Projecting the Clinical and Economic Impacts of Changes to HIV Care Among Adolescents and Young Adults in the United States: Lessons From the COVID-19 Pandemic

BACKGROUND

During the COVID-19 pandemic, many US youth with HIV (YHIV) used telehealth services; others experienced disruptions in clinic and antiretroviral therapy (ART) access.

METHODS

Using the Cost-effectiveness of Preventing AIDS Complications (CEPAC)-Adolescent HIV microsimulation model, we evaluated 3 scenarios: 1) Clinic: in-person care; 2) Telehealth: virtual visits, without CD4 or viral load monitoring for 12 months, followed by return to usual care; and 3) Interruption: complete care interruption with no ART access or laboratory monitoring for 6 months (maximum clinic closure time), followed by return to usual care for 80%. We assigned higher 1-year retention (87% vs 80%) and lower cost/visit ($49 vs $56) for Telehealth vs Clinic. We modeled 2 YHIV cohorts with non-perinatal (YNPHIV) and perinatal (YPHIV) HIV, which differed by mean age (22 vs 16 years), sex at birth (85% vs 47% male), starting CD4 count (527/μL vs 635/μL), ART, mortality, and HIV-related costs. We projected life months (LMs) and costs/100 YHIV over 10 years.

RESULTS

Over 10 years, LMs in Clinic and Telehealth would be similar (YNPHIV: 11 350 vs 11 360 LMs; YPHIV: 11 680 LMs for both strategies); costs would be $0.3M (YNPHIV) and $0.4M (YPHIV) more for Telehealth than Clinic. Interruption would be less effective (YNPHIV: 11 230 LMs; YPHIV: 11 620 LMs) and less costly (YNPHIV: $1.3M less; YPHIV: $0.2M less) than Clinic. Higher retention in Telehealth led to increased ART use and thus higher costs.

CONCLUSIONS

Telehealth could be as effective as in-person care for some YHIV, at slightly increased cost. Short interruptions to ART and laboratory monitoring may have negative long-term clinical implications.

Diurnal Range and Intra-patient Variability of ACTH Is Restored With Remission in Cushing's Disease

CONTEXT

Single ACTH measurements have limited ability to distinguish patients with Cushing's disease (CD) from those in remission or with other conditions.

OBJECTIVE

To investigate the changes in ACTH levels before and after transsphenoidal surgery (TSS) to identify trends that could confirm remission from CD and help establish ACTH cutoffs for targeted clinical trials in CD.

DESIGN

Retrospective analysis of CD patients who underwent TSS from 2005 to -2019.

SETTING

Referral center.

PATIENTS

CD patients (n = 253) with ACTH measurements before and after TSS.

INTERVENTIONS

TSS for CD.

MAIN OUTCOME MEASURES

Remission after TSS.

RESULTS

Remission was observed in 223 patients after TSS. Those in remission had higher ACTH variability at AM (P = .02) and PM (P < .001) time points compared to nonremission. The nonremission group had a significantly narrower diurnal range compared to the remission group (P = <.0001). A decrease in plasma ACTH of ≥50% from mean preoperative levels predicted CD remission after TSS, especially when using PM values. The absolute plasma ACTH concentration and ratio of preoperative to postoperative values were significantly associated with nonremission after multivariable logistic regression (adj P < .001 and .001, respectively).

CONCLUSIONS

Our findings suggest that ACTH variability is suppressed in CD, and remission from CD is associated with the restoration of this variability. Furthermore, a decrease in plasma ACTH by 50% or more may serve as a predictor of remission post-TSS. These insights could guide clinicians in developing rational outcome measures for interventions targeting CD adenomas.

In Silico, In Vitro, and In Vivo Analysis Identifies Endometrial Circadian Clock Genes in Recurrent Implantation Failure

CONTEXT

Previous work has demonstrated the role of the circadian clock in ovarian steroid hormone synthesis and attributed embryo implantation failure associated with arrhythmic circadian clock genes to insufficient ovarian-derived progesterone synthesis. Research on expression of core circadian clock genes in the endometrium itself and possible roles in compromised endometrial receptivity and recurrent implantation failure (RIF) are limited.

OBJECTIVE

We aimed to assess the core circadian clock gene profiling in human endometrium across the menstrual cycle and the possible gene interaction networks in the endometrial receptivity of window of implantation (WOI) as well as RIF.

METHODS

The study was initially an in silico study, with confirmatory lab-based data from primary human endometrial stromal cells (hESCs) as well as endometrial biopsies obtained from 60 women undergoing gynecological surgery in a clinical research center. The study included 30 RIF women and 30 age-matched and body mass index-matched controls.

RESULTS

Initial data mining and bioinformatics analysis of human endometrial microarray datasets across the menstrual cycle and between RIF women versus controls demonstrated the varied expression of core circadian clock genes across menstrual cycle, including the key role of PER2 in WOI and RIF. A PER2-centered network was investigated in the regulation of endometrial receptivity. We also confirmed the evidently increased mRNA expression of SHTN1, RXFP1, KLF5, and STEAP4 in the endometrium of RIF women, displaying the same trend as PER2 did, without any changes in MT1E and FKBP5. Treatment of PER2 siRNA in hESCs verified the positive regulation of PER2 to SHTN1, KLF5, and STEAP4.

CONCLUSION

Aberrant expression of endometrial PER2 might contribute to impaired endometrial receptivity and development of RIF via regulating SHTN1, KLF5, and STEAP4.

Reducing underreporting of abortion in surveys: Results from two test applications of the list experiment method in Malawi and Senegal

BACKGROUND

Accurately measuring abortion incidence poses many challenges. The list experiment is a method designed to increase the reporting of sensitive or stigmatized behaviors in surveys, but has only recently been applied to the measurement of abortion. To further test the utility of the list experiment for measuring abortion incidence, we conducted list experiments in two countries, over two time periods.

MATERIALS AND METHODS

The list experiment is an indirect method of measuring sensitive experiences that protects respondent confidentiality by hiding individual responses to a binary sensitive item (i.e., abortion) by combining this response with answers to other non-sensitive binary control items. Respondents report the number of list items that apply to them, not which ones. We conducted a list experiment to measure cumulative lifetime incidence of abortion in Malawi, and separately to measure cumulative five-year incidence of abortion in Senegal, among cisgender women of reproductive age.

RESULTS

Among 810 eligible respondents in Malawi, list experiment results estimated a cumulative lifetime incidence of abortion of 0.9% (95%CI: 0.0, 7.6). Among 1016 eligible respondents in Senegal, list experiment estimates indicated a cumulative five-year incidence of abortion of 2.8% (95%CI: 0.0, 10.4) which, while lower than anticipated, is seven times the proportion estimated from a direct question on abortion (0.4%).

CONCLUSIONS

Two test applications of the list experiment to measure abortion experiences in Malawi and Senegal likely underestimated abortion incidence. Future efforts should include context-specific formative qualitative research for the development and selection of list items, enumerator training, and method delivery to assess if and how these changes can improve method performance.

Retrospective Review of Pharmacogenetic Testing at an Academic Children's Hospital

There is limited evidence to support pharmacogenetic (PGx) testing in children. We conducted a retrospective review of PGx testing among 452 patients at an academic children's hospital to determine the potential utility of PGx in diseases of childhood and to identify targets for future pediatric pharmacogenetic research. An actionable gene-drug pair associated with the 28 genes tested (Clinical Pharmacogenetics Implementation Consortium (CPIC) level A or B, Pharmacogenomics Knowledge Base (PharmGKB) level 1A or B, or US Food and Drug Administration (FDA) recommendation and a PharmGKB level) was present in 98.7% of patients. We identified 203 actionable gene-drug-diagnosis groups based on the indications for each actionable drug listed in Lexicomp. Among patients with an actionable gene-drug-diagnosis group, 49.3% had a diagnosis where the drug was a therapeutic option and PGx could be used to guide treatment selection. Among patients with an associated diagnosis, 30.9% had a prescription for the actionable drug allowing PGx guided dosing. Three genes (CYP2C19, CYP2D6, and CYP3A5) accounted for all the gene-drug-diagnosis groups with matching diagnoses and prescriptions. The most common gene-drug-diagnosis groups with matching diagnoses and prescriptions were CYP2C19-citalopram-escitalopram-depression 3.3% of patients tested; CYP2C19-dexlansoprazole-gastritis-esophagitis 3.1%; CYP2C19-omeprazole-gastritis-esophagitis 2.4%; CYP2D6-atomoxetine-attention deficit hyperactivity disorder 2.2%; and CYP2C19-citalopram-escitalopram-obsessive-compulsive disorder 1.5%. PGx could be used to guide selection of current treatment options or medication dosing in almost half (48.7%) of pediatric patients tested. Mood disorders and gastritis/esophagitis are promising targets for future study of PGx testing because of the high prevalence of these diagnoses and associated actionable gene-drug pairs in the pediatric population.

Community Influences on Female Genital Mutilation/Cutting: A Comparison of Four Francophone West African Countries

Despite long-term efforts to encourage abandonment of female genital mutilation/cutting (FGMC), the practice remains widespread globally. FGMC is situated in specific social and historical contexts, and both prevalence and rates of decline vary widely across practicing countries. However, cross-national comparative research on the determinants of FGMC is sparse. This paper adds to the limited body of rigorous, theoretically grounded quantitative studies of FGMC and takes a step toward advancing cross-national comparative research. We apply an integrated theoretical framework that brings together norms-based and gender-based explanations of community-level influences on FGMC. We test this framework in four francophone West African countries, drawing on comparable nationally representative data from the Demographic and Health Surveys in Burkina Faso (2010), Côte d'Ivoire (2011-2012), Guinea (2012), and Mali (2012-2013). Results show that community-level FGMC norms and community-level gendered opportunities are associated with girls' risk of FGMC, but that the direct and moderating associations vary qualitatively across countries. Our findings highlight the contribution of context-specific social and institutional processes to the decline or persistence of FGMC.