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1.
Topics in Antiviral Medicine ; 30(1 SUPPL):357-358, 2022.
Article in English | EMBASE | ID: covidwho-1880895

ABSTRACT

Background: After COVID-19 shelter-in-place (SIP) orders on 3/16/2020, viral suppression (VS) rates initially decreased within a safety-net HIV clinic in San Francisco, with greater decreases among homeless people living with HIV (PLWH). We sought to understand if (1) proactive outreach to provide social services, (2) scaling up of in-person visits for most patients and drop-in visits at the clinic, and (3) expansion of housing programs could reverse this decline. Methods: We assessed VS 24 months before and 13 months after SIP using mixed-effects logistic regression and propensity score methods, followed by interrupted time series (ITS) analysis to examine changes in the rate of viral suppression per month. Loss to follow-up was assessed via active clinic outreach and tracing using Kaplan-Meier methods. Results: The cohort contained 1816 patients with a median age of 51;12% female, 14% unstably housed, and 15% with CD4+-cell counts <200 cells/mm3. The adjusted odds of VS increased 1.34-fold following the intervention (95% CI: 1.21-1.46), with similar results using inverse probability weighting (adjusted odds ratio (AOR) 1.31;95% CI: 1.17-1.46). Results from the ITS analysis show that the odds of VS continuously increased by 1.05-fold per month over the post-intervention period (95% CI: 1.01-1.08, Figure). Proactive phone outreach successfully reached 90.0% of the clinic to offer services. The one-year cumulative loss to follow-up rate was 3.2% (95% CI: 2.5-3.9%). The proportion of total attended visits that were telephone visits decreased from a maximum of 64.9% to a minimum of 10.1% at the end of the analysis period. The rate of viral load monitoring decreased by 15% after the institution of SIP (95% CI: 0.83-0.88). Among homeless PLWH, the AOR for VS was 1.70 (95% CI: 1.24-2.34) and there was a 5.9% increase in VS per month using ITS methods (95% CI: 1.0-12.3%). Conclusion: After an initial destabilization in VS in a large safety-net clinic following SIP orders, the VS rate increased following scale-up of in-person visits, clinic outreach to patients, intensification of social services during this time, and access to COVID-related housing programs. The loss to follow-up rate was similar or lower compared to prior years. Maintaining in-person care for underserved patients, with flexible telemedicine options, along with provision of social services and permanent expansion of housing assistance programs, will be needed to support VS among underserved populations during the COVID-19 pandemic.

2.
Topics in Antiviral Medicine ; 30(1 SUPPL):27, 2022.
Article in English | EMBASE | ID: covidwho-1880410

ABSTRACT

Background: Despite longstanding guidelines endorsing isoniazid preventive therapy (IPT) for persons with HIV, uptake is low across sub-Saharan Africa. Mid-level health managers oversee IPT programs nationally;interventions aimed at this group have not been tested. Methods: We conducted a cluster randomized trial in Uganda among district-level health managers from 2017-2021. The unit of randomization was groups of 4-7 managers. Our intervention convened managers into mini-collaboratives facilitated by Ugandan TB/HIV experts and provided business leadership/management training, SMS platform access, and data feedback. The primary outcome was IPT initiation rates among adults with HIV in health facilities overseen by participants over 2 years (2019-2021). We compared incidence rates using cluster-level targeted minimum loss-based estimation. We conducted pre-specified analyses that excluded Q3-2019 to understand intervention effects independent of a national "100-day push" of IPT tied to a financial contingency during Q3-2019. Qualitative interviews were analyzed to ascertain mechanisms of intervention action. Results: Managers from 82/82 eligible districts (61% of Uganda's 135 districts) were enrolled and randomized: 43 districts to intervention, 39 to control. After one year, in 5-point-Likert quantitative surveys, intervention-group managers demonstrated greater increases in familiarity with IPT (by +0.47 points (95%CI:0.14-0.80)) and knowledge of IPT efficacy (+0.59 points (95%CI:0.06-1.12)) as compared to control. Intervention-group managers reported improved within-district communication and inter-district collaboration and feeling empowered to better manage frontline providers, in contrast to control, in qualitative interviews. Over two years, the IPT initiation rate was 0.74 vs. 0.65 starts/person-year in intervention vs control: incidence rate ratio (IRR)=1.14 (95%CI:0.88-1.46;p=0.16). Excluding Q3-2019, IPT initiation was higher in intervention vs control: 0.32 vs. 0.25 starts/person-year (IRR=1.27, 95%CI:1.00-1.61, p=0.03;Figure). Conclusion: Though overall IPT initiation rates were not significantly higher with the mid-level manager intervention in this cluster randomized trial, rates were significantly higher compared to control when excluding the massive MoH-led "100-day IPT push" in both arms. The higher rates were sustained during the COVID-19 pandemic, suggesting benefits of targeted leadership and management training for mid-level health managers.

3.
PubMed; 2020.
Preprint in English | PubMed | ID: ppcovidwho-333633

ABSTRACT

BACKGROUND: Airline travel has been significantly reduced during the COVID-19 pandemic due to concern for individual risk of SARS-CoV-2 infection and population-level transmission risk from importation. Routine viral testing strategies for COVID-19 may facilitate safe airline travel through reduction of individual and/or population-level risk, although the effectiveness and optimal design of these "test-and-travel" strategies remain unclear. METHODS: We developed a microsimulation of SARS-CoV-2 transmission in a cohort of airline travelers to evaluate the effectiveness of various testing strategies to reduce individual risk of infection and population-level risk of transmission. We evaluated five testing strategies in asymptomatic passengers: i) anterior nasal polymerase chain reaction (PCR) within 3 days of departure;ii) PCR within 3 days of departure and PCR 5 days after arrival;iii) rapid antigen test on the day of travel (assuming 90% of the sensitivity of PCR during active infection);iv) rapid antigen test on the day of travel and PCR 5 days after arrival;and v) PCR within 3 days of arrival alone. The travel period was defined as three days prior to the day of travel and two weeks following the day of travel, and we assumed passengers followed guidance on mask wearing during this period. The primary study outcome was cumulative number of infectious days in the cohort over the travel period (population-level transmission risk);the secondary outcome was the proportion of infectious persons detected on the day of travel (individual-level risk of infection). Sensitivity analyses were conducted. FINDINGS: Assuming a community SARS-CoV-2 incidence of 50 daily infections, we estimated that in a cohort of 100,000 airline travelers followed over the travel period, there would be a total of 2,796 (95% UI: 2,031, 4,336) infectious days with 229 (95% UI: 170, 336) actively infectious passengers on the day of travel. The pre-travel PCR test (within 3 days prior to departure) reduced the number of infectious days by 35% (95% UI: 27, 42) and identified 88% (95% UI: 76, 94) of the actively infectious travelers on the day of flight;the addition of PCR 5 days after arrival reduced the number of infectious days by 79% (95% UI: 71, 84). The rapid antigen test on the day of travel reduced the number of infectious days by 32% (95% UI: 25, 39) and identified 87% (95% UI: 81, 92) of the actively infectious travelers;the addition of PCR 5 days after arrival reduced the number of infectious days by 70% (95% UI: 65, 75). The post-travel PCR test alone (within 3 days of landing) reduced the number of infectious days by 42% (95% UI: 31, 51). The ratio of true positives to false positives varied with the incidence of infection. The overall study conclusions were robust in sensitivity analysis. INTERPRETATION: Routine asymptomatic testing for COVID-19 prior to travel can be an effective strategy to reduce individual risk of COVID-19 infection during travel, although post-travel testing with abbreviated quarantine is likely needed to reduce population-level transmission due to importation of infection when traveling from a high to low incidence setting.

4.
PubMed; 2020.
Preprint in English | PubMed | ID: ppcovidwho-333553

ABSTRACT

BACKGROUND: The absence of systematic surveillance for SARS-CoV-2 has curtailed accurate appraisal of transmission intensity. Our objective was to perform case detection of an entire rural community to quantify SARS-CoV-2 transmission using PCR and antibody testing. METHODS: We conducted a cross-sectional survey of the prevalence and cumulative incidence of SARS-CoV-2 infection in the rural town of Bolinas, California (population 1,620), four weeks following shelter-in-place orders. Residents and county essential workers were tested between April 20th-24th, 2020. Prevalence by PCR and seroprevalence combining data from two forms of antibody testing were performed in parallel (Abbott ARCHITECT IgG to nucleocapsid protein and in-house IgG ELISA to the receptor binding domain). RESULTS: Of 1,891 participants, 1,312 were confirmed Bolinas residents (>80% community ascertainment). Zero participants were PCR positive. Assuming 80% sensitivity, it would have been unlikely to observe these results (p<0.05) if there were >3 active infections in the community. Based on antibody results, estimated prevalence of prior infection was 0.16% (95% CrI: 0.02%, 0.46%). Seroprevalence estimates using only one of the two tests would have been higher, with greater uncertainty. The positive predictive value (PPV) of a positive result on both tests was 99.11% (95% CrI: 95.75%, 99.94%), compared to PPV 44.19%-63.32% (95% CrI range 3.25%-98.64%) if only one test was utilized. CONCLUSIONS: Four weeks following shelter-in-place, active and prior SARS-CoV-2 infection in a rural Northern California community was extremely rare. In this low prevalence setting, use of two antibody tests increased the PPV and precision of seroprevalence estimates.

5.
PubMed; 2020.
Preprint in English | PubMed | ID: ppcovidwho-296906

ABSTRACT

We evaluated the performance of the Abbott BinaxNOW TM Covid-19 rapid antigen test to detect virus among persons, regardless of symptoms, at a public plaza site of ongoing community transmission. Titration with cultured clinical SARS-CoV-2 yielded a human observable threshold between 1.6x104-4.3x104 viral RNA copies (cycle threshold (Ct) of 30.3-28.8 in this assay). Among 878 subjects tested, 3% (26/878) were positive by RT-PCR, of which 15/26 had a Ct<30, indicating high viral load. 40% (6/15) of Ct<30 were asymptomatic. Using this Ct<30 threshold for Binax-CoV2 evaluation, the sensitivity of the Binax-CoV2 was 93.3% (14/15), 95% CI: 68.1-99.8%, and the specificity was 99.9% (855/856), 95% CI: 99.4-99.9%.

6.
PubMed; 2021.
Preprint in English | PubMed | ID: ppcovidwho-296900

ABSTRACT

Background: Sequencing of the SARS-CoV-2 viral genome from patient samples is an important epidemiological tool for monitoring and responding to the pandemic, including the emergence of new mutations in specific communities. Methods: SARS-CoV-2 genomic sequences were generated from positive samples collected, along with epidemiological metadata, at a walk-up, rapid testing site in the Mission District of San Francisco, California during November 22-December 2, 2020 and January 10-29, 2021. Secondary household attack rates and mean sample viral load were estimated and compared across observed variants. Results: A total of 12,124 tests were performed yielding 1,099 positives. From these, 811 high quality genomes were generated. Certain viral lineages bearing spike mutations, defined in part by L452R, S13I, and W152C, comprised 54.9% of the total sequences from January, compared to 15.7% in November. Household contacts exposed to "West Coast" variants were at higher risk of infection compared to household contacts exposed to lineages lacking these variants (0.357 vs 0.294, RR=1.29;95% CI:1.01-1.64). The reproductive number was estimated to be modestly higher than other lineages spreading in California during the second half of 2020. Viral loads were similar among persons infected with West Coast versus non-West Coast strains, as was the proportion of individuals with symptoms (60.9% vs 64.1%). Conclusions: The increase in prevalence, relative household attack rates, and reproductive number are consistent with a modest transmissibility increase of the West Coast variants;however, additional laboratory and epidemiological studies are required to better understand differences between these variants. Summary: We observed a growing prevalence and elevated attack rate for "West Coast" SARS-CoV-2 variants in a community testing setting in San Francisco during January 2021, suggesting its modestly higher transmissibility.

7.
Top Antivir Med ; 29(2):344-351, 2021.
Article in English | PubMed | ID: covidwho-1261601

ABSTRACT

Tuberculosis (TB) remains a main driver of morbidity and mortality among people with HIV along with other opportunistic infections. This review summarizes key highlights related to TB, and other opportunistic infections in HIV as well as studies from the virtual 2021 Conference on Retroviruses and Oppoprtunitstic Infections evaluating outcomes among HIV-COVID-19 coinfected patients.

8.
Topics in Antiviral Medicine ; 29(1):284-285, 2021.
Article in English | EMBASE | ID: covidwho-1250690

ABSTRACT

Background: The COVID-19 pandemic has resulted in disruptions to HIV prevention and care services access throughout the US. We sought to evaluate the impact of service disruption from the COVID-19 pandemic response on key Getting to Zero San Francisco (GTZSF) HIV prevention and care metrics of HIV antibody (Ab) and HIV viral load (VL) testing, Pre-exposure prophylaxis (PrEP) use, and the continuum of HIV care. Methods: Reports of positive and negative HIV Ab testing from 4 laboratories and a large community testing site (CTS), and HIV VL testing for people living with HIV reported to the San Francisco Department of Public Health were included. We compared the number of HIV Ab and VL tests, and PrEP visits at the CTS each month from January-October 2020 with the corresponding months in 2019. The continuum of HIV care was calculated for new HIV diagnoses in January-June 2020 compared to the same period in 2019. Results: From January-October 2020, the mean number of monthly laboratorybased HIV Ab tests decreased from 4,400/month in 2019 to 3,644/month in 2020 (Table);and from 1,382/month to 766/month at the CTS. April 2020 had the lowest number of HIV tests, a reduction of 54% in laboratory reporting and 88% in the CTS compared with April 2019;there was a partial rebound through October 2020. While the number of positive HIV tests was lower per month in 2020 compared with 2019, the proportion HIV positive remained stable throughout the study period (2020: Range 0.9-1.4%;2019: Range 1.1-1.6%). HIV VL testing also declined in 2020 similar to the trend of HIV testing with the largest decline (57%) in April 2020. Overall, PrEP visits at the CTS declined more than 31% in the study period;the largest decline (90%) occurred in April 2020 with partial rebound through October 2020. From January to June 2020, 75 new HIV diagnoses were identified, compared with 101 in 2019. Linkage to care within 1 month was 93% in 2020 and 97% in 2019;HIV viral suppression within 6 months was 75% in 2020 and 76% in 2019. Conclusion: We have observed substantial reductions in HIV Ab and VL testing during the COVID-19 pandemic, and likely decreased HIV case finding. PrEP care engagement also declined dramatically;however rapid linkage to care and viral suppression after HIV diagnosis remained robust. Continued monitoring of key HIV prevention and care metrics is essential to assessing the complex impact of COVID-19 on the GTZSF goals, and developing tailored mitigation responses.

10.
Topics in Antiviral Medicine ; 28(2):455-458, 2020.
Article in English | EMBASE | ID: covidwho-718249

ABSTRACT

Due to COVID-19, this year marked the first virtual Conference on Retrovi-ruses and Opportunistic Infections (CROI) in the conference’s 27-year history. There were important studies presented that provided new insights into the prevention, diagnosis, and treatment of tuberculosis (TB) and other HIV coinfections. Highlights related to TB and HIV coinfections from this year’s meeting are reviewed below.

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