Coronary Microcirculatory Dysfunction in People With HIV and Its Association With Antiretroviral Therapy.

BACKGROUND: HIV infection and abacavir-containing antiretroviral regimens are associated with vascular endothelial dysfunction and increased cardiovascular risk. Positron emission tomography (PET)-derived myocardial blood flow reserve (MBFR), the ratio of vasodilator stress to rest myocardial blood flow, is a well-validated measure of coronary microvascular health and marker of cardiovascular risk. Our objective was to compare MBFR among people with HIV (PWH) with matched non-HIV controls and to assess whether switching from dolutegravir/lamivudine/abacavir to the non-abacavir regimen bictegravir/emtricitabine/tenofovir alafenamide (TAF) would improve MBFR. METHODS AND RESULTS: Thirty-seven PWH were 1:2 matched on cardiovascular risk factors to 75 people without HIV, and MBFR corrected for differences in resting hemodynamics was compared in a cross-sectional design. PWH were majority men (68%) with a mean age of 56 years. Mean stress myocardial blood flow (1.83 mL/min per g [95% CI, 1.68-1.98] versus 2.40 mL/min per g [95% CI, 2.25-2.54]; P<0.001) and MBFR (2.18 [95% CI, 1.96-2.40] versus 2.68 [95% CI, 2.47-2.89]; P=0.002) was significantly lower in PWH than in people without HIV. In a single-arm, multicenter trial, a subset of 25 PWH who were virologically suppressed on dolutegravir/lamivudine/abacavir underwent positron emission tomography myocardial perfusion imaging at baseline and after switching to bictegravir/emtricitabine/TAF. MBFR was unchanged after switching to bictegravir/emtricitabine/TAF for a mean of 27 weeks (MBFR, 2.34 to 2.29; P=0.61), except in PWH with impaired MBFR at baseline (<2.00; N=6) in whom MBFR increased from 1.58 to 2.02 (P=0.02). CONCLUSIONS: PWH had reduced coronary microvascular function compared with controls without HIV. Coronary microvascular function did not improve after switching from dolutegravir/lamivudine/abacavir to bictegravir/emtricitabine/TAF. REGISTRATION: URL: https://www.clinicaltrials.gov; unique identifier: NCT03656783.

mHealth for pre-exposure prophylaxis adherence by young adult men who have sex with men.

BACKGROUND: Young adult men who have sex with men (YMSM) are at increased risk for HIV, especially minority YMSM. Pre-exposure prophylaxis (PrEP) is a breakthrough daily pill to prevent HIV. Consistent adherence is key to PrEP effectiveness, which is why the CDC recommends adherence support be provided to all PrEP patients. Mobile health can overcome barriers to the delivery of adherence support, particularly for YMSM who may be most in need of it due, at least in part, to their young age. METHODS: We created a culturally- and developmentally-sensitive PrEP adherence mobile app (called "Dot") that was tailored for culturally-diverse young adult MSM. After formative research and usability testing, we conducted a 6-week pre-post study to evaluate the impact of Dot on self-reported PrEP adherence, PrEP treatment self-efficacy, PrEP knowledge, and intention to practice safe sex among culturally-diverse YMSM, age 20-29. RESULTS: At 6 weeks, there were significant improvements in PrEP adherence, PrEP self-efficacy, and intention to practice safe sex. PrEP knowledge scores did not significantly change. CONCLUSIONS: The Dot app proved feasible and effective at improving PrEP adherence among culturally-diverse YMSM. Moreover, the app had a high-degree of user appeal, which is foundational to success of an mhealth intervention.

A Web-Based HIV/STD Prevention Intervention for Divorced or Separated Older Women.

BACKGROUND AND OBJECTIVE: Sexually transmitted diseases (STDs) are increasing among older adults concomitant with a rise in divorce after the age of 50 years. The objective of this study was to examine the effectiveness of a web-based human immunodeficiency virus (HIV)/STD risk reduction intervention for divorced and separated women aged more than 50 years. RESEARCH DESIGN AND METHODS: Two hundred nineteen divorced or separated women, aged 50 years and older, participated in 60-day randomized pre-post control group study. Recruitment occurred via health agencies in Boston and Columbia, SC, and Craigslist advertisements placed in Boston, Columbia, Charleston, New York City, Washington DC, Baltimore, Chicago, Atlanta, Orlando, and Miami. RESULTS: Intervention group reported greater intention to practice safe sex compared to the control group (B = .55, p = .03). Intention to practice safe sex differed by perceived stress (B = .15, p = .005), with no difference between control and intervention groups for those with low levels of stress. For high levels of stress, intervention group reported greater intention to practice safe sex compared to controls. Sexual risk was reduced by 6.10 points (SD: 1.10), and self-efficacy for sexual discussion was increased by 2.65 points (SD: 0.56) in the intervention group. DISCUSSION AND IMPLICATIONS: A web-based intervention represents a promising tool to reduce HIV/STD risk among older women. Offering HIV/STD education in the context of other topics of interest to at-risk older women, such as divorce, may solve the problem of at-risk older women not seeking out prevention information due to lack of awareness of their heightened risk.

Feasibility of a Texting Intervention to Improve Medication Adherence Among Older HIV+ African Americans: A Mixed-Method Pilot Study.

Antiretroviral therapy (ART) is the primary treatment for HIV, and adherence to it is crucial to addressing health disparities. Approximately half of individuals in the United States living with HIV are African Americans, and those over 45 years of age are more likely to die early from HIV/AIDS than their White counterparts. This mixed-method pilot study evaluated the feasibility of a text-based mobile phone intervention designed to improve ART adherence among older African Americans with HIV. Feasibility was assessed via implementation, participant adherence, acceptability, and satisfaction, as well as short-term impact on medication adherence, adherence-related self-efficacy, and positive affect. The intervention utilized pill reminder, motivational, and health educational texts. Participants (N = 21) ranged in age from 50 to 68 years. Outcomes were evaluated via quantitative results from self-report measures and qualitative data from four focus groups. Attrition to the study was 100%. After 8 weeks, participants reported statistically significant improvements in medication adherence, but not in self-efficacy or affect scores. Qualitative findings highlight the psychologically supportive potential of the intervention, challenges to adherence, as well as suggestions for improvement. The study demonstrates that a text messaging intervention may be feasible for older African Americans with HIV, and helpful in supporting ART adherence.

Pretravel Health Preparation of International Travelers: Results From the Boston Area Travel Medicine Network.

OBJECTIVE: To inform future interventions for advising travelers. PATIENTS AND METHODS: We prospectively collected data on travelers seen at the Boston Area Travel Medicine Network, a Boston area research collaboration of 5 travel medicine clinics. Data from 15,440 travelers were collected from March 1, 2008, through July 31, 2010. We compared traveler and trip characteristics and differences in demographic characteristics and travel plans across the 5 clinics, including an analysis of pretravel preparations for certain high-risk destinations. RESULTS: More than half of the 15,440 travelers were female (8730 [56.5]), and 72.4% (10,528 of 14,545) were white; the median age was 34 years, and 29.4% of travelers (3077 of 10,483) were seen less than 2 weeks before their departure date. Substantial variation in racial background, purpose of travel, and destination risk existed across the 5 clinics. For example, the proportion of travelers visiting friends and relatives ranged from 7.6% (184 of 2436) to 39.0% (1029 of 2639) (18.7% [2876 of 15,360] overall), and the percentage of travelers to areas with malaria risk ranged from 23.7% (333 of 1403) to 52.0% (1306 of 2512). Although most clinics were likely to have prescribed certain vaccines for high-risk destinations (eg, yellow fever for Ghana travel), there was wide variability in influenza vaccine use for China travel. CONCLUSION: Substantial differences in clinic populations can occur within a single metropolitan area, highlighting why individual physicians and travel clinics need to understand the specific needs of the travelers they serve in addition to general travel medicine.

Dengue Virus Seroconversion in Travelers to Dengue-Endemic Areas.

We conducted a prospective study to measure dengue virus (DENV) antibody seroconversion in travelers to dengue-endemic areas. Travelers seen in the Boston Area Travel Medicine Network planning to visit dengue-endemic countries for ≥ 2 weeks were enrolled from 2009 to 2010. Pre- and post-travel blood samples and questionnaires were collected. Post-travel sera were tested for anti-DENV IgG by indirect IgG enzyme-linked immunosorbent assay (ELISA) and anti-DENV IgM by capture IgM ELISA. Participants with positive post-travel anti-DENV IgG or IgM were tested for pre-travel anti-DENV IgG and IgM; they were excluded from the seroconversion calculation if either pre-travel anti-DENV IgG or IgM were positive. Paired sera and questionnaires were collected for 62% (589/955) of enrolled travelers. Most participants were 19-64 years of age, female, and white. The most common purposes of travel were tourism and visiting friends and relatives; most trips were to Asia or Africa. Median length of travel was 21 days. DENV antibody seroconversion by either anti-DENV IgM or IgG ELISA was 2.9-6.8%; lower range percent excluded potential false-positive anti-DENV IgG due to receipt of yellow fever or Japanese encephalitis vaccines at enrollment; upper range percent excluded proven false-positive anti-DENV IgM. Eighteen percent of those with seroconversion reported dengue-like symptoms. Seroconversion was documented for travel to Africa as well as countries and regions known to be highly dengue endemic (India, Brazil, southeast Asia). Given widespread risk of dengue, travel medicine counseling should include information on risk of dengue in endemic areas and advice on preventing insect bites and seeking prompt medical attention for febrile illness.

Health literacy in HIV treatment: accurate understanding of key biological treatment principles is not required for good ART adherence.

Findings on the relationship between health literacy and outcomes in HIV have been inconsistent. Health literacy has previously been operationalized as general functional literacy, but has not included content knowledge about HIV disease and treatment. Semi-structured interviews with people living with HIV in 2 U.S. cities, including questions about the etiology, pathophysiology and treatment of HIV. We compared responses to biomedical conceptions. The 32 respondents were demographically diverse. Although most understood that HIV degrades the immune system, none could explain the nature of a virus, or the mechanism of antiretroviral (ARV) drug action. Fewer than half accurately reported that it is desirable to have a high CD4+ cell count and low viral load. A minority understood the concept of drug resistance. While most believed that strict adherence to ARV regimens was important to maintain health, three believed that periodic treatment interruption was beneficial, and three believed they should not take ARVs when they used alcohol or illicit drugs. Respondents generally had very limited, and often inaccurate biomedical understanding of HIV disease. Most reported good regimen adherence but did not have any mechanistic rationale for it. The failure to find a consistent relationship between health literacy and ARV adherence may be largely because most people simply follow their doctors' instructions, without the need for deep understanding.

Knowledge, attitudes, and practices of US practitioners who provide pre-travel advice.

BACKGROUND: As international travel increases, many health care professionals are being asked to provide pre-travel advice. We designed an anonymous web-based survey to assess the extent to which primary care providers (PCPs) provide travel medicine advice and how their understanding and delivery of itinerary-specific advice and management compare with that of travel medicine specialists. METHODS: We surveyed randomly selected US PCPs registered in the Pri-Med Institute (now pmiCME) database and US travel medicine specialists from the International Society of Travel Medicine (ISTM), American Society of Tropical Medicine and Hygiene (ASTMH), and Centers for Disease Control and Prevention (CDC) yellow fever (YF) vaccine provider mailing lists. SAS software (SAS Institute, Cary, NC, USA) was used for all analyses. RESULTS: Of 14,932 e-mails sent to valid e-mail addresses, 902 yielded complete or partially completed surveys (6.0% response rate). Eighty percent of respondents personally provided pre-travel advice (95% of travel medicine specialists versus 73% of PCPs). About two thirds of PCPs (68%) providing pre-travel consultations saw <50 travelers per year whereas 30% of travel medicine specialists saw <50 travelers per year. More travel medicine specialists (59%) than PCPs (18%) saw >500 travelers per year. Familiarity with travel-specific vaccines (YF, Japanese encephalitis) and provision of written educational materials increased as volume of travelers increased. Familiarity with antimalarial side effects and malaria resistance patterns, and knowledge scores based on brief pre-travel scenarios were higher in travel medicine specialists, ASTMH or ISTM certificate holders, and respondents who saw more pre-travel patients. CONCLUSIONS: Many PCP survey participants provided pre-travel advice, but most saw few travelers. Volume of travelers and holding an ASTMH or ISTM certificate had the greatest influence on knowledge of travel medicine and provision of appropriate advice and recommendations. Creating easily accessible travel medicine education programs for US providers from a wide range of disciplines is needed to improve the management of travelers.

Cognitive and field testing of a new set of medication adherence self-report items for HIV care.

We conducted four rounds of cognitive testing of self-report items that included 66 sociodemographically diverse participants, then field tested the three best items from the cognitive testing in a clinic waiting room (N = 351) and in an online social networking site for men who have sex with men (N = 6,485). As part of the online survey we conducted a randomized assessment of two versions of the adherence questionnaire-one which asked about adherence to a specific antiretroviral medication, and a second which asked about adherence to their "HIV medicines" as a group. Participants were better able to respond using adjectival and adverbial scales than visual analogue or percent items. The internal consistency reliability of the three item adherence scale was 0.89. Mean scores for the two different versions of the online survey were similar (91.0 vs. 90.2, p < 0.05), suggesting that it is not necessary, in general, to ask about individual medications in an antiretroviral therapy regimen when attempting to describe overall adherence.

International travel by persons with medical comorbidities: understanding risks and providing advice.

OBJECTIVE: To describe the medical conditions, travel plans, counseling, and medications prescribed for high-risk international travelers. PATIENTS AND METHODS: This cross-sectional study was conducted from March 1, 2008, through July 31, 2010, in 5 clinics in the greater Boston area. We assessed all travelers seen for pretravel care and compared demographic characteristics, travel plans, pretravel counseling, and interventions for healthy and high-risk travelers (as defined by medical history or pregnancy). RESULTS: Of 15,440 travelers, 2769 (17.9%) were high-risk; 644 of 2769 (23.3%) were immunocompromised travelers, 2056 (74.3%) had medical comorbidities, and 69 (2.5%) were pregnant women. The median age of high-risk travelers was 47 years compared with 32 years for healthy travelers (P=.0001). High-risk travelers visited the clinic a median of 25 days (range, 10-44 days) before departure. Overall, 2562 (93.9%) of high-risk travelers visited countries with medium or high risk of typhoid fever, 2340 (85.7%) visited malaria-risk countries, and 624 (22.8%) visited yellow fever-endemic countries. Of travelers to yellow fever-endemic countries, 8 of 23 (34.8%) pregnant women and 64 of 144 (44.4%) immunocompromised travelers received yellow fever vaccine. Of eligible high-risk travelers, 11 of 76 (14.5%) received a pneumococcal vaccine, 213 of 640 (33.3%) influenza vaccine, and 956 of 2681 (35.7%) either tetanus-diphtheria or tetanus-diphtheria-pertussis vaccine. CONCLUSION: High-risk travelers made up nearly 20% of patients in these travel clinics, and they mostly traveled to destinations with malaria and typhoid risk. For health care professionals caring for travelers with underlying medical problems, providing appropriate travel counseling and making vaccine decisions, such as for yellow fever, are complex. Travelers with complicated medical histories may warrant evaluation by an experienced travel medicine specialist.

Prevalence of dengue virus infection in US travelers who have lived in or traveled to dengue-endemic countries.

BACKGROUND: Dengue virus (DENV) infections may occur in travelers. OBJECTIVES: To determine prevalence of anti-DENV IgG antibody in travelers who lived in or visited dengue-endemic countries and to describe risk factors and characteristics associated with infection and subsequent anti-DENV IgG antibody presence. METHODS: Participants were enrolled from travel clinics of the Boston Area Travel Medicine Network from August 2008 through June 2009. Demographic information, trip duration, travel history, and a blood sample were collected. Serum samples were tested for anti-DENV IgG antibody by indirect IgG enzyme-linked immunosorbent assay (ELISA), and antibody-mediated virus neutralization by plaque reduction neutralization test (PRNT) for anti-DENV IgG antibody-positive and selected negative samples. Participants were stratified into group 1: born in dengue-endemic countries; group 2: born in nonendemic countries but lived continuously for ≥1 year in a dengue-endemic country; group 3: born in nonendemic countries and traveled to a dengue-endemic country for ≥2 weeks but <1 year. RESULTS: Six hundred travelers were enrolled. Anti-DENV IgG antibody was identified in 113 (19%) when tested by ELISA (51% in group 1, 40% in group 2, and 6.9% in group 3) and in 71 (12%) by PRNT (42% primary monotypic and 58% heterotypic reactive responses). Sensitivity and specificity of the ELISA based on PRNT results were 85% to 100% and 79% to 94%, assuming up to 15% misclassification of ELISA negative results. Presence of anti-DENV IgG antibody by ELISA was associated with years lived in dengue-endemic countries and birthplace in the Caribbean for group 1, receipt of Japanese encephalitis vaccine in group 3, and self-reported history of dengue in all three groups. CONCLUSIONS: Nineteen percent of participants who were born, lived in, or traveled to dengue-endemic countries had anti-DENV IgG antibody by ELISA; 12% had antibodies by PRNT, 85% of whom had no history of dengue. Presence of DENV antibodies was associated with years lived in dengue-endemic countries and self-reported history of dengue.

Acceptability of hypothetical dengue vaccines among travelers.

BACKGROUND: Dengue viruses have spread widely in recent decades and cause tens of millions of infections mostly in tropical and subtropical areas. Vaccine candidates are being studied aggressively and may be ready for licensure soon. METHODS: We surveyed patients with past or upcoming travel to dengue-endemic countries to assess rates and determinants of acceptance for four hypothetical dengue vaccines with variable efficacy and adverse event (AE) profiles. Acceptance ratios were calculated for vaccines with varied efficacy and AE risk. RESULTS: Acceptance of the four hypothetical vaccines ranged from 54% for the vaccine with lower efficacy and serious AE risk to 95% for the vaccine with higher efficacy and minor AE risk. Given equal efficacy, vaccines with lower AE risk were better accepted than those with higher AE risk; given equivalent AE risk, vaccines with higher efficacy were better accepted than those with lower efficacy. History of Japanese encephalitis vaccination was associated with lower vaccine acceptance for one of the hypothetical vaccines. US-born travelers were more likely than non-US born travelers to accept a vaccine with 75% efficacy and a risk of minor AEs (p = 0.003). Compared with North American-born travelers, Asian- and African-born travelers were less likely to accept both vaccines with 75% efficacy. CONCLUSIONS: Most travelers would accept a safe and efficacious dengue vaccine if one were available. Travelers valued fewer potential AEs over increased vaccine efficacy.

Hepatitis B screening in US travelers seen at the Boston area travel medicine network.

BACKGROUND: Persons born in countries with hepatitis B surface antigen (HBsAg) prevalence ≥2% have increased risk for unrecognized hepatitis B virus (HBV) infection. Testing at pre-travel consultations is a strategy to identify previously undiagnosed HBV infections. Using records of travelers seen at the Boston Area Travel Medicine Network (BATMN) sites, we assessed how these travel clinics currently assess HBV status, describe test results, and describe characteristics of those tested and immunized for HBV. METHODS: Demographic data and trip information were collected for all travelers seen at the BATMN sites from June 2008 through July 2010. Proportions of those tested for HBV were determined, and differences between those tested and not tested were analyzed. RESULTS: Among 13,732 travelers enrolled during the study period, 2,134 (16%) were born in HBV-risk countries (HBsAg prevalence ≥2%); 532/2134 (25%) had previous HBV test results and 230 (11%) had tests performed at the travel clinic visit. Past results showed that 33/453 (7.3%) were HBV-infected (HBsAg+), 252/481 (52.4%) were immune (anti-HBs+, HBsAg-), 164/303 (54.1%) were susceptible (anti-HBs-, HBsAg-, anti-HBc-), and 38/314 (12.1%) had possible HBV exposure (anti-HBc+, HBsAg-, anti-HBs-). Among 230 travelers tested during the travel clinic visit, 7/213 (3.3%) were HBV-infected, 95/218 (43.6%) were immune, 106/179 (59.2%) were susceptible, and 10/182 (5.5%) had possible HBV exposure. CONCLUSION: The travel clinic offers an opportunity to capture, identify, and educate infected persons unaware of their infection, educate those with known results, and initiate preventive action (eg, vaccination) for those still susceptible.

Treatment acceptance and adherence in HIV disease: patient identity and the perceived impact of physician-patient communication.

Studies have found that physician-patient relationships and communication quality are related to medication adherence and outcomes in HIV care. Few qualitative studies exist of how people living with HIV experience clinical communication about their self-care behavior. Eight focus groups with people living with HIV in two US cities were conducted. Participants responded to a detailed discussion guide and to reenactments of actual physician-patient dialogue about antiretroviral adherence. The 82 participants were diverse in age, sex, and ethnicity. Most had been living with HIV for many years and had stable relationships with providers. They appreciated providers who knew and cared about their personal lives, who were clear and direct about instructions, and who were accessible. Most had struggled to overcome addiction, emotional turmoil, and/or denial before gaining control over their lives and becoming adherent to medications. They made little or no causal attribution for their transformation to any outside agency, including their providers. They generally saw medication adherence as a function of autonomous motivation. Successful coping with HIV with its prevalent behavioral comorbidities, stigma, and other challenges requires a transformation of identity and internalization of motivation to maintain health. Effective methods for clinicians to support such development are needed.

Health challenges of young travelers visiting friends and relatives compared with those traveling for other purposes.

BACKGROUND: The study objective was to assess differences in demographics and travel health challenges between youths ≤18 years old traveling internationally to visit friends and relatives (VFRs) compared with those traveling for other purposes (non-VFR). METHODS: The Boston Area Travel Medicine Network consists of 5 clinics collecting anonymous data from international pretravel consultations. Data on all travelers ≤18 years of age seen between January 2008 and July 2010 were used. VFRs were compared with non-VFRs on demographics, primary language, trip characteristics, travel vaccinations administered, malaria prophylaxis and antidiarrheal medications prescribed. RESULTS: Thirty-five percent (610/1731) listed VFR as their purpose of travel. Almost half of VFRs were <5 (46%) years old compared with <5% of non-VFRs. Thirty percent of US-born VFRs with foreign-born parents were ≤2 years compared with 4% of foreign-born VFR children and 3% of US-born VFRs with US-born parents. More VFRs than non-VFRs planned travel to countries that were yellow fever holoendemic, had malaria risk and were high-risk for typhoid (44% versus 20%, 39% versus 12%, 25% versus 15%, P < 0.01). VFRs were less likely than non-VFRs to be prescribed atovaquone-proguanil (adjusted prevalence ratio = 0.57, confidence interval = 0.44-0.72) and to have had an antidiarrheal medication prescribed (adjusted prevalence ratio = 0.68, confidence interval = 0.60-0.75). CONCLUSIONS: To reduce travel-related morbidity, healthcare providers should be prepared to give travel advice to parents of VFR infants and children, particularly those US-born VFRs with foreign-born parents, regarding antimalarial and antidiarrheal medications and preventing yellow fever, malaria and typhoid.

Tigecycline-induced acute pancreatitis: case report and literature review.

Tigecycline is a broad-spectrum antimicrobial agent structurally related to minocycline. Pancreatitis has been associated with the tetracycline class of antibiotics and concerns about tigecycline-induced acute pancreatitis have recently been raised. We describe a 69-year-old female who received tigecycline for treatment of a complicated skin and skin-structure infection. Following 7 days of tigecycline she developed severe abdominal pain and elevated pancreatic enzymes suggesting acute pancreatitis. According to the Naranjo adverse drug reaction probability scale, tigecycline was the probable cause of her acute pancreatitis. Clinicians should be aware of this potential adverse effect of tigecycline. We recommend that clinicians monitor patients for signs and symptoms of pancreatitis, including abdominal pain, during treatment with tigecycline.