ABSTRACT
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.
ABSTRACT
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.
ABSTRACT
Background: The SARS-CoV-2 pandemic affected care for HIV+ and at-risk persons. The current analyses assess whether the recent Delta Surge (DS) had an impact comparable to the initial pandemic at a Boston community health center (CHC) specializing in HIV care and prevention. Methods: The analyses divided the periods of observation by quarter, comparing the prevalence of HIV and STI tests performed, test positivity, new HIV diagnoses and PrEP starts during 3 quarterly periods: Pre-Pandemic (PP, 12/1/19-2/28/20), Early Pandemic (EP, 3/1/20-5/31/20);DS (6/1/21-8/31/21). Comparisons were made using Student's t tests for means and chi-square tests for proportions. Results: The quarterly N of HIV tests decreased from 5,047 in PP (monthly average=1685) to 1,734 in EP (monthly average=575;p=.017), but increased to 3,973 during the DS (monthly average=1342) (p for EP vs. DS=.037). Although the monthly average of new HIV diagnoses did not significantly decline between PP and EP (7.0 vs. 3.7, p=.206), they increased to a monthly average of 17 during DS (p for EP vs. DS=.031). Virologic suppression rates remained stable, ranging from 92.1% during PP to 90.1% in the EP (p=.375), but rose to 93.6% during DS (p=.032). Total PrEP starts (new and restarts) decreased significantly between PP and EP (monthly average: 176 vs. 91, p=.017), but rebounded during the DS (monthly average=227, p=.233 compared to PP);however, restarts were 63.3% of all PrEP starts during DS compared to only 38.6% PP (p<.00001). Race and ethnicity of patients starting PrEP did not differ across the three periods;however, those who started PrEP during the DS were older (mean=37.1) than those in PP and EP (mean=33.5 and 34.3 respectively, p<.001). The mean number of syphilis, gonorrhea (GC) and chlamydia (CT) tests performed monthly dramatically decreased during EP compared to PP (p=0.01) with a rebound approaching PP levels during DS (p=0.045). Syphilis test positivity rates tended to remain at similar levels throughout the pandemic (p=0.5), but GC/CT positivity increased significantly during EP (p<0.0001), but returned to PP levels during the DS (p=0.476). Conclusion: The onset of the SARS-CoV-2 pandemic was initially asscociated with major decreases in HIV/STI testing, diagnoses, and PrEP starts in a Boston CHC, but by the DS, rates of HIV/STI screening, test positivity, new HIV diagnoses, and PrEP starts/restarts increased, suggesting sexual risk behavior, as well as engagement in care were approaching or exceeding pre-pandemic levels.
ABSTRACT
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).
ABSTRACT
Background: During the COVID-19 pandemic, gay, bisexual and other men who have sex with men (MSM) in the United States (US) have reported similar or fewer sexual partners and reduced access to HIV testing and care. Pre-exposure prophylaxis (PrEP) use has declined. We estimated the potential impact of COVID-19 on HIV incidence and HIV-related mortality among US MSM. Methods: We used a calibrated HIV transmission model for MSM in Baltimore, Maryland, and available data on COVID-19-related disruptions (from national online surveys of US MSM and from a Boston clinic with extensive PrEP experience) to predict impacts of data-driven reductions in sexual partners (0% or 25% - based on different surveys), condom use (5%), HIV testing (20%), viral suppression (VS;10%), PrEP initiations (72%), PrEP use (9%) and ART initiations (50%), exploring different disruption durations. We estimated the median (95% credible interval) relative change in cumulative new HIV infections and HIV-related deaths among MSM over 1 and 5 years from the start of COVID- 19-related disruptions, compared with a scenario without COVID-19-related disruptions. Results: A 6-month 25% reduction in sexual partners among Baltimore MSM, without HIV service changes, could reduce new HIV infections by 12 2%(11 7,12 8%) and 3 0%(2 6,3 4%) over 1 and 5 years, respectively. In the absence of changes in sexual behaviour, the 6-month data-driven disruptions to condom use, testing, VS, PrEP initiations, PrEP use and ART initiations combined were predicted to increase new HIV infections by 10 5%(5 8,16 5%) over 1 year, and by 3 5%(2 1,5 4%) over 5 years. A 25% reduction in partnerships offsets the negative impact of these combined service disruptions on new HIV infections (overall reduction 3 9%(-1 0,7 4%) and 0 0%(-1 4,0 9%) over 1 and 5 years, respectively), but not on HIV-related deaths (corresponding increases 11 0%(6 2,17 7%), 2 6%(1 5,4 3%)). Of the different service disruptions, a 6-month 10% reduction in VS was predicted to have the greatest impact, increasing new infections by 6 4%(2 6,11 9%) and HIV-related deaths by 9 5%(5 2,15 9%) over 1 year, without changes in sexual behaviour. The predicted impacts of reductions in partnerships or VS doubled if they lasted 12 months or if disruptions were twice as large. Conclusion: Maintaining access to ART and adherence support is of the utmost importance to minimise excess HIV-related mortality due to COVID-19 restrictions in the US, even if accompanied by reductions in sexual partnerships.