Correlates of Recent HIV Testing Among People Who Inject Drugs in Rural Areas: A Multi-site Cross-Sectional Study, 2018-2020

The Rural Opioid Initiative surveyed 2693 people who inject drugs (PWID) in eight rural U.S. areas in 2018-2020 about self-reported HIV testing in the past 6 months. Correlates of interest included receipt of any drug-related services, incarceration history, and structural barriers to care (e.g., lack of insurance, proximity to syringe service programs [SSP]). Overall, 20% of participants reported receiving an HIV test within the past 6 months. Multivariable generalized estimating equations showed that attending substance use disorder (SUD) treatment (OR 2.11, 95%CI [1.58, 2.82]), having health insurance (OR 1.42, 95%CI [1.01, 2.00]) and recent incarceration (OR 1.49, 95%CI [1.08, 2.04]) were positively associated with HIV testing, while experiencing a resource barrier to healthcare (inability to pay, lack of transportation, inconvenient hours, or lack of child care) had inverse (OR 0.73, 95%CI [0.56, 0.94]) association with HIV testing. We found that the prevalence of HIV testing among rural PWID is low, indicating an unmet need for testing. While SUD treatment or incarceration may increase chances for HIV testing for rural PWID, other avenues for expanding HIV testing, such as SSP, need to be explored.

Tobacco smoking and binge alcohol use are associated with incident venous thromboembolism in an HIV cohort

BACKGROUND

People with HIV (PWH) are at increased risk of cardiovascular comorbidities and substance use is a potential predisposing factor. We evaluated associations of tobacco smoking and alcohol use with venous thromboembolism (VTE) in PWH.

METHODS

We assessed incident, centrally adjudicated VTE among 12 957 PWH within the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) cohort between January 2009 and December 2018. Using separate Cox proportional hazards models, we evaluated associations of time-updated alcohol and cigarette use with VTE, adjusting for demographic and clinical characteristics. Smoking was evaluated as pack-years and never, former, or current use with current cigarettes per day. Alcohol use was parameterized using categorical and continuous alcohol use score, frequency of use, and binge frequency.

RESULTS

During a median of 3.6 years of follow-up, 213 PWH developed a VTE. One-third of PWH reported binge drinking and 40% reported currently smoking. In adjusted analyses, risk of VTE was increased among both current (HR: 1.44, 95% CI: 1.02-2.03) and former (HR: 1.44, 95% CI: 0.99-2.07) smokers compared to PWH who never smoked. Additionally, total pack-years among ever-smokers (HR: 1.10 per 5 pack-years; 95% CI: 1.03-1.18) was associated with incident VTE in a dose-dependent manner. Frequency of binge drinking was associated with incident VTE (HR: 1.30 per 7 days/month, 95% CI: 1.11-1.52); however, alcohol use frequency was not. Severity of alcohol use was not significantly associated with VTE.

CONCLUSIONS

Current smoking and pack-year smoking history were dose-dependently associated with incident VTE among PWH in CNICS. Binge drinking was also associated with VTE. Interventions for smoking and binge drinking may decrease VTE risk among PWH.

Drug and alcohol use among people living with HIV in care in the United States by geographic region

Substance use in the U.S. varies by geographic region. Opioid prescribing practices and marijuana, heroin, and methamphetamine availability are evolving differently across regions. We examined self-reported substance use among people living with HIV (PLWH) in care at seven sites from 2017-2019 to understand current regional substance use patterns. We calculated the percentage and standardized percentage of PLWH reporting current drug use and at-risk and binge alcohol use by U.S. Census Bureau geographic region and examined associations in adjusted logistic regression analyses. Among 7,686 PLWH, marijuana use was the most prevalent drug (30%), followed by methamphetamine/crystal (8%), cocaine/crack (7%), and illicit opioids (3%). One-third reported binge alcohol use (32%). Differences in percent of current use by region were seen for marijuana (24-41%) and methamphetamine/crystal (2-15%), with more use in the West and Northeast, and binge alcohol use (26-40%). In adjusted analyses, PLWH in the Midwest were significantly less likely to use methamphetamine/crystal (aOR: 0.13;0.06-0.25) or illicit opioids (aOR:0.16;0.05-0.53), and PLWH in the Northeast were more likely to use cocaine/crack (aOR:1.59;1.16-2.17), compared to PLWH in the West. Understanding differences in substance use patterns in the current era, as policies continue to evolve, will enable more targeted interventions in clinical settings among PLWH.

Genetic variation implicates plasma angiopoietin-2 in the development of acute kidney injury sub-phenotypes

BACKGROUND

We previously identified two acute kidney injury (AKI) sub-phenotypes (AKI-SP1 and AKI-SP2) with different risk of poor clinical outcomes and response to vasopressor therapy. Plasma biomarkers of endothelial dysfunction (tumor necrosis factor receptor-1, angiopoietin-1 and 2) differentiated the AKI sub-phenotypes. However, it is unknown whether these biomarkers are simply markers or causal mediators in the development of AKI sub-phenotypes.

METHODS

We tested for associations between single-nucleotide polymorphisms within the Angiopoietin-1, Angiopoietin-2, and Tumor Necrosis Factor Receptor 1A genes and AKI- SP2 in 421 critically ill subjects of European ancestry. Top performing single-nucleotide polymorphisms (FDR < 0.05) were tested for cis-biomarker expression and whether genetic risk for AKI-SP2 is mediated through circulating biomarkers. We also completed in vitro studies using human kidney microvascular endothelial cells. Finally, we calculated the renal clearance of plasma biomarkers using 20 different timed urine collections.

RESULTS

A genetic variant, rs2920656C > T, near ANGPT2 was associated with reduced risk of AKI-SP2 (odds ratio, 0.45; 95% CI, 0.31-0.66; adjusted FDR = 0.003) and decreased plasma angiopoietin-2 (p = 0.002). Causal inference analysis showed that for each minor allele (T) the risk of developing AKI-SP2 decreases by 16%. Plasma angiopoietin-2 mediated 41.5% of the rs2920656 related risk for AKI-SP2. Human kidney microvascular endothelial cells carrying the T allele of rs2920656 produced numerically lower levels of angiopoietin-2 although this was not statistically significant (p = 0.07). Finally, analyses demonstrated that angiopoietin-2 is minimally renally cleared in critically ill subjects.

CONCLUSION

Genetic mediation analysis provides supportive evidence that angiopoietin-2 plays a causal role in risk for AKI-SP2.

Viral Failure Among Persons Living with HIV Initiating Dolutegravir-Based vs. Other Recommended Regimens in Real-World Clinical Care Settings

Background

Much of the prior research on viral failure (VF) with integrase inhibitor (INSTI) therapy is based on results from trials rather than clinical care settings and little is known about recently approved medications such as dolutegravir (DTG). We compared VF in persons living with HIV (PLWH) who initiated DTG-based vs. other guideline recommended regimens in clinical care across the United States.

Methods

PLWH from eight CFAR Network of Integrated Clinical Systems (CNICS) sites who started a recommended regimen between August 2013 and August 2016 were included. We compared DTG vs. other INSTI, and vs. darunavir-based (DRV) regimens included in current guidelines for initiating antiretroviral therapy (ART). VF was defined as a viral load of &gt;400 copies/ml &gt;6 months after initiation. We used Cox models adjusting for age, sex, race/ethnicity, hepatitis B, hepatitis C, tuberculosis, HIV risk factor, CD4 count, days since last HIV viral load, and site. PLWH were censored at death, regimen change or loss to follow-up (LTFU) with sensitivity analyses varying LTFU definitions from 0 to 12 months after last activity and including/excluding inverse probability censoring weights based on variables in the main models.

Results

Among 6636 PLWH who initiated a recommended regimen, a lower proportion on DTG-based regimens experienced VF during follow-up (Figure). The adjusted hazard ratio (HR) for VF for DTG vs. DRV-based regimens was 0.56 (95% confidence interval 0.37–0.86). In sensitivity models, the HR for VF for DTG vs. other INSTI regimens ranged from 0.73 to 1.07 depending on LTFU definitions. The HR for DTG vs. DRV-based regimens ranged from 0.38 to 0.63 depending on LTFU definitions. In sensitivity analyses among the 1,229 PLWH known to be ART-naive at initiation, a similar pattern was found with a lower HR of VF among those who initiated DTG vs. DRV-based regimens (HR 0.25, 95% CI 0.11–0.56).

Conclusion

The observed rate of VF during follow-up was lower among PLWH initiating DTG-based vs. DRV-based regimens in routine clinical care at sites across the US. Results also demonstrated that different definitions of LTFU can have a large impact on the results and highlight the importance of sensitivity analyses in informing study definitions to minimize bias.

Disclosures

V. Vannappagari, ViiV Healthcare: Employee and Shareholder, Salary and Stocks; K. Smith, ViiV Healthcare: Employee, Salary; C. Johannes, VIIV: Research Contractor, Research support; B. Calingaert, VIIV: Research Contractor, Research support; C. Saltus, VIIV: Research Contractor, Research grant; J. Eron, VIIV: Scientific Advisor, Consulting fee; M. S. Saag, VIIV: Grant Investigator and Scientific Advisor, Grant recipient; BMS: Grant Investigator and Scientific Advisor, Consulting fee and Grant recipient; Gilead: Grant Investigator and Scientific Advisor, Consulting fee and Research support; Merck: Grant Investigator and Scientific Advisor, Consulting fee and Grant recipient; H. M. Crane, VIIV: Scientific Advisor, Nothing to date but I have been asked to be an advisor so there may be a relationship in the future.

Seek, test, treat: substance-using women in the HIV treatment cascade in South Africa

Background

Women in South Africa who use alcohol and other drugs face multiple barriers to HIV care. These barriers make it difficult for women to progress through each step in the HIV treatment cascade from diagnosis to treatment initiation and adherence. This paper examines correlates of HIV status, newly diagnosed HIV status, and use of antiretroviral therapy (ART).

Methods

Outreach workers recruited sexually active Black African women who used substances in Pretoria as part of a U.S. National Institutes of Health-funded geographically clustered randomized trial examining the effect of an intervention to reduce alcohol and drug use as well as sexual risk behaviors. To address the question of interest in the current investigation, cross-sectional baseline data were used. At study enrollment, all participants (N = 641) completed an interview, and underwent rapid HIV testing and biological drug screening. Those who tested positive for HIV and were eligible for ART were asked about their barriers to initiating or adhering to ART. Bivariate and multivariable logistic regression analyses were conducted to determine correlates of HIV status, newly diagnosed HIV, and ART use.

Results

At enrollment, 55% of participants tested positive for HIV, and 36% of these women were newly diagnosed. In multivariable analyses of the entire sample, women who had completed 10th grade were less likely to be living with HIV (OR 0.69; CI 0.48, 0.99) and those from the inner city were more likely to be living with HIV (OR 1.83; CI 1.26, 2.67). Among HIV-positive participants, women were less likely to be newly diagnosed if they had ever been in substance abuse treatment (OR 0.15; CI 0.03, 0.69) or used a condom at last sex (OR 0.58; CI 0.34, 0.98) and more likely to be newly diagnosed if they were physically assaulted in the past year (OR 1.97; CI 1.01, 3.84). Among women eligible for ART, fewer were likely to be on treatment (by self-report) if they had a positive urine test for opiates or cocaine (OR 0.27; CI 0.09, 0.80).

Conclusions

These results, although cross-sectional, provide some guidance for provincial authorities to address barriers to HIV care for sexually active, substance-using vulnerable women in Pretoria. Targeting the inner city with prevention campaigns, expanding and improving substance abuse treatment programs, linking clients with simultaneous HIV testing and treatment, and targeting women who have experienced sexual assault and violence may help the government achieve the UNAIDS 90-90-90 treatment target.

Clinical Trials.gov NCT01497405 registered on December 1, 2011.

Smoking intensity (pack/day) is a better measure than pack-years or smoking status for modeling cardiovascular disease outcomes

OBJECTIVES

Smoking as an epidemiological exposure can be quantified in many ways including duration, intensity, pack-years, recency, and age at initiation. However, it is not clear which of these are most important for cardiovascular disease (CVD) and how they should be modeled.

STUDY DESIGN AND SETTING

Using the Multi-Ethnic Study of Atherosclerosis, Cox models for time to incident CVD adjusted for age, sex, race/ethnicity, education category, and income category were compared which included various characterizations of smoking history.

RESULTS

Duration, age at starting, time since quitting, and noncigarette forms of smoking were not independently associated with CVD, whereas baseline current intensity was associated with CVD [e.g., hard CVD hazard ratio 1 pack/d of 1.85 95% confidence interval (1.33, 2.57)]. Former smokers, regardless of duration, intensity, or recency, were not at increased risk, suggesting that risk may risk may drop precipitously from the time of quitting. For CVD events, representing smoking exposure as baseline smoking intensity produced better model fit as measured by Akaike information criterion than models using smoking status or pack-years.

CONCLUSION

The association of smoking with incident CVD events was well captured by including a simple term for baseline smoking intensity.

Development of a new diabetes risk prediction tool for incident coronary heart disease events: the Multi-Ethnic Study of Atherosclerosis and the Heinz Nixdorf Recall Study

OBJECTIVE

We develop a new diabetes CHD risk estimator using traditional risk factors plus coronary artery calcium (CAC), ankle-brachial index (ABI), high sensitivity C-reactive protein, family history of CHD, and carotid intima-media thickness and compared it with United Kingdom Prospective Diabetes study (UKPDS), Framingham risk and the NCEP/ATP III risk scores in type 2 diabetes mellitus (T2DM).

METHODS AND RESULTS

We combined data from T2DM without clinical CVD in the Multi-Ethnic Study of Atherosclerosis (MESA) and the Heinz Nixdorf Recall Study (N = 1343). After a mean follow-up of 8.5 years, 85 (6.3%) participants had incident CHD. Among the novel risk markers, CAC best predicted CHD independent of the FRS [hazard ratio: HR (95% CI): log (CAC +25):1.69 (1.45-1.97), p < 0.0001; CAC categories: CAC ≤ 25 as reference, >25 and ≤125:2.29 (0.87-5.95), >125 and ≤400: 3.87 (1.57-9.57), >400: 5.97 (2.57-13.84), respectively). The MESA-HNR diabetes CHD risk score has better accuracy for the main outcome versus the FRS or UKPDS [area under curve (AUC) of 0.76 vs. 0.70 and 0.69, respectively; all p < 0.05]. The MESA-HNR risk score improved risk classification versus the FRS (net reclassification improvement (NRI) = 0.19 and integrated discrimination improvement (IDI) = 0.046, p < 0.05) and UKPDS (NRI = 0.215 and IDI = 0.046, p < 0.05). Compared with the ATP III guidelines, the MESA-HNR score has an NRI of 0.74 for the main outcome.

CONCLUSIONS

This new CHD risk estimator has better discriminative ability for incident CHD than the FRS, UKPDS, and the ATP III/NCEP recommendations in a multi-ethnic cohort with T2DM.

Mediation of cardiovascular risk factor effects through subclinical vascular disease: the Multi-Ethnic Study of Atherosclerosis

OBJECTIVE

It is unclear to what extent subclinical cardiovascular disease (CVD) such as coronary artery calcium (CAC), carotid intima-media thickness (CIMT), and brachial flow-mediated dilation (FMD) are mediators of the known associations between traditional cardiovascular risk factors and incident CVD events. We assessed the portion of the effects of risk factors on incident CVD events that are mediated through CAC, CIMT, and FMD.

APPROACH AND RESULTS

Six thousand three hundred fifty-five of 6814 Multi-Ethnic Study of Atherosclerosis participants were included. Nonlinear implementation of structural equation modeling (STATA mediation package) was used to assess whether CAC, CIMT, or FMD are mediators of the association between traditional risk factors and incident CVD event. Mean age was 62 years, with 47% men, 12% diabetics, and 13% current smokers. After a mean follow-up of 7.5 years, there were 539 CVD adjudicated events. CAC showed the highest mediation while FMD showed the least. Age had the highest percent of total effect mediated via CAC for CVD outcomes, whereas current cigarette smoking had the least percent of total effect mediated via CAC (percent [95% confidence interval]: 80.2 [58.8-126.7] versus 10.6 [6.1-38.5], respectively). Body mass index showed the highest percent of total effect mediated via CIMT (17.7 [11.6-38.9]); only a negligible amount of the association between traditional risk factors and CVD was mediated via FMD.

CONCLUSIONS

Many of the risk factors for incident CVD (other than age, sex, and body mass index) showed a modest level of mediation via CAC, CIMT, and FMD, suggesting that current subclinical CVD markers may not be optimal intermediaries for gauging upstream risk factor modification.

Identification of root canals in molars by tuned-aperture computed tomography

AIM

To compare the tuned-aperture computed tomography system of imaging to conventional D-speed film for their ability to identify root canals in extracted human molars.

METHODOLOGY

Thirteen maxillary and six mandibular human molars were mounted in acrylic blocks to simulate clinical conditions by surrounding the teeth with a radiodense structure. The teeth were then imaged with conventional D-speed film using a standard paralleling technique, and with a modified orthopantomograph OP100 machine using a Schick no. 2 size CCD sensor as the image receptor. The source images were registered and TACT slices were generated using TACT Workbench Software. Three observers were asked to identify the number of canals in the conventional film group and the TACT image group using specific criteria. Ground truth was established by cross-sectioning the teeth at the coronal, middle, and apical thirds of the roots and directly visualizing the root canal morphology.

RESULTS

TACT imaging detected 36% of 4th canals in maxillary molars and 80% of third canals in mandibular molars. Conventional film detected 0% of fourth canals in maxillary molars and 0% of third canals in mandibular molars. The differences in canal detection between the two techniques were statistically significant (Wilcoxon matched pair sign rank test, P = 0.001).

CONCLUSIONS

In this study, the TACT system of digital imaging was superior to conventional film in the detection of root canals in human molars and may be useful for the detection of root canals that will probably be missed upon conventional X-ray examination.

Detection of occult gastrinomas with iodine 125-labeled lanreotide and intraoperative gamma detection

BACKGROUND

Surgical exploration for gastrinoma has a high failure rate because of small primary tumors and occult metastasis. Despite extensive preoperative and intraoperative tumor localization, only 30% to 40% of patients with gastrinoma are cured by surgery. Two patients with unlocalized gastrinomas were studied with intraoperative gamma detection of an iodine 125-labeled somatostatin analog, lanreotide, to localize their tumors.

METHODS

Both patients were challenged before operation with 100 micrograms of octreotide acetate, and both had circulating gastrin levels suppressed by greater than 50%. Iodine 125-labeled lanreotide (100 to 150 muCi) was injected during exploration, and an intraoperative gamma detector was used to detect tumor binding of the analog.

RESULTS

In patient 1 a single source of increased counts was discovered in a retroduodenal lymph node, which was excised; no other tissue was removed. Histologic study of this node failed to demonstrate tumor; however, the patient's gastrin level was normal (63 pg/ml) 4 months after operation. In patient 2 five areas of increased counts were discovered and excised. Three of these five areas had visible tumor on microscopic examination. Three months after operation the patient's fasting gastrin level was 103 pg/ml.

CONCLUSIONS

Intraoperative gamma detection of radiolabeled peptides may allow the localization of occult tumors that contain specific peptide receptors.

P-32 bremsstrahlung SPECT helps assess intracavitary therapy

A patient underwent intracavitary P-32 chromic phosphate therapy for a chest tumor. Tc-99m sulfur colloid instilled before the P-32 demonstrated uniform distribution of activity throughout the right pleural space, and the P-32 was immediately administered. Ten days later, SPECT imaging using bremsstrahlung radiation of the P-32 showed an unexpected loculation of the P-32. A subsequent chest CT scan demonstrated pleural infolding and fluid localization in the same area as the P-32, indicating that the bremsstrahlung SPECT study had, in fact, documented the final localization of the P-32, which was unexpected and different from the initial localization. The procedure used in this case may be of value in documenting the ultimate distribution of intracavitary P-32.

A preliminary report of oral tactile sensation and responses to delayed auditory feedback

Individual speakers vary widely in their reactions to delayed auditory feedback. In this pilot investigation, 21 adults with normal speech and hearing completed standardized readings under simultaneous and 200-msec. delayed auditory feedback. Minimally and maximally affected speakers were identified. Vibrotactile thresholds were obtained from the tongue and thenar eminence of the right hand for a group of five minimally and a group of five maximally affected speakers. Analysis showed that vibrotactile thresholds were lower (more sensitive) at both assessment sites for the group of maximally affected speakers. This finding is discussed in relation to the possible implications of heightened tactile sensitivity in the control of speech under delayed auditory feedback.