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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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INTRODUCTION: To examine the patient-centered outcomes and the occurrence of lung fibrotic changes on Chest computed tomography (CT) imaging following pneumonia-related acute respiratory distress syndrome (ARDS). We sought to investigate outpatient clinic chest CT imaging in survivors of COVID19-related ARDS and non-COVID-related ARDS, to determine group differences and explore relationships between lung fibrotic changes and functional outcomes. METHOD(S): Retrospective practice analysis of electronic health records at an ICU Recovery Clinic in tertiary academic medical center. RESULT(S): One-hundred four patients with mean age 54 +/- 13 and 52% male were included (n=74 COVID-19 and n=30 non-COVID groups). There were no differences for age, sex, mechanical ventilation duration, tracheotomy, or sequential organ failure assessment (SOFA) scores between two groups. Six-weeks after hospital discharge, fibrotic changes visualized on CT imaging occurred in a higher proportion of COVID-19 survivors (69%) compared to non-COVID (43%, chi2 = 5.6, p = 0.018). In general, across both groups, patients with fibrotic changes (n=64) were older, had a lower BMI, and had longer duration of mechanical ventilation. Overall, patients performed poorly on six-minute walk test (44 +/- 27% of predictive distance), had poor respiratory function (FEV1% = 66 +/- 27% and FVC% = 65 +/- 20%), and had high occurrences of anxiety, depression, emotional distress, and mild cognitive impairment regardless of presence of fibrotic changes. CONCLUSION(S): Patients surviving pneumonia-ARDS are at high risk of impairments in physical, emotional, and cognitive health related to Post-Intensive Care Syndrome. Of clinical importance, pulmonary fibrotic changes on chest CT occurred in a higher proportion in COVID-ARDS group;however, no differences were measured in spirometry or functional assessments at six weeks post hospital discharge. Whether COVID infection imparts a unique recovery is not evident from these data but suggest that long-term follow up is necessary for all survivors of ARDS.
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Aims: To describe longitudinal associations between health-related quality of life (HR-QoL) scores and demographic, clinical, and health behavioral characteristics in a multisite U.S. cohort of adults in HIV care. Method(s): People with HIV (PWH) completed an electronic assessment of patient-reported outcomes (PROs) as part of routine clinical care between 2016 and 2021 including measures for HR-QoL (EQ-5D-3L), substance use (ASSIST, AUDIT/AUDIT-C), smoking, and HIV stigma, among others. We used generalized linear latent and mixed models with nonparametric random effects for the intercept term to accommodate repeated measures on individuals to examine longitudinal factors associated with HR-QoL overall and stratified by birth-sex. Result(s): PWH (n = 10,559, median age at first assessment = 49, 17.8% cis-gender women, 1.4% transgender women;68.3% non-White) completed 33,866 assessments. Lower HR-QoL scores were associated with increasing age (p <= 0.0001);identifying as female (cis or transgender) compared to cisgender male (p <= 0.0001, p = 0.005, respectively);living in the Southeast or Western US relative to Northeast (both p <= 0.0001);identifying as a sexual orientation other than gay (heterosexual p = 0.03, bisexual p = 0.009, other p <= 0.0001);higher internalized HIV stigma (p <= 0.0001);current or former smoking (both p <= 0.0001);past methamphetamine use (p = 0.015) and current cocaine/crack, methamphetamine, opioid and cannabis use (p <= 0.0001 for each except cannabis, which was p = 0.007). Higher HR-QoL scores were associated with race/ethnicities other than White (Black: p = 0.002, Hispanic: p = 0.002, other: p <= 0.0001);the COVID-19 pandemic period (March 2020-December 2021) (p <= 0.0001);and increased AUDIT/AUDIT-C score (p = 0.001). In sex stratified models men (n = 8666) had higher HR-QoL scores among non-white compared to white (Black p = 0.0006, Hispanic p = 0.007, Other p <= 0.0001);and during the COVID period (p <= 0.0001). Men had lower HR-QoL scores among heterosexual and bisexual men relative to gay (p = 0.004, p = 0.005), if they were a former smoker (p <= 0.0001), and among past or current methamphetamine users relative to nonusers (p = 0.002, p <= 0.0001). Women (n = 1893) had higher HR-QoL scores if in care longer (p = 0.005), and lower HR-QoL if in the South (p <= 0.0001), if previously used cocaine/crack (p <= 0.0001), or if currently uses marijuana (p = 0.001). Conclusion(s): Our findings describe HR-QoL and its associations among a large diverse cohort of PWH, identifying potentially modifiable factors to improve HR-QoL, such as substance use, smoking, and impact of HIV-related stigma.
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Over the course of the COVID-19 pandemic, the contributions of the social sciences to discussions about pandemic management have become more visible and more significant. In this essay, I review major aspects of a sociology of the pandemic. After providing an overview of the potential contributions of the different fields of sociology (the “toolbox” of sociology), I discuss two main domains: first, social inequalities and how they relate to the process of the spread of COVID-19 from exposure and infection, and to the consequences of the pandemic in the wider population;and, second, the potential long-term effects of the pandemic on the life course. © 2022. All Rights Reserved.
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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.
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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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PURPOSE/HYPOTHESIS: Patients surviving critical COVID-19 are at risk of developing Post Intensive Care Syndrome (PICS), which may lead to deficits in concurrent multi-tasking or the ability to perform a motor and cognitive task simultaneously i.e., a dual-task (DT). To our knowledge no study has assessed DT in survivors of critical COVID-19. Thus, the primary aim of this study was to examine DT performance in patients recovering from critical COVID-19. Secondarily, we examined the psychometric properties of the Timed Up-and-Go (TUG) and DTTUG in patients recovering COVID-19. NUMBER OF SUBJECTS: Thirty-one survivors of COVID-19 requiring mechanical ventilation (COVID+MV) (Age: 55.6 (11.6);BMI: 36.2 (9.0);Sex:Female: 13 (43.3%)), 17 patients recovering from COVID-19 requiring supplemental oxygen with hospitalization (COVID+O2) (Age: 60.4 (9.8);BMI: 35.1 (7.0);Sex:Female:8 (57%)), and 24 patients with chronic lung disease (CLD) (Age: 65.5 (8.8);BMI: 31.1 (7.1);Sex:Female: 12 (50%)). MATERIALS AND METHODS: A prospective, cross-sectional study was conducted and performed 1- and 3-months after hospital discharge for patients post-COVID-19 or at initiation of outpatient physical therapy for patients with CLD. Patients completed the TUG and DT-TUG. A subset of 19 COVID+MV patients returned for follow up testing 8-weeks after the initial appointment and repeated TUG and DT-TUG tests. A physical therapist administered all tests. The minimal detectable change (MDC) was calculated for each TUG and DT-TUG times as well as DT Cost of TUG (DTC-TUG). An analysis of covariance was used to assess group differences in TUG, DT-TUG, and DTC-TUG. When necessary, pairwise comparisons, with Bonferroni adjustments for multiple comparisons were ran using estimated marginal means. Significance was set a-priori at P = 0.05. RESULTS: Twenty-four (n = 29, 83%) of COVID+MV and ten (n = 17, 59%) COVID+O2 patients demonstrated deficits indicative of a PICS diagnosis. The COVID+MV group was significantly worse at the DT-TUG compared to the CLD group (COVID+MV: 16.8 (7.3) s;CLD: 13.9 (4.8) s: F = 4.4, P = 0.03). DTC-TUG was also significantly worse in COVID+MV group (-21%) compared to CLD (-10%) and COVID+O2 (-13.1%;F = 4.1, P = 0.021). The MDC for TUG, DT-TUG, and DTC-TUG in COVID+MV patients was 3.8 s, 4.9 s, and 14.0% respectively. The MDC for TUG, DT-TUG, and DTC-TUG in post-ICU COVID1 O2 patients was 1.6 s, 1.9 s, and 7.8% respectively. CONCLUSIONS: These novel findings suggest a singular bout of critical illness results in worse DT performance during a clinical test of mobility. Survivors of COVID+MV exhibit a comparable pattern of DT deficits to those of advanced aged older-adults and neurologic disease. Additionally, the lack of single task deficits highlights the need for integrating DT mobility tests into clinical practice. CLINICAL RELEVANCE: These data suggest physical therapists need to integrate DT tests and measures into clinical practice for patients with PICS, particularly in patients who received MV. By providing MDC values, this study also provides data to use in clinical practice to monitor patient progress with rehabilitation.
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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).
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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.
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Donald Trump's erratic and unpredictable behavior as president was, metaphorically at least, a Random Walk. Combined with an inexperienced White House staff and a near total absence of any meaningful decision-making processes, the result was, routinely, unforced errors that both impeded the president’s ability to see his policy goals implemented effectively, led to poor congressional relations and, in several key cases, failures of leadership that played a role in his defeat in the 2020 election. The worst policy outcome was his catastrophic response to the COVID-19 pandemic, which laid bare the pathologies of poor decision-making processes. As president, Trump’s record exposed institutional weaknesses that a more skilled populist or authoritarian successor may be able to exploit. © 2021 Center for the Study of the Presidency and Congress