A COVID-19 monitoring process for healthcare workers utilizing occupational health

BACKGROUND

Hospital-based occupational health (HBOH) is uniquely positioned to not only prevent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission, but to care for healthcare workers (HCWs) sick with coronavirus disease 2019 (COVID-19).

AIMS

The primary objective of this study is to describe a system where HBOH services were adapted to provide a monitoring programme whereby HCWs with SARS-CoV-2 received daily evaluations and treatment options in order to improve access to care, and to report the clinical outcomes and predictors of hospitalization in HCWs enrolled in the programme. A secondary objective is to compare clinical outcomes to data on national HCWs with COVID-19.

METHODS

This retrospective cohort study used survey data collected on HCWs at a university health system with COVID-19 from 1 March 2020 through 1 December 2021. A firth regression model was used to examine the unadjusted and adjusted association between clinical factors and hospitalization.

RESULTS

The study cohort included 4814 HCWs with COVID-19. Overall hospitalizations were 119 (2%), and there were six deaths (0.12%). Predictors of hospitalization include several co-morbidities and symptoms. A total of 1835 HCWs monitored before vaccine or monoclonal antibody availability were compared with data on U.S. HCWs in a similar time period. The monitored HCWs had a lower rate of co-morbidities (19% versus 44%, P < 0.001), a lower hospitalization rate (3% versus 8% P < 0.001) and case-fatality rate (0.11% versus 0.95% P < 0.001).

CONCLUSIONS

This monitoring strategy for COVID-19 may be feasible for HBOH systems to implement and improve access to care, but more data are needed to determine if it improves outcomes.

Brief Report: Intracellular Cystatin B Levels Are Altered in HIV-Infected Participants With Respect to Neurocognitive Status and Antiretroviral Therapy

ABSTRACT

With advances in HIV treatment, people with HIV (PWH) are living longer but experience aging-related comorbidities, including cognitive deficits, at higher rates than the general population. Previous studies have shown alterations in lysosomal proteins in blood from PWH with severe dementia. However, these markers have not been evaluated in PWH with milder neurocognitive impairment. We sought to determine whether levels of the lysosomal cysteine protease cathepsin B (CatB) and its endogenous inhibitor cystatin B (CysB) were altered in PWH with neurocognitive impairment and whether antiretroviral therapy (ART) further influenced these levels. Peripheral blood mononuclear cells were obtained from the tenofovir arm of a multicenter clinical trial in which ART-naive, HIV+ participants received treatment for 48 weeks (ACTG A5303, NCT01400412). PWH were divided by neurocognitive status (eg, with or without neurocognitive impairment) before ART initiation. Intracellular levels of CatB and CysB were measured in T cells and monocytes by means of flow cytometry. Levels of CysB were significantly decreased in both CD4 + T cells and CD8 + T cells after 48 weeks of ART in HIV+ participants without neurocognitive impairment but not in participants with neurocognitive impairment. Levels of CysB were increased in CD14 + monocytes from the participants with neurocognitive impairment after ART. Levels of CysB and CatB positively correlated regardless of HIV, neurocognitive status, or exposure to ART. These findings suggest that CysB has the potential to provide mechanistic insight into HIV-associated neurocognitive disorders or provide a molecular target for systemic monitoring or treatment of neurocognitive impairment in the context of ART and should be investigated further.

Associations of food insecurity and psychosocial measures with diet quality in adults aging with HIV

People aging with HIV face social stressors which may negatively affect their overall nutrition. Here, we assess relationships between self-reported measures of depression, perceived stress, social support, and food insecurity with diet quality in older adults with HIV. A retrospective analysis of self-reported data from parent study at The University of Alabama at Birmingham 1917 HIV Clinic was performed. The study sample consisted of sixty people living with HIV (PLWH) with controlled HIV infection (<50 copies/mL), aged 50 years or older who participated in a cross-sectional microbiome study. Dietary intake was measured using the NHANES 12-month Food Frequency Questionnaire (FFQ) and three Automated Self-Administered (ASA) 24-hr diet recalls to calculate diet quality scores using the Mediterranean Diet Score (MDS); alternative Healthy Eating Index (aHEI); and the Recommended Food Score (RFS) indices. Food insecurity was measured with the Food Security Questionnaire (FSQ). Participants completed the following psychosocial scales: (1) depression - Patient Health Questionnaire-8 (PHQ8); (2) perceived stress - Perceived Stress Scale (PSS-10); (3) social support - Multidimensional Scale of Perceived Social Support (MSPSS). Linear regression models were used to investigate relationships among variables controlling for gender and income. The cohort was characterized as follows: Mean age 56 ± 4.6 years, 80% African-American, and 32% women. Mean body mass index (BMI) was 28.4 ± 7.2 with 55% reporting food insecurity. Most participants reported having post-secondary education (53%), although 77% reported annual incomes <$20,000. Food insecurity was independently associated with measures of poor dietary intake: aHEI (β = -0.08, p = .02) and MDS (β = -0.23, p < 0.01) and with low dietary intake of fibre (β = -0.27, p = .04), vitamin E (β = -0.35, p = .01), folate (β = -0.31, p = .02), magnesium (β = -0.34, p = .01) and copper (β = -0.36, p = .01). These data indicate food insecurity is associated with poor diet quality among PLWH. Clinical interventions are needed to improve food access for PLWH of low SES.

Frailty and Pre-Frailty in a Contemporary Cohort of HIV-Infected Adults

OBJECTIVES

To determine the prevalence of pre-frailty among HIV-infected persons and associations with pre-frailty and frailty in this population.

DESIGN, SETTING AND PARTICIPANTS

From a contemporary, prospective observational cohort of HIV-infected persons (SUN Study), we determined, using a cross-sectional analytic study design, the proportions of non-frail, pre-frail, and frail persons by the respective presence of 0, 1-2, and ≥ 3 of 5 established frailty criteria: unintentional weight loss, exhaustion, physical-inactivity, weak-grip and slow-walk. We evaluated associations with pre-frailty/frailty using multivariate analysis.

RESULTS

Of 322 participants assessed (79% men, 58% white non-Hispanic, median age 47 years, 95% on combination antiretroviral therapy [cART], median CD4 + cell count 641 cells/mm3 and 93% HIV RNA < 400 copies/mL), 57% were non-frail, 38% pre-frail, and 5% frail. Age increased from non-frailty through frailty. Notably, however, half of pre-frail and frail participants were < 50 years, and of those, 42% and 100%, respectively, were long-term unemployed (versus 16% of non-frail counterparts). In multivariate analysis, pre-frail/frail participants were more likely to have Hepatitis C seropositivity (adjusted odds ratio [aOR] 3.24, 95% CI: 1.35-7.78), a history of AIDS-defining-illness (aOR 3.51, 95% CI: 1.82-6.76), greater depressive symptoms (aOR 1.16, 95% CI:1.09-1.23), higher D-dimer levels (aOR 2.94, 95% CI:1.10-7.87), and were less likely to be white non-Hispanic (aOR 0.35, 95% CI: 0.20-0.61).

CONCLUSIONS

Pre-frailty and frailty are prevalent in the cART era and are associated with unemployment even among persons < 50 years. Pre-frailty appears to be an intermediate state in the spectrum from non-frailty through frailty and our characterization of pre-frailty/frailty suggests complex multifactorial associations.

Are neighborhood conditions associated with HIV management?

OBJECTIVES

HIV infection has become a manageable chronic disease as a result of treatment advances. Secondary prevention efforts have proved inadequate to reduce the estimated incidence of new HIV infections. Epidemiological data suggest that geographical clustering of new HIV infections is a common phenomenon, particularly in urban areas among populations of low socioeconomic status. This study aimed to assess the relationship between neighbourhood conditions and HIV management and engagement in high-risk behaviours.

METHODS

During routine out-patient HIV clinic visits, 762 individuals from the St Louis metropolitan area completed behavioural assessments in 2008. Biomedical markers were abstracted from their medical records. Multi-level analyses were conducted based on individuals' census tracts.

RESULTS

The majority of the sample were male and African American. In the adjusted models, individuals residing in neighbourhoods with higher poverty rates were more likely to have lower CD4 cell counts and be current smokers. In neighbourhoods with higher rates of unemployment, individuals were less likely to have a current antiretroviral prescription. In more racially segregated neighbourhoods, individuals reported more depressive symptoms.

CONCLUSIONS

Despite the advances in HIV disease management, neighbourhood characteristics contribute to disparities in HIV care. Interventions that address neighbourhood conditions as barriers to HIV management may provide improved health outcomes.

Effect of statin therapy in reducing the risk of serious non-AIDS-defining events and nonaccidental death

BACKGROUND

Excessive inflammation persists despite antiretroviral treatment. Statins decrease cardiovascular (CV) disease risk by reducing low-density lipoprotein cholesterol and inflammation. We performed an exploratory analysis to evaluate whether statin therapy decreased risk of non-AIDS-defining events and nonaccidental death.

METHODS

A total of 3601 subjects not on a statin from the AIDS Clinical Trials Group Longitudinal Linked Randomized Trials cohort were included. Outcome was time to first clinical event (CV event, renal or hepatic disease, incident diabetes, thrombotic/embolic event, nontraumatic fracture, non-AIDS-defining malignancy, serious bacterial infection, or nonaccidental death); event categories were also analyzed separately. Inverse probability of treatment and censoring weighted Cox proportional hazard models were used to assess the causal statin effect. Differential statin effects by baseline covariates were evaluated.

RESULTS

Over 15 135 person-years (PY) of follow-up, 484 subjects initiated statins; 616 experienced an event (crude event rate, 4.4/100 PY on a statin and 4.1/100 PY not on a statin); the unadjusted hazard ratio (HR) was 1.17 (95% confidence interval [CI], .91-1.50). In a final weighted model, the adjusted HR (AHR) was 0.81 (95% CI, .53- 1.24). Results for other clinical events were similar, except for malignancies (AHR, 0.43 [95% CI, .19-.94]) and bacterial infections (AHR, 1.30 [95% CI, .64-2.65]). No differential statin effects by baseline covariates were detected.

CONCLUSIONS

Although statin therapy was not associated with a reduction in time to all non-AIDS-defining event or nonaccidental death, it was associated with a statistically significant 57% reduction in non-AIDS-defining malignancies. Confirmatory studies are needed to evaluate statin-associated reduction in risk of cancer and non-AIDS-associated morbidities.

Lower peripheral blood CD14+ monocyte frequency and higher CD34+ progenitor cell frequency are associated with HBV vaccine induced response in HIV infected individuals

We evaluated immunologic predictors of response to HBV vaccine administered in the presence or absence of GM-CSF in HIV infected individuals. We measured peripheral blood hematopoietic progenitor, monocyte and myeloid-derived suppressor cell (MDSC) frequencies, and expression of GMCSF receptor on monocytes and MDSCs, at baseline and 4weeks after immunization in relation to antibody response. We observed higher baseline progenitor and lower monocyte frequencies among week 16 antibody responders. Week 4 decline in MDSC frequency was associated with week 16 antibody response, while administration of GM-CSF was associated with preservation of these cells. No significant differences in GM-CSF receptor expression were observed in the presence vs. absence of GM-CSF. These findings are consistent with a positive role of progenitor cells and a potential negative role of monocytes in vaccine response. Additionally, GM-CSF augmented the preservation of peripheral blood MDSC, which may contribute to the lack of improved vaccine responses.

Immune response to hepatitis B vaccine in HIV-infected subjects using granulocyte-macrophage colony-stimulating factor (GM-CSF) as a vaccine adjuvant: ACTG study 5220

HIV-infected persons are at risk for HBV co-infection which is associated with increased morbidity and mortality. Unfortunately, protective immunity following HBV vaccination in HIV-infected persons is poor. This randomized, phase II, open-label study aimed to evaluate efficacy and safety of 40 mcg HBV vaccine with or without 250 mcg GM-CSF administered at day 0, weeks 4 and 12. HIV-infected individuals >or=18 years of age, CD4 count >or=200 cells/mm(3), seronegative for HBV and HCV, and naïve to HBV vaccination were eligible. Primary endpoints were quantitative HBsAb titers and adverse events. The study enrolled 48 subjects. Median age and baseline CD4 were 41 years and 446 cells/mm(3), 37 were on ART, and 26 subjects had undetectable VL. Vaccination was well tolerated. Seven subjects in the GM-CSF arm reported transient grade >or=2 signs/symptoms (six grade 2, one grade 3), mostly aches and nausea. GM-CSF had no significant effect on VL or CD4. Four weeks after vaccination, 26 subjects (59%) developed a protective antibody response (HBsAb >or=10 mIU/mL; 52% in the GM-CSF arm and 65% in the control arm) without improved Ab titer in the GM-CSF vs. control arm (median 11 mIU/mL vs. 92 mIU/mL, respectively). Response was more frequent in those with CD4 >or=350 cells/mm(3) (64%) than with CD4 <350 cells/mm(3) (50%), though not statistically significant. GM-CSF as an adjuvant did not improve the Ab titer or the development of protective immunity to HBV vaccination in those receiving an accelerated vaccine schedule. Given the common routes of transmission for HIV and HBV, additional HBV vaccine research is warranted.

Can you hear me now? Limited use of technology among an urban HIV-infected cohort

Recent studies support technology-based behavioral interventions for individuals with HIV. This study focused on the use of cell phone and internet technologies among a cohort of 515 HIV-infected individuals. Socio-demographic and clinic data were collected among individuals presenting at an urban Midwestern university HIV clinic in 2007. Regular internet usage occurred more often with males, Caucasians, those who were employed, had higher income, and were more educated. Higher levels of education and income >$10,000 predicted regular usage when controlling for race, employment, and gender. Cell phone ownership was associated with being Caucasian, employed, more educated, and salary >$10,000. Employment was the only predictor of owning a cell phone when controlling for income, race, and education. Individuals who were <40 years of age, employed, and more educated were more likely to know how to text message. Employment and post-high school education predicted knowledge of text messaging, when controlling for age. Disparities among internet, cell phone, and text messaging usage exist among HIV-infected individuals.

Routine screening for depression: identifying a challenge for successful HIV care

Individuals with HIV experience fluctuating levels of distress throughout the course of HIV infection. This study was conducted to examine the associations of depressive symptomatology with HIV disease in a cohort of individuals who are engaged in routine medical care. This cross-sectional study examined the prevalence of depressive symptoms that were measured as part of a standard of care behavioral assessment among individuals at an urban HIV clinic in the Midwest. Demographic characteristics, depressive symptoms, and behavioral risk factors were collected. A total of 514 individuals participated in the study, the majority of whom was male and African American. One quarter of the sample endorsed symptoms of other depressive disorder, while 18% (n = 91) endorsed symptoms of major depressive disorder as measured by the Patient Health Questionnaire-9 (PHQ-9). Among those on highly active antiretroviral therapy (HAART), individuals who were unemployed (adjusted odds ratio [AOR] = 2.47, 95% confidence interval [CI] = 1.54, 3.97), had a minor dependent (AOR = 2.17, 95% CI = 1.25, 3.77), or between the ages of 18 and 34 years (AOR = 1.37, CI = 1.03, 1.94) and detectable HIV viral load (AOR = 2.52, 95% CI = 1.22, 5.23) were more likely to report depressive disorder symptoms when controlling for age, gender, race, and education. Nearly 15% of the sample endorsed having suicidal thoughts at least once in the past two weeks. Regardless of HAART prescription, individuals who were unemployed had a higher likelihood of expressing suicidal ideation (AOR = 3.43, 95% CI = 1.66, 7.06). Given the association between depressive symptomatology and poor rates of HIV viral suppression, screening and appropriate interventions for depressive symptoms are warranted in the HIV outpatient setting to improve outcomes.

Factors associated with renal dysfunction within an urban HIV-infected cohort in the era of highly active antiretroviral therapy

BACKGROUND

Kidney disease remains a prevalent problem in HIV care. The contribution of highly active antiretroviral therapy (HAART), HIV disease factors and traditional factors needs further evaluation.

METHODS

A cross-sectional study of all patients seen at an HIV outpatient clinic during 2005 was performed. All data were collected from medical record review. Multivariate regression modelling was used to identify independent predictors of lower glomerular filtration rate (eGFR) and chronic renal failure (CRF) from factors significant in univariate analysis. eGFR was calculated using the simplified modification of diet in renal disease equation. Results were compared with those for persons from the National Health and Nutrition Examination Survey (NHANES) matched for age, race and gender.

RESULTS

Of 845 HIV-infected persons, 64% were men and 34% were Caucasian, and the mean age was 39.8 years. Thirty per cent of the patients had proteinuria and 43% had eGFR<90 mL/min/1.73 m2. Persons on HAART (63%) had a lower mean eGFR than those not on HAART (92.0 vs. 101.6). In multivariate analyses, significant predictors of eGFR decline were diagnoses of hypertension, hyperlipidaemia, proteinuria, use of tenofovir or stavudine, and lower viral load. Compared with those in NHANES, HIV-infected persons had a lower mean eGFR (94.9 vs. 104.2) and a higher prevalence of CRF (8% vs. 2%).

CONCLUSION

In this cohort, the prevalence of CRF is low, but remains higher than that of the general population. Clinicians should routinely screen for early asymptomatic kidney disease to address risk factors that can be treated.

Safety and tolerability of sequential pegylated IFN-alpha2a and tenofovir for hepatitis B infection in HIV(+) individuals

Chronic hepatitis B virus infections are a major cause of morbidity and mortality in HIV co-infected patients. The standard of care for treating HCV co-infection has been guided by major clinical trials, but the treatment of HBV co-infection has not been as thoroughly studied and the standard of care remains largely untested. The single pill formulation of tenofovir with emtricitabine has become a standard treatment approach in HBV co-infected patients. WU114 was a phase 1 clinical trial that examined the safety and tolerability of sequential treatment of HBV with pegylated interferon-alpha2a plus delayed-initiation tenofovir in HIV co-infected individuals. We postulated that initial HBV viral load reduction with pegylated interferon prior to initiation of nucleoside/nucleotide therapy would increase seroconversion events and durability of HBV virologic suppression. No severe pegylated IFN-alpha2a drug toxicities were seen in either the monotherapy or delayed tenofovir arms. Sequential pegylated interferon and tenofovir-based therapy was tolerable and should be compared with dual nucleoside/nucleotide suppression to determine relative frequencies of seroconversion and durability of HBV suppression in co-infected patients.

Persistent low-level viraemia and virological failure in HIV-1-infected patients treated with highly active antiretroviral therapy

OBJECTIVE

To assess the prognostic significance of persistent low-level viraemia (PLV, defined as persistent plasma viral loads of 51-1000 HIV-1 RNA copies/mL for at least 3 months) in patients who had achieved viral suppression on antiretroviral therapy (ART).

METHODS

A retrospective cohort of HIV-infected patients who received ART, were followed-up for > or =12 months, made regular visits to the clinic during which blood tests were performed for an ultrasensitive HIV RNA assay every 3 months, and achieved viral loads <50 copies/mL were evaluated. Virological failure was defined as two consecutive viral load measurements >1000 copies/mL.

RESULTS

Of 362 patients, 78 (27.5%) experienced PLV. The demographics of patients with and without PLV were similar. PLV occurred at a mean (+/-standard deviation) of 22.6+/-16.9 months after ART initiation and lasted for 6.4+/-3.4 months. During a median follow-up of 29.5 months, patients with PLV had a higher rate of virological failure (39.7% vs 9.2%; P < 0.001). The median time to failure was 68.4 months [95% confidence interval (CI) 37.0-99.7] for patients with PLV and >72 months for patients without PLV (log rank test, P < 0.001). By Cox regression, patients with PLV had a greater risk of virological failure [hazard ratio (HR) 3.8; 95% CI 2.2-6.4; P < 0.001]. Among patients with PLV, a PLV of >400 copies/mL (HR 3.3; 95% CI 1.5-7.1; P = 0.003) and a history of ART (HR 2.4; 95% CI 1.0-5.7; P = 0.042) predicted virological failure.

CONCLUSIONS

PLV is associated with virological failure. Patients with a PLV >400 copies/mL and a history of ART experience are more likely to experience virological failure. Patients with PLV should be considered for treatment optimization and interventional studies.

Predictors of immunity after hepatitis A vaccination in HIV-infected persons

Hepatitis A virus (HAV) infection remains a health risk for human immunodeficiency virus (HIV)-infected persons. While the inactivated HAV vaccine affords protection to immunocompetent persons >95% of the time, rates of developing protective antibody (anti-HAV) in HIV+ persons are considerably lower. Although low CD4+ T-cell counts have previously been reported to be correlated with this poor response, the effect of HIV viraemia on HAV vaccine response has not previously been reported. The medical records of HIV-infected patients who had received at least one dose of HAV vaccine (Havrix, 1440 EIU) were reviewed for factors associated with the development of a protective anti-HAV response. Serological data with regard to anti-HAV status after vaccination were available in 238 patients with 133 individuals (49.6%) developing immunity after vaccination. In a logistic regression model, the only factors associated with a protective antibody response were an HIV plasma RNA level <1000 copies/mL at the time of vaccination (P = 0.011) and male gender (P = 0.016). Neither nadir CD4+ T cell count nor CD4+ T-cell count at time of vaccination were predictive of the development of anti-HAV. Suppression of HIV replication at time of vaccination is associated with a protective antibody response to HAV vaccination in HIV-infected adults. The low rate of response warrants further research in alternative strategies for HAV vaccination among HIV-infected persons.