National HIV and HCV Screening Rates for Hospitalized People who Use Drugs Are Suboptimal and Heterogeneous Across 11 US Hospitals.

Background: To end the HIV and hepatitis C virus (HCV) epidemics, people who use drugs (PWUD) need more opportunities for testing. While inpatient hospitalizations are an essential opportunity to test people who use drugs (PWUD) for HIV and HCV, there is limited research on rates of inpatient testing for HIV and HCV among PWUD. Methods: Eleven hospital sites were included in the study. Each site created a cohort of inpatient encounters associated with injection drug use. From these cohorts, we collected data on HCV and HIV testing rates and HIV testing consent policies from 65 276 PWUD hospitalizations. Results: Hospitals had average screening rates of 40% for HIV and 32% for HCV, with widespread heterogeneity in screening rates across facilities. State consent laws and opt-out testing policies were not associated with statistically significant differences in HIV screening rates. On average, hospitals that reflexed HCV viral load testing on HCV antibody testing did not have statistically significant differences in HCV viral load testing rates. We found suboptimal testing rates during inpatient encounters for PWUD. As treatment (HIV) and cure (HCV) are necessary to end these epidemics, we need to prioritize understanding and overcoming barriers to testing.

HIV-1-infected T cell clones are shared across cerebrospinal fluid and blood during ART.

The central nervous system HIV reservoir is incompletely understood and is a major barrier to HIV cure. We profiled people with HIV (PWH) and uninfected controls through single-cell transcriptomic and T cell receptor (TCR) sequencing to understand the dynamics of HIV persistence in the CNS. In PWH on ART, we found that most participants had single cells containing HIV-1 RNA, which was found predominantly in CD4 central memory T cells, in both cerebrospinal fluid (CSF) and blood. HIV-1 RNA-containing cells were found more frequently in CSF than blood, indicating a higher burden of reservoir cells in the CNS than blood for some PWH. Most CD4 T cell clones containing infected cells were compartment specific, while some (22%) - including rare clones with members of the clone containing detectable HIV RNA in both blood and CSF - were found in both CSF and blood. These results suggest that infected T cells trafficked between tissue compartments and that maintenance and expansion of infected T cell clones contributed to the CNS reservoir in PWH on ART.

Equity and use of telehealth modalities among people living with HIV during the COVID-19 pandemic.

Background: COVID-19 forced a rapid transition to telehealth. Little is known about the use of telephone versus video visits among people living with or at risk for HIV (PWH). Setting: We studied electronic health record data from an urban HIV clinic. Our sample included visit- and person-level data. Visit-level data came from appointments scheduled from 30 March 2020 to 31 May 2020. Person-level data came from patients 18+ years of age who completed at least one telephone or video visit during the period of interest. Methods: We performed a cross-sectional analysis. Our primary outcome was telehealth modality (telephone or video). We compared visit completion status by telehealth modality. We evaluated associations between patient characteristics and telehealth modality using logistic regression. Results: In total, 1742 visits included information on telehealth modality: 1432 telephone (82%) and 310 (18%) video visits. 77% of telephone visits were completed compared to 75% of video visits (p = 0.449). The clinic recorded 643 completed telehealth visits in April and 623 in May 2020. The proportion of telephone visits decreased from 84% in April to 79% in May (p = 0.031). Most patients participated in telephone versus video visits (415 vs. 88 patients). Older age (adjusted odds ratio [AOR] 3.28; 95% confidence interval [CI], 1.37-7.82) and Black race (AOR 2.42; 95% CI, 1.20-4.49) were positively associated with telephone visits. Patient portal enrollment (AOR 0.06; 95% CI, 0.02-0.16) was negatively associated with telephone visits. Conclusion: PWH used telephone more than video visits, suggesting that telephone visits are a vital healthcare resource for this population.

Prevalence and Correlates of Physical Inactivity Among Individuals with HIV During the First COVID-19 Wave: A Cross-sectional Survey.

Physical activity is associated with improved health outcomes among people with HIV (PWH). In the recent pandemic context, policies designed to mitigate COVID-19 transmission may result in an increase in sedentary lifestyle and decreased physical activity. In this study, we aimed to characterize self-reported physical activity and factors associated with physical inactivity during the first wave of the COVID-19 pandemic among a sample of PWH engaged in care. We also described whether psychological coping strategies measured by the Brief COPE differed based on physical activity levels. Among 260 surveyed PWH in two HIV clinics in the US Northeast, 28.5% (n = 74) met the criteria for being physically active according to the Centers for Disease Control and Prevention (CDC)'s physical activity guidelines. Receiving care in New Haven, CT, presence of a detectable HIV viral load, every day tobacco use, and unhealthy alcohol use were associated with physical inactivity. Problem-focused coping, emotion-focused coping, and avoidance-focused coping strategies were found to be protective against physical inactivity. In adjusted analysis, only problem-focused coping continued to be significantly associated with lower odds of reporting physical inactivity. Efforts are urgently needed to promote physical activity among PWH, including among those without problem-focused coping strategies.

RESUMEN: La actividad física se asocia con mejores resultados de salud entre las personas con VIH (PCV). En el contexto de la reciente pandemia, las políticas diseñadas para mitigar la transmisión de COVID-19 pueden resultar en un aumento del estilo de vida sedentario y una disminución de la actividad física. En este estudio, nuestro objetivo fue caracterizar la actividad física autoinformada y los factores asociados con la inactividad física durante la primera ola de la pandemia de COVID-19 entre una muestra de PCV dedicados a la atención. También describimos si las estrategias psicológicas de afrontamiento medidas por el Brief COPE diferían según los niveles de actividad física. Entre las 260 PCV encuestadas en dos clínicas de VIH en el noreste de EE. UU., el 28,5% (n = 74) cumplía con los criterios para ser físicamente activo de acuerdo con las pautas de actividad física del Centros para el Control y la Prevención de Enfermedades (CDC). Recibir atención en New Haven, CT, la presencia de una carga viral de VIH detectable, el consumo diario de tabaco, y el consumo insano de alcohol se asociaron con la inactividad física. Se encontró que el afrontamiento centrado en el problema, el afrontamiento centrado en la emoción, y las estrategias de afrontamiento centradas en la evitación, protegen contra la inactividad física. En el análisis ajustado, solo el afrontamiento centrado en el problema siguió estando significativamente asociado con menores probabilidades de informar sobre la inactividad física. Se necesitan esfuerzos urgentes para promover la actividad física entre las PCV, incluso entre aquellas que no tienen estrategias de afrontamiento centradas en el problema.

Dectin-1 stimulation promotes a distinct inflammatory signature in the setting of HIV-infection and aging.

Dectin-1 is an innate immune receptor that recognizes and binds ß-1, 3/1, 6 glucans on fungi. We evaluated Dectin-1 function in myeloid cells in a cohort of HIV-positive and HIV-negative young and older adults. Stimulation of monocytes with ß-D-glucans induced a pro-inflammatory phenotype in monocytes of HIV-infected individuals that was characterized by increased levels of IL-12, TNF-α, and IL-6, with some age-associated cytokine increases also noted. Dendritic cells showed a striking HIV-associated increase in IFN-α production. These increases in cytokine production paralleled increases in Dectin-1 surface expression in both monocytes and dendritic cells that were noted with both HIV and aging. Differential gene expression analysis showed that HIV-positive older adults had a distinct gene signature compared to other cohorts characterized by a robust TNF-α and coagulation response (increased at baseline), a persistent IFN-α and IFN-γ response, and an activated dendritic cell signature/M1 macrophage signature upon Dectin-1 stimulation. Dectin-1 stimulation induced a strong upregulation of MTORC1 signaling in all cohorts, although increased in the HIV-Older cohort (stimulation and baseline). Overall, our study demonstrates that the HIV Aging population has a distinct immune signature in response to Dectin-1 stimulation. This signature may contribute to the pro-inflammatory environment that is associated with HIV and aging.

Expanded or Risk Factor-Based Annual Screening for Hepatitis C Virus (HCV) Among Persons With HIV: Which Is the Best Approach?

Introduction. Universal one-time screening for hepatitis C virus (HCV) is recommended for all adults. For persons with HIV (PWH), guidelines recommend HCV screening at entry into care and annually in men who have unprotected sex with other men (MSM) and persons who inject drugs (PWID). Public health experts recommend expanded annual screening in all PWH given concerns for undiagnosed new HCV diagnoses when risk factors are not assessed. Electronic medical record (EMR) with clinical decision support using a Best Practice Advisory (BPA) tool can aid HCV risk factor assessment. We conducted a prospective study among three HIV clinics to compare the two screening approaches. Methods. Two clinics implemented the EMR-triggered risk factor-based screening; one clinic used the expanded screening approach. We evaluated BPA uptake and compared HCV testing and positivity rates from August 12, 2019 to March 12, 2020. Results. In the risk factor-based screening clinics, of 1,343 PWH, 239 tests were performed with 139 attributed to the BPA (testing rate 10%). At the expanded screening site, among 434 patients, 237 HCV tests were performed (testing rate 55%). The risk factor-based screening sites were less likely to test for HCV (odds ratio [OR] = 0.0884, p < .01) and identify positive cases (OR = 0.55, p = .025). Conclusions. An EMR-based clinical-decision support tool was successfully implemented for HCV risk factor-based screening resulting in a lower HCV annual screening rate compared with an expanded approach. Although in this group of HIV clinics with limited longitudinal follow-up, no previously undiagnosed HCV cases were detected, additional work is needed to guide the design of the best approach.

Building an Infectious Disease Diversity, Equity, and Antiracism (ID2EA) Curriculum: A Single Center's Experience and Reflections.

In response to longstanding healthcare inequities unmasked by the Coronavirus Disease 2019 pandemic, the infectious diseases (ID) section at the Yale School of Medicine designed and implemented a pilot curriculum integrating Infectious Disease Diversity, Equity, and Antiracism (ID2EA) into ID educational training and measured program outcomes. We herein describe a mixed-methods assessment of section members on whether the ID2EA curriculum affected their beliefs and behaviors regarding racism and healthcare inequities. Participants rated the curriculum as useful (92% averaging across sessions) and effective in achieving stated learning objectives (89% averaging across sessions), including fostering understanding of how inequities and racism are linked to health disparities and identifying strategies to effectively deal with racism and inequities. Despite limitations in response rates and assessment of longer-term behavioral change, this work demonstrates that training in diversity, equity, and antiracism can be successfully integrated into ID physicians' educational activities and affect physicians' perspectives on these topics.

HIV risk profile and prevention needs of individuals seeking monkeypox (mpox) vaccination in an urban clinic in the U.S.: a brief report.

BACKGROUND: Our study survey assessed HIV risk profile and pre-exposure prophylaxis (PrEP) use among HIV-negative individuals seeking mpox vaccination, elucidating HIV prevention gaps and opportunities. METHODS: Anonymous cross-sectional surveys were self-administered at an urban academic center clinic in New Haven, CT, U.S. (August 18-November 18, 2022). Inclusion criteria included adults presenting for mpox vaccination who consented to the study. The study assessed STI risk (sexual practices, STI history, substance use). For HIV-negative participants, PrEP knowledge, attitudes, and preferences were assessed. RESULTS: Eighty-one of 210 individuals approached completed surveys (survey acceptance and completion rate 38.6%). Majority were cisgender-male (76/81; 93.8%), Caucasian (48/79; 60.8%), with median age 28 years (IQR-15). Nine of 81 (11.5%) self-reported HIV-positivity. Median sexual partner number (6 months prior) was 4 (IQR-5.8). Majority, 89.9% and 75.9%, reported insertive and receptive anal intercourse, respectively. 41% reported lifetime STI history, of whom 12.3% had an STI 6 months prior. Majority (55.8%) used ≥ 1 illicit substance; 87.7% moderate alcohol use. Among HIV-negative respondents, most (95.7%) were aware of PrEP, but only 48.4% used PrEP. CONCLUSION: Individuals seeking mpox vaccination engage in behaviors placing them at increased STI risk and would benefit from PrEP assessment.

Long-term quantitative assessment of anti-SARS-CoV-2 spike protein immunogenicity (QUASI) after COVID-19 vaccination in older people living with HIV (PWH).

BACKGROUND: The durability of immune responses to COVID-19 vaccines among older people living with HIV (PWH) is clinically important. METHODS: We aimed to assess vaccine-induced humoral immunity and durability in older PWH (≥ 55 years, n = 26) over 6 months (post-initial BNT162b2 series). A secondary and exploratory objective was to assess T-cell response and BNT162b2 booster reactogenicity, respectively. Our Visit 1 (3 weeks post-initial BNT162b2 dose) SARS-CoV-2 humoral immunity results are previously reported; these subjects were recruited for Visit 2 [2 weeks (+ 1 week window) post-second vaccination] and Visit 3 [6 months (± 2 week window) post-initial vaccination] in a single-center longitudinal observational study. Twelve participants had paired Visit 2/3 SARS-CoV-2 Anti-Spike IgG data. At Visit 3, SARS-CoV-2 Anti-Spike IgG testing occurred, and 5 subjects underwent T-cell immune response evaluation. Thereafter, subjects were offered BNT162b2 booster (concurrent day outside our study) per US FDA/CDC guidance; reactogenicity was assessed. The primary study outcome was presence of detectable Visit 3 SARS-CoV-2 Anti-Spike-1-RBD IgG levels. Secondary and exploratory outcomes were T-cell immune response and BNT162b2 booster reactogenicity, respectively. Wilcoxon signed-rank tests analyzed median SARS-CoV-2 Anti-Spike IgG 6-month trends. RESULTS: At Visit 3, 26 subjects underwent primary analysis with demographics noted: Median age 61 years; male n = 16 (62%), female n = 10 (38%); Black n = 13 (50%), White n = 13 (50%). Most subjects (n = 20, 77%) had suppressed HIV viremia on antiretroviral therapy, majority (n = 24, 92%) with CD4 > 200 cells/µL. At Visit 3, 26/26 (100%) had detectable Anti-Spike-1-RBD (≥ 0.8 U/mL). Among 12 subjects presenting to Visit 2/3, median SARS-CoV-2 Anti-Spike 1-RBD was 2087 U/mL at Visit 2, falling to 581.5 U/mL at Visit 3 (p = 0.0923), with a median 3.305-fold decrease over 6 months. Among subjects (n = 5) with 6-month T-cell responses measured, all had detectable cytokine-secreting anti-spike CD4 responses; 3 had detectable CD4 + Activation induced marker (AIM) + cells. Two had detectable cytokine-secreting CD8 responses, but all had positive CD8 + AIM + cells. CONCLUSIONS: Among older PWH, SARS-CoV-2 Anti-Spike IgG and virus-specific T-cell responses are present 6 months post-primary BNT162b2 vaccination, and although waning, suggest retention of some degree of long-term protective immunity.

Longitudinal Improvements in Viral Suppression for Persons With New HIV Diagnosis Receiving Care in the Ryan White Program: A 10-Year Experience in New Haven, CT (2009-2018).

Background: The Ryan White (RW) program funds medical and other support services for low-income persons with HIV, significantly improving progress along the HIV care continuum. Although the program has shown overall improvements in achievement of viral suppression, the relative contributions of changes in clinical practice and RW service components to the optimization of the HIV care continuum, particularly for those with new HIV diagnoses, remain unknown. Methods: The target population was patients with recent HIV diagnoses who received care at RW-funded clinics in the greater New Haven area between 2009 and 2018. Client data were extracted from the RW-funded database, CAREWare, and the electronic medical record. Primary outcomes included time between HIV diagnosis and first HIV primary care (PC) visit, antiretroviral therapy (ART) initiation, and viral suppression (VS). Results: There were 386 eligible patients. Between 2009 and 2018, the median number of days from HIV diagnosis to first PC visit decreased from 58.5 to 8.5 days, and ART initiation decreased from 155 to 9 days. In 2018, 86% of participants achieved viral suppression within 1 year, compared with 2.5% in 2009. Patients who initiated single-tablet ART and integrase inhibitor-containing regimens were more likely to reach viral suppression within 1 year (P < .001). Receipt of medical case management services was also associated with achieving viral suppression (P < .001). Conclusions: Longitudinal improvements over 10 years in ART initiation and viral suppression were observed due to clinical advances and their effective implementation through the RW comprehensive care model. Further study of the essential components promoting these outcomes is needed.

Willingness to Be Vaccinated Against COVID-19 Among People With HIV in the United States: Results From a National Survey.

Background: Approximately 215 million Americans have been fully vaccinated for COVID-19, representing over 65% of the total population. People with HIV (PWH) may be more susceptible to COVID-19 infection or severe disease, elevating the importance of COVID-19 vaccination uptake in the population. We report results from a national survey of PWH to evaluate the likelihood of receiving a COVID-19 vaccine. Methods: We conducted an online survey of 1,030 PWH living in the United States between December 6, 2020 and January 8, 2021 to evaluate likelihood of receiving a COVID-19 vaccine. Results: Overall, participants were highly willing to be vaccinated, with 83.8% stating they "strongly agree" (65.7%) or "somewhat agree" (18.1%). Participants' top vaccine-related concerns were side-effects (39.3%), safety (14.7%), and fair/equitable distribution of the vaccine to affected communities (13.6%). Participants were more willing to be vaccinated if they reported receiving an annual influenza vaccination (p < 0.001), had previously tested positive for (p = 0.043) COVID-19, had been hospitalized for (p = 0.027) COVID-19 infection, or had an undetectable HIV viral load (p = 0.002). Black (p < 0.001), politically conservative (p < 0.001), and participants with an annual income of ≤ $19,999 (p = 0.005) were significantly less willing to be vaccinated for COVID-19. Conclusions: The vast majority of PWH were willing to be vaccinated, though predominantly those who were already engaged in HIV care or directly affected by COVID-19. Findings from this large survey of PWH suggest intensive outreach efforts are needed to support engagement in vaccination programs, particularly among Black and politically conservative PWH.

Tenofovir disoproxil fumarate and coronavirus disease 2019 outcomes in men with HIV.

OBJECTIVE: To compare the risk of coronavirus disease 2019 (COVID-19) outcomes by antiretroviral therapy (ART) regimens among men with HIV. DESIGN: We included men with HIV on ART in the Veterans Aging Cohort Study who, between February 2020 and October 2021, were 18 years or older and had adequate virological control, CD4 + cell count, and HIV viral load measured in the previous 12 months, and no previous COVID-19 diagnosis or vaccination. METHODS: We compared the adjusted risks of documented severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, COVID-19-related hospitalization, and intensive care unit (ICU) admission by baseline ART regimen: tenofovir alafenamide (TAF)/emtricitabine (FTC), tenofovir disoproxil fumarate (TDF)/FTC, abacavir (ABC)/lamivudine (3TC), and other. We fit pooled logistic regressions to estimate the 18-month risks standardized by demographic and clinical factors. RESULTS: Among 20 494 eligible individuals, the baseline characteristics were similar across regimens, except that TDF/FTC and TAF/FTC had lower prevalences of chronic kidney disease and estimated glomerular filtration rate <60 ml/min. Compared with TAF/FTC, the estimated 18-month risk ratio (95% confidence interval) of documented SARS-CoV-2 infection was 0.65 (0.43, 0.89) for TDF/FTC, 1.00 (0.85, 1.18) for ABC/3TC, and 0.87 (0.70, 1.04) for others. The corresponding risk ratios for COVID-19 hospitalization were 0.43 (0.07, 0.87), 1.09 (0.79, 1.48), and 1.21 (0.88, 1.62). The risk of COVID-19 ICU admission was lowest for TDF/FTC, but the estimates were imprecise. CONCLUSION: Our study suggests that, in men living with HIV, TDF/FTC may protect against COVID-19-related events. Randomized trials are needed to investigate the effectiveness of TDF as prophylaxis for, and early treatment of, COVID-19 in the general population.

COVID-19 Vaccine Hesitancy and Associated Factors among People with HIV in the United States: Findings from a National Survey.

Introduction: Scaling up vaccination against COVID-19 is central to controlling the COVID-19 epidemic in the United States. Several vaccines are now approved for the prevention of COVID-19, but public concerns over safety and efficacy have heightened distrust and vaccine hesitancy. This is particularly concerning among people with HIV (PWH) who may be vulnerable to more severe COVID-19 disease. Here, we aimed to identify and understand COVID-19 vaccine hesitancy in a sample of PWH in the U.S. Methods: We conducted a cross-sectional online survey among PWH in the U.S. between 6 December 2020 and 8 January 2021. Measures included demographics, participants' HIV and health-related attributes, COVID-19 history and experiences, COVID-19 vaccine-related concerns, and standardized measures of attitudes towards COVID-19 vaccines. Multivariate linear regression was used to identify factors associated with vaccine hesitancy in this sample. Results: Among the 1030 respondents, most were male (89.7%), White (66.0%), and identified as gay or lesbian (84.5%). Participants' mean time living with HIV was 17.0 years (standard deviation (SD) = 11.1). The mean score for vaccine hesitancy was 1.5 (SD = 0.5; range: 1−5); 935 participants (90.8%) had a score greater than 1.0, indicating most participants had some degree of vaccine hesitancy. The final multivariate linear regression showed that greater vaccine hesitancy was associated with being Black (b = 0.149, p = 0.005), single (b = 0.070, p = 0.018), politically conservative (b = 0.157, p = 0.010), "anti-vaxxer" (b = 1.791, p < 0.001), concern about side effects (b = 0.226, p < 0.001), concern about safety (b = 0.260, p < 0.001), and being worried that the vaccine will not be effective (b = 0.169, p = 0.008) and they were being experimented on (b = 0.287, p < 0.001). Participants who were male White (b = −0.093, p = 0.008) and university graduates (b = −0.093, p < 0.001) and had a CD4 count of 200 cells/mm3 (b = −0.082, p = 0.048) and a liberal political orientation (b = −0.131, p < 0.001) were associated with lower vaccine hesitancy. Conclusions: Our findings provide important insights regarding COVID-19 vaccine hesitancy among PWH. Further efforts are required to understand how various social, political, and psychological factors contribute to COVID-19 vaccine hesitancy among key populations.

Experiences with Telemedicine for HIV Care During the COVID-19 Pandemic: A Mixed-Methods Study.

To characterize perspectives and experiences with telemedicine during the COVID-19 pandemic, we conducted a mixed-methods study in two HIV clinics in the US Northeast. Among surveyed patients with HIV (PWH) who had a telemedicine appointment (n = 205), 42.4% perceived telemedicine visits as useful during the pandemic. PWH and clinical staff identified benefits of telemedicine: (1) ability to engage and re-engage patients in care; (2) perceived patient-centeredness and flexibility; (3) opportunity to engage family and multidisciplinary care team members; and (4) opportunity to enhance telemedicine use proficiency through practice and support. Identified barriers included: (1) technical challenges; (2) privacy concerns; (3) loss of routine clinical experiences and interactions; (4) limited objective patient remote monitoring; and (5) reimbursement concerns. Efforts to optimize telemedicine for HIV care should consider strategies to improve technology support for PWH, flexible options to access care, additional platforms to allow patient remote monitoring, and appropriate billing and reimbursement methods.

RESUMEN: Para caracterizar las perspectivas sobre y las experiencias con la telemedicina durante la pandemia de COVID-19, realizamos un estudio de métodos mixtos en dos clínicas de VIH en el noreste de los Estados Unidos. Entre los pacientes con VIH (PWH) encuestados que tuvieron una cita de telemedicina (n = 205), el 42.4% percibió las visitas de telemedicina como útiles durante la pandemia. Los PWH y el personal clínico identificaron como beneficios de la telemedicina: 1) la capacidad para involucrar y reinvolucrar a los pacientes en el cuidado; 2) el cuidado centrado en el paciente y flexibilidad percibidos; 3) la oportunidad de involucrar a la familia y miembros del equipo de cuidado multidisciplinario; y 4) la oportunidad de mejorar la capacidad para usar la telemedicina a través de la práctica y el apoyo. Las barreras identificadas incluyeron: 1) retos tecnológicos; 2) preocupaciones sobre la privacidad; 3) falta de experiencias e interacciones clínicas de rutina; 4) limitada monitorización remota objetiva del paciente; y 5) preocupaciones sobre los reembolsos. Los esfuerzos para optimizar la telemedicina para el cuidado del VIH deben considerar estrategias para mejorar el soporte tecnológico para los PWH, opciones flexibles para acceder a el cuidado, plataformas adicionales que permitan el monitoreo remoto del paciente, y métodos apropiados de facturación y reembolso.

Qualitative assessment of anti-SARS-CoV-2 spike protein immunogenicity (QUASI) after COVID-19 vaccination in older people living with HIV.

OBJECTIVES: Effective and safe COVID-19 vaccines have been developed and have resulted in decreased incidence and severity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and can decrease secondary transmission. However, there are concerns about dampened immune responses to COVID-19 vaccination among immunocompromised patients, including people living with HIV (PLWH), which may blunt the vaccine's efficacy and durability of protection. This study aimed to assess the qualitative SARS-CoV-2 vaccine immunogenicity among PLWH after vaccination. METHODS: We conducted targeted COVID-19 vaccination (all received BNT162b2 vaccine) of PLWH (aged ≥ 55 years per state guidelines) at Yale New Haven Health System and established a longitudinal survey to assess their qualitative antibody responses at 3 weeks after the first vaccination (and prior to receipt of the second dose of the COVID-19 vaccine) (visit 1) and at 2-3 weeks after the second vaccination (visit 2) but excluded patients with prior COVID-19 infection. Our goal was to assess vaccine-induced immunity in the population we studied. Qualitative immunogenicity testing was performed using Healgen COVID-19 anti-Spike IgG/IgM rapid testing. Poisson regression with robust standard errors was used to determine factors associated with a positive IgG response. RESULTS: At visit 1, 45 of 78 subjects (57.7%) tested positive for SARS-CoV-2 anti-Spike IgG after the first dose of COVID-19 vaccine. Thirty-nine subjects returned for visit 2. Of these, 38 had positive IgG (97.5%), including 20 of 21 subjects (95.2%) with an initial negative anti-Spike IgG. Our bivariate analysis suggested that participants on an antiretroviral regimen containing integrase strand transfer inhibitors [relative risk (RR) = 1.81, 95% confidence interval (CI): 0.92-3.56, p = 0.085] were more likely to seroconvert after the first dose of the COVID-19 vaccine, while those with a CD4 count < 500 cells/µL (RR = 0.59, 95% CI: 0.33-1.05, p = 0.071), and those diagnosed with cancer or another immunosuppressive condition (RR = 0.49, 95% CI: 0.18-1.28, p = 0.15) may have been less likely to seroconvert after the first dose of the COVID-19 vaccine. The direction of these associations was similar in the multivariate model, although none of these findings reached statistical significance (RRintegrase inhibitor  = 1.71, 95% CI: 0.90-3.25, p = 0.10; RRCD4 count  = 0.68, 95% CI: 0.39-1.19, p = 0.18; RRcancer or another immunosuppressive condition  = 0.50, 95% CI: 0.19-1.33, p = 0.16). With regard to immunogenicity, we were able to record very high rates of new seroconversion following the second dose of the COVID-19 vaccine. CONCLUSIONS: Our study suggests that completing a two-dose series of BNT162b2 vaccine is critical for PLWH given suboptimal seroconversion rates after the first dose and subsequent improved seroconversion rates after the second dose.

High HIV Detection in a Tertiary Facility in Liberia: Implications and Opportunities.

Background: HIV/AIDS remains one of the world's most significant public health challenges; sub-Saharan Africa accounts for 71% of the global burden of HIV. Testing for HIV is pivotal to achieving UNAIDS 95-95-95 target towards bringing an end to the epidemic. Objective: The study assessed five-year HIV testing data from the largest tertiary hospital in Monrovia, Liberia and highlights risk groups that would benefit from targeted testing and prevention interventions. Methods: This was a single-center academic hospital-based retrospective analysis of HIV testing data from January 2014 to December 2018 obtained from all testing sites at John F. Kennedy Medical Center in Monrovia, Liberia. Pooled HIV testing data during the study period were analyzed using descriptive statistics and stratified by age, gender and pregnancy status. Annual diagnoses rates were reported as proportion of individuals tested within a specified category (age [<15 years, age 15-24 years and >=25 years], gender, and pregnancy status) that had a positive HIV test. Five-year trends were analyzed. Results: Over the study period, 41,343 non-pregnant individuals were screened for HIV. In addition, the antenatal clinic performed 24,913 tests. Of non-pregnant individuals tested, 4,066 (10%) were diagnosed with HIV ranging from 7% (909/12821) in 2018 to 13% (678/5079) in 2014. Case detection rates for individuals aged 15-24 were 7%, 5%, 4%, 6% and 3% for years 2014, 2015, 2016, 2017 and 2018 respectively. Annually, 2-3% of all pregnant women tested were diagnosed with HIV. While HIV detection rates decreased over time overall, children less than 15 years of age showed an annual increase from 6.7% in 2014 to 12.3% in 2018. Conclusion: A large five-year dataset from the largest tertiary facility in Liberia shows broad HIV detection rates that are much higher than national prevalence estimates. Ramping up HIV testing and prevention interventions including pre-exposure prophylaxis are sorely needed.

Cumulative burden of non-communicable diseases predicts COVID hospitalization among people with HIV: A one-year retrospective cohort study.

There continue to be conflicting data regarding the outcomes of people with HIV (PWH) who have COVID-19 infection with most studies describing the early epidemic. We present a single site experience spanning a later timeframe from the first report on January 21, 2020 to January 20, 2021 and describe clinical outcomes and predictors of hospitalization among a cohort of PWH in an urban center in Connecticut, USA. Among 103 PWH with controlled HIV disease, hospitalization occurred in 33% and overall mortality was 1%. HIV associated factors (CD4 count, HIV viral suppression) were not associated with hospitalization. Chronic lung disease (OR: 3.35, 95% CI:1.28-8.72), and cardiovascular disease (OR: 3.4, 95% CI:1.27-9.12) were independently associated with hospitalization. An increasing number of non-communicable comorbidities increased the likelihood of hospitalization (OR: 1.61, 95% CI:1.22-2.13).

Lower Gastrointestinal Syphilis: Case Series and Literature Review.

BACKGROUND: Syphilis infections are increasing globally. Lower gastrointestinal syphilis (LGIS) is a rare manifestation of early syphilis transmitted through anal sexual contact. Misdiagnosis of LGIS as inflammatory bowel disease may result from clinician underawareness. METHODS: We searched the literature for articles describing cases of LGIS, and identified additional cases diagnosed within our institution. Data were extracted from the articles and medical records and analyzed to provide a summative account. RESULTS: Fifty-four cases of LGIS were identified in 39 articles published between 1958 and 2020. Eight additional cases were diagnosed at our institution between 2011 and 2020, totaling 62 cases. All cases were described in men and transwomen aged 15-73 years. Fifty (93%) individuals reported having sex with men. In 26 cases (52%), the individuals were human immunodeficiency virus (HIV) coinfected. LGIS presented most commonly with hematochezia (67%) and anal pain (46%). The most common physical examination findings were rectal mass (38%), lymphadenopathy (31%), and rash (26%). Nontreponemal titers ranged from 1:2 to 1:1024. Of the 52 cases in which endoscopy was reported, 22 (42%) showed anorectal mass and 18 (35%) showed anorectal ulcer. In 44 cases (75%), histopathology revealed a chronic inflammatory infiltrate with a prominent lymphocyte component (45%) and/or plasma cells (36%). Seventy-eight percent of specimens to which a tissue stain was applied were positive for spirochetes. CONCLUSIONS: LGIS should be suspected in men and transwomen presenting with a lower gastrointestinal symptom or mucosal abnormality. A sexual history must be elicited and guide testing. Misdiagnosis can delay treatment and threatens patient and public health.