Inconsistencies in Overdose Suicide Death Investigation Practice and Potential Remedies Using Technology: A Centers for Disease Control and Prevention Consultation Meeting Summary.

INTRODUCTION: It is widely accepted that suicides-which account for more than 47 500 deaths per year in the United States-are undercounted by 10% to 30%, partially due to incomplete death scene investigations (DSI) and varying burden-of-proof standards across jurisdictions. This may result in the misclassification of overdose-related suicides as accidents or undetermined intent. METHODS: Virtual and in-person meetings were held with suicidologists and DSI experts from five states (Spring-Summer 2017) to explore how features of a hypothetical electronic DSI tool may help address these challenges. RESULTS: Participants envisioned a mobile DSI application for cell phones, tablets, or laptop computers. Features for systematic information collection, scene description, and guiding key informant interviews were perceived as useful for less-experienced investigators. DISCUSSION: Wide adoption may be challenging due to differences in DSI standards, practices, costs, data privacy and security, and system integration needs. However, technological tools that support consistent and complete DSIs could strengthen the information needed to accurately identify overdose suicides.

The Association Between Sports- or Physical Activity-Related Concussions and Suicidality Among US High School Students, 2017.

BACKGROUND: This study examined the association between sports- or physical activity-related concussions and having seriously considered attempting suicide, made a suicide plan, or attempted suicide (ie, suicidality), and tested potential moderators of the association. HYPOTHESIS: Risk factors such as persistent feelings of sadness or hopelessness, low academic grades, few hours of sleep, and current alcohol or marijuana use will increase the odds of suicidality among those who self-reported sports- or physical activity-related concussions, while protective factors such as physical activity and having played on a sports team will decrease the odds. STUDY DESIGN: Cross-sectional study. LEVEL OF EVIDENCE: Level 4. METHODS: This study used data from the 2017 Youth Risk Behavior Survey, a biennial, school-based, nationally representative survey of US students in grade levels 9 to 12 (N = 14,765). Logistic regression models examined associations between self-reported sports- or physical activity-related concussions and suicidality among the students, and whether physical activity, having played on a sports team, persistent feelings of sadness or hopelessness, academic grades, hours of sleep, or current alcohol or marijuana use moderated those associations. RESULTS: Sports- or physical activity-related concussions were found to be associated with suicidality. The associations remained significant in models that adjusted for demographic characteristics, and they did not appear to be moderated by physical activity, having played on sports team, academic grades, or sleep. CONCLUSIONS: Given the findings of this study and others, health care providers are advised to ask students who have experienced a concussion about their emotional well-being as part of their symptom-based assessment, using validated, age- appropriate concussion symptom scales. Comprehensively assessing students who have experienced a sports- or physical activity-related concussion for persistent feelings of sadness or hopelessness may alert providers to thoughts of suicidal ideation and will allow for earlier intervention. CLINICAL RELEVANCE: If thoughts of suicide are discovered among adolescents with a concussion, or if other risk factors are observed, referrals to medical and mental health providers for a more comprehensive assessment may be warranted.

Circumcision status and HIV infection among MSM: reanalysis of a Phase III HIV vaccine clinical trial.

OBJECTIVE: Determine whether male circumcision would be effective in reducing HIV transmission among men who have sex with men (MSM). DESIGN: Retrospective analysis of the VAXGen VAX004 HIV vaccine clinical trial data. METHODS: Survival analysis was used to associate time to HIV infection with multiple predictors. Unprotected insertive and receptive anal sex predictors were highly correlated, thus separate models were run. RESULTS: Four thousand eight hundred and eighty-nine participants were included in this reanalysis; 86.1% were circumcised. Three hundred and forty-two (7.0%) men became infected during the study; 87.4% were circumcised. Controlling for demographic characteristics and risk behaviors, in the model that included unprotected insertive anal sex, being uncircumcised was not associated with incident HIV infection [adjusted hazards ratio (AHR) = 0.97, confidence interval (CI) = 0.56-1.68]. Furthermore, while having unprotected insertive (AHR = 2.25, CI = 1.72-2.93) or receptive (AHR = 3.45, CI = 2.58-4.61) anal sex with an HIV-positive partner were associated with HIV infection, the associations between HIV incidence and the interaction between being uncircumcised and reporting unprotected insertive (AHR = 1.78, CI = 0.90-3.53) or receptive (AHR = 1.26, CI = 0.62-2.57) anal sex with an HIV-positive partner were not statistically significant. Of the study visits when a participant reported unprotected insertive anal sex with an HIV-positive partner, HIV infection among circumcised men was reported in 3.16% of the visits (80/2532) and among uncircumcised men in 3.93% of the visits (14/356) [relative risk (RR) = 0.80, CI = 0.46-1.39]. CONCLUSIONS: Among men who reported unprotected insertive anal sex with HIV-positive partners, being uncircumcised did not confer a statistically significant increase in HIV infection risk. Additional studies with more incident HIV infections or that include a larger proportion of uncircumcised men may provide a more definitive result.

HIV testing outside of the study among men who have sex with men participating in an HIV vaccine efficacy trial.

OBJECTIVES: Participants who obtain an HIV test outside of an HIV vaccine efficacy trial could potentially unblind themselves which could result in differential behavior change and loss to follow-up based on assignment status. In a reanalysis of the VaxGen VAX004 data, the objectives were to determine: 1) the proportion of participants who were tested for HIV outside of the study (despite instructions not to do this) and reasons why; 2) demographic and risk factors associated with reported testing outside of the study; and 3) if outside testing was related to participant loss to follow-up. METHODS: Analyses were restricted to men who have sex with men (MSM) who completed a survey at one or more annual visits in a randomized, double-blind, placebo-controlled efficacy trial of a bivalent rgp 120 vaccine conducted from 1998-2002. A generalized linear mixture model assessed associations with outside testing. RESULTS: Despite instructions to the contrary, 16.9% (791/4670) of MSM reported being tested for HIV outside of the study, with the top two reasons being a) medical provider request (28.1%) and b) insurance requirement (17.1%). Increased odds of self-reported outside testing was associated with site location, reporting one or more sexually transmitted infections (STIs), joining the trial because of the belief that participation might confer some protection against HIV infection, engaging in unprotected anal sex, and being lost to follow-up. Decreased odds of self-reported outside testing was associated with perceived study arm assignment to vaccine or uncertainty about study arm assignment compared to placebo. CONCLUSIONS: To avoid biases such as differential risk behavior and loss to follow-up based on perceived assignment status, initiating additional procedures to reduce the likelihood of outside testing will be important to assure the validity of future study results.

Repeat HIV testing, risk behaviors, and HIV seroconversion among young men who have sex with men: a call to monitor and improve the practice of prevention.

OBJECTIVES: We compared recent risk behaviors and HIV seroconversion among young men who have sex with men (MSM) who were first-time, infrequent, and repeat HIV testers. METHODS: Male adolescents and young men aged 15 to 22 years were randomly sampled, interviewed, counseled, and tested for HIV at 194 gay-identified venues in seven U.S. cities from 1994 through 1998. Analyses were restricted to MSM who reported having never tested or last tested HIV-negative. RESULTS: Of 3430 participants, 36% tested for the first time, 39% had tested infrequently (one or two times), and 26% had tested repeatedly (> or = three times). Compared with first-time testers, repeat testers were more likely to report recent risk behaviors and to acquire HIV (7% versus 4%). Over 75% of repeat testers who seroconverted acquired HIV within 1 year of their last test. Compared with repeat testers, first-time testers reported similar use of health care but delayed testing for nearly 2 additional years after initiating risk. CONCLUSIONS: Many young MSM soon acquire HIV after repeated use of HIV counseling and testing services. Providers must strengthen practices to identify, counsel, and test young MSM and provide enhanced behavioral interventions for those with persistent risks.