Telemedicine became the primary mode of delivering care during the COVID-19 pandemic. We describe the impact of telemedicine on access to care for people with HIV (PWH) by comparing the proportion of ...PWH engaged in care prior to and during the COVID-19 pandemic.
We conducted an observational analysis of patients enrolled in the Johns Hopkins HIV Clinical Cohort, a single-center cohort of patients at an urban HIV subspecialty clinic affiliated with an academic center. Due to the COVID-19 pandemic, the clinic transitioned from in-person to mostly telemedicine visits. We compared patients receiving care in two time periods. The prepandemic period included 2010 people with at least one visit scheduled between 1 September 2019 and 15 March 2020. The pandemic period included 1929 people with at least one visit scheduled between 16 March 2020 and 30 September 2020. We determined the proportion of patients completing at least one of their scheduled visits during each period.
Visit completion increased significantly from 88% prepandemic to 91% during the pandemic (P = 0.008). Visit completion improved significantly for patients age 20-39 (82 to 92%, P < 0.001), women (86 to 93%, P < 0.001), Black patients (88 to 91%, P = 0.002) and patients with detectable viremia (77 to 85%, P = 0.06) during the pandemic. Only 29% of people who completed at least one telemedicine visit during the pandemic did so as a video (versus telephone) visit.
During the pandemic when care was widely delivered via telemedicine, visit completion improved among groups with lower prepandemic engagement but most were limited to telephone visits.
Background. Anal cancer is one of the most common cancers affecting individuals infected with human immunodeficiency virus (HIV), although few have evaluated rates separately for men who have sex ...with men (MSM), other men, and women. There are also conflicting data regarding calendar trends. Methods. In a study involving 13 cohorts from North America with follow-up between 1996 and 2007, we compared anal cancer incidence rates among 34 189 HIV-infected (55% MSM, 19% other men, 26% women) and 114 260 HIV-uninfected individuals (90% men). Results. Among men, the unadjusted anal cancer incidence rates per 100 000 person-years were 131 for HIV-infected MSM, 46 for other HIV-infected men, and 2 for HIV-uninfected men, corresponding to demographically adjusted rate ratios (RRs) of 80.3 (95% confidence interval CI, 42.7—151.1) for HIV-infected MSM and 26.7 (95% CI, 11.5—61.7) for other HIV-infected men compared with HIV-uninfected men. HIV-infected women had an anal cancer rate of 30/100 000 person-years, and no cases were observed for HIV-uninfected women. In a multivariable Poisson regression model, among HIV-infected individuals, the risk was higher for MSM compared with other men (RR, 3.3; 95% CI, 1.8—6.0), but no difference was observed comparing women with other men (RR, 1.0; 95% CI, 0.5—2.2). In comparison with the period 2000—2003, HIV-infected individuals had an adjusted RR of 0.5 (95% CI, .3—.9) in 1996—1999 and 0.9 (95% CI, .6—1.2) in 2004—2007. Conclusions. Anal cancer rates were substantially higher for HIV-infected MSM, other men, and women compared with HIV-uninfected individuals, suggesting a need for universal prevention efforts. Rates increased after the early antiretroviral therapy era and then plateaued.
Abstract Purpose In the United States, 21 years is a critical age of legal and social transition, with changes in social programs such as public insurance coverage. Human immunodeficiency virus ...(HIV)–infected youth have lower adherence to care and medications and may be at risk of loss to follow-up (LTFU) at this benchmark age. We evaluated LTFU after the 22nd birthday for HIV-infected youth engaged in care. LTFU was defined as having no primary HIV visits in the year after the 22nd birthday. Methods All HIV-infected 21-year-olds engaged in care (2002–2011) at the HIV Research Network clinics were included. We assessed the proportion LTFU and used multivariable logistic regression to evaluate demographic and clinical characteristics associated with LTFU after the 22nd birthday. We compared LTFU at other age transitions during the adolescent/young adult years. Results Six hundred forty-seven 21-year-olds were engaged in care; 91 (19.8%) were LTFU in the year after turning 22 years. Receiving care at an adult versus pediatric HIV clinic (adjusted odds ratio AOR, 2.91; 95% confidence interval CI, 1.42–5.93), having fewer than four primary HIV visits/year (AOR, 2.72; 95% CI, 1.67–4.42), and antiretroviral therapy prescription (AOR, .50; 95% CI, .41–.60) were independently associated with LTFU. LTFU was prevalent at each age transition, with factors associated with LTFU similar to that identified for 21-year-olds. Conclusions Although 19.8% of 21-year-olds at the HIV Research Network sites were LTFU after their 22nd birthday, significant proportions of youth of all ages were LTFU. Fewer than four primary HIV care visits/year, receiving care at adult clinics and not prescribed antiretroviral therapy, were associated with LTFU and may inform targeted interventions to reduce LTFU for these vulnerable patients.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract
Background
Widespread viral and serological testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may present a unique opportunity to also test for human immunodeficiency ...virus (HIV) infection. We estimated the potential impact of adding linked, opt-out HIV testing alongside SARS-CoV-2 testing on the HIV incidence and the cost-effectiveness of this strategy in 6 US cities.
Methods
Using a previously calibrated dynamic HIV transmission model, we constructed 3 sets of scenarios for each city: (1) sustained current levels of HIV-related treatment and prevention services (status quo); (2) temporary disruptions in health services and changes in sexual and injection risk behaviors at discrete levels between 0%–50%; and (3) linked HIV and SARS-CoV-2 testing offered to 10%–90% of the adult population in addition to Scenario 2. We estimated the cumulative number of HIV infections between 2020–2025 and the incremental cost-effectiveness ratios of linked HIV testing over 20 years.
Results
In the absence of linked, opt-out HIV testing, we estimated a total of a 16.5% decrease in HIV infections between 2020–2025 in the best-case scenario (50% reduction in risk behaviors and no service disruptions), and a 9.0% increase in the worst-case scenario (no behavioral change and 50% reduction in service access). We estimated that HIV testing (offered at 10%–90% levels) could avert a total of 576–7225 (1.6%–17.2%) new infections. The intervention would require an initial investment of $20.6M–$220.7M across cities; however, the intervention would ultimately result in savings in health-care costs in each city.
Conclusions
A campaign in which HIV testing is linked with SARS-CoV-2 testing could substantially reduce the HIV incidence and reduce direct and indirect health care costs attributable to HIV.
The delivery of HIV healthcare historically has been expensive. The most recent national data regarding HIV healthcare costs were from 1996-1998. We provide updated estimates of expenditures for HIV ...management.
We performed a cross-sectional review of medical records at 10 sites in the HIV Research Network, a consortium of high-volume HIV care providers across the United States. We assessed inpatient days, outpatient visits, and prescribed antiretroviral and opportunistic illness prophylaxis medications for 14 691 adult HIV-infected patients in primary HIV care in 2006. We estimated total care expenditures, stratified by the median CD4 cell count obtained in 2006 (≤50, 51-200, 201-350, 351-500, >500 cells/μl). Per-unit costs of care were based on Healthcare Cost and Utilization Project (HCUP) data for inpatient care, discounted average wholesale prices for medications, and Medicare physician fees for outpatient care.
Averaging over all CD4 strata, the mean annual total expenditures per person for HIV care in 2006 in three sites was US $19 912, with an interquartile range from US $11 045 to 22 626. Average annual per-person expenditures for care were greatest for those with CD4 cell counts 50 cell/μl or less (US $40 678) and lowest for those with CD4 cell counts more than 500 cells/μl (US $16 614). The majority of costs were attributable to medications, except for those with CD4 cell counts 50 cells/μl or less, for whom inpatient costs were highest.
HIV healthcare in the United States continues to be expensive, with the majority of expenditures attributable to medications. With improved HIV survival, costs may increase and should be monitored in the future.
BACKGROUND:Despite the high prevalence of Hepatitis C Virus (HCV) among persons living with HIV (PWH), the prevalence of HCV screening, treatment, and sustained virologic response (SVR) is unknown. ...This study aims to characterize the continuum of HCV screening and treatment among PWH in HIV care.
SETTING:Adult patients enrolled at 12 sites of the HIV Research Network located in three regions of the United States were included.
METHODS:We examined the prevalence of HCV screening, HCV coinfection, direct-acting antiretroviral (DAA) treatment, and SVR-12 between 2014-15. Multivariate logistic regression was performed to identify characteristics associated with outcomes, adjusted for site.
RESULTS:Among 29,071 PWH (age 18-87, 74.8% male, 44.4% black), 77.9% were screened for HCV antibodies; 95% of those screened had a confirmatory HCV-RNA viral load test. Among those tested, 61% were determined to have chronic HCV. We estimate that only 23.4% of those eligible for DAA were prescribed DAA, but only 17.8% of those eligible evidenced initiating DAA treatment. Those who initiated treatment achieved SVR-12 at a rate of 95.2%. Blacks and people who inject drugs (PWID) were more likely to be screened for HCV than whites or those with heterosexual risk. Persons over age 40, whites, Hispanics, and PWID (AOR 8.70 7.74-9.78) were more likely to be coinfected than their counterparts. When examining treatment with DAA, persons over age 50, on ART (AOR, 2.27 1.11-4.64), with HIV-1 RNA <400 (AOR, 2.67 1.71-4.18), and those with higher Fib-4 scores were more likely to be treated with DAA.
CONCLUSIONS:While rates of screening for HCV among PWH are high, screening remains far from comprehensive. Rates of SVR were high, consistent with previously published literature. Additional programs to improve screening and make treatment more widely available will help reduce the impact of HCV morbidity among PWH.
OBJECTIVE:Effective interventions to reduce the public health burden of HIV/AIDS can vary in their ability to deliver value at different levels of scale and in different epidemiological contexts. Our ...objective was to determine the cost-effectiveness of HIV treatment and prevention interventions implemented at previously documented scales of delivery in six US cities with diverse HIV microepidemics.
DESIGN:Dynamic HIV transmission model-based cost-effectiveness analysis.
METHODS:We identified and estimated previously documented scale of delivery and costs for 16 evidence-based interventions from the US CDCʼs Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention. Using a model calibrated for Atlanta, Baltimore, Los Angeles, Miami, New York City and Seattle, we estimated averted HIV infections, quality-adjusted life years (QALY) gained and incremental cost-effectiveness ratios (healthcare perspective; 3% discount rate, 2018$US), for each intervention and city (10-year implementation) compared with the status quo over a 20-year time horizon.
RESULTS:Increased HIV testing was cost-saving or cost-effective across cities. Targeted preexposure prophylaxis for high-risk MSM was cost-saving in Miami and cost-effective in Atlanta ($6123/QALY), Baltimore ($18 333/QALY) and Los Angeles ($86 117/QALY). Interventions designed to improve antiretroviral therapy initiation provided greater value than other treatment engagement interventions. No single intervention was projected to reduce HIV incidence by more than 10.1% in any city.
CONCLUSION:Combination implementation strategies should be tailored to local epidemiological contexts to provide the most value. Complementary strategies addressing factors hindering access to HIV care will be necessary to meet targets for HIV elimination in the United States.
Retention in care is key to improving HIV outcomes. The goal of this study was to describe 'churn' in patterns of entry, exit, and retention in HIV care in the United States and Canada.
Adults ...contributing ≥1 CD4 count or HIV-1 RNA (HIV-lab) from 2000 to 2008 in North American AIDS Cohort Collaboration on Research and Design clinical cohorts were included. Incomplete retention was defined as lack of 2 HIV-laboratories (≥90 days apart) within 12 months, summarized by calendar year. Beta-binomial regression models were used to estimate adjusted odds ratios (OR) and 95% confidence intervals (CI) of factors associated with incomplete retention.
Among 61,438 participants, 15,360 (25%) with incomplete retention significantly differed in univariate analyses (P < 0.001) from 46,078 (75%) consistently retained by age, race/ethnicity, HIV risk, CD4, antiretroviral therapy use, and country of care (United States vs. Canada). From 2000 to 2004, females (OR = 0.82, CI: 0.70 to 0.95), older individuals (OR = 0.78, CI: 0.74 to 0.83 per 10 years), and antiretroviral therapy users (OR = 0.61, CI: 0.54 to 0.68 vs. all others) were less likely to have incomplete retention, whereas black individuals (OR = 1.31, CI: 1.16 to 1.49, vs. white), those with injection drug use HIV risk (OR = 1.68, CI: 1.49 to 1.89, vs. noninjection drug use), and those in care longer (OR = 1.09, CI: 1.07 to 1.11 per year) were more likely to have incomplete retention. Results from 2005 to 2008 were similar.
From 2000 to 2008, 75% of the North American AIDS Cohort Collaboration on Research and Design population was consistently retained in care with 25% experiencing some changes in status or churn. In addition to the programmatic and policy implications, the findings of this study identify patient groups who may benefit from focused retention efforts.
Abstract
Background
With limited severe acute respiratory syndrome coronavirus (SARS-CoV-2) testing capacity in the United States at the start of the epidemic (January–March 2020), testing was ...focused on symptomatic patients with a travel history throughout February, obscuring the picture of SARS-CoV-2 seeding and community transmission. We sought to identify individuals with SARS-CoV-2 antibodies in the early weeks of the US epidemic.
Methods
All of Us study participants in all 50 US states provided blood specimens during study visits from 2 January to 18 March 2020. Participants were considered seropositive if they tested positive for SARS-CoV-2 immunoglobulin G (IgG) antibodies with the Abbott Architect SARS-CoV-2 IgG enzyme-linked immunosorbent assay (ELISA) and the EUROIMMUN SARS-CoV-2 ELISA in a sequential testing algorithm. The sensitivity and specificity of these ELISAs and the net sensitivity and specificity of the sequential testing algorithm were estimated, along with 95% confidence intervals (CIs).
Results
The estimated sensitivities of the Abbott and EUROIMMUN assays were 100% (107 of 107 95% CI: 96.6%–100%) and 90.7% (97 of 107 83.5%–95.4%), respectively, and the estimated specificities were 99.5% (995 of 1000 98.8%–99.8%) and 99.7% (997 of 1000 99.1%–99.9%), respectively. The net sensitivity and specificity of our sequential testing algorithm were 90.7% (97 of 107 95% CI: 83.5%–95.4%) and 100.0% (1000 of 1000 99.6%–100%), respectively. Of the 24 079 study participants with blood specimens from 2 January to 18 March 2020, 9 were seropositive, 7 before the first confirmed case in the states of Illinois, Massachusetts, Wisconsin, Pennsylvania, and Mississippi.
Conclusions
Our findings identified SARS-CoV-2 infections weeks before the first recognized cases in 5 US states.
Seven individuals had detectable severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immunoglobulin G before the first confirmed cases in Illinois, Massachusetts, Wisconsin, Pennsylvania, and Mississippi, suggesting that SARS-CoV-2 infections occurred weeks before recognized cases in at least 5 US states.
Background. Elite controllers spontaneously suppress human immunodeficiency virus (HIV) viremia but also demonstrate chronic inflammation that may increase risk of comorbid conditions. We compared ...hospitalization rates and causes among elite controllers to those of immunologically intact persons with medically controlled HIV. Methods. For adults in care at 11 sites from 2005 to 2011, person-years with CD4 T-cell counts ≥350 cells/mm² were categorized as medical control, elite control, low viremia, or high viremia. All-cause and diagnostic categoryspecific hospitalization rates were compared between groups using negative binomial regression. Results. We identified 149 elite controllers (0.4%) among 34 354 persons in care. Unadjusted hospitalization rates among the medical control, elite control, low-viremia, and high-viremia groups were 10.5, 23.3, 12.6, and 16.9 per 100 person-years, respectively. After adjustment for demographic and clinical factors, elite control was associated with higher rates of all-cause (adjusted incidence rate ratio, 1.77 95% confidence interval, 1.21-2.60), cardiovascular (3.19 1.50-6.79) and psychiatric (3.98 1.54-10.28) hospitalization than was medical control. Non-AIDS-defining infections were the most common reason for admission overall (24.1% of hospitalizations) but were rare among elite controllers (2.7%), in whom cardiovascular hospitalizations were most common (31.1%). Conclusions. Elite controllers are hospitalized more frequently than persons with medically controlled HIV and cardiovascular hospitalizations are an important contributor.
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BFBNIB, NMLJ, NUK, PNG, SAZU, UL, UM, UPUK
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