Prevalence of Anal Human Papillomavirus Infection and Anal High-Grade Squamous Intraepithelial Lesions Among Men Who Have Sex With Men 50 Years and Older Living With or Without HIV.

BACKGROUND: Anal cancer is caused by human papillomavirus (HPV), particularly HPV-16, and is preceded by anal high-grade squamous intraepithelial lesions (HSILs). The incidence of anal cancer is highest among men who have sex with men (MSM) living with HIV (MSMLWH) and increases with age. However, most previous studies of anal HPV infection and anal HSIL were performed on men under 50 years old, and relatively little is known about HSIL among older MSMLWH or MSM not living with HIV (MSM-Not-LWH). SETTING: We enrolled MSM who were aged 50+ during 2018-2022 in San Francisco, CA. METHODS: One hundred twenty-nine MSMLWH and 109 MSM-not-LWH participated. All participants had anal HPV DNA testing (Atila Biosystems) and high-resolution anoscopy with a biopsy of visible lesions. RESULTS: Among MSMLWH, 47% had anal HSIL, 19% had HPV-16, and 51% had other oncogenic anal HPV types (excluding HPV-16). Among MSM-not-LWH, 37% had anal HSIL, 22% had HPV-16, and 34% had other oncogenic anal HPV types. Increasing age was not statistically associated with prevalent HSIL, HPV-16, or other oncogenic HPV infections in MSMLWH or MSM-not-LWH. HPV-16 (odds ratio: 45.1, 95% confidence interval: 15.8-129); other oncogenic HPV types (odds ratio: 5.95, 95% confidence interval: 2.74-12.9) were associated with increased odds of anal HSIL, adjusted for age, income, education, and HIV status. CONCLUSION: The prevalence of oncogenic anal HPV, anal HPV-16, and anal HSIL remains very high in older MSMLWH and MSM-not-LWH. With recent evidence showing that treating anal HSIL prevents anal cancer, MSM aged 50+ should be considered for anal cancer screening.

Somos Esenciales, We are Essential: Our Mental Health is Essential. Research for, by and of the Latinx Community in the Mission District during the Pandemic.

We are Latinx immigrants and children of Latinx immigrants. We provided emergency volunteer services at the Mission Food Bank during the pandemic to provide food assistance to low-income families in the Mission District and the city of San Francisco. In March 2021, we were invited to lead a research project that we call "We are Essential". Here we share our process and a few of our findings on the mental health of San Francisco's Latinx community during the pandemic, with a focus on our children and youth. A full report of our findings will be published in 2024.

Transoceanic pathogen transfer in the age of sail and steam.

In the centuries following Christopher Columbus's 1492 voyage to the Americas, transoceanic travel opened unprecedented pathways in global pathogen circulation. Yet no biological transfer is a single, discrete event. We use mathematical modeling to quantify historical risk of shipborne pathogen introduction, exploring the respective contributions of journey time, ship size, population susceptibility, transmission intensity, density dependence, and pathogen biology. We contextualize our results using port arrivals data from San Francisco, 1850 to 1852, and from a selection of historically significant voyages, 1492 to 1918. We offer numerical estimates of introduction risk across historically realistic ranges of journey time and ship population size, and show that both steam travel and shipping regimes that involved frequent, large-scale movement of people substantially increased risk of transoceanic pathogen circulation.

The University of California San Francisco Adult Longitudinal Post-Treatment Diffuse Glioma MRI Dataset.

Supplemental material is available for this article.

Use of a Large Language Model to Assess Clinical Acuity of Adults in the Emergency Department.

Importance: The introduction of large language models (LLMs), such as Generative Pre-trained Transformer 4 (GPT-4; OpenAI), has generated significant interest in health care, yet studies evaluating their performance in a clinical setting are lacking. Determination of clinical acuity, a measure of a patient's illness severity and level of required medical attention, is one of the foundational elements of medical reasoning in emergency medicine. Objective: To determine whether an LLM can accurately assess clinical acuity in the emergency department (ED). Design, Setting, and Participants: This cross-sectional study identified all adult ED visits from January 1, 2012, to January 17, 2023, at the University of California, San Francisco, with a documented Emergency Severity Index (ESI) acuity level (immediate, emergent, urgent, less urgent, or nonurgent) and with a corresponding ED physician note. A sample of 10 000 pairs of ED visits with nonequivalent ESI scores, balanced for each of the 10 possible pairs of 5 ESI scores, was selected at random. Exposure: The potential of the LLM to classify acuity levels of patients in the ED based on the ESI across 10 000 patient pairs. Using deidentified clinical text, the LLM was queried to identify the patient with a higher-acuity presentation within each pair based on the patients' clinical history. An earlier LLM was queried to allow comparison with this model. Main Outcomes and Measures: Accuracy score was calculated to evaluate the performance of both LLMs across the 10 000-pair sample. A 500-pair subsample was manually classified by a physician reviewer to compare performance between the LLMs and human classification. Results: From a total of 251 401 adult ED visits, a balanced sample of 10 000 patient pairs was created wherein each pair comprised patients with disparate ESI acuity scores. Across this sample, the LLM correctly inferred the patient with higher acuity for 8940 of 10 000 pairs (accuracy, 0.89 [95% CI, 0.89-0.90]). Performance of the comparator LLM (accuracy, 0.84 [95% CI, 0.83-0.84]) was below that of its successor. Among the 500-pair subsample that was also manually classified, LLM performance (accuracy, 0.88 [95% CI, 0.86-0.91]) was comparable with that of the physician reviewer (accuracy, 0.86 [95% CI, 0.83-0.89]). Conclusions and Relevance: In this cross-sectional study of 10 000 pairs of ED visits, the LLM accurately identified the patient with higher acuity when given pairs of presenting histories extracted from patients' first ED documentation. These findings suggest that the integration of an LLM into ED workflows could enhance triage processes while maintaining triage quality and warrants further investigation.

Innovation and adaptation: The rise of a fentanyl smoking culture in San Francisco.

BACKGROUND: Illicitly manufactured fentanyls and stimulants are implicated in the escalating US mortality from drug overdose. San Francisco, California (SF) has seen declining fentanyl injection while smoking has increased. Beliefs and behaviors surrounding this development are not well understood. METHODS: The study used rapid ethnography to explore fentanyl and methamphetamine use in SF. The team conducted semi-structured interviews (n = 34) with participants recruited from syringe service programs. Video-recorded smoking sequences (n = 12), photography and daily field notes supplemented interview data. RESULTS: Difficulty injecting and fear of overdose motivated transitions from injecting to smoking. Fentanyl was extremely cheap-$10/gram-with variability in quality. Foil was the most commonly used smoking material but glass bubbles, bongs and dabbing devices were also popular. No reliable visible methods for determining fentanyl quality existed, however, participants could gauge potency upon inhalation, and developed techniques to regulate dosage. Several participants reported at least hourly use, some reporting one or more grams of daily fentanyl consumption. Smoking was also very social, with people sharing equipment, drugs and information. Participants raised concerns about hygiene and overdose risk to others arising from shared equipment. Reportedly potent fentanyl 'residue' accumulated on smoking materials and was commonly shared/traded/stolen or consumed accidentally with diverse preferences for its use. CONCLUSION: Our data highlight fentanyl residue as a new overdose risk with potential mismatch between the potency of the residual drug and the recipient's tolerance. Further, large doses of fentanyl are being consumed (estimated at approximately 50 mg of pure fentanyl/day). Smoking fentanyl has potential health benefits over injecting and may be protective against overdose, but substantial uncertainty exists. However, SF overdose mortality hit a record high in 2023. Recommendations to reduce fentanyl smoking overdose risks through pacing, greater awareness of dosages consumed and checking tolerance of residue recipients are potentially viable interventions deserving further exploration.

Environmental Justice and Systems Analysis for Air Quality Planning in the Port of Oakland in California.

Many frontline communities experience adverse health impacts from living in proximity to high-polluting industrial sources. Securing environmental justice requires, in part, a comprehensive set of quantitative indicators. We incorporate environmental justice and life-cycle thinking into air quality planning to assess fine particulate matter (PM2.5) exposure and monetized damages from operating and maintaining the Port of Oakland, a major multimodal marine port located in the historically marginalized West Oakland community in the San Francisco Bay Area. The exposure domain for the assessment is the entire San Francisco Bay Area, a home to more than 7.5 million people. Of the more than 14 sources included in the emissions inventory, emissions from large container ships, or ocean-going vessels (OGVs), dominate the PM2.5 intake, and supply chain sources (material production and delivery, fuel production) represent between 3.5% and 7.5% of annual intake. Exposure damages, which model the costs from excess mortalities resulting from exposure from the study's emission sources, range from USD 100 to 270 million per annum. Variations in damages are due to the use of different concentration-response relationships, hazard ratios, and Port resurfacing area assumptions. Racial and income-based exposure disparities are stark. The Black population and people within the lowest income quintile are 2.2 and 1.9 times more disproportionately exposed, respectively, to the Port's pollution sources relative to the general population. Mitigation efforts focused on electrifying in-port trucking operations yield modest reductions (3.5%) compared to strategies that prioritize emission reductions from OGVs and commercial harbor craft operations (8.7-55%). Our recommendations emphasize that a systems-based approach is critical for identifying all relevant emission sources and mitigation strategies for improving equity in civil infrastructure systems.

Conceptual framework for preterm birth review in San Francisco.

Preterm birth persists as a leading cause of infant mortality and morbidity despite decades of intervention effort. Intervention null effects may reflect failure to account for social determinants of health (SDH) or jointly acting risk factors. In some communities, persistent preterm birth trends and disparities have been consistently associated with SDH such as race/ethnicity, zip code, and housing conditions. Health authorities recommend conceptual frameworks for targeted action on SDH and precision public health approaches for preterm birth prevention. We document San Francisco, California's experience identifying the need, rationale, methods, and pilot work for developing a conceptual framework for preterm birth review (PTBR) in San Francisco. The PTBR conceptual framework is intended to enable essential public health services in San Francisco that prevent a range of preterm birth phenotypes by guiding plans for data collection, hypothesis testing, analytical methods, reports, and intervention strategy. Key elements of the PTBR conceptual framework are described including, 10 domains of SDH, 9 domains at the whole person level, such as lived experience and health behaviors, 8 domains at the within-person level, such as biomarkers and clinical measures, 18 preterm birth phenotypes, and the interconnections between domains. Assumptions for the PTBR conceptual framework were supported by a scoping review of literature on SDH effects on preterm birth, health authority consensus reports, and PTBR pilot data. Researcher and health authority interest in each of the domains warrants the framework to prompt systematic consideration of variables in each proposed domain. PTBR pilot data, illustrated in heatmaps, confirm the feasibility of data collection based on the framework, prevalence of co-occurring risk factors, potential for joint effects on specific preterm birth phenotypes, and opportunity for intervention to block SDH effects on preterm birth. The proposed PTBR conceptual framework has practical implications for specifying (1) population groups at risk, (2) grids or heatmap visualization of risk factors, (3) multi-level analyses, and (4) multi-component intervention design in terms of patterns of co-occurring risk factors. Lessons learned about PTBR data collection logistics, variable choice, and data management will be incorporated into future work to build PTBR infrastructure based on the PTBR conceptual framework.

Soft Tissue Reconstruction After Sacral Neoplasm Resection: The University of California San Francisco Experience.

PURPOSE: Resection of sacral neoplasms such as chordoma and chondrosarcoma with subsequent reconstruction of large soft tissue defects is a complex multidisciplinary process. Radiotherapy and prior abdominal surgery play a role in reconstructive planning; however, there is no consensus on how to maximize outcomes. In this study, we present our institution's experience with the reconstructive surgical management of this unique patient population. METHODS: We conducted a retrospective review of patients who underwent reconstruction after resection of primary or recurrent pelvic chordoma or chondrosarcoma between 2002 and 2019. Surgical details, hospital stay, and postoperative outcomes were assessed. Patients were divided into 3 groups for comparison based on reconstruction technique: gluteal-based flaps, vertical rectus abdominus myocutaneous (VRAM) flaps, and locoregional fasciocutaneous flaps. RESULTS: Twenty-eight patients (17 males, 11 females), with mean age of 62 years (range, 34-86 years), were reviewed. Twenty-two patients (78.6%) received gluteal-based flaps, 3 patients (10.7%) received VRAM flaps, and 3 patients (10.7%) were reconstructed with locoregional fasciocutaneous flaps. Patients in the VRAM group were significantly more likely to have undergone total sacrectomy (P < 0.01) in a 2-stage operation (P < 0.01) compared with patients in the other 2 groups. Patients in the VRAM group also had a significantly greater average number of reoperations (2 ± 3.5, P = 0.04) and length of stay (29.7 ± 20.4 days, P = 0.01) compared with the 2 other groups. The overall minor and major wound complication rates were 17.9% and 42.9%, respectively, with 17.9% of patients experiencing at least 1 infection or seroma. There was no association between prior abdominal surgery, surgical stages, or radiation therapy and an increased risk of wound complications. CONCLUSIONS: Vertical rectus abdominus myocutaneous flaps are a more suitable option for patients with larger defects after total sacrectomy via 2-staged anteroposterior resections, whereas gluteal myocutaneous flaps are effective options for posterior-only resections. For patients with small- to moderate-sized defects, local fasciocutaneous flaps are a less invasive and effective option. Paraspinous flaps may be used in combination with other techniques to provide additional bulk and coverage for especially long postresection wounds. Furthermore, mesh is a useful adjunct for any reconstruction aimed at protecting against intra-abdominal complications.

"Hate has chipped away at my sense of security": A survey study of the impacts of anti-Asian hate on the health of older Asians.

BACKGROUND: Since the beginning of the COVID-19 pandemic, older Asians have experienced a rise in racism and discrimination based on their race and ethnicity. This study examines how anti-Asian hate impacts older Asians' mental, social, and physical health. METHODS: From March 18, 2022 to January 24, 2023, we conducted a cross-sectional survey study of community-dwelling Asian/Asian American adults aged ≥50 years from the San Francisco Bay Area. Measures included perceptions of anti-Asian hate; direct encounters with hate incidents; indirect experiences with hate incidents (e.g. knowing a friend who was a victim); reports of anxiety, depression, loneliness, and changes in daily activities; ways to address these issues; and discussions with clinicians about hate incidents. RESULTS: Of the 293 older Asians, 158 (54%) were Vietnamese and 97 (33%) Chinese. Eighty-five (29%) participants were direct victims of anti-Asian hate, 112 (38%) reported anxiety, 105 (36%) reported depression, 161 (55%) reported loneliness, and 142 (48%) reported decreased daily activities. Compared with those who were "not-at-all" to "moderately" worried about hate incidents, participants who were "very" to "extremely" worried experienced heightened anxiety (42% versus 16%), loneliness (30% versus 14%), and changes in daily activities (66% versus 31%), p < 0.01 for all. Most participants (72%) felt comfortable discussing hate incidents with clinicians; however, only 31 (11%) reported that a clinician had talked with them about these incidents. CONCLUSION: Both directly and indirectly, anti-Asian hate negatively impacts older Asians' mental, social, and physical health. Clinicians have a role in addressing the health impacts of anti-Asian hate.

How do we understand the value of drug checking as a component of harm reduction services? A qualitative exploration of client and provider perspectives.

BACKGROUND: Mortality related to opioid overdose in the U.S. has risen sharply in the past decade. In California, opioid overdose death rates more than tripled from 2018 to 2021, and deaths from synthetic opioids such as fentanyl increased more than seven times in those three years alone. Heightened attention to this crisis has attracted funding and programming opportunities for prevention and harm reduction interventions. Drug checking services offer people who use drugs the opportunity to test the chemical content of their own supply, but are not widely used in North America. We report on qualitative data from providers and clients of harm reduction and drug checking services, to explore how these services are used, experienced, and considered. METHODS: We conducted in-depth semi-structured key informant interviews across two samples of drug checking stakeholders: "clients" (individuals who use drugs and receive harm reduction services) and "providers" (subject matter experts and those providing clinical and harm reduction services to people who use drugs). Provider interviews were conducted via Zoom from June-November, 2022. Client interviews were conducted in person in San Francisco over a one-week period in November 2022. Data were analyzed following the tenets of thematic analysis. RESULTS: We found that the value of drug checking includes but extends well beyond overdose prevention. Participants discussed ways that drug checking can fill a regulatory vacuum, serve as a tool of informal market regulation at the community level, and empower public health surveillance systems and clinical response. We present our findings within three key themes: (1) the role of drug checking in overdose prevention; (2) benefits to the overall agency, health, and wellbeing of people who use drugs; and (3) impacts of drug checking services at the community and systems levels. CONCLUSION: This study contributes to growing evidence of the effectiveness of drug checking services in mitigating risks associated with substance use, including overdose, through enabling people who use and sell drugs to test their own supply. It further contributes to discussions around the utility of drug checking and harm reduction, in order to inform legislation and funding allocation.

Antigenic Characterization of Novel Human Norovirus GII.4 Variants San Francisco 2017 and Hong Kong 2019.

Norovirus is a major cause of acute gastroenteritis; GII.4 is the predominant strain in humans. Recently, 2 new GII.4 variants, Hong Kong 2019 and San Francisco 2017, were reported. Characterization using GII.4 monoclonal antibodies and serum demonstrated different antigenic profiles for the new variants compared with historical variants.

First record of a structural infestation by the bird flea Dasypsyllus gallinulae perpinnatus (Siphonaptera: Ceratophyllidae) in the San Francisco Bay Area, California, USA.

Herein we present the first-known case report of a structural infestation by the bird flea (Dasypsyllus gallinulae perpinnatus) (Dale 1878) in the United States. In March of 2023, the San Mateo County Mosquito and Vector Control District was contacted by a resident in South San Francisco, CA who reported the presence of fleas inside their condominium. The resident had 2 dogs who were on oral flea medication and only 1 inhabitant out of 4 reported receiving flea bites. The front walkway, backyard, and garage were flagged and a small passerine nest was removed from a fire alarm bell in the front walkway. A total of 31 fleas (13 males, 18 females) were collected by flagging from the front entryway underneath the nest. One female flea was collected from the backyard, and 20 (9 males, 11 females) were collected by the resident from inside the house. A total of 387 fleas (163 males, 224 females) were collected from the nest of a small passerine. All life stages (egg, larvae, pupae, and adult) were observed within the nest. Additional parasites in the nest included bird lice and larval western black-legged ticks (Ixodes pacificus, Cooley and Kohls 1943). Research should be conducted into whether bird fleas are capable of transmitting avian pathogens to humans and this information should be communicated to healthcare providers as part of a One Health approach. Additionally, resources to aid in species-level flea identification should be made accessible to pest control operators as this will aid the development of targeted treatments as part of an integrated pest management plan.

An Historical Case Study of Trans Exclusion and Empowerment: Implications for Transgender Older Adults and Aging.

Transgender older adults have a long history of exclusion that shapes current experiences with social services. However, scant gerontological research uses archival data, which can provide critical context for service providers. Moreover, sparse research examines how exclusion can be a catalyst for change that social workers could leverage. Empowerment theory provides a theoretical tool to explain how this is possible. This multidisciplinary case study blends community member interviews and archival data to answer this question: How did exclusion shape empowerment and social change for transgender Americans? This study focuses on the events before and after the Compton's Cafeteria Riot, one of the first acts of LGBTQIA+ collective resistance that led to new services for and by transgender Americans. Data reveal how exclusion facilitated the emergence of collective empowerment among transgender women and queer youth in San Francisco. Archival data shows how exclusion preceded self-efficacy, critical consciousness, involvement with similar others, acquisition of new skills, and ultimately action to eliminate social, economic, and political barriers and power imbalances. This study provides both empirical and theoretical tools to contribute new data and perspectives on trans exclusion and empowerment and its implications for social workers serving transgender older adults.

Overdose from Unintentional Fentanyl Use when Intending to Use a Non-opioid Substance: An Analysis of Medically Attended Opioid Overdose Events.

Fentanyl-mixed and substituted heroin is well-documented, but less is known about unintentional fentanyl use among people using stimulants. To determine the prevalence of and racial and ethnic disparities in unintentional fentanyl use among people experiencing a medically attended opioid overdose, we reviewed 448 suspected non-fatal overdose cases attended by a community paramedic overdose response team in San Francisco from June to September 2022. We applied a case definition for opioid overdose to paramedic records and abstracted data on intended substance use prior to overdose. Among events meeting case criteria with data on intended substance use, intentional opioid use was reported by 57.3%, 98.0% of whom intended to use fentanyl. No intentional opioid use was reported by 42.7%, with most intending to use stimulants (72.6%), including methamphetamine and cocaine. No intentional opioid use was reported by 58.5% of Black, 52.4% of Latinx, and 28.8% of White individuals (p = 0.021), and by 57.6% of women and 39.5% of men (p = 0.061). These findings suggest that unintentional fentanyl use among people without opioid tolerance may cause a significant proportion of opioid overdoses in San Francisco. While intentional fentanyl use might be underreported, the magnitude of self-reported unintentional use merits further investigation to confirm this phenomenon, explore mechanisms of use and disparities by race and ethnicity, and deploy targeted overdose prevention interventions.

Association Between Coronary Assessment in Heart Failure and Clinical Outcomes Within a Safety-Net Setting Using a Target Trial Emulation Observational Design.

BACKGROUND: Ischemic cardiomyopathy is the leading cause of heart failure (HF). Most patients do not undergo coronary assessment after HF diagnosis. There are no randomized clinical trials of coronary assessment after HF diagnosis. METHODS: Using an electronic health record cohort of all individuals with HF within the San Francisco Health Network from 2001 to 2019, we identified factors associated with coronary assessment. Then, we studied the association of coronary assessment within 30 days of HF diagnosis with all-cause mortality and a composite of mortality and emergent angiography using a target trial emulation observational comparative-effectiveness approach. Target trial emulation is an approach to causal inference based on creating a hypothetical randomized clinical trial protocol and using observational data to emulate the protocol. We used propensity scores for covariate adjustment. We used national death records to improve the ascertainment of mortality and included falsification end points for the cause of death. RESULTS: Among 14 829 individuals with HF (median, 62 years old; 5855 [40%] women), 3987 (26.9%) ever completed coronary assessment, with 2467/13 301 (18.5%) with unknown coronary artery disease status at HF diagnosis assessed. Women, older individuals, and people without stable housing were less likely to complete coronary assessment. Among 5972 eligible persons of whom 627 underwent early elective coronary assessment, coronary assessment was associated with lower mortality (hazard ratio, 0.84 [95% CI, 0.72-0.97]; P=0.025), reduced risk of the composite outcome (hazard ratio, 0.86 [95% CI, 0.73-1.00]), higher rates of revascularization (odds ratio, 7.6 [95% CI, 5.4-10.6]), and higher use of medical therapy (odds ratio, 2.5 [95% CI, 1.7-3.6]), but not the falsification end points. CONCLUSIONS: In a safety-net population, disparities in coronary assessment after HF diagnosis are not fully explained by coronary artery disease risk factors. Early coronary assessment is associated with improved HF outcomes possibly related to higher rates of revascularization and guideline-directed medical therapy but with low certainty that this finding is not attributable to unmeasured confounding.

Acceptability of Long-Acting Injectable Antiretroviral Therapy Among People with HIV Receiving Care at Three Ryan White Funded Clinics in the United States.

Understanding the acceptability of long-acting injectable antiretroviral therapy (LAI-ART) among people with HIV (PWH), especially priority populations, is essential for effective implementation. We conducted semi-structured interviews with patients in three Ryan White-funded HIV clinics in San Francisco, Chicago, and Atlanta. We employed maximal variation sampling across age, gender, race, ethnicity, and time living with HIV and oversampled for individuals with suboptimal clinical engagement. An 8-step hybrid deductive and inductive thematic analysis approach guided data analysis. Between August 2020 and July 2021, we conducted 72 interviews. Median age was 46 years; 28% were ciswomen, 7% transwomen, 44% Black/African-American and 35% Latinx, 43% endorsed a psychiatric diagnosis, 35% were experiencing homelessness/unstable housing, and 10% had recent substance use. Approximately 24% were sub-optimally engaged in care. We observed a spectrum of LAI-ART acceptability, ranging from enthusiasm to hesitancy to rejection. We also characterized four emergent orientations towards LAI-ART: innovator, pragmatist, deliberator, and skeptic. Overall, the majority of participants expressed favorable initial reactions towards LAI-ART. Most approached LAI-ART pragmatically, but acceptability was not static, often increasing over the course of the interview. Participants considered their HIV providers as essential for affirming personal relevance. HIV stigma, privacy concerns, and medical mistrust had varied impacts, sometimes facilitating and other times hindering personal relevance. These findings held across priority populations, specifically young adults, cis/trans women, racial/ethnic minorities, and individuals with suboptimal clinical engagement. Further research is needed to explore the transition from hypothetical acceptance to uptake and to confirm the actual benefits and drawbacks of this treatment.

RESUMEN: La aceptabilidad de la terapia antirretroviral inyectable de acción prolongada (LAI-ART, por su sigla en inglés) entre personas con VIH es esencial para una implementación efectiva. Durante el periodo de agosto de 2020 a julio de 2021, realizamos 72 entrevistas semiestructuradas con personas con VIH en clínicas públicas ubicadas en San Francisco, Chicago y Atlanta. Un análisis temático, tanto deductivo como inductivo, guio nuestra investigación. Observamos un espectro de aceptabilidad de LAI-ART que va desde el entusiasmo hasta la indecisión y el rechazo. También caracterizamos cuatro orientaciones actitudinales emergentes hacia LAI-ART: innovadora, pragmática, deliberativa y escéptica. Los participantes también señalaron la importancia de sus proveedores de VIH para validar su relevancia personal. El estigma asociado al VIH, preocupaciones sobre la privacidad y desconfianza en el sistema médico tuvieron diversos impactos, a veces facilitando y otras veces obstaculizando la relevancia personal. Entre las poblaciones prioritarias del estudio, los resultados fueron consistentes.

The surge of bromazolam-related fatalities replacing other novel designer benzodiazepines-related fatalities in San Francisco.

BACKGROUND AND AIM: Bromazolam, a novel designer benzodiazepine (NBD), exhibits potent sedative, hypnotic and anxiolytic effects, raising concerns regarding its potential for misuse and fatal outcomes, particularly when combined with opioids such as fentanyl. Despite limited documented fatalities globally, its use poses a significant threat, exacerbated by under-reporting and a lack of routine testing. This study analysed NBD-related deaths in a major US city over a 4-year period. METHODS: Analysis of accidental overdose deaths involving NBDs in San Francisco, CA, USA from 2020 to 2023, was performed utilizing medico-legal death investigations including comprehensive forensic toxicology, pathology and demographic information. San Francisco conducts thorough investigations into all non-natural and sudden unexpected deaths, including routine alcohol and drug testing of decedents under its jurisdiction, including etizolam, flualprazolam, flubromazolam and bromazolam analysis. RESULTS: There was a sudden surge in bromazolam-related deaths, with 44 fatalities documented in 2023, contrasting with relatively fewer deaths related to other NBDs. Bromazolam fatalities frequently involved co-ingestion with opioids, primarily fentanyl, and stimulants such as methamphetamine and cocaine. Demographic characteristics indicated a predominance of males, with a significant proportion lacking fixed addresses. Blood concentrations of bromazolam increased during the study period, suggesting heightened availability and/or purity in the community. CONCLUSION: There was a surge in bromazolam-related deaths during 2023 in San Francisco, CA, USA, contrasting with relatively stable numbers of deaths associated with other NBDs over the preceding years. The findings underscore the urgency for enhanced death investigation, testing and reporting to facilitate targeted harm reduction strategies for individuals at risk of bromazolam-related morbidity and mortality.