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Background: People with HIV (PWH) have a higher risk of COVID-19 morbidity and mortality. SARS-CoV-2 vaccination is highly effective in preventing severe COVID-19, although medical mistrust may contribute to vaccine hesitancy among PWH. Method(s): PWH from 8 sites in the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) completed the clinical assessment of patient-reported outcomes including a vaccine hesitancy instrument as part of routine care from 2/21-4/22. Participants were defined as vaccine hesitant if they had not yet received the SARS-CoV-2 vaccine and would probably or definitely not receive it. We assessed factors associated with SARS-CoV-2 vaccine hesitancy using logistic regression, and adjusted for demographics, unsuppressed viral load >200 copies/mL, calendar month and time on ART. Result(s): Overall, 3,278 PWH with a median age of 55 responded;19% were female sex at birth;93% were virally suppressed. At the time of survey, 27% reported they had not received the SARS-CoV-2 vaccine, of whom 27% (n=242;7% overall) reported vaccine hesitancy. Of these 242, 82% expressed concerns about vaccine efficacy;86% about side effects;38% reported distrust of healthcare, 53% reported concerns about vaccine contents (i.e. trackers, live virus);and 24% did not perceive risk from COVID-19. Factors associated with vaccine hesitancy included female sex (Adjusted Odds Ratio [AOR] 2.0;95% Confidence Interval (CI): 1.5-2.8;Table), Black vs. White race (AOR 1.8;95% CI: 1.3-2.5), age< 30 years (AOR 2.8;95% CI: 1.5-5.2), South/Midwest vs. Northeast region (AOR 1.7;95% CI: 1.2-2.4), years on ART (0.8;0.7-0.9) and unsuppressed viral load (AOR 2.2;95% CI: 1.4-3.5). Hesitancy decreased over time (AOR 0.9 per month;95% CI: 0.8-0.9). Vaccine side effects were the primary concern for women;vaccine contents for Black PWH and those who were unsuppressed;and lack of perceived COVID-19 risk for youth. Conclusion(s): Vaccine hesitancy was reported by approximately 7% of a U.S. multi-site cohort of PWH, and it was more prevalent among Black PWH, women, youth, those with unsuppressed viral loads, and residents of the South/ Midwest. The association between virologic non-suppression and vaccine hesitancy highlights the intertwined challenge of medical mistrust for both HIV and COVID-19. Although vaccine hesitancy decreased over time, renewed efforts will be needed to address concerns of PWH about the COVID-19 vaccine, given the ongoing need for revaccination with the evolution of the pandemic.
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Background: Disruptions in clinical services during the COVID-19 pandemic could compromise past progress towards meeting U.S. Ending the HIV Epidemic (EHE) goals. We examined changes in the proportion with virologic suppression (VS) before and since the onset of COVID-19 in a multi-site U.S. cohort of people with HIV (PWH) using an interrupted time series design. Method(s): We assessed VS (< 200 copies/mL) trajectories 1/1/2018-1/1/2022, comparing trends before and after March 21, 2020 at 8 HIV clinics within the U.S. Center for AIDS Research Network of Integrated Clinical Systems (CNICS'). Hierarchical mixed-effects logistic regression and interrupted time series analyses examined changes in the trend (i.e., slope) of VS over time, and maximum likelihood estimation was used to account for missing VS data among those lost to follow-up (LTFU) post-COVID-19. Analyses were adjusted for demographics, site, CDC transmission group, CD4 nadir, VS, time on ART. Result(s): Data from 17,999 participants were included, providing a total of 120,918 VS assessments. Median age was 53 (interquartile range 42-61);19% were female sex at birth;the mean time on ART was 9.5 years;18% were unsuppressed at any point;17.7% were LTFU. Among the overall population, prior gains in VS slowed during COVID-19 (adjusted odds ratio [AOR] 0.93 per quarter-year;95% CI: 0.88-0.98;p=0.004;Figure). Greater impacts occurred among women (AOR 0.90;95% CI 0.81-0.99;p=0.05), persons with a history of injection drug use (PWID) (AOR 0.77 95% CI: 0.66-0.90;p=0.001), and Black PWH (AOR 0.90;95% CI: 0.84-0.96;p=0.001) in whom prior positive VS trends plateaued or began to reverse (Figure). VS remained lower among those with unstable housing (AOR 0.44;95% CI: 0.40-0.50;p< 0.001) but stayed unchanged from the pre-pandemic period. Conclusion(s): Previous gains in VS slowed during the COVID-19 pandemic among PWH in a multi-site network of U.S. HIV clinics. Known disparities in VS according to housing status remain unchanged, but VS disparities worsened for PWH who were women, PWID, or Black. Changes in VS trends could be related to socioeconomic impacts of the pandemic, insurance lapses, reduction of in-person clinic services, fear of coming to clinics, or other factors. Renewed investment in HIV public health and clinical services will be vital to achieve the U.S. EHE goals following COVID-19, with additional targeted interventions to support key populations with persistent or worsening disparities needed.
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We are pleased to publish the second regular issue (Volume 12, Issue 2) of Higher Learning Research Communications (HLRC) for 2022. This year, we published two regular issues and a special issue, Education Technologies and COVID-19: Experiences and Lessons Learned. COVID-19 and the implications of the switch to emergency online teaching continue to capture the interest of researchers. In the present issue, some of the manuscripts focus directly on COVID-19;still others examine different aspects of digital teaching and learning. As is typical with the HLRC, articles represent the voices of academics from various parts of the globe, demonstrating the importance and reach of digital education. The focus of the HLRC is on digital teaching and learning, higher education and the public good, and the preparation of students in key 21st-century employability skills, and the present issue reflects each of these focus areas. Summaries of the manuscripts for this issue are provided below. © The Author(s).
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Background: Amid the COVID-19 pandemic, healthcare systems experienced significant challenges, including lower revenues from elective procedures, limited supplies, a massive influx of patients and psychologically distressed employees. National reports of well-being showed striking rates of burnout among healthcare workers. Prior research depicted how the pandemic affected all categories of healthcare workers, yet there is little evidence showing what specific factors hinder each type of employee. Methods: Employees from a large medical center in the Southeastern United States (US) (n=1,130) participated in an online survey, responding to a series of questions about their daily stressors, working conditions, and distress as measured by a 9-item Well-Being Index (WBI), and providing open-ended responses about additional stressors and positive changes in their work. With an analytic sample of 1,037, we used stepwise analysis for each employee group to identify which stressors have a significant association with their overall distress. Using a convergent mixed methods approach, we corroborate our quantitative findings with qualitative themes from the open-ended responses. Results: Among all types of employees i.e., physicians, nurses, Advanced Practice Providers (APPs), Clinical support staff and Non-clinical staff, moral distress was associated with higher WBI distress. Qualitative themes showed employees were mainly concerned with quality of and access to care for patients. Stress triggered by heavy workload in the setting of increased pandemic-related responsibilities and decreased personnel was associated with a high level of WBI distress among all types of employees, whereas other significant stressors differed by role. Conclusions: The COVID-19 pandemic created a myriad of work and non-work-related stressors hindering all healthcare workers' psychological well-being differently. Working conditions and responsibilities for each role are unique. Institutional policies must contemplate the distinctiveness of stressors and distress across employee sub-groups to properly mitigate psychological distress. © 2022 Journal of Hospital Management and Health Policy.
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Background. Little is known about how race and ethnicity, imperfect (albeit accessible) proxies for structural racism, impact COVID-19 incidence among people with HIV (PWH). We report the cumulative incidence and incidence rate ratios (IRR) for COVID-19 in a long-term multi-site cohort of PWH across the US Figure 1. Cumulative incidence of COVID-19 in the CNICS cohort Methods. We examined COVID-19 cumulative incidence and IRR among PWH in care between 3/1/2020 and 12/31/2020 at seven sites in the CFAR Network of Integrated Clinical Systems (CNICS) cohort. We define COVID-19 incident case as having a laboratory-confirmed (RT-PCR/Ag) SARS-CoV-2 positive result or diagnosis verified by chart review. Reinfections were excluded. Results are presented as monthly and quarterly cumulative incidence and IRR with 95% CI stratified by CD4 count, self-reported race/ethnicity, and site. Follow-up was censored on the earliest of diagnosis of COVID-19 disease, loss to follow up, or 12/31/2020 Results. Among 15,780 PWH in care in the CNICS cohort during the study period, 62% were non-white, with a median (IQR) age of 52 (IQR 40-59), 95% were on antiretroviral therapy, 17% had a CD4 count less than 350, and 6% less than 200. Overall, 651 PWH tested positive for COVID-19 for a cumulative incidence of 4.13%. COVID-19 cumulative incidence increased from 0.77% at the end of the first quarter to 4.12% by the end of December 2020. At the peak of the pandemic in December 2020, the cumulative incidence in Black PWH was 1.68 fold higher than in white PWH (p=.033) and 2.35 fold higher in Hispanics than in whites (P< .0001), figure 1. Similarly, the IRR for COVID-19 was 1.71 (95% CI 1.42-2.07) for Black and 2.40 (95% CI 1.91-3.01) for Hispanic PWH relative to white. Although there was variation across sites, reflecting geographic differences in pandemic waves and access to COVID-19 testing, overall individual trends remained the same. COVID-19 cumulative incidence was similar across CD4 cell count strata Conclusion. Our results suggest effects of structural racial disparities on COVID-19 incidence in this diverse population of PWH across the US, with higher and disproportionate rates of COVID-19 in Black and Hispanic PWH. Incidence estimates are conservative because testing was not uniform, and no systematic testing was conducted.
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Background COVID-19 has posed a public health problem leading to considerably higher healthcare costs in the U.S. population. Additionally, social connectedness has been demonstrated to be directly correlated with improved disease management and outcome of treatment. The purpose of the current study was to explore 10-year mortality outcomes of loneliness. Methods We assessed data from the 1999-2008 National Health and Nutrition Examination Survey, with mortality data obtained through 2015. All individuals from this nationally representative study were 20 years and older. Hazard ratios with 95% confidence intervals (CIs) for all-cause and cardiovascular disease (CVD) mortality were estimated using Cox Regression models. Results Out of 994 participants (54% females vs. 46% males) with loneliness, 324 deaths were reported (including 71 CVD deaths) during an average of 10-year follow-up. The hazard ratio for mortality among those experiencing social isolation was 1.28 (95% CI = 1.17-1.39). The adjusted HR for all-cause mortality [1.24 (CI 1.12-1.38, p < 0.05)] and CVD mortality [1.31 (CI 1.09-2.56, p < 0.05)] were significant, after additional adjustment for demographic and health risk factors. There was also an increase in COVID-19 related loneliness search behavior. Conclusions Individuals who experience loneliness have a significantly higher likelihood of overall and CVD-mortality than those who are socially connected. Consequently, addressing loneliness in the face of social distancing and isolation may contribute to lower premature death risk and improve CVD-mortality in this vulnerable population. Key messages Loneliness may longitudinally lead to increased mortality from cardiovascular disease. Future public health interventions should incorporate active efforts to address loneliness.
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Background As many as one out of every three individuals develop depression after stroke. Numerous studies have also shown a link between depression and increased rates of mortality after stroke. Additionally, the risk factors and characteristics of stroke are different between men and women. However, the association between stroke and depression has not been investigated in postmenopausal women in a nationally representative sample. Methods The association between currently active depression [score ≥ 10 on a Patient Health Questionnaire (PHQ)-9 scale] and self-reported history of stroke were assessed among participants from the 2005-2010 National Health and Nutrition Examination Survey (NHANES). All post-menopausal women from the nationally representative NHANES study were included in the analysis. Multivariable complex samples logistic regression was used to calculate multivariate-adjusted odds ratios (ORs) of depression. Results Out of the 3,636 (representative sample=44,110,822) postmenopausal women, the mean age was 62.6 ± 0.33. The ethnic distribution was 77.3% non-Hispanic Whites, 10.9% non-Hispanic Blacks, 7.5% Hispanics, and 4.3% other nationalities. In age-adjusted analysis, individuals with a history of stroke had 2.5-fold higher odds of active depression than those without a history of stroke (OR 2.57, 95% CI 1.57-4.19, p < .001). Controlling for vascular risk factors (diabetes, hypertension, C-reactive protein, and BMI) of depression and socio-demographic risk factors (age, ethnicity, and income level) attenuated the effect (OR 2.16, 95% CI 1.17-3.99, p < .05). Conclusions A significant association between previous stroke and current depression was found in this population, independent of vascular disease risk measures among post-menopausal women. These findings highlight the possible importance of screening for and treating depression among stroke survivors. Longitudinal studies need to be conducted assessing the mental health impact of stroke. Key messages Occurrence of stroke may lead to an increased likelihood of depression, especially among post-menopausal women. Due to the global COVID-19 pandemic, surveillance efforts should include mental health complication including those related to stroke.
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Background: COVID-19 outcomes among people with HIV (PWH) remain inconclusive. We characterized all cases of COVID-19 identified in a long-term multi-site cohort of PWH, as well as factors associated with increasing severity of COVID-19 during the early months of the COVID-19 pandemic. Methods: We examined all PWH with SARS-CoV-2 infection and COVID-19 disease identified from laboratory testing data (RT-PCR, antigen test results) and ICD-10 codes March-July 2020 from seven sites in the CFAR Network of Integrated Clinical Systems (CNICS) cohort. Cases were verified by medical record review. We evaluated predictors of increased disease severity, indicated by hospitalization. Relative risks were estimated using Poisson regression, adjusted for clinical and demographic characteristics using disease risk scores. Results: Among 13,862 PWH in care (20% female, median age 52 (IQR 40-59), 58% Black or Hispanic race/ethnicity), 198 COVID-19 cases were detected during the study period. A higher proportion of PWH with COVID-19 were female (27%), Black or Hispanic (76%), and had BMI ≥30 (45%). No significant differences in CD4+ count (current or lowest) were seen between PWH with and without COVID-19. We found evidence suggesting more unstable housing among COVID-19 cases compared to non-cases (14% vs. 9%). Among PWH with COVID-19, 38 (19%) were hospitalized, 10 (5%) required intensive care, 8 (4%) received invasive mechanical ventilation, and 4 (2%) died. Hospitalization among PWH with COVID-19 was associated with: CD4+ count ≤350 (aRR 1.77;95% CI 1.05, 2.98);age ≥60 (aRR 2.0;95%CI 1.13, 3.54);pre-existing kidney disease with eGFR <60 (aRR 1.76;95% CI 0.99, 3.13);and BMI ≥30 (aRR 1.96;95% CI 1.02, 3.78) (Table). Conclusion: The population frequency of COVID-19 detected in PWH was 1.4%, likely an underestimate of the true frequency of SARS-CoV-2 infection and COVID-19 disease due to evolving testing availability and access over time. A higher proportion of PWH with COVID-19 were Black or Hispanic, in excess of the overrepresentation of people of color with HIV compared to the general population. PWH with decreased eGFR, low CD4+ count, and obesity had greater risk of more severe COVID-19 disease. Our results highlight disparities in risk of COVID-19 acquisition among PWH in the US and indicate additional vigilance in screening and monitoring of COVID-19 among PWH with these characteristics. The expected accrual of additional COVID-19 cases will allow more precise evaluation of the impact of comorbidities. (Figure Presented).