Audio computer assisted self interview and face to face interview modes in assessing response bias among STD clinic patients

BACKGROUND

Audio computer assisted self interview (ACASI) may minimise social desirability bias in the ascertainment of sensitive behaviours. The aim of this study was to describe the difference in reporting risk behaviour in ACASI compared to a face to face interview (FFI) among public sexually transmitted diseases (STD) clinic attendees.

STUDY DESIGN

Randomly selected patients attending a public STD clinic in Baltimore, Maryland, sequentially took an ACASI formatted risk behaviour assessment followed by an FFI conducted by a single clinician, with both interview modalities surveying sexual and drug use behaviours. Binary responses were compared using the sign test, and categorical responses were compared using the Wilcoxon signed rank test to account for repeated measures.

RESULTS

671 (52% men, mean age 30 years, 95% African American) of 795 clinic attendees screened consented to participate. Subjects affirmed sensitive sexual behaviours such as same sex contact (p = 0.012), receptive rectal sexual exposure (p < 0.001), orogenital contact (p < 0.001), and a greater number of sex partners in the past month (p < 0.001) more frequently with ACASI than with an FFI. However, there were no differences in participant responses to questions on use of illicit drugs or needle sharing.

CONCLUSIONS

Among STD clinic patients, reporting of sensitive sexual risk behaviours to clinicians was much more susceptible to social desirability bias than was reporting of illegal drug use behaviours. In STD clinics where screening of sexual risk is an essential component of STD prevention, the use of ACASI may be a more reliable assessment method than traditional FFI.

Determinants and Trends of COVID-19 Vaccine Hesitancy and Vaccine Uptake in a National Cohort of US Adults: A Longitudinal Study

We estimated the trends and correlates of vaccine hesitancy and its association with subsequent vaccine uptake among 5,458 adults in the United States. Participants belonged to the Communities, Households, and SARS-CoV-2 Epidemiology COVID (CHASING COVID) Cohort, a national longitudinal study. Trends and correlates of vaccine hesitancy were examined longitudinally in 8 interview rounds from October 2020 to July 2021. We also estimated the association between willingness to vaccinate and subsequent vaccine uptake through July 2021. Vaccine delay and refusal decreased from 51% and 8% in October 2020 to 8% and 6% in July 2021, respectively. Compared with non-Hispanic (NH) White participants, NH Black and Hispanic participants had higher adjusted odds ratios (aOR) for both vaccine delay (for NH Black, aOR = 2.0 (95% confidence interval (CI): 1.5, 2.7), and for Hispanic, 1.3 (95% CI: 1.0, 1.7)) and vaccine refusal (for NH Black, aOR = 2.5 (95% CI: 1.8, 3.6), and for Hispanic, 1.4 (95% CI: 1.0, 2.0)) in June 2021. COVID-19 vaccine hesitancy, compared with vaccine-willingness, was associated with lower odds of subsequent vaccine uptake (for vaccine delayers, aOR = 0.15, 95% CI: 0.13, 0.18; for vaccine refusers, aOR = 0.02; 95% CI: 0.01, 0.03 ), adjusted for sociodemographic factors and COVID-19 history. Vaccination awareness and distribution efforts should focus on vaccine delayers.

Cohort profile: a national, community-based prospective cohort study of SARS-CoV-2 pandemic outcomes in the USA-the CHASING COVID Cohort study

PURPOSE

The Communities, Households and SARS-CoV-2 Epidemiology (CHASING) COVID Cohort Study is a community-based prospective cohort study launched during the upswing of the USA COVID-19 epidemic. The objectives of the cohort study are to: (1) estimate and evaluate determinants of the incidence of SARS-CoV-2 infection, disease and deaths; (2) assess the impact of the pandemic on psychosocial and economic outcomes and (3) assess the uptake of pandemic mitigation strategies.

PARTICIPANTS

We began enrolling participants from 28 March 2020 using internet-based strategies. Adults≥18 years residing anywhere in the USA or US territories were eligible. 6740 people are enrolled in the cohort, including participants from all 50 US states, the District of Columbia, Puerto Rico and Guam. Participants are contacted regularly to complete study assessments, including interviews and dried blood spot specimen collection for serologic testing.

FINDINGS TO DATE

Participants are geographically and sociodemographically diverse and include essential workers (19%). 84.2% remain engaged in cohort follow-up activities after enrolment. Data have been used to assess SARS-CoV-2 cumulative incidence, seroincidence and related risk factors at different phases of the US pandemic; the role of household crowding and the presence of children in the household as potential risk factors for severe COVID-19 early in the US pandemic; to describe the prevalence of anxiety symptoms and its relationship to COVID-19 outcomes and other potential stressors; to identify preferences for SARS-CoV-2 diagnostic testing when community transmission is on the rise via a discrete choice experiment and to assess vaccine hesitancy over time and its relationship to vaccine uptake.

FUTURE PLANS

The CHASING COVID Cohort Study has outlined a research agenda that involves ongoing monitoring of the incidence and determinants of SARS-CoV-2 outcomes, mental health outcomes and economic outcomes. Additional priorities include assessing the incidence, prevalence and correlates of long-haul COVID-19.

Missed routine pediatric care and vaccinations in US children during the first year of the COVID-19 pandemic

The COVID-19 pandemic has decreased uptake of pediatric preventive care, including immunizations. We estimate the prevalence of missed pediatric routine medical visits and vaccinations over the first year of the COVID-19 pandemic. We conducted a cross-sectional online survey of 2074 US parents of children ≤12 years in March 2021 to measure the proportion of children who missed pediatric care and vaccinations over the first 12 months of the COVID-19 pandemic. Poisson regression models were fitted to estimate adjusted prevalence ratios (aPR). All analyses were weighted to represent the target population. Overall, 41.3% (95%CI 38.3-43.8) of parents reported their youngest child missed a routine medical visit due to the COVID-19 pandemic. Missed care was more common among children ≥2 years compared to <2 years (aPR 1.82; 95%CI 1.47-2.26) and Hispanics compared to non-Hispanic Whites (aPR 1.31; 95%CI 1.14-1.51). A third of parents (33.1%; 95%CI 30.7-35.5) reported their child had missed a vaccination. Compared to the 2019-20 flu season, pediatric influenza vaccination decreased in 2020-21 (51.3% vs. 62.2%; p < 0.0001). A high proportion of US children ≤12 years missed routine pediatric care during the COVID-19 pandemic. Catch-up efforts are needed to ensure continuity of preventive care for all children.

SARS-CoV-2 Testing Service Preferences of Adults in the United States: Discrete Choice Experiment

Background

Ascertaining preferences for SARS-CoV-2 testing and incorporating findings into the design and implementation of strategies for delivering testing services may enhance testing uptake and engagement, a prerequisite to reducing onward transmission.

Objective

This study aims to determine important drivers of decisions to obtain a SARS-CoV-2 test in the context of increasing community transmission.

Methods

We used a discrete choice experiment to assess preferences for SARS-CoV-2 test type, specimen type, testing venue, and results turnaround time. Participants (n=4793) from the US national longitudinal Communities, Households and SARS-CoV-2 Epidemiology (CHASING) COVID Cohort Study completed our online survey from July 30 to September 8, 2020. We estimated the relative importance of testing method attributes and part-worth utilities of attribute levels, and simulated the uptake of an optimized testing scenario relative to the current typical testing scenario of polymerase chain reaction (PCR) via nasopharyngeal swab in a provider’s office or urgent care clinic with results in >5 days.

Results

Test result turnaround time had the highest relative importance (30.4%), followed by test type (28.3%), specimen type (26.2%), and venue (15.0%). In simulations, immediate or same-day test results, both PCR and serology, or oral specimens substantially increased testing uptake over the current typical testing option. Simulated uptake of a hypothetical testing scenario of PCR and serology via a saliva sample at a pharmacy with same-day results was 97.7%, compared to 0.6% for the current typical testing scenario, with 1.8% opting for no test.

Conclusions

Testing strategies that offer both PCR and serology with noninvasive methods and rapid turnaround time would likely have the most uptake and engagement among residents in communities with increasing community transmission of SARS-CoV-2.

Racial/Ethnic Disparities in Exposure, Disease Susceptibility, and Clinical Outcomes during COVID-19 Pandemic in National Cohort of Adults, United States

We examined racial/ethnic disparities for COVID-19 seroconversion and hospitalization within a prospective cohort (n = 6,740) in the United States enrolled in March 2020 and followed-up through October 2021. Potential SARS-CoV-2 exposure, susceptibility to COVID-19 complications, and access to healthcare varied by race/ethnicity. Hispanic and Black non-Hispanic participants had more exposure risk and difficulty with healthcare access than white participants. Participants with more exposure had greater odds of seroconversion. Participants with more susceptibility and more barriers to healthcare had greater odds of hospitalization. Race/ethnicity positively modified the association between susceptibility and hospitalization. Findings might help to explain the disproportionate burden of SARS-CoV-2 infections and complications among Hispanic/Latino/a and Black non-Hispanic persons. Primary and secondary prevention efforts should address disparities in exposure, vaccination, and treatment for COVID-19.

The Importance of Incorporating At-Home Testing Into SARS-CoV-2 Point Prevalence Estimates: Findings From a US National Cohort, February 2022

BACKGROUND

Passive, case-based surveillance underestimates the true extent of active infections in the population due to undiagnosed and untested cases, the exclusion of probable cases diagnosed point-of-care rapid antigen tests, and the exclusive use of at-home rapid tests which are not reported as part of case-based surveillance. The extent in which COVID-19 surveillance may be underestimating the burden of infection is likely due to time-varying factors such as decreased test-seeking behaviors and increased access to and availability of at-home testing.

OBJECTIVE

The objective of this study is to estimate the prevalence of SARS-CoV-2 based on different definitions of a case to ascertain the extent to which cases of SARS-CoV-2 may be underestimated by case-based surveillance.

METHODS

A survey on COVID-19 exposure, infection, and testing was administered to calculate point prevalence of SARS-CoV-2 among a diverse sample of cohort adults from February 8, 2022, to February 22, 2022. Three-point prevalence estimates were calculated among the cohort, as follows: (1) proportion positives based on polymerase chain reaction (PCR) and rapid antigen tests; (2) proportion positives based on testing exclusively with rapid at-home tests; and (3) proportion of probable undiagnosed cases. Test positivity and prevalence differences across booster status were also examined.

RESULTS

Among a cohort of 4328, there were a total of 644 (14.9%) cases. The point prevalence estimate based on PCR or rapid antigen tests was 5.5% (95% CI 4.8%-6.2%), 3.7% (95% CI 3.1%-4.2%) based on at-home rapid tests, and 5.7% (95% CI 5.0%-6.4%) based on the case definition of a probable case. The total point prevalence across all definitions was 14.9% (95% CI 13.8%-16.0%). The percent positivity among PCR or rapid tests was 50.2%. No statistically significant differences were observed in prevalence between participants with a COVID-19 booster compared to fully vaccinated and nonboosted participants except among exclusive at-home rapid testers.

CONCLUSIONS

Our findings suggest a substantial number of cases were missed by case-based surveillance systems during the Omicron B.1.1.529 surge, when at-home testing was common. Point prevalence surveys may be a rapid tool to be used to understand SARS-CoV-2 prevalence and would be especially important during case surges to measure the scope and spread of active infections in the population.

SARS-CoV-2 incidence and risk factors in a national, community-based prospective cohort of U.S. adults

BACKGROUND

Epidemiologic risk factors for incident SARS-CoV-2 infection as determined via prospective cohort studies greatly augment and complement information from case-based surveillance and cross-sectional seroprevalence surveys.

METHODS

We estimated the incidence of SARS-CoV-2 infection and risk factors in a well-characterized, national prospective cohort of 6,738 U.S. adults, enrolled March-August 2020, a subset of whom (n=4,510) underwent repeat serologic testing between May 2020 and January 2021. We examined the crude associations of sociodemographic factors, epidemiologic risk factors, and county-level community transmission with the incidence of seroconversion. In multivariable Poisson models we examined the association of social distancing and a composite score of several epidemiologic risk factors with the rate of seroconversion.

FINDINGS

Among the 4,510 individuals with at least one serologic test, 323 (7.3%, 95% confidence interval [CI] 6.5%-8.1%) seroconverted by January 2021. Among 3,422 participants seronegative in May-September 2020 and tested during November 2020-January 2021, we observed 161 seroconversions over 1,646 person-years of follow-up (incidence rate of 9.8 per 100 person-years [95%CI 8.3-11.5]). In adjusted models, participants who reported always or sometimes social distancing with people they knew (IRRalways vs. never 0.43, 95%CI 0.21-1.0; IRRsometimes vs. never 0.47, 95%CI 0.22-1.2) and people they did not know (IRRalways vs. never 0.64, 95%CI 0.39-1.1; IRRsometimes vs. never 0.60, 95%CI 0.38-0.97) had lower rates of seroconversion. The rate of seroconversion increased across tertiles of the composite score of epidemiologic risk (IRRmedium vs. low 1.5, 95%CI 0.92-2.4; IRRhigh vs. low 3.0, 95%CI 2.0-4.6). Among the 161 observed seroconversions, 28% reported no symptoms of COVID-like illness (i.e., were asymptomatic), and 27% reported a positive SARS-CoV-2 diagnostic test. Ultimately, only 29% reported isolating and 19% were asked about contacts.

INTERPRETATION

Modifiable epidemiologic risk factors and poor reach of public health strategies drove SARS-CoV-2 transmission across the U.S during May 2020-January 2021.

FUNDING

U.S. National Institutes of Allergy and Infectious Diseases (NIAID).

Severe Acute Respiratory Syndrome Coronavirus 2 Incidence and Risk Factors in a National, Community-Based Prospective Cohort of US Adults

BACKGROUND

Prospective cohort studies of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) incidence complement case-based surveillance and cross-sectional seroprevalence surveys.

METHODS

We estimated the incidence of SARS-CoV-2 infection in a national cohort of 6738 US adults, enrolled in March-August 2020. Using Poisson models, we examined the association of social distancing and a composite epidemiologic risk score with seroconversion. The risk score was created using least absolute shrinkage selection operator (LASSO) regression to identify factors predictive of seroconversion. The selected factors were household crowding, confirmed case in household, indoor dining, gathering with groups of ≥10, and no masking in gyms or salons.

RESULTS

Among 4510 individuals with ≥1 serologic test, 323 (7.3% [95% confidence interval (CI), 6.5%-8.1%]) seroconverted by January 2021. Among 3422 participants seronegative in May-September 2020 and retested from November 2020 to January 2021, 161 seroconverted over 1646 person-years of follow-up (9.8 per 100 person-years [95% CI, 8.3-11.5]). The seroincidence rate was lower among women compared with men (incidence rate ratio [IRR], 0.69 [95% CI, .50-.94]) and higher among Hispanic (2.09 [1.41-3.05]) than white non-Hispanic participants. In adjusted models, participants who reported social distancing with people they did not know (IRR for always vs never social distancing, 0.42 [95% CI, .20-1.0]) and with people they knew (IRR for always vs never, 0.64 [.39-1.06]; IRR for sometimes vs never, 0.60 [.38-.96]) had lower seroconversion risk. Seroconversion risk increased with epidemiologic risk score (IRR for medium vs low score, 1.68 [95% CI, 1.03-2.81]; IRR for high vs low score, 3.49 [2.26-5.58]). Only 29% of those who seroconverted reported isolating, and only 19% were asked about contacts.

CONCLUSIONS

Modifiable risk factors and poor reach of public health strategies drove SARS-CoV-2 transmission across the United States.

Household factors and the risk of severe COVID-like illness early in the U.S. pandemic

OBJECTIVE

To investigate the role of children in the home and household crowding as risk factors for severe COVID-19 disease.

METHODS

We used interview data from 6,831 U.S. adults screened for the Communities, Households and SARS/CoV-2 Epidemiology (CHASING) COVID Cohort Study in April 2020.

RESULTS

In logistic regression models, the adjusted odds ratio [aOR] of hospitalization due to COVID-19 for having (versus not having) children in the home was 10.5 (95% CI:5.7-19.1) among study participants living in multi-unit dwellings and 2.2 (95% CI:1.2-6.5) among those living in single unit dwellings. Among participants living in multi-unit dwellings, the aOR for COVID-19 hospitalization among participants with more than 4 persons in their household (versus 1 person) was 2.5 (95% CI:1.0-6.1), and 0.8 (95% CI:0.15-4.1) among those living in single unit dwellings.

CONCLUSION

Early in the US SARS-CoV-2 pandemic, certain household exposures likely increased the risk of both SARS-CoV-2 acquisition and the risk of severe COVID-19 disease.

Household factors and the risk of severe COVID-like illness early in the US pandemic

OBJECTIVE

To investigate the role of children in the home and household crowding as risk factors for severe COVID-19 disease.

METHODS

We used interview data from 6,831 U.S. adults screened for the Communities, Households and SARS/CoV-2 Epidemiology (CHASING) COVID Cohort Study in April 2020.

RESULTS

In logistic regression models, the adjusted odds ratio [aOR] of hospitalization due to COVID-19 for having (versus not having) children in the home was 10.5 (95% CI:5.7-19.1) among study participants living in multi-unit dwellings and 2.2 (95% CI:1.2-6.5) among those living in single unit dwellings. Among participants living in multi-unit dwellings, the aOR for COVID-19 hospitalization among participants with more than 4 persons in their household (versus 1 person) was 2.5 (95% CI:1.0-6.1), and 0.8 (95% CI:0.15-4.1) among those living in single unit dwellings.

CONCLUSION

Early in the US SARS-CoV-2 pandemic, certain household exposures likely increased the risk of both SARS-CoV-2 acquisition and the risk of severe COVID-19 disease.

Patterns of SARS-CoV-2 testing preferences in a national cohort in the United States

In order to understand preferences about SARS-CoV-2 testing, we conducted a discrete choice experiment among 4793 participants in the Communities, Households, and SARS-CoV-2 Epidemiology (CHASING COVID) Cohort Study from July 30-September 8, 2020. We used latent class analysis to identify distinct patterns of preferences related to testing and conducted a simulation to predict testing uptake if additional testing scenarios were offered. Five distinct patterns of SARS-CoV-2 testing emerged. "Comprehensive testers" (18.9%) ranked specimen type as most important and favored less invasive specimen types, with saliva most preferred, and also ranked venue and result turnaround time as highly important, with preferences for home testing and fast result turnaround time. "Fast track testers" (26.0%) ranked result turnaround time as most important and favored immediate and same day turnaround time. "Dual testers" (18.5%) ranked test type as most important and preferred both antibody and viral tests. "Non-invasive dual testers" (33.0%) ranked specimen type and test type as similarly most important, preferring cheek swab specimen type and both antibody and viral tests. "Home testers" (3.6%) ranked venue as most important and favored home-based testing. By offering less invasive (saliva specimen type), dual testing (both viral and antibody tests), and at home testing scenarios in addition to standard testing scenarios, simulation models predicted that testing uptake would increase from 81.7% to 98.1%. We identified substantial differences in preferences for SARS-CoV-2 testing and found that offering additional testing options, which consider this heterogeneity, would likely increase testing uptake.

SIGNIFICANCE

During the COVID-19 pandemic, diagnostic testing has allowed for early detection of cases and implementation of measures to reduce community transmission of SARS-CoV-2 infection. Understanding individuals' preferences about testing and the service models that deliver tests are relevant in efforts to increase and sustain uptake of SARS-CoV-2 testing, which, despite vaccine availability, will be required for the foreseeable future. We identified substantial differences in preferences for SARS-CoV-2 testing in a discrete choice experiment among a large national cohort of adults in the US. Offering additional testing options that account for or anticipate this heterogeneity in preferences (e.g., both viral and antibody tests, at home testing), would likely increase testing uptake.

CLASSIFICATION

Biological Sciences (major); Psychological and Cognitive Sciences (minor).

The relationship between anxiety, health, and potential stressors among adults in the United States during the COVID-19 pandemic

Objective

To estimate the prevalence of anxiety symptoms and the association between moderate or severe anxiety symptoms and health and potential stressors among adults in the U.S. during the COVID-19 pandemic.

Methods

This analysis includes data from 5,250 adults in the Communities, Households and SARS/CoV-2 Epidemiology (CHASING) COVID Cohort Study surveyed in April 2020. Poisson models were used to estimate the association between moderate or severe anxiety symptoms and health and potential stressors among U.S. adults during the COVID-19 pandemic.

Results

Greater than one-third (35%) of participants reported moderate or severe anxiety symptoms. Having lost income due to COVID-19 (adjusted prevalence ratio [aPR] 1.27 (95% CI 1.16, 1.30), having recent COVID-like symptoms (aPR 1.17 (95% CI 1.05, 1,31), and having been previously diagnosed with depression (aPR 1.49, (95% CI 1.35, 1.64) were positively associated with anxiety symptoms.

Conclusions

Anxiety symptoms were common among adults in the U.S. during the COVID-19 pandemic. Strategies to screen and treat individuals at increased risk of anxiety, such as individuals experiencing financial hardship and individuals with prior diagnoses of depression, should be developed and implemented.

Testing, Testing: What SARS-CoV-2 testing services do adults in the United States actually want?

Importance: Ascertaining preferences for SARS-CoV-2 testing and incorporating findings into the design and implementation of strategies for delivering testing services may enhance testing uptake and engagement, a prerequisite to reducing onward transmission. Objective: To determine important drivers of decisions to obtain a SARS-CoV-2 test in the context of increasing community transmission. Design : A discrete choice experiment (DCE) was used to assess the relative importance of type of SARS-CoV-2 test, specimen type, testing venue, and results turnaround time. Uptake of an optimized testing scenario was simulated relative to the current typical testing scenario of polymerase chain reaction (PCR) via nasopharyngeal (NP) swab in a provider office or urgent care clinic with results in >5 days. Setting: ​ Online survey, embedded in an existing cohort study, conducted during July 30 - September 8, 2020. Participants: ​Participants (n=4,793) were enrolled in the CHASING COVID Cohort Study, a national longitudinal cohort of adults >18 years residing in the 50 US states, Washington, DC, Puerto Rico, or Guam. Main Outcome(s) and Measure(s): Relative importance of SARS-CoV-2 testing method attributes, utilities of specific attribute levels, and probability of choosing a testing scenario based on preferences estimated from the DCE, the current typical testing option, or choosing not to test. Results: ​Turnaround time for test results had the highest relative importance (30.4%), followed by test type (28.3%), specimen type (26.2%), and venue (15.0%). Participants preferred fast results on both past and current infection and using a noninvasive specimen, preferably collected at home. Simulations suggested that providing immediate or same day test results, providing both PCR and serology, or collecting oral specimens would substantially increase testing uptake over the current typical testing option. Simulated uptake of a hypothetical testing scenario of PCR and serology via a saliva sample at a pharmacy with same day results was 97.7%, compared to 0.6% for the current typical testing scenario, with 1.8% opting for no test. Conclusions and Relevance: ​Testing strategies that offer both PCR and serology with non-invasive methods and rapid turnaround time would likely have the most uptake and engagement among residents in communities with increasing community transmission of SARS-CoV-2.

Patterns of SARS-CoV-2 Testing Preferences in a National Cohort in the United States: Latent Class Analysis of a Discrete Choice Experiment

BACKGROUND

Inadequate screening and diagnostic testing in the United States throughout the first several months of the COVID-19 pandemic led to undetected cases transmitting disease in the community and an underestimation of cases. Though testing supply has increased, maintaining testing uptake remains a public health priority in the efforts to control community transmission considering the availability of vaccinations and threats from variants.

OBJECTIVE

This study aimed to identify patterns of preferences for SARS-CoV-2 screening and diagnostic testing prior to widespread vaccine availability and uptake.

METHODS

We conducted a discrete choice experiment (DCE) among participants in the national, prospective CHASING COVID (Communities, Households, and SARS-CoV-2 Epidemiology) Cohort Study from July 30 to September 8, 2020. The DCE elicited preferences for SARS-CoV-2 test type, specimen type, testing venue, and result turnaround time. We used latent class multinomial logit to identify distinct patterns of preferences related to testing as measured by attribute-level part-worth utilities and conducted a simulation based on the utility estimates to predict testing uptake if additional testing scenarios were offered.

RESULTS

Of the 5098 invited cohort participants, 4793 (94.0%) completed the DCE. Five distinct patterns of SARS-CoV-2 testing emerged. Noninvasive home testers (n=920, 19.2% of participants) were most influenced by specimen type and favored less invasive specimen collection methods, with saliva being most preferred; this group was the least likely to opt out of testing. Fast-track testers (n=1235, 25.8%) were most influenced by result turnaround time and favored immediate and same-day turnaround time. Among dual testers (n=889, 18.5%), test type was the most important attribute, and preference was given to both antibody and viral tests. Noninvasive dual testers (n=1578, 32.9%) were most strongly influenced by specimen type and test type, preferring saliva and cheek swab specimens and both antibody and viral tests. Among hesitant home testers (n=171, 3.6%), the venue was the most important attribute; notably, this group was the most likely to opt out of testing. In addition to variability in preferences for testing features, heterogeneity was observed in the distribution of certain demographic characteristics (age, race/ethnicity, education, and employment), history of SARS-CoV-2 testing, COVID-19 diagnosis, and concern about the pandemic. Simulation models predicted that testing uptake would increase from 81.6% (with a status quo scenario of polymerase chain reaction by nasal swab in a provider's office and a turnaround time of several days) to 98.1% by offering additional scenarios using less invasive specimens, both viral and antibody tests from a single specimen, faster turnaround time, and at-home testing.

CONCLUSIONS

We identified substantial differences in preferences for SARS-CoV-2 testing and found that offering additional testing options would likely increase testing uptake in line with public health goals. Additional studies may be warranted to understand if preferences for testing have changed since the availability and widespread uptake of vaccines.

Racial/ethnic disparities in exposure to COVID-19, susceptibility to COVID-19 and access to health care - findings from a U.S. national cohort

We examined the influence of racial/ethnic differences in socioeconomic position on COVID-19 seroconversion and hospitalization within a community-based prospective cohort enrolled in March 2020 and followed through October 2021 (N=6740). The ability to social distance as a measure of exposure to COVID-19, susceptibility to COVID-19 complications, and access to healthcare varied by race/ethnicity with non-white participants having more exposure risk and more difficulty with healthcare access than white participants. Participants with more (versus less) exposure had greater odds of seroconversion (aOR:1.64, 95% Confidence Interval [CI] 1.18-2.29). Participants with more susceptibility and more barriers to healthcare had greater odds of hospitalization (respective aOR:2.36; 1.90-2.96 and 2.31; 1.69-2.68). Race/ethnicity positively modified the association between susceptibility and hospitalization (aORnon-White:2.79, 2.06-3.78). Findings may explain the disproportionate burden of COVID-19 infections and complications among Hispanic and non-Hispanic Black persons. Primary and secondary prevention efforts should address disparities in exposure, COVID-19 vaccination, and treatment.

Barriers to initial COVID-19 booster among U.S. adults who completed a primary vaccine series in the CHASING COVID cohort, September 2021 - October 2022

It is crucial to understand factors associated with COVID-19 booster uptake in the U.S. given the updated COVID-19 vaccine recommendations. Using data from a national prospective cohort (N=4,616) between September 2021-October 2022, we examined socioeconomic, demographic, and behavioral factors of initial booster uptake among participants fully-vaccinated with the primary COVID-19 vaccines series. Cox proportional hazards models were used to estimate the associations of each factor with time to initial booster uptake. Most participants (86.5%) reported receiving their initial booster. After adjusting for age, race/ethnicity, education, region, and employment, participants with greater risk for severe COVID-19 had similar booster uptake compared with those with lower risk (aHR: 1.04; 95% CI: 0.95, 1.14). Participants with greater barriers to healthcare (aHR: 0.89; 95% CI: 0.84, 0.96), food insecurity (aHR: 0.82; 95% CI: 0.75, 0.89), and housing instability (aHR: 0.81; 95% CI: 0.73, 0.90) were less likely to report receiving initial booster compared with those without those barriers. Factors motivating the decision to vaccinate changed from safety-related concerns for the primary series to perceived need for the booster. It is key to address economic and health access barriers to achieve equitable COVID-19 vaccine uptake and continued protection against COVID-19.

Oral COVID-19 Antiviral Uptake Among a Highly Vaccinated US Cohort of Adults With SARS-CoV-2 Infection Between December 2021 and October 2022

Background

We described the oral nirmatrelvir/ritonavir (NMV/r) and molnupiravir (MOV) uptake among a subgroup of highly vaccinated adults in a US national prospective cohort who were infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) between 12/2021 and 10/2022.

Methods

We estimate antiviral uptake within 5 days of SARS-CoV-2 infection, as well as age- and gender-adjusted antiviral uptake prevalence ratios by antiviral eligibility (based on age and comorbidities), sociodemographic characteristics, and clinical characteristics including vaccination status and history of long coronavirus disease 2019 (COVID).

Results

NMV/r uptake was 13.6% (95% CI, 11.9%-15.2%) among 1594 participants, and MOV uptake was 1.4% (95% CI, 0.8%-2.1%) among 1398 participants. NMV/r uptake increased over time (1.9%; 95% CI, 1.0%-2.9%; between 12/2021 and 3/2022; 16.5%; 95% CI, 13.0%-20.0%; between 4/2022 and 7/2022; and 25.3%; 95% CI, 21.6%-29.0%; between 8/2022 and 10/2022). Participants age ≥65 and those who had comorbidities for severe COVID-19 had higher NMV/r uptake. There was lower NMV/r uptake among non-Hispanic Black participants (7.2%; 95% CI, 2.4%-12.0%; relative to other racial/ethnic groups) and among individuals in the lowest income groups (10.6%; 95% CI, 7.3%-13.8%; relative to higher income groups). Among a subset of 278 participants with SARS-CoV-2 infection after 12/2021 who also had a history of prior SARS-CoV-2 infection, those with (vs without) a history of long COVID reported greater NMV/r uptake (22.0% vs 7.9%; P = .001). Among those prescribed NMV/r (n = 216), 137 (63%; 95% CI, 57%-70%) reported that NMV/r was helpful for reducing COVID-19 symptoms.

Conclusions

Despite proven effectiveness against severe outcomes, COVID-19 antiviral uptake remains low among those with SARS-CoV-2 infection in the United States. Further outreach to providers and patients to improve awareness of COVID-19 oral antivirals and indications is needed.

Patient Education and Decision Support for Long-Acting Injectable HIV Antiretroviral Therapy: Protocol for Tool Development and Pilot Testing with Ryan White HIV/AIDS Program Medical Case Management Programs in New York

BACKGROUND

Long-acting injectable (LAI) HIV antiretroviral therapy (ART) presents a major opportunity to facilitate and sustain HIV viral suppression, thus improving health and survival among people living with HIV and reducing the risk of onward transmission. However, realizing the public health potential of LAI ART requires reaching patients who face barriers to daily oral ART adherence and thus can clinically benefit from alternative treatment modalities. Ryan White HIV/AIDS Program Part A medical case management (MCM) programs provide an array of services to address barriers to HIV care and treatment among economically and socially marginalized people living with HIV. These programs have demonstrated effectiveness in improving engagement along the continuum of care, but findings of limited program impact on durable viral suppression highlight the need to further innovate and hone strategies to support long-term ART adherence.

OBJECTIVE

This study aims to adapt and expand Ryan White MCM service strategies to integrate LAI ART regimen options, with the larger goal of improving health outcomes in the populations that could most benefit from alternatives to daily oral ART regimens.

METHODS

In 3 phases of work involving patient and provider participants, this study uses role-specific focus groups to elicit perceptions of LAI versus daily oral ART; discrete choice experiment (DCE) surveys to quantify preferences for different ART delivery options and related supports; and a nonrandomized trial to assess the implementation and utility of newly developed tools at 6 partnering Ryan White HIV/AIDS Program Part A MCM programs based in urban, suburban, and semirural areas of New York. Findings from the focus groups and DCEs, as well as feedback from advisory board meetings, informed the design and selection of the tools: a patient-facing, 2-page fact sheet, including frequently asked questions and a side-by-side comparison of LAI with daily oral ART; a patient-facing informational video available on YouTube (Google Inc); and a patient-provider decision aid. Implementation outcomes, measured through provider interviews, surveys, and service reporting, will guide further specification of strategies to integrate LAI ART options into MCM program workflows.

RESULTS

The study was funded in late April 2021 and received approval from the institutional review board in May 2021 under protocol 20-096. Focus groups were conducted in late 2021 (n=21), DCEs ran from June 2022 to January 2023 (n=378), and tools for piloting were developed by May 2023. The trial (May 2023 through January 2024) has enrolled >200 patients.

CONCLUSIONS

This study is designed to provide evidence regarding the acceptability, feasibility, appropriateness, and utility of a package of patient-oriented tools for comparing and deciding between LAI ART and daily oral ART options. Study strengths include formative work to guide tool development, a mixed methods approach, and the testing of tools in real-world safety-net service settings.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05833542; https://clinicaltrials.gov/study/NCT05833542.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56892.

Client preferences for HIV Care Coordination Program features in New York City: latent class analysis of a discrete choice experiment

INTRODUCTION

The PROMISE study, launched in 2018, evaluates the implementation of revisions to the HIV Care Coordination Program (CCP) designed to minimize persistent disparities in HIV outcomes among high-need persons living with HIV in New York City. We conducted a discrete choice experiment (DCE) assessing the preferences of CCP clients to inform improvements to the program's design.

METHODS

Clients chose between two hypothetical CCP options that varied across four program attributes: help with antiretroviral therapy (ART) adherence (directly observed therapy [DOT] vs. remind via phone/text vs. adherence assessment), help with primary care appointments (remind and accompany vs. remind and transport vs. remind only), help with issues other than primary care (coverage and benefits vs. housing and food vs. mental health vs. specialty medical care) and visit location (meet at home vs. via phone/video vs. program visit 30 or 60 minutes away). The latent class analysis identified different preference patterns. A choice simulation was performed to model client preferences for hypothetical CCPs as a whole.

RESULTS

One hundred and eighty-one CCP clients from six sites implementing the revised CCP completed the DCE January 2020-March 2021. Most clients had stable housing (68.5%), reported no problem substance use in the last 3 months (72.4%) and achieved viral suppression (78.5) with only 26.5% receiving DOT within a CCP. 77.3% of responses were obtained before the COVID-19 pandemic. Preferences clustered into three groups. Visit location and ART adherence support were the most important attributes. Group 1 (40%) endorsed telehealth for visit location; telehealth for ART adherence support; and help with securing housing/food; Group 2 (37%) endorsed telehealth for visit location; telehealth for ART adherence support; and staff reminding/arranging appointment transportation; Group 3 (23%) endorsed staff meeting clients at program location and staff working with clients for medication adherence. In the choice simulation, Basic and Medium hypothetical CCPs were endorsed more than Intensive CCPs.

CONCLUSIONS

This DCE revealed a strong preference for telehealth and a relatively low preference for intensive services, such as DOT and home visits; preferences were heterogeneous. The findings support differentiated care and remote service delivery options in the NYC CCP, and can inform improvements to CCP design.

Psychosocial Stressors and Maternal Mental Health in the U.S. During the First Wave of the COVID-19 Pandemic: A Cross-Sectional Analysis

OBJECTIVES

The COVID pandemic has had widespread impacts on maternal mental health. This research aims to examine the relationship between psychosocial stressors and symptoms of depression and anxiety and the extent to which emotional support or resilient coping moderates the relationship between psychosocial stressors and maternal mental health during the first wave of the COVID pandemic.

METHODS

This analysis includes data collected in October and November 2020 from a geographically and sociodemographically diverse sample of 776 mothers in the U.S. with children ≤ 18 years of age. Log binomial models were used to estimate the association between moderate or severe symptoms of anxiety and depression and psychosocial stressors.

RESULTS

Symptoms of moderate or severe anxiety and depression were reported by 37.5% and 37.6% of participants, respectively. Moderate (aRR 2.76 [95% CI 1.87, 4.07]) and high (aRR 4.95 [95% CI 3.40, 7.20]) levels of perceived stress were associated with greater risk of moderate or severe anxiety symptoms. Moderate and high levels of parental burnout were also associated with greater prevalence of moderate or severe anxiety symptoms in multivariable models. Results were similar when examining the relationship among stress, parental burnout, and depressive symptoms. Neither resilient coping nor social support modified the relationship between psychosocial stressors and mental health.

CONCLUSIONS FOR PRACTICE

Evidence-based strategies to reduce stress and parental burnout and improve the mental health of mothers are urgently needed. Strategies focused on bolstering coping and social support may be insufficient to improve maternal mental health during acute public health emergencies.

Seroincidence of SARS-CoV-2 infection prior to and during the rollout of vaccines in a community-based prospective cohort of U.S. adults

Background

Infectious disease surveillance systems, which largely rely on diagnosed cases, underestimate the true incidence of SARS-CoV-2 infection, due to under-ascertainment and underreporting. We used repeat serologic testing to measure N-protein seroconversion in a well-characterized cohort of U.S. adults with no serologic evidence of SARS-CoV-2 infection to estimate the incidence of SARS-CoV-2 infection and characterize risk factors, with comparisons before and after the start of the SARS-CoV-2 vaccine and variant eras.

Methods

We assessed the incidence rate of infection and risk factors in two sub-groups (cohorts) that were SARS-CoV-2 N-protein seronegative at the start of each follow-up period: 1) the pre-vaccine/wild-type era cohort (n=3,421), followed from April to November 2020; and 2) the vaccine/variant era cohort (n=2,735), followed from November 2020 to June 2022. Both cohorts underwent repeat serologic testing with an assay for antibodies to the SARS-CoV-2 N protein (Bio-Rad Platelia SARS-CoV-2 total Ab). We estimated crude incidence and sociodemographic/epidemiologic risk factors in both cohorts. We used multivariate Poisson models to compare the risk of SARS-CoV-2 infection in the pre-vaccine/wild-type era cohort (referent group) to that in the vaccine/variant era cohort, within strata of vaccination status and epidemiologic risk factors (essential worker status, child in the household, case in the household, social distancing).

Findings

In the pre-vaccine/wild-type era cohort, only 18 of the 3,421 participants (0.53%) had ≥1 vaccine dose by the end of follow-up, compared with 2,497/2,735 (91.3%) in the vaccine/variant era cohort. We observed 323 and 815 seroconversions in the pre-vaccine/wild-type era and the vaccine/variant era and cohorts, respectively, with corresponding incidence rates of 9.6 (95% CI: 8.3-11.5) and 25.7 (95% CI: 24.2-27.3) per 100 person-years. Associations of sociodemographic and epidemiologic risk factors with SARS-CoV-2 incidence were largely similar in the pre-vaccine/wild-type and vaccine/variant era cohorts. However, some new epidemiologic risk factors emerged in the vaccine/variant era cohort, including having a child in the household, and never wearing a mask while using public transit. Adjusted incidence rate ratios (aIRR), with the entire pre-vaccine/wild-type era cohort as the referent group, showed markedly higher incidence in the vaccine/variant era cohort, but with more vaccine doses associated with lower incidence: aIRRun/undervaccinated=5.3 (95% CI: 4.2-6.7); aIRRprimary series only=5.1 (95% CI: 4.2-7.3); aIRRboosted once=2.5 (95% CI: 2.1-3.0), and aIRRboosted twice=1.65 (95% CI: 1.3-2.1). These associations were essentially unchanged in risk factor-stratified models.

Interpretation

In SARS-CoV-2 N protein seronegative individuals, large increases in incidence and newly emerging epidemiologic risk factors in the vaccine/variant era likely resulted from multiple co-occurring factors, including policy changes, behavior changes, surges in transmission, and changes in SARS-CoV-2 variant properties. While SARS-CoV-2 incidence increased markedly in most groups in the vaccine/variant era, being up to date on vaccines and the use of non-pharmaceutical interventions (NPIs), such as masking and social distancing, remained reliable strategies to mitigate the risk of SARS-CoV-2 infection, even through major surges due to immune evasive variants. Repeat serologic testing in cohort studies is a useful and complementary strategy to characterize SARS-CoV-2 incidence and risk factors.

Provider preferences for delivery of HIV care coordination services: results from a discrete choice experiment

INTRODUCTION

The PROMISE study was launched in 2018 to assess and document the implementation of changes to an existing HIV Care Coordination Programme (CCP) designed to address persistent disparities in care and treatment engagement among persons with HIV in New York City. We evaluated provider endorsement of features of the CCP to understand drivers of engagement with the programme.

METHODS

We used a discrete choice experiment to measure provider endorsement of four CCP attributes, including: (1) how CCP helps with medication adherence, (2) how CCP helps with primary care appointments, (3) how CCP helps with issues other than primary care and (4) where CCP visits take place (visit location). Each attribute had three to four levels. Our primary outcomes were relative importance and part-worth utilities, measures of preference for the levels of the four CCP program attributes, estimated using a hierarchical-Bayesian multinomial logit model. All non-medical providers in the core CCP positions of patient navigator, care coordinator and programme director or other administrator from each of the 25 revised CCP-implementing agencies were eligible to participate.

RESULTS

We received responses from 152 providers, 68% of whom identified as women, 49% identified as Latino/a, 34% identified as Black and 60% were 30-49 years old. Visit location (28.6%, 95% confidence interval [CI] 27.0-30.3%) had the highest relative importance, followed by how staff help with ART adherence (24.3%, 95% CI 22.4-26.1%), how staff help with issues other than primary care (24.2%, 95% CI 22.7-25.7%) and how staff help with primary care appointments (22.9%, 95% CI 21.7-24.1%). Within each of the above attributes, respectively, the levels with the highest part-worth utilities were home visits 60 minutes from the program or agency (utility 19.9, 95% CI 10.7-29.0), directly observed therapy (utility 26.1, 95% CI 19.1-33.1), help with non-HIV specialty medical care (utility 26.5, 95% CI 21.5-31.6) and reminding clients about and accompanying them to primary care appointments (utility 20.8, 95% CI 15.6-26.0).

CONCLUSIONS

Ongoing CCP refinements should account for how best to support and evaluate the intensive CCP components endorsed by providers in this study.

Food Insecurity During the First Year of COVID-19: Employment and Sociodemographic Factors Among Participants in the CHASING COVID Cohort Study

OBJECTIVE

While much has been reported about the impact of the COVID-19 pandemic on food insecurity, longitudinal data and the variability experienced by people working in various industries are limited. This study aims to further characterize people experiencing food insecurity during the pandemic in terms of employment, sociodemographic characteristics, and degree of food insecurity.

METHODS

The study sample consisted of people enrolled in the Communities, Households and SARS-CoV-2 Epidemiology (CHASING) COVID Cohort Study from visit 1 (April-July 2020) through visit 7 (May-June 2021). We created weights to account for participants with incomplete or missing data. We used descriptive statistics and logistic regression models to determine employment and sociodemographic correlates of food insecurity. We also examined patterns of food insecurity and use of food support programs.

RESULTS

Of 6740 participants, 39.6% (n = 2670) were food insecure. Non-Hispanic Black and Hispanic (vs non-Hispanic White) participants, participants in households with children (vs no children), and participants with lower (vs higher) income and education levels had higher odds of food insecurity. By industry, people employed in construction, leisure and hospitality, and trade, transportation, and utilities industries had the highest prevalence of both food insecurity and income loss. Among participants reporting food insecurity, 42.0% (1122 of 2670) were persistently food insecure (≥4 consecutive visits) and 43.9% (1172 of 2670) did not use any food support programs.

CONCLUSIONS

The pandemic resulted in widespread food insecurity in our cohort, much of which was persistent. In addition to addressing sociodemographic disparities, future policies should focus on the needs of those working in industries vulnerable to economic disruption and ensure those experiencing food insecurity can access food support programs for which they are eligible.