Length of Time in the United States and Cardiometabolic Outcomes Among Foreign and US-Born Black Adults.

INTRODUCTION: Among certain immigrant groups, length of time spent living in the United States (LOT) is associated with poor cardiometabolic health. We aimed to evaluate the association between LOT and cardiometabolic outcomes among US Black adults. METHODS: The National Health Interview Survey is an annual representative survey of non-institutionalized US civilians. We combined 2016-2018 data and included all Black adults (N = 10,034). LOT was defined as the number of years lived in the US, if foreign-born. Obesity, hypertension, diabetes, and high cholesterol were each self-reported. We used logistic regression models to determine whether LOT was associated with cardiometabolic health factors overall and by origin subgroups-US-born non-Hispanic, Hispanic, African-born, and Caribbean/Central American (CA)-born groups. RESULTS: Our study population was 81% US-born non-Hispanic, 5% Hispanic (both foreign- and US-born), 6% African-born, and 6% Caribbean/CA-born groups. Among Black adults, compared with the US-born, being foreign-born with < 15 years in the US was associated with lower odds of obesity (OR: 0.31, 95%CI: 0.23-0.42) and hypertension (OR: 0.35, 95%CI: 0.24-0.49). In subgroup analyses, Caribbean/CA-born individuals with < 15 years in the US had 64% lower odds of obesity (OR: 0.36, 95%CI 0.15-0.84) and 63% lower odds of hypertension (OR: 0.37, 95%CI 0.15-0.88) compared with those with ≥ 15 years. CONCLUSION: Shorter LOT was associated with more favorable cardiometabolic health, with differential associations among foreign-born Black adults based on origin. This heterogeneity suggests a need to examine the implications of acculturation in the context of the specific population of interest.

Effect of 2018 American College of Cardiology/American Heart Association Guideline Change on Statin Prescription for People Living with HIV.

The American College of Cardiology (ACC)/American Heart Association (AHA) guidelines were updated in 2018 to explicitly recommend statin use for primary cardiovascular disease prevention among people living with HIV (PLWH), but little is known about the effect of this guideline change. We aimed to assess the effect of the 2018 ACC/AHA guideline change on statin prescription among PLWH. We used data from an institutional HIV registry to identify PLWH aged 40-75 years, engaged in HIV care between June 2016 and May 2021, had a LDL cholesterol between 70 and 189 mg/dl, 10-year atherosclerotic cardiovascular disease (ASCVD) risk score ≥7.5%, no prior statin prescription, and no history of diabetes or ASCVD. Our outcome of interest was a new statin prescription within 12 months of eligibility. We estimated standardized risk difference (RD) with 95% confidence limits (CL) by comparing prescription probabilities before and after guideline change. Our study population comprised 251 PLWH (171 before, 80 after the guideline change), of whom 57% were aged <55 years, 82% were male, and 45% were non-Hispanic black. The standardized 12-month statin prescription risk was 43% (95% CL: 31%, 60%) after the guideline change and 19% (95% CL: 13%, 26%) before the guideline change (RD = 25%, 95% CL: 9.1%, 40%). Our results suggest that the 2018 ACC/AHA guideline change increased statin prescription among PLWH, but a sizable proportion of eligible PLWH were not prescribed statin. Future studies are needed to identify strategies to enhance implementation of statin prescription guidelines among PLWH.

HIV mortality trends among older adults in the United States, 1999-2020.

BACKGROUND: Despite the progress made in managing HIV, the mortality trends among older adults in the US remains understudied. The lack of evidence in this demographic hampers the ability to implement evidence-based interventions. Our aim is to analyze the trends in HIV-related mortality among US citizens aged 65 years and above by demographic characteristics such as age, gender, race/ethnicity, and census region. METHODS: We abstracted national mortality data from the underlying cause of death files in the CDC WONDER database. The ICD-10 Codes- B20-B24 were used to identify HIV deaths among US older adults from 1999 to 2020. Trends in age-adjusted mortality rate (AAMR) were assessed using a five-year simple moving average and Joinpoint analysis. Results were expressed as annual percentage changes (APC), average annual percentage changes, and 95% confidence intervals (CI). RESULTS: Between 1999 and 2020, a total of 15,694 older adults died from HIV in the US (AAMR= 1.7 per 100,000; 95% CI: 1.6 - 1.7). Overall mortality trends increased at an annual rate of 1.5% (95% CI: 1.2, 1.8) from 1999 through 2020. The trends increased among Non-Hispanic Whites, stabilized among Non-Hispanic Blacks, and decreased among Hispanics from 1999 to 2020. Further, the trends increased consistently across categories of age (65 to 74 years; 75 to 84 years), sex, and census region. CONCLUSIONS: HIV mortality among older adults in the US has risen overall from 1999 to 2020, but with varying trends by race and ethnicity. This highlights the need for enhanced public health surveillance to better understand the scope of HIV mortality among older adults and identify high-risk demographic and regional subgroups for targeted interventions. Improving timely diagnosis, managing comorbidities, and stigma surrounding HIV among older adults are crucial to reducing HIV mortality in this population.

Cardiotoxicity among socioeconomically marginalized breast cancer patients.

PURPOSE: Evidence of cardiotoxicity risk related to anthracycline or trastuzumab exposure is largely derived from breast cancer cohorts that under-represent socioeconomically marginalized women, who may be at increased risk of cardiotoxicity because of high prevalence of cardiovascular disease risk factors. Therefore, we aimed to estimate cardiotoxicity risk among socioeconomically marginalized breast cancer patients treated with anthracyclines or trastuzumab and describe clinical consequences of cardiotoxicity. METHODS: We linked electronic health records with institutional registry data from a Comprehensive Community Cancer Program within a safety-net health system. Eligible patients were adult females, diagnosed with first primary invasive breast cancer between 2013 and 2017, and initiated anthracyclines or trastuzumab as part of first-line therapy. We estimated cumulative incidence (risk) of cardiotoxicity with corresponding 95% confidence limits (CL) using the Aalen-Johansen estimator with death as competing risk. RESULTS: Our study population comprised 169 women with breast cancer (103 initiated anthracyclines and 66 initiated trastuzumab). Cumulative incidence of cardiotoxicity was 21% (95% CL: 12%, 32%) at one year and 25% (95% CL: 15%, 35%) at three years among women who initiated trastuzumab, whereas cumulative incidence was 3.9% (95% CL: 1.3%, 8.9%) at one year and 5.9% (95% CL: 2.4%, 12%) at three years among women who initiated anthracyclines. More than half of patients with cardiotoxicity experienced interruption of cancer treatment. CONCLUSION: Our findings suggest high risk of cardiotoxicity among socioeconomically marginalized breast cancer patients after initiation of anthracyclines or trastuzumab. Strategies are needed for optimizing cancer treatment effectiveness while minimizing cardiotoxicity in this population.

The data-collection on adverse effects of anti-HIV drugs (D:A:D) model for predicting cardiovascular events: External validation in a diverse cohort of people living with HIV.

OBJECTIVES: Little is known about the external validity of the Data-collection on Adverse Effects of Anti-HIV Drugs (D:A:D) model for predicting cardiovascular disease (CVD) risk among people living with HIV (PLWH). We aimed to evaluate the performance of the updated D:A:D model for 5-year CVD risk in a diverse group of PLWH engaged in HIV care. METHODS: We used data from an institutional HIV registry, which includes PLWH engaged in care at a safety-net HIV clinic. Eligible individuals had a baseline clinical encounter between 1 January 2013 and 31 December 2014, with follow-up through to 31 December 2019. We estimated 5-year predicted risks of CVD as a function of the prognostic index and baseline survival of the D:A:D model, which were used to assess model discrimination (C-index), calibration and net benefit. RESULTS: Our evaluable population comprised 1029 PLWH, of whom 30% were female, 50% were non-Hispanic black, and median age was 45 years. The C-index was 0.70 [95% confidence limits (CL): 0.64-0.75]. The predicted 5-year CVD risk was 3.0% and the observed 5-year risk was 8.9% (expected/observed ratio = 0.33, 95% CL: 0.26-0.54). The model had a greater net benefit than treating all or treating none at a risk threshold of 10%. CONCLUSIONS: The D:A:D model was miscalibrated for CVD risk among PLWH engaged in HIV care at an urban safety-net HIV clinic, which may be related to differences in case-mix and baseline CVD risk. Nevertheless, the HIV D:A:D model may be useful for decisions about CVD intervention for high-risk patients.

Brief Report: HIV Pre-exposure Prophylaxis Prescribing in an Urban Safety-Net Health System.

INTRODUCTION: Safety-net health systems are key settings for HIV pre-exposure prophylaxis (PrEP) implementation, but little evidence is available about the frequency of PrEP prescribing in safety-net settings. We assessed PrEP prescribing among people with indications for PrEP at an urban safety-net health system that serves a county designated as an Ending the HIV Epidemic priority jurisdiction. METHODS: We identified adults (aged 18 years or older) who engaged in primary care between January 2015 and December 2019 and had a documented indication for PrEP. PrEP indications included the presence of a behavioral or sexual risk factor of HIV acquisition or a positive bacterial sexually transmitted infection at the index visit. PrEP prescribing was defined as the proportion of patients with indications for PrEP who received a new prescription for PrEP. We estimated the cumulative incidence of PrEP prescription with corresponding 95% confidence limits (CL). RESULTS: Our study population comprised 2957 individuals, of whom 58% was aged younger than 45 years, 56% was women, 67% was racial or ethnic minorities, and 60% was uninsured or provided care as part of a hospital-based managed care plan for individuals without insurance. We identified 41 individuals who were prescribed PrEP. The cumulative incidence of PrEP prescribing within 1 year of the first documented PrEP indication was 1.3% (95% CL: 0.91% to 1.7%). CONCLUSIONS: Our results suggest extremely low frequency of PrEP prescribing among people with indications for PrEP in an urban safety-net health system. Strategies are needed to improve PrEP implementation in high-priority populations and safety-net settings.

Knowledge needs for implementing HIV pre-exposure prophylaxis among primary care providers in a safety-net health system.

Safety-net health systems are a primary source of care for socioeconomically disadvantaged individuals who may be eligible for HIV pre-exposure prophylaxis (PrEP) and are priority groups under the Ending the HIV Epidemic (EHE) initiative. Nevertheless, little evidence is available about barriers to PrEP implementation in safety-net settings. We aimed to assess the association between PrEP knowledge and prescribing practices, and to ascertain unmet knowledge needs to implement PrEP. In 2019, we surveyed primary care providers (PCPs) in a safety-net health system that serves an EHE priority jurisdiction located in North Texas. Our questionnaire ascertained self-reported prescribing practices, knowledge, and training needs related to PrEP. We used penalized logistic regression to estimate odds ratio (OR) and 95% posterior limits (PL) for the association between provider self-rated knowledge of PrEP and PrEP prescribing. Our study population comprised 62 primary care providers, of whom 61% were female, 60% were non-Hispanic White, 76% were physicians (76%), 57% had ≥ 10 years of practice experience, 45% reported low self-rated PrEP knowledge, and 35% prescribed PrEP in the past year. Providers with low PrEP knowledge had 69% lower odds of prescribing PrEP within the past year (OR = 0.31, 95% PL: 0.12, 0.82). Eligibility for PrEP, side effects and adherence concerns were key unmet knowledge needs. Our findings suggest that low provider PrEP knowledge may be a barrier to PrEP prescribing among safety-net PCPs. Our results provide insight about specific educational needs of PCPs in a safety-net health system, which are amenable to educational intervention.