threshold for the incremental cost-effectiveness ratio (ICER) was $100 000/quality-adjusted life-year (QALY). RESULTS: With MCC, life expectancy increased from 10.07 to 10.94 QALYs, and costs increased from $311 300 to $335 100 compared with No MCC (ICER, $27 400/QALY). ICERs for high/severe, moderate, and low acuity were $30 500/QALY, $25 200/QALY, and $77 400/QALY. In sensitivity analysis, MCC remained cost-effective if 2-year viral suppression was ≥39% even if MCC costs increased 3-fold. CONCLUSIONS: The LAC MCC program improved survival and was cost-effective. Similar programs should be considered in other settings to improve outcomes for high-risk PWH.

Differentiating Nonoccupational Postexposure Prophylaxis Seroconverters and Non-Seroconverters in a Community-Based Clinic in Los Angeles, California.

BACKGROUND: Nonoccupational postexposure prophylaxis (nPEP) is a 28-day regimen of antiretroviral medications taken within 72 hours of human immunodeficiency virus (HIV) exposure to prevent HIV acquisition. Although nPEP has been recommended since 1998, few studies have analyzed the characteristics that distinguish nPEP failures (seroconverters) and successes (non-seroconverters). METHODS: This retrospective study analyzed all nPEP courses prompted by sexual exposure that were prescribed at the Los Angeles LGBT Center between March 2010 and July 2014. Fisher exact tests and logistic regressions were used to determine characteristics that distinguished nPEP seroconverters from non-seroconverters. RESULTS: Of the nPEP courses administered, 1744 had a follow-up visit for HIV testing within 24 weeks of exposure and 17 individuals seroconverted. Seven reported a known re-exposure, 8 self-reported only condom-protected sex subsequent to the initial exposure, and 2 reported abstinence since the exposure. In multivariable analyses, seroconverters were more likely than non-seroconverters to report methamphetamine use, incomplete medication adherence, and nPEP initiation later in the 72-hour window. CONCLUSIONS: Nonoccupational postexposure prophylaxis is an important emergency tool for HIV prevention. Our findings corroborate that timing of the initial nPEP dose is an important predictor of seroconversion. Although the current study did not offer the initial nPEP dose at the beginning of the visit, use of this fast-track dosing schedule will ensure that the first dose is taken as early as possible postexposure and may lower the likelihood for seroconversion. Furthermore, we recommend systematic screening for substance use because these individuals may be well suited for pre-exposure prophylaxis given their sustained risk.

Project Engage: Snowball Sampling and Direct Recruitment to Identify and Link Hard-to-Reach HIV-Infected Persons Who Are Out of Care.

INTRODUCTION: Innovative strategies are needed to identify and link hard-to-find persons living with HIV (PLWH) who are out of care (OOC). Project Engage, a health department-based project in Los Angeles County, used a mixed-methods approach to locate and provide linkage for PLWH who have limited contact with HIV medical and nonmedical services. METHODS: Incentivized social network recruitment (SNR) and direct recruitment (DR) was used to identify eligible OOC alters for a linkage intervention that included HIV clinic selection, appointment and transportation support, reminder calls/texts, and clinic navigation. RESULTS: Between 2012 and 2015, 112 alters were identified using SNR (n = 74) and DR (n = 38). Most alters were male (80%), African American (38%), and gay (60%). Sizable percentages were homeless (78%), had engaged in sex work (32%) in the previous 6 months, had injected drugs (47%), were incarcerated in the previous 12 months (50%), and had only received HIV care during the previous 5 years while incarcerated (24%). SNR alters were more likely than DR alters to be African American, uninsured, unemployed, homeless, sex workers, injection drug users, recently incarcerated, and have unmet service needs. Alters linked to care within 3 (69%), 4-6 (5%), and 7-12 months (8%), and 72% were retained at 6-12 months. The percent virally suppressed increased (27% vs. 41%) and the median viral load decreased (P = 0.003) between linkage and follow-up at 6-12 months. DISCUSSION: The alternative approaches presented were effective at locating marginalized HIV-positive persons who are OOC for linkage and retention. The SNR approach was most successful at identifying alters with serious social challenges and gaps in needed medical/ancillary services.

Implementation and Operational Research: The Navigation Program: An Intervention to Reengage Lost Patients at 7 HIV Clinics in Los Angeles County, 2012-2014.

The Navigation Program is a health department-community agency collaboration to reengage lost HIV clinic patients in Los Angeles County using best practices from disease investigator services locator activities and the Antiretroviral Treatment Access Study (ARTAS), a CDC-recommended intervention. Clinic databases were reviewed to identify HIV patients who: (1) had no HIV care visits in 6-12 months and last viral load was greater than 200 copies per milliliter; (2) had no HIV care visits in >12 months; (3) were newly diagnosed and never in care; or (4) were recently released from jail/prison/other institution with no regular HIV medical provider. Patients were contacted by trained Navigators using locator information from clinic medical records, HIV/sexually transmitted disease surveillance, and people-finder databases and offered enrollment in a modified ARTAS intervention. Among the 1139 lost clinic patients identified, 36% were in care elsewhere, 29% could not be located, 8% returned to the clinic independently, 4% declined enrollment, and 7% (n = 78) were located and enrolled in the intervention. Participants received an average of 4.5 Navigator sessions over 11.6 hours. Among reengaged patients, 68% linked within 3 months, 85% linked within 6 months, and 94% linked within 12 months, and 82% of linked patients were retained in care 12 months after study enrollment. The percentage of linked patients virally suppressed was compared at time of linkage by the Navigators (52%) with a second viral load measure after linkage to care (63%) (χ(2) = 11.8; P = 0.01). The combined disease investigator services/ARTAS model of reengagement was effective for locating and reengaging lost HIV clinic patients. Access to HIV surveillance data is critical for the efficient identification of persons truly in need of reengagement.

Uptake and repeat use of postexposure prophylaxis in a community-based clinic in Los Angeles, California.

Postexposure prophylaxis (PEP) has become an important tool for HIV prevention in the men who have sex with men (MSM) communities within Los Angeles County. However, it is unclear as to whether the most sexually at-risk MSM populations are accessing PEP services. Furthermore, it is unclear what behavioral risk factors differentiate individuals who utilize PEP once (single PEP) versus those who utilize it multiple times (re-PEP). Data were collected between May 2011 and December 2012 on all clients enrolled in the Los Angeles LGBT Center's (the Center) PEP-LA program as well as on all sexually transmitted infection (STI) screening clients visiting the Center. Multivariate logistic regression models were used to analyze results. PEP clients had greater odds of having a history of gonorrhea in the past year when compared to high-risk, non-PEP clients (OR: 1.71; CI: 1.25-2.35). Furthermore, they had greater odds of using methamphetamines (OR: 1.71; CI: 1.30-2.24) and inhaled nitrates (OR: 1.62; CI: 1.30-2.01) in the past 12 months when compared to high-risk, non-PEP clients. Re-PEP clients had greater odds of methamphetamine use than single PEP clients (OR: 2.80; CI: 1.65-4.75). There were no significant differences by race/ethnicity between high-risk, non-PEP clients and PEP clients in either the entire cohort or MSM only sample. However, African Americans made up 8.5% of persons accessing PEP services but 16.7% of persons who tested HIV positive. Similar proportions of PEP use by race/ethnicity are problematic considering the disproportionate burden of HIV infections in the African American community. Although uptake among the highest risk populations has been brisk (n=649), inequities based upon race/ethnicity suggest the need for increased outreach.

Data-driven decision-making tools to improve public resource allocation for care and prevention of HIV/AIDS.

Public health agencies face difficult decisions when allocating scarce resources to control the spread of HIV/AIDS. Decisions are often made with few local empirical data. We demonstrated the use of the robust decision making approach in Los Angeles County, an approach that is data driven and allows decision makers to compare the performance of various intervention strategies across thousands of simulated future scenarios. We found that the prevailing strategy of emphasizing behavioral risk reduction interventions was unlikely to achieve the policy goals of the national HIV/AIDS strategy. Of the alternative strategies we examined, those that invested most heavily in interventions to initiate antiretroviral treatment and support treatment adherence were the most likely to achieve policy objectives. By employing similar methods, other public health agencies can identify robust strategies and invest in interventions more likely to achieve HIV/AIDS policy goals.

Clinical uncertainties, health service challenges, and ethical complexities of HIV "test-and-treat": a systematic review.

Despite the HIV "test-and-treat" strategy's promise, questions about its clinical rationale, operational feasibility, and ethical appropriateness have led to vigorous debate in the global HIV community. We performed a systematic review of the literature published between January 2009 and May 2012 using PubMed, SCOPUS, Global Health, Web of Science, BIOSIS, Cochrane CENTRAL, EBSCO Africa-Wide Information, and EBSCO CINAHL Plus databases to summarize clinical uncertainties, health service challenges, and ethical complexities that may affect the test-and-treat strategy's success. A thoughtful approach to research and implementation to address clinical and health service questions and meaningful community engagement regarding ethical complexities may bring us closer to safe, feasible, and effective test-and-treat implementation.

Selecting performance indicators for prison health care.

Improving prison health care requires a robust measurement dashboard that addresses multiple domains of care. We sought to identify tested indicators of clinical quality and access that prison health managers could use to ascertain gaps in performance and guide quality improvement. We used the RAND/UCLA modified Delphi method to select the best indicators for correctional health. An expert panel rated 111 indicators on validity and feasibility. They voted to retain 79 indicators in areas such as access, cardiac conditions, geriatrics, infectious diseases, medication monitoring, metabolic diseases, obstetrics/gynecology, screening/prevention, psychiatric disorders/substance abuse, pulmonary conditions, and urgent conditions. Prison health institutions, like all other large health institutions, need robust measurement systems. The indicators presented here provide a basic library for prison health managers developing such systems.

Physician use of advance care planning discussions in a diverse hospitalized population.

Two decades after the Patient Self Determination Act it is unknown how often physicians have advance care planning (ACP) discussions with hospitalized patients. The objective of this study is to investigate use of ACP discussions in a multi-ethnic, multi-lingual hospitalized population. Cross-sectional communication study of hospitalized patients. The Participants are 369 patients at one urban county hospital and one academic medical center. Interventions are not applicable. Participants were asked at baseline and a post-discharge interview whether hospital physicians had discussed either (a) what type of treatment they would want if they could not make decisions for themselves or (b) whether they would want cardiopulmonary resuscitation if needed. We compared patient characteristics for those who did and did not have an ACP discussion. Only 151 (41%) participants reported an ACP discussion. Rates of ACP were low across ethnic, language, education and age groups. In a multivariate model, scoring higher on a co-morbidity scale was associated with higher odds of reporting having had an ACP discussion during hospitalization; this finding remained after adjusting for time period and site of data collection. Multiethnic, multi-lingual hospitalized patients reported low rates of ACP discussions with their physicians regardless of ethnicity, English proficiency, education level or age.

Is incarceration a contributor to health disparities? Access to care of formerly incarcerated adults.

Despite the disproportionate prevalence of incarceration in communities of color, few studies have examined its contribution to health disparities. We examined whether a lifetime history of incarceration is associated with recent access to medical and dental care. We performed a secondary data analysis of the 2007 Los Angeles County Health Survey, a population-based random-digit-dialing telephone survey of county households. Any history of incarceration in a prison/jail/detention center as an adult was assessed for a random subsample. Bivariate and multivariate logistic regression analyses examined whether incarceration history was associated with access to care, controlling for other characteristics. Ten percent of our study population reported a history of incarceration. While persons with an incarceration history were similar to their peers with regard to health and insurance status, their access to medical and dental care was worse. Incarceration history was independently associated with disparities in access to care. Interventions to improve the health of communities affected by high rates of incarceration could include efforts that enable access to care for formerly incarcerated adults.

Long-term adherence with cardiovascular drug regimens.

BACKGROUND: An increasing number of medications are prescribed for patients with coronary artery disease, but poor adherence may limit realization of their benefits. OBJECTIVE: To characterize adherence to evidence-based cardiovascular medications prescribed at hospital discharge at 1 year. METHODS: We studied 1326 patients with coronary artery disease undergoing cardiac catheterization between 1998 and 2001. We examined adherence to angiotensin-converting enzyme (ACE) inhibitors, aspirin, beta-blockers (BBs), and statins by comparing baseline prescription at hospital discharge to self-reported medical regimen at 12 months. Patients who reported use of each cardiac medication at 1 year were considered adherent. Clinical and demographic predictors of nonadherence are described. RESULTS: The population had a mean age of 65.7 +/- 10.5 years, and 36% were women. At discharge, aspirin was prescribed in 95%, BBs in 86%, ACE inhibitors in 65%, and statins in 55%. The proportion of patients who discontinued medications was lowest for aspirin (18%) and BBs (22%) and highest for ACE inhibitors/angiotensin receptor blockers (28%) and statins (28%). Only 54% were adherent to all of their initial medications. Patients who discontinued medications were more likely to be older, women, unmarried, and less educated. Multivariable predictors of better adherence were higher mental health, education level, marital status, and no antidepressant use. A higher number of prescribed medications were associated with lower adherence to the recommended regimen. Insurance coverage and physical function did not correlate with adherence. CONCLUSIONS: Patients frequently stop medications within 1 year of prescription. Adherence is influenced by marital status, mental health, education, and total number of medications prescribed. Physicians need to be aware of patient factors which influence adherence to facilitate higher use of evidence-based medications.