Testing and Treatment Interventions in Community Settings Key to Controlling a Recent Human Immunodeficiency Virus Outbreak Among People Who Inject Drugs in Glasgow: A Modeling Study.

BACKGROUND: A human immunodeficiency virus (HIV) outbreak was identified among people who inject drugs (PWID) in Glasgow in 2015, with >150 diagnoses by the end of 2019. The outbreak response involved scaling up HIV testing and improving HIV treatment initiation and retention. METHODS: We parameterized and calibrated a dynamic, deterministic model of HIV transmission among PWID in Glasgow to epidemiological data. We use this model to evaluate HIV testing and treatment interventions. We present results in terms of relative changes in HIV prevalence, incidence, and cases averted. RESULTS: If the improvements in both testing and treatment had not occurred, we predict that HIV prevalence would have reached 17.8% (95% credible interval [CrI], 14.1%-22.6%) by the beginning of 2020, compared to 5.9% (95% CrI, 4.7%-7.4%) with the improvements. If the improvements had been made on detection of the outbreak in 2015, we predict that peak incidence would have been 26.2% (95% CrI, 8.8%-49.3%) lower and 62.7% (95% CrI, 43.6%-76.6%) of the outbreak cases could have been averted. The outbreak could have been avoided if the improvements had already been in place. CONCLUSIONS: Our modeling suggests that the HIV testing and treatment interventions successfully brought the HIV outbreak in Glasgow under control by the beginning of 2020.

Impact of the COVID-19 Pandemic on HIV Test Uptake Among People Who Inject Drugs in the Context of an HIV Outbreak.

Glasgow, Scotland's largest city, has been experiencing an HIV outbreak among people who inject drugs (PWID) since 2015. A key focus of the public health response has been to increase HIV testing among those at risk of infection. Our aim was to assess the impact of COVID-19 on HIV testing among PWID in Glasgow. HIV test uptake in the last 12 months was quantified among: (1) PWID recruited in six Needle Exchange Surveillance Initiative (NESI) surveys (n = 6110); linked laboratory data for (2) people prescribed opioid agonist therapy (OAT) (n = 14,527) and (3) people hospitalised for an injecting-related hospital admission (IRHA) (n = 12,621) across four time periods: pre-outbreak (2010-2014); early-outbreak (2015-2016); ongoing-outbreak (2017-2019); and COVID-19 (2020-June 21). From the pre to ongoing period, HIV testing increased: the highest among people recruited in NESI (from 28% to 56%) and on OAT (from 17% to 54%) while the lowest was among people with an IRHA (from 15% to 42%). From the ongoing to the COVID-19 period, HIV testing decreased markedly among people prescribed OAT, from 54% to 37% (aOR 0.50, 95% CI 0.48-0.53), but increased marginally among people with an IRHA from 42% to 47% (aOR 1.19, 95% CI 1.08-1.31). In conclusion, progress in increasing testing in response to the HIV outbreak has been eroded by COVID-19. Adoption of a linked data approach could be warranted in other settings to inform efforts to eliminate HIV transmission.

Understanding what patients and physicians need to improve their decision-making about antenatal corticosteroids in late preterm gestation: a qualitative framework analysis.

BACKGROUND: It is unclear whether the benefits of administration of antenatal corticosteroids in late preterm gestation outweigh its harms. We sought to understand whether patients and physicians need increased support to decide whether to administer antenatal corticosteroids in late preterm gestation, and their informational needs and preferences for decision-making roles related to this intervention; we also wanted to know if creation of a decision-support tool would be useful. METHODS: We conducted individual, semistructured interviews with pregnant people, obstetricians and pediatricians in Vancouver, Canada, in 2019. Using a qualitative framework analysis method, we coded, charted and interpreted interview transcripts into categories that formed an analytical framework. RESULTS: We included 20 pregnant participants, 10 obstetricians and 10 pediatricians. We organized codes into the following categories: informational needs to decide whether to administer antenatal corticosteroids; preferences for decision-making roles regarding this treatment; the need for support to make this treatment decision; and the preferred format and content of a decision-support tool. Pregnant participants wanted to be involved in decision-making about antenatal corticosteroids in late preterm gestation. They wanted information on the medication, respiratory distress, hypoglycemia, parent-neonate bonding and long-term neurodevelopment. There was variation in physician counselling practices, and in how patients and physicians perceived the balance of treatment harms and benefits. Responses suggested a decision-support tool may be useful. Participants desired clear descriptions of risk magnitude and uncertainty. INTERPRETATION: Pregnant people and physicians would likely benefit from increased support to consider the harms and benefits of antenatal corticosteroids in late preterm gestation. Creation of a decision-support tool may be useful.

IMplementing Predictive Analytics towards efficient COPD Treatments (IMPACT): protocol for a stepped-wedge cluster randomized impact study.

INTRODUCTION: Personalized disease management informed by quantitative risk prediction has the potential to improve patient care and outcomes. The integration of risk prediction into clinical workflow should be informed by the experiences and preferences of stakeholders, and the impact of such integration should be evaluated in prospective comparative studies. The objectives of the IMplementing Predictive Analytics towards efficient chronic obstructive pulmonary disease (COPD) treatments (IMPACT) study are to integrate an exacerbation risk prediction tool into routine care and to determine its impact on prescription appropriateness (primary outcome), medication adherence, quality of life, exacerbation rates, and sex and gender disparities in COPD care (secondary outcomes). METHODS: IMPACT will be conducted in two phases. Phase 1 will include the systematic and user-centered development of two decision support tools: (1) a decision tool for pulmonologists called the ACCEPT decision intervention (ADI), which combines risk prediction from the previously developed Acute COPD Exacerbation Prediction Tool with treatment algorithms recommended by the Canadian Thoracic Society's COPD pharmacotherapy guidelines, and (2) an information pamphlet for COPD patients (patient tool), tailored to their prescribed medication, clinical needs, and lung function. In phase 2, we will conduct a stepped-wedge cluster randomized controlled trial in two outpatient respiratory clinics to evaluate the impact of the decision support tools on quality of care and patient outcomes. Clusters will be practicing pulmonologists (n ≥ 24), who will progressively switch to the intervention over 18 months. At the end of the study, a qualitative process evaluation will be carried out to determine the barriers and enablers of uptake of the tools. DISCUSSION: The IMPACT study coincides with a planned harmonization of electronic health record systems across tertiary care centers in British Columbia, Canada. The harmonization of these systems combined with IMPACT's implementation-oriented design and partnership with stakeholders will facilitate integration of the tools into routine care, if the results of the proposed study reveal positive association with improvement in the process and outcomes of clinical care. The process evaluation at the end of the trial will inform subsequent design iterations before largescale implementation. TRIAL REGISTRATION: NCT05309356.

Using a patient-centred composite endpoint in a secondary analysis of the Control of Hypertension in Pregnancy Study (CHIPS) Trial.

BACKGROUND: Clinical trials commonly use multiple endpoints to measure the impact of an intervention. While this improves the comprehensiveness of outcomes, it can make trial results difficult to interpret. We examined the impact of integrating patient weights into a composite endpoint on the interpretation of Control of Hypertension in Pregnancy Study (CHIPS) Trial results. METHODS: Outcome weights were extracted from a previous patient preferences study in pregnancy hypertension (N = 183 women) which identified (i) seven outcomes most important to women (taking medication, severe hypertension, pre-eclampsia, blood transfusion, Caesarean, delivery < 34 weeks, and baby born smaller-than-expected) and (ii) three preference subgroups: (1) 'equal prioritizers', 62%; (2) 'early delivery avoiders', 23%; and (3) 'medication minimizers', 14%. Outcome weights from the preference subgroups were integrated with CHIPS data for the seven outcomes identified in the preference study. A weighted composite score was derived for each participant by multiplying the preference weight for each outcome by the binary outcome if it occurred. Analyses considered equal weights and those from the preference subgroups. The mean composite scores were compared between trial arms (t-tests). RESULTS: Composite scores were similar between trial arms with the use of equal weights or those of subgroup (1) (95% confidence intervals [CIs]: - 0.03, 0.02; p > 0.50 for each). 'Tight' control was superior when using subgroup (2) weights (95% CIs: 0.002, 0.07; p = 0.03), and 'less-tight' control was superior when using subgroup (3) weights (95% CIs: - 0.11, - 0.04; p < 0.01). CONCLUSIONS: Evidence-based recommendations for 'tight' control are consistent with most women's preferences, but for a sixth of women, 'less-tight' control is more preference consistent. Depending on patient preferences, a single trial may support different interventions. Future trials should specify component weights to improve interpretation. TRIAL REGISTRATION: ClinicalTrials.gov NCT01192412.

Measuring the preferences of injectable opioid agonist treatment (iOAT) clients: Development of a person-centered scale (best-worst scaling).

BACKGROUND: Injectable opioid agonist treatment (iOAT) is effective for opioid use disorder (OUD), yet little is known about client preferences for accessing iOAT (e.g., with diacetylmorphine, hydromorphone, buprenorphine, fentanyl, etc.). Best-worst scaling (BWS) is a preference elicitation method from health economics that has never been applied to addiction care broadly, or iOAT specifically. We describe the stages of developing a BWS scale that assesses iOAT clients' treatment delivery preferences to inform program planning and maximize healthcare efficiency. METHODS: We underwent several steps to reveal the relevant attributes/levels and design the scale structure. An initial list of potential attributes and levels was established from a literature review and prior qualitative data. Then, we conducted semi-structured interviews and focus groups with clients (n=21) on their iOAT preferences to confirm the attributes and prioritize/include new ones. Next, we conducted semi-structured interviews and focus groups with iOAT experts and stakeholders to receive their input on the draft list of attributes and levels. A BWS profile case design was piloted with iOAT clients (n=18) from different sites during a think aloud interview. After several rounds of revisions, the final version was tested by iOAT clients (n=2) before the scale was launched. RESULTS: We developed a person-centered scale that assesses current and former iOAT clients' most and least wanted aspects of iOAT delivery. The final version yielded 7 unique attributes: choice of medication, choice of dose, convenience, location & space, scheduling & routines, staff & training, and types of services offered. CONCLUSION: This scale can help expand iOAT programs in a way that is person-centered, rapid, and affordable. The methodology is a guide for other regions with similar populations who aim to develop strong quantitative methodologies that prioritize client collaboration.

Feasibility of Testing Client Preferences for Accessing Injectable Opioid Agonist Treatment (iOAT): A Pilot Study.

Purpose: Injectable opioid agonist treatment (iOAT) is an effective treatment for opioid use disorder (OUD). To our knowledge, no research has systematically studied client preferences for accessing iOAT. Incorporating preferences could help meet the heterogenous needs of clients and make addiction care more person-centred. This paper presents a pilot study of a best-worst scaling (BWS) preference elicitation survey that aimed to assess if the survey was feasible and accessible for our population and to test that the survey could gather sound data that would suit our planned analyses. Patients and Methods: Current and former iOAT clients (n = 18) completed a BWS survey supported by an interviewer using a think-aloud approach. The survey was administered on PowerPoint, and responses and contextual field notes were recorded manually. Think-aloud audio was recorded on Audacity. Results: Clients' feedback fell into five categories: framing of the task, accessibility, conceptualization of attributes and levels, formatting, and behaviour predicting questions. Survey repetitiveness was the most consistent feedback. The data simulation showed that 100 responses should provide an adequate sample size. Conclusion: This pilot demonstrates the type of analysis that can be done with BWS in our population, suggests that such analysis is feasible, and highlights the importance of the interviewer and participant working side-by-side throughout the task.

Estimation of a Canadian preference-based scoring algorithm for the Veterans RAND 12-Item Health Survey: a population survey using a discrete-choice experiment.

BACKGROUND: The Veterans RAND 12-Item Health Survey (VR-12) is a generic patient-reported outcome measure derived from the widely used 36- and 12-item Short Form Health Surveys. We aimed to estimate a Canadian preference-based scoring algorithm for the VR-12, enabling the derivation of health utility values for generating quality-adjusted life years (QALYs). METHODS: We conducted a discrete-choice experiment in a sample of the Canadian population in January and February 2019. Participants - recruited from a consumer research panel - completed an online survey, in English or French, that included 11 discrete-choice questions, each comprising 2 health profiles. We defined the health profiles using 8 VR-12 items and a duration attribute. Using conditional logit regressions, where each level of the respective VR-12 items was interacted with duration, we applied the coefficients to estimate health utility values interpretable on a scale of 0 (dead) to 1 (full health). Negative values reflect states considered worse than dead. RESULTS: A total of 3380 individuals completed the survey. Of these, 1688 (49.9%) were females, and 3101 (91.7%) completed the English version of the survey. Across all models, "feel downhearted and blue all of the time" and "pain interferes with your normal work extremely" were associated with the largest decrements in health utility. Excluding the 685 respondents (20.3%) who provided inconsistent responses had a negligible effect on the results. The recommended model, weighted to match population demographics, had health utility values ranging from -0.589 to 1.000. INTERPRETATION: Health utility values that reflect the preferences of the Canadian population can now be derived from responses to the VR-12. These values can be used to generate QALYs in future analyses.

Evaluation of an inner city HIV pre-exposure prophylaxis service tailored to the needs of people who inject drugs.

OBJECTIVES: HIV prevention strategies including pre-exposure prophylaxis (PrEP) must reach all in need to achieve elimination of transmission by 2030. Mainstream provision may inadvertently exclude key populations. Incidence of HIV in people who inject drugs (PWID) in Glasgow, Scotland's largest city, is increasing, partly due to sexual transmission. Scotland provides publicly funded oral PrEP for individuals at sexual risk of HIV through sexual health services; however, uptake by PWID has been negligible. We developed a tailored outreach PrEP service based in the local homeless health centre. We used active case finding, flexibility of assessment location, supervised community daily dispensing and active follow-up to optimise uptake and adherence. We describe a two-year service evaluation. METHODS: We reviewed the case records of all PWID identified by the outreach team as being at higher risk of sexual acquisition for whom PrEP was considered between November 2018 and November 2020. Evaluation focused on PrEP uptake, adherence and monitoring. We conducted a descriptive statistical analysis. RESULTS: Of 41 PWID assessed as eligible, 32 (78.0%) commenced PrEP. The proportion of PrEP-covered days was 3320/3400 days (97.6%); 31/32 (96.9%) had regular HIV serology monitoring. The service was feasible to run, but it relied on outreach provision and liaison with other services. DISCUSSION: Tailored PrEP services can reach PWID effectively. Uptake and adherence were high but the model was resource-intensive. Appropriately tailored PrEP delivery may be required to meet the needs of this and other key populations who experience barriers to accessing mainstream services.

Recurrent Vulvovaginal Candidiasis: a Dynamic Interkingdom Biofilm Disease of Candida and Lactobacillus.

Despite the strikingly high worldwide prevalence of vulvovaginal candidiasis (VVC), treatment options for recurrent VVC (RVVC) remain limited, with many women experiencing failed clinical treatment with frontline azoles. Further, the cause of onset and recurrence of disease is largely unknown, with few studies identifying potential mechanisms of treatment failure. This study aimed to assess a panel of clinical samples from healthy women and those with RVVC to investigate the influence of Candida, the vaginal microbiome, and how their interaction influences disease pathology. 16S rRNA sequencing characterized disease by a reduction in specific health-associated Lactobacillus species, such as Lactobacillus crispatus, coupled with an increase in Lactobacillus iners. In vitro analysis showed that Candida albicans clinical isolates are capable of heterogeneous biofilm formation, and we found the presence of hyphae and C. albicans aggregates in vaginal lavage fluid. Additionally, the ability of Lactobacillus to inhibit C. albicans biofilm formation and biofilm-related gene expression was demonstrated. Using RNA sequencing technology, we were able to identify a possible mechanism by which L. crispatus may contribute to re-establishing a healthy vaginal environment through amino acid acquisition from C. albicans. This study highlights the potential formation and impact of Candida biofilms in RVVC. Additionally, it suggests that RVVC is not entirely due to an arbitrary switch in C. albicans from commensal to pathogen and that understanding interactions between this yeast and vaginal Lactobacillus species may be crucial to elucidating the cause of RVVC and developing appropriate therapies. IMPORTANCE RVVC is a significant burden, both economically and for women's health, but its prevalence is poorly documented globally due to the levels of self-treatment. Identifying triggers for development and recurrence of VVC and the pathogenesis of the microbes involved could considerably improve prevention and treatment options for women with recurrent, azole-resistant cases. This study therefore aimed to examine the interkingdom dynamics from healthy women and those with RVVC using next-generation sequencing techniques and to further investigate the molecular interactions between C. albicans and L. crispatus in a relevant biofilm coculture system.

Preliminary testing of a patient decision aid for patients with relapsing-remitting multiple sclerosis.

BACKGROUND: Multiple first-line disease modifying therapies (DMTs) are available for relapsing-remitting multiple sclerosis (RRMS), each with different characteristics. We developed an interactive patient decision aid (PtDA) to promote informed shared decision-making (SDM). OBJECTIVE: To test the preliminary effectiveness of the PtDA in participants with RRMS. METHODS: Knowledge, and decisional conflict were measured pre- and post- implementation of the PtDA, SDM after the consultation, and 6-month treatment patterns were observed. Differences in scores were analyzed using descriptive statistics and paired t-tests. Qualitative interviews with patients and neurologists were analyzed using thematic analysis. RESULTS: 52 participants were recruited: most were female (81%), 40 years of age or younger (62%), and had experienced MS for less than 5 years (56%). After participants used the PtDA, there was a significant improvement in decisional conflict (change = 1.00; p < 0.001) and knowledge (change = 2.15, p < 0.001). Nearly all patients wanted SDM, and 25 (56%) reported this occurred in their consult. Qualitative results suggested the PtDA supported both patients and neurologists in making decisions. CONCLUSION: This pilot study suggests that PtDA use helps RRMS patients and their clinician select a DMT. Future studies will assess the feasibility of implementation and the impact of the PtDA on timely DMT initiation and longer-term adherence.

Evaluation of the scale-up of HIV testing among people who inject drugs in Scotland in the context of an ongoing HIV outbreak.

BACKGROUND: A large outbreak of HIV among people who inject drugs (PWID) has been ongoing in Glasgow city centre (GCC), Scotland since early 2015. The outbreak is associated with high levels of homelessness, cocaine injecting and injecting in public places. A key component of the public health response was the scale-up of HIV testing in a range of services engaged with PWID. Our aims were to: 1) evaluate the extent of and change in HIV testing over the course of the outbreak and 2) examine factors associated with reporting an HIV test. METHODS: Self-report of an HIV test in the last 12 months was collected for 15,081 PWID interviewed in six national cross-sectional bio-behavioural surveys during 2008-2018. Multi-variate logistic regression was undertaken to determine trends in HIV testing by region of recruitment (GCC; rest of Glasgow; other Scottish city centres (SCC); and rest of Scotland) and outbreak period (pre: 2008-14; early: 2015-16; ongoing: 2017-18). RESULTS: HIV testing increased across all regions and was most pronounced in GCC comparing the ongoing (67%) to the pre-outbreak period (33%) (aOR=4.68, 95% CI 3.23 to 6.77, p<0.001). However, compared to other SCCs pre-outbreak (with 46% reporting testing), those recruited in GCC had a lower odds of HIV testing early outbreak (aOR=0.37, 95% CI 0.27 to 0.54, p<0.001) and more modest increased odds in the ongoing outbreak period (aOR=1.41, 95% CI 0.97 to 2.05, p=0.069). Among PWID recruited in the whole of Glasgow in the ongoing phase, reporting an HIV test was associated with injecting cocaine or in public places (aOR=2.20, 95% CI 1.53 to 3.17, p<0.001), receipt of methadone (aOR=1.48, 95% CI 1.01 to 2.17, p=0.042) and incarceration in the last year (aOR=1.72, 95% CI 1.18 to 2.51, p=0.004). CONCLUSIONS: Relatively low levels of HIV testing pre- and early-outbreak likely hindered efforts to control the spread of infection among PWID in Glasgow. Uptake has since increased with expansion of testing across multiple settings, particularly among those at high risk of infection. Further effort is needed to ensure the vast majority of PWID are regularly tested, not just in the epicentre of the outbreak but in other areas with low population prevalence of infection.

Understanding cancer survivors' reasons to medicate with cannabis: A qualitative study based on the theory of planned behavior.

BACKGROUND: Prior to nonmedical cannabis legalization in Canada, individuals were only able to access cannabis legally through licensed producers with medical authorization. Now with an additional legal access system designed for nonmedical purposes, it is unclear what factors influence cancer survivors' decisions to medicate or not medicate cannabis as a complementary therapy to alleviate their cancer symptoms. METHODS: We recruited cancer survivors via social media. Interested individuals were purposively sampled to ensure maximization in terms of age, sex, and province of residence. Constructs of the Theory of Planned Behavior were explored during the telephone interviews as participants described what influenced their decisions to medicate or not medicate cannabis to manage their symptoms. RESULTS: Interviews were conducted with 33 cancer survivors. All individuals believed that cannabis would manage their cancer symptoms. Those that chose to medicate with cannabis provided a variety of reasons, including that cannabis was a more natural alternative; that it reduced their overall number of prescription drugs; and that safer products had become available with the legalization of nonmedical cannabis. Some individuals also indicated that support from physicians and validation from family and friends were important in their decision to medicate with cannabis. Individuals who opted not to medicate with cannabis raised concerns about the lack of scientific evidence and/or possible dependency issues. Some also felt their physician's disapproval was a barrier to considering cannabis use. CONCLUSIONS: The findings revealed that recreational legalization made using cannabis appear safer and easier to access for some cancer survivors. However, physicians' censure of cannabis use for symptom management was a barrier for survivors considering its use.

Perspectives on pre-exposure prophylaxis for people who inject drugs in the context of an hiv outbreak: A qualitative study.

BACKGROUND: There is an ongoing HIV outbreak amongst people who inject drugs (PWID) in Glasgow, Scotland, and one response which has not yet been widely implemented is the provision of Pre-exposure prophylaxis (PrEP). PrEP is the use of HIV anti-retrovirals prior to HIV infection to provide a barrier to infection. This has been shown to be effective amongst various at-risk populations in preventing HIV spread. The present study aimed to explore views of PWID who might benefit from PrEP provision and Service Providers working with PWID to understand will to use PrEP and literacy of PrEP, contributing to the development of a PrEP service. METHODS: A qualitative approach was taken, with semi structured interviews conducted in Glasgow at two third sector service sites. 11 Service Providers and 21 PWID participated in the study. Data was analysed thematically. RESULTS: Participants, both PWID and Service Providers, were keen to engage with PrEP and perceived substantial potential benefits of PrEP for this population. Potential barriers to engagement were identified as a lack of health literacy, motivation, and self-ascribed risk, as well as the overwhelming unpredictability of substance use. Participants wanted PrEP to be provided within already existing structures, particularly community pharmacies, and for promotion and provision to involve peers. CONCLUSION: This sample reported willingness to engage with PrEP, and suggested there is a specific need amongst PWID for PrEP. However, PWID have specific lived experienced contexts and needs, and are burdened by social and economic marginalisation and inequality at every level. This contrasts them from other populations currently being provided with PrEP, and must be considered in the development of provision.

From Hospital to the Community: Redesigning the Human Immunodeficiency Virus (HIV) Clinical Service Model to Respond to an Outbreak of HIV Among People Who Inject Drugs.

An outbreak of human immunodeficiency virus (HIV) among people who inject drugs in Glasgow, Scotland started in 2014. We describe 156 cases over 5 years and evaluate the impact of clinical interventions using virological and phylogenetic analysis. We established (1) HIV services within homeless health facilities, including outreach nurses, and (2) antiretroviral therapy (ART) via community pharmacies. Implementation of the new model reduced time to ART initiation from 264 to 23 days and increased community viral load suppression rates to 86%. Phylogenetic analysis demonstrated that 2019 diagnoses were concentrated within a single network. Traditional HIV care models require adaptation for this highly complex population.

Patient Preferences and Decisional Needs When Choosing a Treatment Approach for Pregnancy Hypertension: A Stated Preference Study.

The Hypertension Canada 2018 clinical guidance for pregnancy hypertension recommends antihypertensive therapy for raised blood pressure in pregnancy to a target diastolic blood pressure (BP) of 85 mm Hg (ie, "tight" control). Although evidence shows this approach reduces the incidence of severe maternal hypertension without increasing risk to the baby, we do not know how pregnant women feel about this approach, particularly as they are generally medication averse. An online survey assessed pregnant women's preferences for management of pregnancy hypertension and explored decisional needs. The survey included information provision and knowledge assessment, a preference elicitation task, and a decisional needs assessment. Survey responses were analysed descriptively, by latent class analysis to identify treatment priority subgroups, and by logistic regression to assess predictors of treatment preference. For the 183 pregnant respondents, 3 treatment priority subgroups were identified, with most respondents expressing equal prioritization of treatment outcomes and components (eg, taking medication). Participants who preferred tight control (49%) were more often white (odds ratio [OR]: 2.38; 95% confidence interval [CI]: 1.18-4.55), with a university education/professional qualification (OR 1.95; 95% CI: 1.02-3.7), and had greater knowledge about pregnancy hypertension and pregnancy complications (OR 1.37; 95% CI: 1.15-1.65). Participants reported diverse decisional needs, but most preferred to make final treatment decisions themselves (70%), with (48%) or without (22%) physician input. The diversity of priorities, preferences, and decisional needs for management of pregnancy hypertension identified in this study emphasises the importance of an individualized approach to treatment recommendations.

Development and usability testing of a patient decision aid for newly diagnosed relapsing multiple sclerosis patients.

BACKGROUND: Multiple sclerosis (MS) patients often struggle with treatment decisions, in part due to the increasing number of approved disease modifying therapies, each with different characteristics, and also since physicians can struggle to identify which of these characteristics matter most to each individual patient. Decision uncertainty can contribute to late treatment initiation and treatment non-adherence-causes of 'undertreatment' in MS. An interactive online patient decision aid that informs patients of their options, considers their individual preferences and goals, and facilitates conversations with their physicians, could improve how patients with relapsing forms of MS make evidence-based treatment decisions. OBJECTIVE: To develop and evaluate a prototype patient decision aid (PtDA) for first-line disease modifying therapies for relapsing-remitting multiple sclerosis. METHODS: Informed by previous studies and International Patient Decision Aid Standards guidelines, a prototype PtDA was developed for patients with relapsing multiple sclerosis considering first line treatment. Patients with relapsing multiple sclerosis were recruited from the University of British Columbia's Multiple Sclerosis Clinic to participate in either an online survey or a focus group. Online survey participants completed the PtDA, followed by measures of acceptability, usability, and preparedness for decision-making, and provided general feedback. Focus group participants assessed usability of the revised PtDA. The analysis of qualitative and quantitative data led to improvements of the PtDA prototype. RESULTS: The prototype PtDA received high ratings for acceptability and usability, and after its use, participants reported high-levels of preparedness for decision-making. Analysis of all qualitative data identified three key themes: the need for credible information; the usefulness of the PtDA; and the importance of normalizing and sharing experiences. Nine content areas were identified for revision. Overall, participants found the PtDA to be a valuable tool for facilitating treatment decisions. CONCLUSIONS: This mixed methods study has led to the development of a PtDA that can support patients with RRMS as they make treatment decisions. Future studies will assess the feasibility of implementation and the impact of the PtDA on both the timely treatment initiation and longer-term adherence.

Re-emergence of HIV related to injecting drug use despite a comprehensive harm reduction environment: a cross-sectional analysis.

BACKGROUND: In 2015, an outbreak of HIV was identified among people who inject drugs (PWID) in the Greater Glasgow and Clyde (GGC) area of Scotland, an area which distributes more than 1 million needles and syringes per year. This is the largest such incident in the UK for 30 years. Here, we provide an epidemiological analysis of the impact of the outbreak on HIV prevalence trends in the population and the individual and environmental risk factors associated with infection. METHODS: Four cross-sectional, anonymous, bio-behavioural surveys of almost 4000 PWID attending services providing injecting equipment across GGC between 2011 and 2018 were analysed. Participants were recruited by trained independent interviewers and eligible if they had a history of injecting drug use, either current (within the past 6 months) or historical. Interviewers asked participants questions about demographics, behaviours, and service use and to give a dried blood spot sample that was tested anonymously for the presence of blood-borne viruses. Our primary outcome measure was HIV infection status, as determined by the dried blood spot sample. We removed duplicates and participants with missing data and used all remaining participants to examine trends in prevalence of HIV infection, risk behaviours, and intervention coverage. We then did multivariate analysis with adjusted and unadjusted logistic regression to determine individual and environmental factors associated with HIV infection. FINDINGS: The overall GGC sample comprised 3641 PWID; data from 2712 PWID were available for multivariate analysis after further removal of duplicate participants and missing data. Between 2011 and 2018, HIV prevalence in GGC rose from 0·1% (95% CI 0·0-0·6) to 4·8% (3·4-6·2) overall, and from 1·1% (0·2-6·2) to 10·8% (7·4-15·5) in Glasgow city centre. Over the same period, the prevalence of cocaine injecting in all individuals in GGC in our sample rose from 16% (129/805) to 50% (291/583) overall, and from 37% (26/70) to 77% (117/153) in Glasgow city centre. HIV infection was more likely among PWID who had participated in surveys after the start of the outbreak in 2014 (adjusted odds ratio 3·4, 95% CI 1·7-6·7; p=0·00052), been homeless in the past 6 months (3·0, 1·7-5·0; p<0·0001), had had more than five incarcerations since they first began injecting (2·1, 1·2-3·7; p=0·0098); and had injected cocaine within the past 6 months (6·7, 3·8-12·1; p<0·0001). Age (per 1-year increase) was also a significant factor (1·1, 1·0-1·1; p=0·0016) but sex was not (1·7, 0·9-3·2; p=0·083). INTERPRETATION: Despite high coverage of harm reduction interventions, Glasgow has experienced a rapid rise in prevalence of HIV among its PWID population, associated with homelessness, incarceration, and a major shift to injection of cocaine. Robust surveillance through regular HIV testing of high-risk populations is crucial to ensure outbreaks are detected and rapid responses are informed by the best available evidence. FUNDING: Health Protection Scotland.