Let's Connect: Impact Evaluation of an Intervention to Reduce Mental Health Disparities Among People Who are LGBTQ+

Lesbian, gay, bisexual, transgender, queer, or similarly identified (LGBTQ+) people experience substantial mental health disparities compared to heterosexuals. The "Let's Connect" intervention was designed to improve mental health outcomes for LGBTQ+ people. This impact evaluation aimed to assess effectiveness of this intervention during its pilot phase, using a single arm pilot trial. Respondents completed baseline surveys at intervention start, a post survey on the last day of the intervention (at 6 weeks), then a follow-up survey 6 weeks after the intervention ended (at 12 weeks). Pre-post differences in outcomes were analyzed using paired t-tests, chi-square tests, and generalized estimating equations to evaluate impact on mental health outcomes at 6 and 12 weeks, and identify characteristics associated with loss to follow-up. The average value of all three outcome measures decreased substantially between the baseline and post surveys; all of these differences were highly statistically significant, and further decreased between the end of the intervention at 6 weeks and the 12 week follow-up survey. Let's Connect participants did experience substantial improvements in mental health outcomes, on average, between the start and end of this intervention. Further study of this intervention using a randomized design and control group is warranted.

Funding and Delivery of Syringe Services Programs in the United States, 2022

Objectives. To describe the current financial health of syringe services programs (SSPs) in the United States and to assess the predictors of SSP budget levels and associations with delivery of public health interventions. Methods. We surveyed all known SSPs operating in the United States from February to June 2022 (n = 456), of which 68% responded (n = 311). We used general estimating equations to assess factors influencing SSP budget size and estimated the effects of budget size on multiple measures of SSP services. Results. The median SSP annual budget was $100 000 (interquartile range = $20 159‒$290 000). SSPs operating in urban counties and counties with higher levels of opioid overdose mortality had significantly higher budget levels, while SSPs located in counties with higher levels of Republican voting in 2020 had significantly lower budget levels. SSP budget levels were significantly and positively associated with syringe and naloxone distribution coverage. Conclusions. Current SSP funding levels do not meet minimum benchmarks. Increased funding would help SSPs meet community health needs. Public Health Implications. Federal, state, and local initiatives should prioritize sustained SSP funding to optimize their potential in addressing multiple public health crises. (Am J Public Health. 2024;114(4):435-443. https://doi.org/10.2105/AJPH.2024.307583).

Anticipated and Experienced Stigma After Testing Positive for SARS-CoV-2: A Qualitative Study

INTRODUCTION

Stigma has inhibited public health practitioners' influence during the COVID-19 pandemic. We explore the experienced and anticipated stigma of people affiliated with a large university in the United States, using the Health Stigma and Discrimination Framework.

METHODS

We conducted a qualitative secondary substudy of 20 people who tested SARS-CoV-2 positive and 10 who tested negative in the summer of 2020, selected from a study of 3,324 university students and employees.

FINDINGS

No participants reported anticipated stigmatization prior to testing positive. However, eight of 20 participants recounted stigma marking (being marked by COVID-19 diagnosis or membership in a "high-risk" group) or manifestations of stigma after testing positive, including feelings of guilt or shame, and concerns about being judged as selfish or irresponsible. Three described being denied services or social interactions as a result of having had COVID-19, long after their infectiousness ended. Participants noted that clear public health messaging must be paired with detailed scientific information, rather than leaving people to resort to non-experts to understand the science.

DISCUSSION

Public health messaging designed to mitigate spread of SARS-CoV-2 and protect the community may perpetuate stigma and exacerbate inequities. As a result, people may avoid testing or treatment, mistrust public health messaging, or even use risk-increasing behavior as coping mechanisms.

IMPLICATIONS FOR PRACTICE

Intentional use of language that promotes equity and deters discrimination must be high priority for any COVID-19-related public health messaging. Partnership with community leaders to co-create programs and disseminate messaging is a critical strategy for reducing stigma, especially for historically mistreated groups.

Impact of HCV Testing and Treatment on HCV Transmission Among Men Who Have Sex With Men and Who Inject Drugs in San Francisco: A Modelling Analysis

BACKGROUND

Men who have sex with men who ever injected drugs (ever MSM-IDU) carry a high hepatitis C virus (HCV) burden. We estimated whether current HCV testing and treatment in San Francisco can achieve the 2030 World Health Organization (WHO) HCV elimination target on HCV incidence among ever MSM-IDU.

METHODS

A dynamic HCV/HIV transmission model among MSM was calibrated to San Francisco data, including HCV antibody (15.5%, 2011) and HIV prevalence (32.8%, 2017) among ever MSM-IDU. MSM had high HCV testing (79%-86% ever tested, 2011-2019) and diagnosed MSM had high HCV treatment (65% ever treated, 2018). Following coronavirus disease 2019 (COVID-19)-related lockdowns, HCV testing and treatment decreased by 59%.

RESULTS

Among all MSM, 43% of incident HCV infections in 2022 were IDU-related. Among ever MSM-IDU in 2015, HCV incidence was 1.2/100 person-years (95% credibility interval [CrI], 0.8-1.6). Assuming COVID-19-related declines in HCV testing/treatment persist until 2030, HCV incidence among ever MSM-IDU will decrease by 84.9% (95% CrI, 72.3%-90.8%) over 2015-2030. This decline is largely attributed to HCV testing and treatment (75.8%; 95% CrI, 66.7%-89.5%). Slightly greater decreases in HCV incidence (94%-95%) are projected if COVID-19 disruptions recover by 2025 or 2022.

CONCLUSIONS

We estimate that HCV incidence will decline by >80% over 2015-2030 among ever MSM-IDU in San Francisco, achieving the WHO target.

Monitoring SARS-CoV-2 incidence and seroconversion among university students and employees: a longitudinal cohort study in California, June-August 2020

OBJECTIVES

To identify incident SARS-CoV-2 infections and inform effective mitigation strategies in university settings, we piloted an integrated symptom and exposure monitoring and testing system among a cohort of university students and employees.

DESIGN

Prospective cohort study.

SETTING

A public university in California from June to August 2020.

PARTICIPANTS

2180 university students and 738 university employees.

PRIMARY OUTCOME MEASURES

At baseline and endline, we tested participants for active SARS-CoV-2 infection via quantitative PCR (qPCR) test and collected blood samples for antibody testing. Participants received notifications to complete additional qPCR tests throughout the study if they reported symptoms or exposures in daily surveys or were selected for surveillance testing. Viral whole genome sequencing was performed on positive qPCR samples, and phylogenetic trees were constructed with these genomes and external genomes.

RESULTS

Over the study period, 57 students (2.6%) and 3 employees (0.4%) were diagnosed with SARS-CoV-2 infection via qPCR test. Phylogenetic analyses revealed that a super-spreader event among undergraduates in congregate housing accounted for at least 48% of cases among study participants but did not spread beyond campus. Test positivity was higher among participants who self-reported symptoms (incidence rate ratio (IRR) 12.7; 95% CI 7.4 to 21.8) or had household exposures (IRR 10.3; 95% CI 4.8 to 22.0) that triggered notifications to test. Most (91%) participants with newly identified antibodies at endline had been diagnosed with incident infection via qPCR test during the study.

CONCLUSIONS

Our findings suggest that integrated monitoring systems can successfully identify and link at-risk students to SARS-CoV-2 testing. As the study took place before the evolution of highly transmissible variants and widespread availability of vaccines and rapid antigen tests, further research is necessary to adapt and evaluate similar systems in the present context.

2079. Comparison of Recency Assays to Estimate HIV Incidence in the SIENA (eStimating hIv incidEnce amoNg Agyw) Study in Uganda

Background

HIV-1 recent infection testing algorithms (RITAs) use recency assays to estimate population level HIV incidence rates (IRs), and are currently being employed in PrEP trials to estimate background HIV incidence rates (bHIV-IR). The SIENA study was conducted to determine the HIV incidence rate among young women in and around central and mid-western Uganda, and to assess the suitability of different recency assay platforms for use in determining bHIV-IR in future PrEP trials.

Methods

Diagnosis of HIV was confirmed by positive results on both the Alere Determine HIV-1/2 and Oraquick HIV-1/2 rapid tests. Positive samples were analyzed for recent infection using the Sedia HIV-1 Limiting Antigen Avidity Enzyme ImmunoAssay (LAg-EIA; Sedia Biosciences, Beaverton, OR) and the Sedia Asante HIV-1 Rapid Recency Assay (Asante; Sedia Biosciences). The Asante assay was performed by electronic reader (Asante-Reader) or visual read (Asante-Visual). VL was determined by COBAS TaqMan HIV-1 Test (LabCorp, Indianapolis, IN). HIV incidence was calculated based on previously determined MDRI and FRRs that were specific for the study population.

Results

Of 743 women screened, 191 were diagnosed with HIV, of whom 44 (23%) had a viral load of < 75 copies/mL. The 3 recency assays identified between 43 and 57 samples as recent and between 35 and 37 samples when the VL cutoff of < 75 copies/mL was used (Table). When no VL cutoff was used the calculated bHIV-IR was 17.9/100 person-years (PY) for the LAg-EIA, 12.8/100PY for the Asante-Reader and 20.3/100PY for the Asante-Visual. Using the VL cutoff, the calculated bHIV-IR was 11.4/100 PY with the LAg-EIA assay and 10.9/100 PY with the Asante-Reader. No MDRI or FRR for the Asante-Visual with a VL cutoff was available for calculation of the Asante-Visual HIV incidence.

Conclusion

When the RITA included a VL cutoff of 75 cp/mL, the LAg-EIA and Asante assays classified the number of recent and long-term infections similarly, resulting in comparable bHIV-IR results. Overall, these analyses support the use of these recency assays in the RITA to estimate the bHIV-IR in future PrEP trials. Our results demonstrate extremely high prevalence and incidence of HIV in young women in central and mid-western Uganda, highlighting the need for expanded HIV prevention options in these areas.

Disclosures

Stephanie Cox, BS, Gilead Sciences: Paid employee|Gilead Sciences: Stocks/Bonds Shelley N. Facente, PhD, MPH, CDC-funded TRACE program: Grant/Research Support|Gilead Sciences: Advisor/Consultant|Sedia Biosciences Corporation: Grant/Research Support Eduard Grebe, PhD, CDC-funded TRACE program: Grant/Research Support|Gilead Sciences: Advisor/Consultant|Sedia Biosciences Corp: Grant/Research Support Ramin Ebrahimi, MS, Gilead Sciences: Paid employee|Gilead Sciences: Stocks/Bonds Christoph C. Carter, MD, PhD, Gilead Sciences: Employee|Gilead Sciences: Employee|Gilead Sciences: Stocks/Bonds|Gilead Sciences: Stocks/Bonds Christian Callebaut, PhD, Gilead Sciences: Paid employee|Gilead Sciences: Stocks/Bonds Jared Baeten, MD, PhD, Gilead Sciences: Employee|Gilead Sciences: Stocks/Bonds Moupali Das, MD, Gilead Sciences: Employee|Gilead Sciences: Employee|Gilead Sciences: Stocks/Bonds|Gilead Sciences: Stocks/Bonds.

Factors associated with stigma related to HIV pre-exposure prophylaxis (PrEP) use among men who have sex with men (MSM)

BACKGROUND

Pre-exposure prophylaxis (PrEP) is a noteworthy scientific development that increases the opportunities for men who have sex with men (MSM) to prevent HIV infection, but stigma is a major barrier to its uptake. This study aims to determine the associations between PrEP-related stigma and individual characteristics among MSM.

METHODS

Self-reported cross-sectional data were collected from routine-collected electronic healthcare record data from 4084 MSM receiving PrEP in San Francisco, California, between July 2018 and June 2020. Multivariable logistic regression was performed to determine the associations between individual characteristics and PrEP-related stigma, adjusting for age, race, gender identity, injection history, housing status and mental health status.

RESULTS

PrEP-related stigma was experienced by 9.0% of the participants in our study. PrEP-related stigma was significantly associated with being transgender or gender non-conforming (adjusted OR (AOR): 1.81, 95% CI 1.21 to 2.72), having a history of injection drug use (AOR: 2.02, 95% CI 1.18 to 3.46), being unstably housed (AOR: 1.58, 95% CI 1.11 to 2.26) and having mental health concerns (AOR: 1.99, 95% CI 1.35 to 2.92), after controlling for age, race, gender, injection history, housing status and mental health status.

CONCLUSION

Participants who reported being transgender or gender non-conforming, having a history of injection drug use, or having mental health concerns were more likely to report experiencing PrEP-related stigma. It is crucial to develop culturally appropriate interventions to reduce PrEP-related stigma among populations who are at high risk of HIV infection and may benefit strongly from improved PrEP uptake.

Risky business: A mixed methods study of decision-making regarding COVID-19 risk at a public university in the United States

Introduction

Until vaccines became available in late 2020, our ability to prevent the spread of COVID-19 within countries depended largely on voluntary adherence to mitigation measures. However, individual decision-making regarding acceptable COVID-19 risk is complex. To better understand decision-making regarding COVID-19 risk, we conducted a qualitative substudy within a larger Berkeley COVID-19 Safe Campus Initiative (BCSCI) during the summer of 2020, and completed a mixed-methods analysis of factors influencing decision-making.

Materials and methods

We interviewed 20 participants who tested positive for SARS-CoV-2 and 10 who remained negative, and analyzed quantitative survey data from 3,324 BCSCI participants. The BCSCI study enrolled university-affiliated people living in the local area during summer of 2020, collected data on behaviors and attitudes toward COVID-19, and conducted SARS-CoV-2 testing at baseline and endline.

Results

At baseline, 1362 students (57.5%) and 285 non-students (35.1%) said it had been somewhat or very difficult to comply with COVID-19-related mandates. Most-cited reasons were the need to go out for food/essentials, difficulty of being away from family/friends, and loneliness. Eight interviewees explicitly noted they made decisions partially because of others who may be at high risk. We did not find significant differences between the behaviors of students and non-students.

Discussion

Despite prevailing attitudes about irresponsibility of college students during the COVID-19 pandemic, students in our study demonstrated a commitment to making rational choices about risk behavior, not unlike non-students around them. Decision-making was driven by perceived susceptibility to severe disease, need for social interaction, and concern about risk to others. A harm reduction public health approach may be beneficial.

Hepatitis C Elimination During a Global Pandemic: A Case Study of Resilience in Action

Until the COVID-19 pandemic, San Francisco's hepatitis C virus (HCV) elimination initiative, End Hep C SF, was expanding and refining HCV testing and treatment strategies citywide, making progress toward local HCV elimination goals. Although a shelter-in-place health order issued in March 2020 categorized HCV testing as an "essential service," most HCV testing and treatment immediately stopped until COVID-19-safe protocols could be implemented. During the 14 months of pandemic-related organizational closures, End Hep C SF transitioned to a 100% virtual model, maintaining regularly scheduled meetings. Community-based HCV antibody testing decreased 80% from February to April 2020, and HCV treatment initiation also decreased, although both services started to rebound in mid-to-late 2020, partially as a result of End Hep C SF collaborations. End Hep C SF service providers, clinicians, and advocates reported that the continuous communication and common agenda of End Hep C SF-2 principles of the collective impact initiative-served as a familiar touchpoint and helpful source of information during this isolating and uncertain time. Ultimately, End Hep C SF allowed us to continue HCV elimination strategies through 6 lessons learned: maintaining HCV treatment access through telehealth and mobile services; leveraging research studies that provided HCV testing and treatment; offering HCV screening and linkage to care in tandem with COVID-19-related initiatives; being flexible and inventive, such as administering HCV treatment to residents of shelter-in-place hotels; establishing a data dashboard to track HCV testing and treatment; and relying on partnerships to solve problems and avoid burnout.

Acceptability and feasibility of leveraging community-based HIV counselling and testing platforms for same-day oral PrEP initiation among adolescent girls and young women in Eastern Cape, South Africa

INTRODUCTION

Community-based delivery of HIV pre-exposure prophylaxis (PrEP) to South African adolescent girls and young women's (AGYW) could increase access but needs evaluation. We integrated PrEP services via home-based services and pop-up tents into existing community-based HIV testing services (CB-HTS) in Eastern Cape Province, South Africa.

METHODS

After accessing CB-HTS via a "pop-up" tent or home-based services, HIV-negative AGYW aged 16-25 years were invited to complete a baseline questionnaire and referred for PrEP services at a community-based PrEP site co-located with pop-up HTS tents. A 30-day supply of PrEP was dispensed. PrEP uptake, time-to-initiation, cohort characteristics and first medication refill within 90 days were measured using descriptive statistics.

RESULTS

Of the 1164 AGYW who tested for HIV, 825 (74.3%) completed a questionnaire and 806 (97.7%) were referred for community-based PrEP. Of those, 624 (77.4%) presented for PrEP (482/483 [99.8%] from pop-up HTS and 142/323 [44.0%] from home-based HTS), of which 603 (96.6%) initiated PrEP. Of those initiating PrEP following home-based HTS, 59.1% initiated within 0-3 days, 25.6% within 4-14 days and 15.3% took ≥15 days to initiate; 100% of AGYW who used pop-up HTS initiated PrEP the same day. Among AGWY initiating PrEP, 37.5% had a detectable sexually transmitted infection (STI). Although AGYW reported a low self-perception of HIV risk, post-hoc application of HIV risk assessment measures to available data classified most study participants as high risk for HIV acquisition. Cumulatively, 329 (54.6%) AGYW presented for a first medication refill within 90 days of accepting their first bottle of PrEP.

CONCLUSIONS

Leveraging CB-HTS platforms to provide same-day PrEP initiation and refill services was acceptable to AGYW. A higher proportion of AGYW initiated PrEP when co-located with CB-HTS sites compared to those referred following home-based HTS, suggesting that proximity of CB-HTS and PrEP services facilitates PrEP uptake among AGYW. The high prevalence of STIs among those initiating PrEP necessitates the integration of STI and HIV prevention programs for AGYW. Eligibility for PrEP initiation should not be required among AHYW in high HIV burden communities. Community-based service delivery will be crucial to maintaining access to PrEP services during the COVID-19 pandemic and future health and humanitarian emergencies.

Hepatitis C prevalence and key population size estimate updates in San Francisco: 2015 to 2019

BACKGROUND

In 2017, San Francisco's initiative to locally eliminate hepatitis C virus (HCV) as a public health threat, End Hep C SF, generated an estimate of city-wide HCV prevalence in 2015, but only incorporated limited information about population HCV treatment. Using additional data and updated methods, we aimed to update the 2015 estimate to 2019 and provide a more accurate estimate of the number of people with untreated, active HCV infection overall and in key subgroups-people who inject drugs (PWID), men who have sex with men (MSM), and low socioeconomic status transgender women (low SES TW).

METHODS

Our estimates are based on triangulation of data from blood bank testing records, cross-sectional and longitudinal observational studies, and published literature. We calculated subpopulation estimates based on biological sex, age and/or HCV risk group. When multiple sources of data were available for subpopulation estimates, we calculated an average using inverse variance weighting. Plausible ranges (PRs) were conservatively estimated to convey uncertainty.

RESULTS

The total number of people estimated to have anti-HCV antibodies in San Francisco in 2019 was 22,585 (PR:12,014-44,152), with a citywide seroprevalence of 2.6% (PR:1.4%-5.0%)-similar to the 2015 estimate of 21,758 (PR:10,274-42,067). Of all people with evidence of past or present infection, an estimated 11,582 (PR:4,864-35,094) still had untreated, active HCV infection, representing 51.3% (PR:40.5%-79.5%) of all people with anti-HCV antibodies, and 1.3% (PR:0.6%-4.0%) of all San Franciscans. PWID comprised an estimated 2.8% of the total population of San Francisco, yet 73.1% of people with anti-HCV antibodies and 90.4% (n = 10,468, PR:4,690-17,628) of untreated, active HCV infections were among PWID. MSM comprised 7.8% of the total population, yet 11.7% of people with anti-HCV antibodies and 1.0% (n = 119, PR:0-423) of those with untreated active infections. Low SES TW comprised an estimated 0.1% of the total population, yet 1.4% of people with HCV antibodies and 1.6% (n = 183, PR:130-252) of people with untreated active infections.

CONCLUSIONS

Despite the above-average number (2.6%) of people with anti-HCV antibodies, we estimate that only 1.3% (PR:0.6%-4.0%) of all San Francisco residents have untreated, active HCV infection-likely a reflection of San Francisco's robust efforts to diagnose infection among high-risk groups and initiate curative treatment with as many people as possible. While plausible ranges of infections are wide, these findings indicate that while the overall number of people with anti-HCV antibodies may have increased slightly, the number of people with active HCV infection may have decreased slightly since 2015. This estimate improves upon the 2015 calculations by directly estimating the impact of curative treatment citywide and in subgroups. However, more research is needed to better understand the burden of HCV disease among other subgroups at high risk, such as Blacks/African Americans, people with a history of injection drug use (but not injecting drugs in the last 12 months), people who are currently or formerly incarcerated, and people who are currently or formerly unhoused.

Impact of Racial Categorization on Effect Estimates: An HIV Stigma Analysis

Suboptimal racial categorization potentially introduces bias in epidemiologic analysis and interpretation, making it difficult to appropriately measure factors leading to racial health disparities. As part of an analysis focused on predictors of experiencing human immunodeficiency status (HIV)-related stigma among men who have sex with men living with HIV in San Francisco, we struggled with the most appropriate ways to categorize people who reported more than 1 racial identity, and we aimed to explore the implications of different methodological choices in this analysis. We fitted 3 different multivariable linear regression models, each utilizing a different approach to racial categorization: the "multiracial," "othering," and "hypodescent" models. We estimated an adjusted risk difference in mean score for reported frequency of experiencing HIV-related stigma on a 4-point scale, adjusting for age, race, gender identity, injection history, housing, mental health concerns, and viral load. Use of a hypodescent model for racial categorization led to a shift in the point estimate through the null for Blacks/African Americans, and it improved precision for that group. However, it obscured the association of increased stigma and race for multiracial people, compared with monoracial counterparts. We conclude that methodological decisions related to racial categorization of participants can dramatically affect race-related study findings in predictor regression models.

Use of HIV Recency Assays for HIV Incidence Estimation and Other Surveillance Use Cases: Systematic Review

BACKGROUND

HIV assays designed to detect recent infection, also known as "recency assays," are often used to estimate HIV incidence in a specific country, region, or subpopulation, alone or as part of recent infection testing algorithms (RITAs). Recently, many countries and organizations have become interested in using recency assays within case surveillance systems and routine HIV testing services to measure other indicators beyond incidence, generally referred to as "non-incidence surveillance use cases."

OBJECTIVE

This review aims to identify published evidence that can be used to validate methodological approaches to recency-based incidence estimation and non-incidence use cases. The evidence identified through this review will be used in the forthcoming technical guidance by the World Health Organization (WHO) and United Nations Programme on HIV/AIDS (UNAIDS) on the use of HIV recency assays for identification of epidemic trends, whether for HIV incidence estimation or non-incidence indicators of recency.

METHODS

To identify the best methodological and field implementation practices for the use of recency assays to estimate HIV incidence and trends in recent infections for specific populations or geographic areas, we conducted a systematic review of the literature to (1) understand the use of recency testing for surveillance in programmatic and laboratory settings, (2) review methodologies for implementing recency testing for both incidence estimation and non-incidence use cases, and (3) assess the field performance characteristics of commercially available recency assays.

RESULTS

Among the 167 documents included in the final review, 91 (54.5%) focused on assay or algorithm performance or methodological descriptions, with high-quality evidence of accurate age- and sex-disaggregated HIV incidence estimation at national or regional levels in general population settings, but not at finer geographic levels for prevention prioritization. The remaining 76 (45.5%) described the field use of incidence assays including field-derived incidence (n=45), non-incidence (n=25), and both incidence and non-incidence use cases (n=6). The field use of incidence assays included integrating RITAs into routine surveillance and assisting with molecular genetic analyses, but evidence was generally weaker or only reported on what was done, without validation data or findings related to effectiveness of using non-incidence indicators calculated through the use of recency assays as a proxy for HIV incidence.

CONCLUSIONS

HIV recency assays have been widely validated for estimating HIV incidence in age- and sex-specific populations at national and subnational regional levels; however, there is a lack of evidence validating the accuracy and effectiveness of using recency assays to identify epidemic trends in non-incidence surveillance use cases. More research is needed to validate the use of recency assays within HIV testing services, to ensure findings can be accurately interpreted to guide prioritization of public health programming.

Hepatitis C mortality trends in San Francisco: can we reach elimination targets?

PURPOSE

Hepatitis C virus (HCV) is the most common blood-borne infection in the United States, and a leading cause of liver disease, transplant, and mortality. CDC HCV elimination goals include reducing HCV-related mortality by 65% (from 2015) by 2030.

METHODS

We used vital registry data (CDC WONDER) to estimate overall and demographic-specific HCV-related mortality from 1999 to 2019 in San Francisco and then used an exponential model to project progress toward HCV elimination. Local trends were compared to state and national trends.

RESULTS

Between 1999 and 2019, there were 1819 HCV-related deaths in San Francisco, representing an overall age-adjusted mortality rate of 9.4 (95% CI 9.0, 9.9) per 100,000 population. The age-adjusted HCV-related mortality rates were significantly higher among males (13.7), persons aged 55 years and older (28.0), Black and/or African Americans (32.2) compared to other racial groups, and Hispanic/Latinos (11.6) compared to non-Hispanic and/or Latinos. Overall and in most subgroups, mortality rates were lowest between 2015 and 2019. Since 2015, San Francisco observed a significantly larger reduction in agbe-adjusted HCV-related mortality than California or the U.S. Projected age-adjusted HCV-related mortality rates for San Francisco for 2020 and 2030 were 4.7 (95% CI 3.5, 6.2) and 1.1 (95% CI 0.7, 1.8), respectively.

CONCLUSIONS

Based on trends between 2015 and 2019, San Francisco, California, and the U.S. are projected to achieve 65% reduction in HCV-mortality at or before 2030. Based on current trends, San Francisco is projected to achieve this goal earlier.

Feasibility and effectiveness of daily temperature screening to detect COVID-19 in a prospective cohort at a large public university

BACKGROUND

Many persons with active SARS-CoV-2 infection experience mild or no symptoms, presenting barriers to COVID-19 prevention. Regular temperature screening is nonetheless used in some settings, including university campuses, to reduce transmission potential. We evaluated the potential impact of this strategy using a prospective university-affiliated cohort.

METHODS

Between June and August 2020, 2912 participants were enrolled and tested for SARS-CoV-2 by PCR at least once (median: 3, range: 1-9). Participants reported temperature and symptoms daily via electronic survey using a previously owned or study-provided thermometer. We assessed feasibility and acceptability of daily temperature monitoring, calculated sensitivity and specificity of various fever-based strategies for restricting campus access to reduce transmission, and estimated the association between measured temperature and SARS-CoV-2 test positivity using a longitudinal binomial mixed model.

RESULTS

Most participants (70.2%) did not initially have a thermometer for taking their temperature daily. Across 5481 total person months, the average daily completion rate of temperature values was 61.6% (median: 67.6%, IQR: 41.8-86.2%). Sensitivity for SARS-CoV-2 ranged from 0% (95% CI 0-9.7%) to 40.5% (95% CI 25.6-56.7%) across all strategies for self-report of possible COVID-19 symptoms on day of specimen collection, with corresponding specificity of 99.9% (95% CI 99.8-100%) to 95.3% (95% CI 94.7-95.9%). An increase of 0.1 °F in individual mean body temperature on the same day as specimen collection was associated with 1.11 increased odds of SARS-CoV-2 positivity (95% CI 1.06-1.17).

CONCLUSIONS

Our study is the first, to our knowledge, that examines the feasibility, acceptability, and effectiveness of daily temperature screening in a prospective cohort during an infectious disease outbreak, and the only study to assess these strategies in a university population. Daily temperature monitoring was feasible and acceptable; however, the majority of potentially infectious individuals were not detected by temperature monitoring, suggesting that temperature screening is insufficient as a primary means of detection to reduce transmission of SARS-CoV-2.

What Surgeons Want: Access to Online Surgical Education and Peer-to-Peer Counseling-A Qualitative Study

Study Design

Mixed methods study including quantitative data analysis and qualitative analysis of semi-structured interviews.

Objectives

Utilizing information and communication technology can facilitate professional communication within health care on a global scale. This study aimed to identify the educational and peer-to-peer communication needs of craniomaxillofacial (CMF) surgeons across the globe, determine preferred modes of communication, and assess technological and other barriers to online education and peer-to-peer communication.

Methods

We performed semi-structured videoconference interviews of 92 CMF surgeons from around the globe, with the largest number in the Asia/Pacific region, the Middle East, and Latin America. We triangulated quantitative summaries with qualitative themes to improve validity and enable a more comprehensive understanding of participant perspectives.

Results

The interviews revealed 3 main areas of technology use: new surgical technology, technology that enables information exchange, and communication technology. When asked about technology and communication platforms used in the course of their work, 33 participants (36%) mentioned PubMed or other journal-related sites; 25% recalled using YouTube as a resource; 23% described conducting internet searches using Google or other search engines; 21% used WhatsApp groups; and 11% used closed Facebook groups.

Conclusion

CMF surgeons embraced communication technologies that allowed them to quickly obtain knowledge especially on new surgical technology, discuss cases on demand, and maintain strong communication with their global peers.

Hepatitis C Care Cascades for 3 Populations at High Risk: Low-income Trans Women, Young People Who Inject Drugs, and Men Who Have Sex With Men and Inject Drugs

BACKGROUND

To achieve elimination of hepatitis C virus (HCV) infection, limited resources can be best allocated through estimation of "care cascades" among groups disproportionately affected. In San Francisco and elsewhere, these groups include young (age ≤ 30 years) people who inject drugs (YPWID), men who have sex with men who inject drugs (MSM-IDU), and low-income trans women.

METHODS

We developed cross-sectional HCV care cascades for YPWID, MSM-IDU, and trans women using diverse data sources. Population sizes were estimated using an inverse variance-weighted average of estimates from the peer-reviewed literature between 2013 and 2019. Proportions of past/current HCV infection, diagnosed infection, treatment initiation, and evidence of cure (sustained virologic response at 12 weeks posttreatment) were estimated from the literature using data from 7 programs and studies in San Francisco between 2015 and 2020.

RESULTS

The estimated number of YPWID in San Francisco was 3748; 58.4% had past/current HCV infection, of whom 66.4% were diagnosed with current infection, 9.1% had initiated treatment, and 50% had confirmed cure. The corresponding figures for the 8135 estimated MSM-IDU were: 29.4% with past/current HCV infection, 70.3% diagnosed with current infection, 28.4% initiated treatment, and 38.9% with confirmed cure. For the estimated 951 low-income trans women, 24.8% had past/current HCV infection, 68.9% were diagnosed with current infection, 56.5% initiated treatment, and 75.5% had confirmed cure.

CONCLUSIONS

In all 3 populations, diagnosis rates were relatively high; however, attention is needed to urgently increase treatment initiation in all groups, with a particular unmet need among YPWID.

Smoking-Cessation Interventions in Appalachia: A Systematic Review and Meta-Analysis

CONTEXT

Appalachia, a socioeconomically disadvantaged rural region in the eastern U.S., has one of the nation's highest prevalence rates of smoking and some of the poorest health outcomes. Effective interventions that lower smoking rates in Appalachia have great potential to reduce health disparities and preventable illness; however, a better understanding of effective interventions is needed.

EVIDENCE ACQUISITION

This review included trials that evaluated the impact of smoking-cessation programs among populations living in Appalachia. The search was carried out on October 9, 2018 and comprised the Cochrane Central Register of Controlled Trials, Medline, Embase, and Scopus for academic journal articles published in English, with no date restrictions. After preliminary screening, potentially relevant full-text articles were independently reviewed by the authors with a Cohen's κ of 0.72, leading to the final inclusion of 9 articles.

EVIDENCE SYNTHESIS

Eligible studies were assessed qualitatively for heterogeneity and risk of bias. Six of the 9 included studies had extractable data related to dichotomous smoking status and reported a measure of association suitable for inclusion in a meta-analysis. For those 6 studies, the pooled RR and pooled OR were estimated using random effects models, with an I² index demonstrating substantial heterogeneity. A funnel plot of the 6 trials appeared relatively symmetric.

CONCLUSIONS

Participation in smoking-cessation interventions increased the probability of smoking abstinence among Appalachian smokers by an estimated 2.33 times (pooled RR=2.33, 95% CI=1.03, 5.25, p=0.04). Given the low number of studies, their substantial heterogeneity, and high risk of bias, the evidence of the effectiveness of smoking-cessation interventions in Appalachia must be interpreted with caution.

Interpreting HIV diagnostic histories into infection time estimates: analytical framework and online tool

Background

It is frequently of epidemiological and/or clinical interest to estimate the date of HIV infection or time-since-infection of individuals. Yet, for over 15 years, the only widely-referenced infection dating algorithm that utilises diagnostic testing data to estimate time-since-infection has been the ‘Fiebig staging’ system. This defines a number of stages of early HIV infection through various standard combinations of contemporaneous discordant diagnostic results using tests of different sensitivity. To develop a new, more nuanced infection dating algorithm, we generalised the Fiebig approach to accommodate positive and negative diagnostic results generated on the same or different dates, and arbitrary current or future tests – as long as the test sensitivity is known. For this purpose, test sensitivity is the probability of a positive result as a function of time since infection.

Methods

The present work outlines the analytical framework for infection date estimation using subject-level diagnostic testing histories, and data on test sensitivity. We introduce a publicly-available online HIV infection dating tool that implements this estimation method, bringing together 1) curatorship of HIV test performance data, and 2) infection date estimation functionality, to calculate plausible intervals within which infection likely became detectable for each individual. The midpoints of these intervals are interpreted as infection time ‘point estimates’ and referred to as Estimated Dates of Detectable Infection (EDDIs). The tool is designed for easy bulk processing of information (as may be appropriate for research studies) but can also be used for individual patients (such as in clinical practice).

Results

In many settings, including most research studies, detailed diagnostic testing data are routinely recorded, and can provide reasonably precise estimates of the timing of HIV infection. We present a simple logic to the interpretation of diagnostic testing histories into infection time estimates, either as a point estimate (EDDI) or an interval (earliest plausible to latest plausible dates of detectable infection), along with a publicly-accessible online tool that supports wide application of this logic.

Conclusions

This tool, available at https://tools.incidence-estimation.org/idt/, is readily updatable as test technology evolves, given the simple architecture of the system and its nature as an open source project.

Performance comparison of the Maxim and Sedia Limiting Antigen Avidity assays for HIV incidence surveillance

BACKGROUND

Two manufacturers, Maxim Biomedical and Sedia Biosciences Corporation, supply CDC-approved versions of the HIV-1 Limiting Antigen Avidity EIA (LAg) for detecting 'recent' HIV infection in cross-sectional incidence estimation. This study assesses and compares the performance of the two assays for incidence surveillance.

METHODS

We ran both assays on a panel of 2,500 well-characterized HIV-1-infected specimens. We analysed concordance of assay results, assessed reproducibility using repeat testing and estimated mean durations of recent infection (MDRIs) and false-recent rates (FRRs) for a range of normalized optical density (ODn) thresholds, alone and in combination with viral load thresholds. We defined three hypothetical surveillance scenarios, similar to the Kenyan and South African epidemics, and a concentrated epidemic. These scenarios allowed us to evaluate the precision of incidence estimates obtained by means of various recent infection testing algorithms (RITAs) based on each of the two assays.

RESULTS

The Maxim assay produced lower ODn values than the Sedia assay on average, largely as a result of higher calibrator readings (mean OD of 0.749 vs. 0.643), with correlation of normalized readings lower (R2 = 0.908 vs. R2 = 0.938). Reproducibility on blinded control specimens was slightly better for Maxim. The MDRI of a Maxim-based algorithm at the 'standard' threshold (ODn ≤1.5 & VL >1,000) was 201 days (95% CI: 180,223) and for Sedia 171 (152,191). The difference Differences in MDRI were estimated at 32.7 (22.9,42.8) and 30.9 days (21.7,40.7) for the two algorithms, respectively. Commensurately, the Maxim algorithm had a higher FRR in treatment-naive subjects (1.7% vs. 1.1%). The two assays produced similar precision of incidence estimates in the three surveillance scenarios.

CONCLUSIONS

Differences between the assays can be primarily attributed to the calibrators supplied by the manufacturers. Performance for surveillance was extremely similar, although different thresholds were optimal (i.e. produced the lowest variance of incidence estimates) and at any given ODn threshold, different estimates of MDRI and FRR were obtained. The two assays cannot be treated as interchangeable: assay and algorithm-specific performance characteristic estimates must be used for survey planning and incidence estimation.

Challenges to the performance of current HIV diagnostic assays and the need for centralized specimen archives: a review of the Consortium for the Evaluation and Performance of HIV Incidence Assays (CEPHIA) repository

Background: New challenges for diagnosis of HIV infection abound, including the impact on key viral and immunological markers of HIV vaccine studies, pre-exposure prophylaxis usage and breakthrough infections, and very early initiation of anti-retroviral treatment. These challenges impact the performance of current diagnostic assays, and require suitable specimens for development and evaluation. In this article we review and describe an archive developed by the Consortium for the Evaluation and Performance of HIV Incidence Assays (CEPHIA), in order to identify the critical features required to create a centralized specimen archive to support these current and future developments. Review and Findings: We review and describe the CEPHIA repository, a large, consolidated repository comprised of over 31,000 highly-selected plasma samples and other body fluid specimen types, with over 50 purposely designed specimen panels distributed to 19 groups since 2012. The CEPHIA repository provided financial return on investment, supported the standardization of HIV incidence assays, and informed guidance and standards set by the World Health Organization and UNAIDS. Unified data from extensively characterized specimens has allowed this resource to support biomarker discovery, assay optimization, and development of new strategies for estimating duration of HIV infection. Critical features of a high-value repository include 1) extensively-characterized samples, 2) high-quality clinical background data, 3) multiple collaborations facilitating ongoing sample replenishment, and 4) sustained history of high-level specimen utilization. Conclusion: With strong governance and leadership, a large consolidated archive of samples from multiple studies provides investigators and assay developers with easy access to diverse samples designed to address challenges associated with HIV diagnosis, helping to enable improvements to HIV diagnostic assays and ultimately elimination of HIV. Its creation and ongoing utilization should compel funders, institutions and researchers to address and improve upon current approaches to sharing specimens.

Localized US Efforts to Eliminate Hepatitis C

The United States has national plans for the elimination of hepatitis C virus but much of US health care is organized on the state level and requires local solutions. This article describes the plans developed by New York, Massachusetts, and the city/county of San Francisco for hepatitis C virus elimination. Coalitions capitalize on existing resources and advocate for new resources to address barriers in hepatitis C virus care. Although each coalition has distinct plans, all share a commitment to groups that are disproportionately affected and are at risk for being excluded from advances in hepatitis C virus treatment and cure.

New Treatments Have Changed the Game: Hepatitis C Treatment in Primary Care

In the pre-direct-acting antiviral era, hepatitis C virus (HCV) treatments were complex and largely managed by hepatologists, gastroenterologists, and infectious disease physicians. As direct-acting antivirals have driven up demand for treatment, the relative scarcity of these specialists has created a bottleneck effect, resulting in only a fraction of HCV-infected individuals offered treatment. The San Francisco Health Network is a safety net system of care. Its intervention was designed to be sustainable and scalable; with minimal time commitments for training providers, primary care-based HCV treatment increased 3-fold in a period of just over 3 years.

Correction: Estimated hepatitis C prevalence and key population sizes in San Francisco: A foundation for elimination

[This corrects the article DOI: 10.1371/journal.pone.0195575.].

HIV Antibody Level as a Marker of HIV Persistence and Low-Level Viral Replication

Background

Human immunodeficiency virus (HIV) antibodies are generated and maintained by ongoing systemic expression of HIV antigen. We investigated whether HIV antibody responses as measured by high-throughput quantitative and qualitative assays could be used to indirectly measure persistent HIV replication in individuals receiving antiretroviral therapy (ART).

Methods

HIV antibody responses were measured over time in the presence or absence of suppressive ART and were compared to the HIV reservoir size and expression of antiviral restriction factors.

Results

Among untreated individuals, including both elite controllers (ie, persons with a viral load of ≤40 copies/mL) and noncontrollers, antibody parameters were stable over time and correlated with the individual viral load. Viral suppression with ART led to a progressive decline in antibody responses after treatment induction that persisted for 5-7 years. Higher levels of HIV antibodies during suppressive therapy were associated with later initiation of ART after infection, with higher DNA and cell-associated RNA levels, and with lower expression of multiple anti-HIV host restriction factors.

Discussion

These findings suggest that declining antibody levels during ART reflect lower levels of antigen production and/or viral replication in the persistent HIV reservoir. Results of relatively inexpensive and quantitative HIV antibody assays may be useful indirect markers that enable efficient monitoring of the viral reservoir and suppression during functional-cure interventions.

Viral load criteria and threshold optimization to improve HIV incidence assay characteristics

OBJECTIVE

Assays for classifying HIV infections as 'recent' or 'nonrecent' for incidence surveillance fail to simultaneously achieve large mean durations of 'recent' infection (MDRIs) and low 'false-recent' rates (FRRs), particularly in virally suppressed persons. The potential for optimizing recent infection testing algorithms (RITAs), by introducing viral load criteria and tuning thresholds used to dichotomize quantitative measures, is explored.

DESIGN

The Consortium for the Evaluation and Performance of HIV Incidence Assays characterized over 2000 possible RITAs constructed from seven assays (Limiting Antigen, BED, Less-sensitive Vitros, Vitros Avidity, BioRad Avidity, Architect Avidity, and Geenius) applied to 2500 diverse specimens.

METHODS

MDRIs were estimated using regression, and FRRs as observed 'recent' proportions, in various specimen sets. Context-specific FRRs were estimated for hypothetical scenarios. FRRs were made directly comparable by constructing RITAs with the same MDRI through the tuning of thresholds. RITA utility was summarized by the precision of incidence estimation.

RESULTS

All assays produce high FRRs among treated patients and elite controllers (10-80%). Viral load testing reduces FRRs, but diminishes MDRIs. Context-specific FRRs vary substantially by scenario - BioRad Avidity and Limiting Antigen provided the lowest FRRs and highest incidence precision in scenarios considered.

CONCLUSION

The introduction of a low viral load threshold provides crucial improvements in RITAs. However, it does not eliminate nonzero FRRs, and MDRIs must be consistently estimated. The tuning of thresholds is essential for comparing and optimizing the use of assays. The translation of directly measured FRRs into context-specific FRRs critically affects their magnitudes and our understanding of the utility of assays.

Performance of risk-based criteria for targeting acute HIV screening in San Francisco

Background

Federal guidelines now recommend supplemental HIV RNA testing for persons at high risk for acute HIV infection. However, many rapid HIV testing sites do not include HIV RNA or p24 antigen testing due to concerns about cost, the need for results follow-up, and the impact of expanded venipuncture on clinic flow. We developed criteria to identify patients in a municipal STD clinic in San Francisco who are asymptomatic but may still be likely to have acute infection.

Methods

Data were from patients tested with serial HIV antibody and HIV RNA tests to identify acute HIV infection. BED-CEIA results were used to classify non-acute cases as recent or longstanding. Demographics and self-reported risk behaviors were collected at time of testing. Multivariate models were developed and preliminarily evaluated using predictors associated with recent infection in bivariate analyses as a proxy for acute HIV infection. Multivariate models demonstrating ≥70% sensitivity for recent infection while testing ≤60% of patients in this development dataset were then validated by determining their performance in identifying acute infections.

Results

From 2004–2007, 137 of 12,622 testers had recent and 36 had acute infections. A model limiting acute HIV screening to MSM plus any one of a series of other predictors resulted in a sensitivity of 83.3% and only 47.6% of patients requiring testing. A single-factor model testing only patients reporting any receptive anal intercourse resulted in 88.9% sensitivity with only 55.2% of patients requiring testing.

Conclusions

In similar high risk HIV testing sites, acute screening using “supplemental” HIV p24 antigen or RNA tests can be rationally targeted to testers who report particular HIV risk behaviors. By improving the efficiency of acute HIV testing, such criteria could facilitate expanded acute case identification.

False positive rate of rapid oral fluid HIV tests increases as kits near expiration date

Background

Because a recent cluster of false positive results on the OraQuick ADVANCE® Rapid HIV-1/2 Antibody Test occurred in San Francisco on test kits close to their expiration date, we decided to assess the relationship between time to expiration and rate of false positive results from tests used with oral fluid.

Methodology/Principal Findings

We analyzed results of 20,904 tests with either an initial HIV-negative result (n = 20,828) or a preliminary positive result that was then negative on confirmatory tests (n = 76). We computed specificity for kits with time to expiration from ≤1 to ≥6 months, with exact binomial confidence intervals, then used logistic regression to estimate the independent association of time to expiration with false positive results, adjusting for site and technician effects. For 1,108 kits used in the last month before expiration, specificity was 98.83% (95% exact binomial confidence interval (CI) 98.00%–99.37%); the upper bound is below the claimed specificity of 99.60%. After adjustment using regression standardization for the effects of site, test lot, and technician factors, adjusted specificity in the last month before expiration was 99.18% (95% bootstrap confidence interval 98.60–99.57%).

Conclusions/Significance

We found that specificity of the OraQuick ADVANCE® with oral fluid declined significantly with ≤1 month remaining to expiration, leaving little margin for error from other sources.

Post-marketing surveillance of OraQuick whole blood and oral fluid rapid HIV testing

OBJECTIVE

Post-marketing surveillance was conducted to monitor the performance of the OraQuick Advance rapid HIV-1/2 antibody test (OraQuick) on whole blood and oral fluid.

DESIGN

Surveillance of routinely collected data on clients tested with OraQuick in 368 testing sites affiliated with 17 state and city health departments between 11 August 2004 and 30 June 2005.

METHODS

For whole blood and oral fluid, we report the median (range) health department OraQuick specificity and positive predictive value (PPV), and the number of clients with discordant results (e.g. who had a reactive rapid test not confirmed positive by Western blot or indirect immunofluorescence). At one site with lower than expected oral-fluid specificity, we evaluated whether device expiration, manufacturing lot, operator practices, or device-storage or testing-area temperatures were associated with false-positive tests.

RESULTS

During the surveillance period, 135 724 whole blood and 26 066 oral fluid rapid tests were conducted. The median health department whole blood OraQuick specificity was 99.98% (range: 99.73-100%) and PPV was 99.24% (range: 66.67-100%); the median oral fluid specificity was 99.89% (range: 99.44-100%) and PPV was 90.00% (range: 50.00-100%). A total of 124 discordant results were reported from 68 (0.05%) whole blood and 56 (0.22%) oral fluid rapid tests. The oral fluid specificity at the site with excess oral fluid false-positive tests was 98.7% (95% confidence interval: 98.18-99.11%). The increase in false-positive tests at that site was not associated with any specific device characteristic, operator procedure or temperature condition.

CONCLUSION

The specificity of OraQuick performed on whole blood and oral fluid during post-marketing surveillance was compatible with the manufacturer's claim within the package insert. However, one site experienced lower than expected oral fluid specificity. Sites that observe that the specificity of OraQuick is lower than the range indicated in the package insert should notify the manufacturer and evaluate quality assurance procedures.