SARS-CoV-2 Infection Among Pregnant People at Labor and Delivery and Changes in Infection Rates in the General Population: Lessons Learned From Illinois.

OBJECTIVES: The Illinois Department of Public Health (IDPH) assessed whether increases in the SARS-CoV-2 test positivity rate among pregnant people at labor and delivery (L&D) could signal increases in SARS-CoV-2 prevalence in the general Illinois population earlier than current state metrics. MATERIALS AND METHODS: Twenty-six birthing hospitals universally testing for SARS-CoV-2 at L&D voluntarily submitted data from June 21, 2020 through January 23, 2021, to IDPH. Hospitals reported the daily number of people who delivered, SARS-CoV-2 tests, and test results as well as symptom status. We compared the test positivity rate at L&D with the test positivity rate of the general population and the number of hospital admissions for COVID-19-like illness by quantifying correlations in trends and identifying a lead time. RESULTS: Of 26 633 reported pregnant people who delivered, 96.8% (n = 25 772) were tested for SARS-CoV-2. The overall test positivity rate was 2.4% (n = 615); 77.7% (n = 478) were asymptomatic. In Chicago, the only region with a sufficient sample size for analysis, the test positivity rate at L&D (peak of 5% on December 7, 2020) was lower and more stable than the test positivity rate of the general population (peak of 14% on November 13, 2020) and lagged hospital admissions for COVID-19-like illness (peak of 118 on November 15, 2020) and the test positivity rate of the general population by about 10 days (Pearson correlation = 0.73 and 0.75, respectively). PRACTICE IMPLICATIONS: Trends in the test positivity rate at L&D did not provide an earlier signal of increases in Illinois's SARS-CoV-2 prevalence than current state metrics did. Nonetheless, the role of universal testing protocols in identifying asymptomatic infection is important for clinical decision making and patient education about infection prevention and control.

Acquired HIV drug resistance and virologic monitoring in a HIV hyper-endemic setting in KwaZulu-Natal Province, South Africa.

BACKGROUND: Introduction of tenofovir (TDF) plus lamivudine (3TC) and dolutegravir (DTG) in first- and second-line HIV treatment regimens in South Africa warrants characterization of acquired HIV-1 drug resistance (ADR) mutations that could impact DTG-based antiretroviral therapy (ART). In this study, we sought to determine prevalence of ADR mutations and their potential impact on susceptibility to drugs used in combination with DTG among HIV-positive adults (≥ 18 years) accessing routine care at a selected ART facility in KwaZulu-Natal, South Africa. METHODS: We enrolled adult participants in a cross-sectional study between May and September 2019. Eligible participants had a most recent documented viral load (VL) ≥ 1000 copies/mL after at least 6 months on ART. We genotyped HIV-1 reverse transcriptase and protease genes by Sanger sequencing and assessed ADR. We characterized the effect of ADR mutations on the predicted susceptibility to drugs used in combination with DTG. RESULTS: From 143 participants enrolled, we obtained sequence data for 115 (80%), and 92.2% (95% CI 85.7-96.4) had ADR. The proportion with ADR was similar for participants on first-line ART (65/70, 92.9%, 95% CI 84.1-97.6) and those on second-line ART (40/44, 90.9%, 95% CI 78.3-97.5), and was present for the single participant on third-line ART. Approximately 89% (62/70) of those on first-line ART had dual class NRTI and NNRTI resistance and only six (13.6%) of those on second-line ART had major PI mutations. Most participants (82%) with first-line viraemia maintained susceptibility to Zidovudine (AZT), and the majority of them had lost susceptibility to TDF (71%) and 3TC (84%). Approximately two in every five TDF-treated individuals had thymidine analogue mutations (TAMs). CONCLUSIONS: Susceptibility to AZT among most participants with first-line viraemia suggests that a new second-line regimen of AZT + 3TC + DTG could be effective. However, atypical occurrence of TAMs in TDF-treated individuals suggests a less effective AZT + 3TC + DTG regimen in a subpopulation of patients. As most patients with first-line viraemia had at least low-level resistance to TDF and 3TC, identifying viraemia before switch to TDF + 3TC + DTG is important to avoid DTG functional monotherapy. These findings highlight a need for close monitoring of outcomes on new standardized treatment regimens.

Geographic and demographic heterogeneity of SARS-CoV-2 diagnostic testing in Illinois, USA, March to December 2020.

BACKGROUND: Availability of SARS-CoV-2 testing in the United States (U.S.) has fluctuated through the course of the COVID-19 pandemic, including in the U.S. state of Illinois. Despite substantial ramp-up in test volume, access to SARS-CoV-2 testing remains limited, heterogeneous, and insufficient to control spread. METHODS: We compared SARS-CoV-2 testing rates across geographic regions, over time, and by demographic characteristics (i.e., age and racial/ethnic groups) in Illinois during March through December 2020. We compared age-matched case fatality ratios and infection fatality ratios through time to estimate the fraction of SARS-CoV-2 infections that have been detected through diagnostic testing. RESULTS: By the end of 2020, initial geographic differences in testing rates had closed substantially. Case fatality ratios were higher in non-Hispanic Black and Hispanic/Latino populations in Illinois relative to non-Hispanic White populations, suggesting that tests were insufficient to accurately capture the true burden of COVID-19 disease in the minority populations during the initial epidemic wave. While testing disparities decreased during 2020, Hispanic/Latino populations consistently remained the least tested at 1.87 tests per 1000 population per day compared with 2.58 and 2.87 for non-Hispanic Black and non-Hispanic White populations, respectively, at the end of 2020. Despite a large expansion in testing since the beginning of the first wave of the epidemic, we estimated that over half (50-80%) of all SARS-CoV-2 infections were not detected by diagnostic testing and continued to evade surveillance. CONCLUSIONS: Systematic methods for identifying relatively under-tested geographic regions and demographic groups may enable policymakers to regularly monitor and evaluate the shifting landscape of diagnostic testing, allowing officials to prioritize allocation of testing resources to reduce disparities in COVID-19 burden and eventually reduce SARS-CoV-2 transmission.

Geographic and demographic heterogeneity of SARS-CoV-2 diagnostic testing in Illinois, USA, March to December 2020.

Background: Availability of SARS-CoV-2 testing in the United States (U.S.) has fluctuated through the course of the COVID-19 pandemic, including in the U.S. state of Illinois. Despite substantial ramp-up in test volume, access to SARS-CoV-2 testing remains limited, heterogeneous, and insufficient to control spread. Methods: We compared SARS-CoV-2 testing rates across geographic regions, over time, and by demographic characteristics (i.e., age and racial/ethnic groups) in Illinois during March through December 2020. We compared age-matched case fatality ratios and infection fatality ratios through time to estimate the fraction of SARS-CoV-2 infections that have been detected through diagnostic testing. Results: By the end of 2020, initial geographic differences in testing rates had closed substantially. Case fatality ratios were higher in non-Hispanic Black and Hispanic/Latino populations in Illinois relative to non-Hispanic White populations, suggesting that tests were insufficient to accurately capture the true burden of COVID-19 disease in the minority populations during the initial epidemic wave. While testing disparities decreased during 2020, Hispanic/Latino populations consistently remained the least tested at 1.87 tests per 1000 population per day compared with 2.58 and 2.87 for non-Hispanic Black and non-Hispanic White populations, respectively, at the end of 2020. Despite a large expansion in testing since the beginning of the first wave of the epidemic, we estimated that over half (50-80%) of all SARS-CoV-2 infections were not detected by diagnostic testing and continued to evade surveillance. Conclusions: Systematic methods for identifying relatively under-tested geographic regions and demographic groups may enable policymakers to regularly monitor and evaluate the shifting landscape of diagnostic testing, allowing officials to prioritize allocation of testing resources to reduce disparities in COVID-19 burden and eventually reduce SARS-CoV-2 transmission.

Community Transmission of SARS-CoV-2 Associated with a Local Bar Opening Event - Illinois, February 2021.

During February 2021, an opening event was held indoors at a rural Illinois bar that accommodates approximately 100 persons. The Illinois Department of Public Health (IDPH) and local health department staff members investigated a COVID-19 outbreak associated with this opening event. Overall, 46 COVID-19 cases were linked to the event, including cases in 26 patrons and three staff members who attended the opening event and 17 secondary cases. Four persons with cases had COVID-19-like symptoms on the same day they attended the event. Secondary cases included 12 cases in eight households with children, two on a school sports team, and three in a long-term care facility (LTCF). Transmission associated with the opening event resulted in one school closure affecting 650 children (9,100 lost person-days of school) and hospitalization of one LTCF resident with COVID-19. These findings demonstrate that opening up settings such as bars, where mask wearing and physical distancing are challenging, can increase the risk for community transmission of SARS-CoV-2, the virus that causes COVID-19. As community businesses begin to reopen, a multicomponent approach should be emphasized in settings such as bars to prevent transmission* (1). This includes enforcing consistent and correct mask use, maintaining ≥6 ft of physical distance between persons, reducing indoor bar occupancy, prioritizing outdoor seating, improving building ventilation, and promoting behaviors such as staying at home when ill, as well as implementing contact tracing in combination with isolation and quarantine when COVID-19 cases are diagnosed.

Missed Opportunities to Prescribe Preexposure Prophylaxis in South Carolina, 2013-2016.

Background: Expanding use of preexposure prophylaxis (PrEP) in ways that address current racial/ethnic disparities is an important human immunodeficiency virus (HIV) prevention goal. We investigated missed opportunities to provide PrEP during healthcare visits that occur prior to HIV infection. Methods: This retrospective cohort study linked South Carolina HIV case surveillance data to 3 statewide healthcare databases. Characteristics of patients, healthcare visits and providers, sexually transmitted diseases (STDs), and other diagnoses were assessed for medical encounters occurring before an initial HIV diagnosis. Adjusted odds ratios were used to identify correlates of missed opportunities for PrEP provision. Results: Of 885 persons newly diagnosed during the study period, 586 (66%) had 4029 visits to a healthcare facility prior to their HIV diagnosis (mean of 6.9 visits) with missed opportunities for provision of PrEP. Emergency medicine-trained clinicians conducted (61%) and primary care clinicians (family practice or internal medicine) conducted 10% of visits. Also, 42% of visits were by persons who were uninsured or self-paid, 36% had public insurance, and 18% had commercial insurance. In multivariable analyses, being female, black, or aged <30 years were statistically significant predictors of having prior healthcare visits. Among persons with at least 1 healthcare visit prior to their HIV diagnosis, 28.5% had a diagnosis of gonorrhea, syphilis, or chlamydia at any visit. Conclusions: Healthcare visits occurring among persons who would benefit from provision of PrEP, especially persons with diagnosed STDs, should be leveraged to increase use of PrEP and reduce the risk of HIV acquisition.

HIV Infection-Related Care Outcomes among U.S.-Born and Non-U.S.-Born Blacks with Diagnosed HIV in 40 U.S. Areas: The National HIV Surveillance System, 2016.

HIV care outcomes must be improved to reduce new human immunodeficiency virus (HIV) infections and health disparities. HIV infection-related care outcome measures were examined for U.S.-born and non-U.S.-born black persons aged ≥13 years by using National HIV Surveillance System data from 40 U.S. areas. These measures include late-stage HIV diagnosis, timing of linkage to medical care after HIV diagnosis, retention in care, and viral suppression. Ninety-five percent of non-U.S.-born blacks had been born in Africa or the Caribbean. Compared with U.S.-born blacks, higher percentages of non-U.S.-born blacks with HIV infection diagnosed during 2016 received a late-stage diagnoses (28.3% versus 19.1%) and were linked to care in ≤1 month after HIV infection diagnosis (76.8% versus 71.3%). Among persons with HIV diagnosed in 2014 and who were alive at year-end 2015, a higher percentage of non-U.S.-born blacks were retained in care (67.8% versus 61.1%) and achieved viral suppression (68.7% versus 57.8%). Care outcomes varied between African- and Caribbean-born blacks. Non-U.S.-born blacks achieved higher care outcomes than U.S.-born blacks, despite delayed entry to care. Possible explanations include a late-stage presentation that requires immediate linkage and optimal treatment and care provided through government-funded programs.

Screening for Latent Tuberculosis Infection Among HIV-Infected Medicaid Enrollees.

OBJECTIVES: In the United States, universal screening for latent tuberculosis (TB) infection among people with HIV is recommended, but the percentage receiving screening is unknown. This study assessed screening for latent TB infection among people with HIV enrolled in Medicaid during 2006-2010. METHODS: We used nationwide fee-for-service Medicaid records to identify people with HIV, measure screening for latent TB infection, and examine associated demographic, social, and clinical factors. We used logistic regression analysis to calculate odds ratios (ORs) and 95% confidence intervals (CIs). We created 2 multivariate models to prevent collinearity between variables for length of HIV infection. RESULTS: Of 152 831 people with HIV, 26 239 (17.2%) were screened for latent TB infection. The factor most strongly associated with screening was TB exposure or suspected TB (OR = 3.78; 95% CI, 3.27-4.37). Significant demographic characteristics associated with screening included being African American (OR = 1.28; 95% CI, 1.24-1.32) or ≤20 years of age (OR = 1.35; 95% CI, 1.28-1.42). Significant clinical and social factors associated with screening included poor housing conditions, low body mass index, chemotherapy treatment, and use of certain substances (ORs ranged from 1.24 [95% CI, 1.20-1.27] to 1.47 [95% CI, 1.22-1.76]). The screening rate for latent TB infection was higher among people with newly diagnosed HIV infection than among those with established infection (OR = 1.37; 95% CI, 1.32-1.41) and among people with a longer established HIV infection than among those with shorter HIV infection (OR = 1.24; 95% CI, 1.23-1.26 for each additional year). CONCLUSION: Screening for latent TB infection among fee-for-service Medicaid beneficiaries with HIV was suboptimal, despite the presence of demographic, social, or clinical characteristics that should have increased the likelihood of screening. The lack of certain data in Medicaid may have resulted in an underestimation of screening.

Incorporation of Social Determinants of Health in the Peer-Reviewed Literature: A Systematic Review of Articles Authored by the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention.

OBJECTIVES: Social determinants of health (SDHs) are the complex, structural, and societal factors that are responsible for most health inequities. Since 2003, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) has researched how SDHs place communities at risk for communicable diseases and poor adolescent health. We described the frequency and types of SDHs discussed in articles authored by NCHHSTP. METHODS: We used the MEDLINE/PubMed search engine to systematically review the frequency and type of SDHs that appeared in peer-reviewed publications available in PubMed from January 1, 2009, through December 31, 2014, with a NCHHSTP affiliation. We chose search terms to identify articles with a focus on the following SDH categories: income and employment, housing and homelessness, education and schooling, stigma or discrimination, social or community context, health and health care, and neighborhood or built environment. We classified articles based on the depth of topic coverage as "substantial" (ie, one of ≤3 foci of the article) or "minimal" (ie, one of ≥4 foci of the article). RESULTS: Of 862 articles authored by NCHHSTP, 366 (42%) addressed the SDH factors of interest. Some articles addressed >1 SDH factor (366 articles appeared 568 times across the 7 categories examined), and we examined them for each category that they addressed. Most articles that addressed SDHs (449/568 articles; 79%) had a minimal SDH focus. SDH categories that were most represented in the literature were health and health care (190/568 articles; 33%) and education and schooling (118/568 articles; 21%). CONCLUSIONS: This assessment serves as a baseline measurement of inclusion of SDH topics from NCHHSTP authors in the literature and creates a methodology that can be used in future assessments of this topic.

Comparing Patient Demographics and Tumor Characteristics of HIV-Positive and HIV-Negative Patients with Cancer in South Carolina.

We compared the demographic and disease characteristics of HIV-positive (HIV+) and HIV-negative (HIV-) individuals with a diagnosis of cancer in South Carolina. HIV-positive patients with cancer were reflective of the HIV+ caseload in South Carolina, with HIV+ patients with cancer more likely to be male (odds ratio [OR]: 2.78: 95% confidence interval [CI]: 2.33-3.32), black (OR: 7.68; 95% CI: 6.52-9.06), and younger at cancer diagnosis (OR: 0.92; 95% CI: 0.91-0.92). Controlling for year of birth, HIV+ patients with cancer did not receive cancer diagnoses at a younger age than HIV- controls. HIV-positive individuals did not have more advanced tumor stages or grades at cancer diagnosis; however, after controlling for other factors, HIV+ individuals were still more likely to be deceased at follow-up (OR: 2.64; 95% CI: 2.20-3.17) when compared to HIV- controls. Future studies should use survival analysis methods to identify the characteristics that shorten survival among HIV+ patients with cancer.

Social Determinants of Health Associated with HBV Testing and Access to Care among Foreign-born Persons Residing in the United States: 2009 - 2012.

OBJECTIVES: To describe how select Social Determinants of Health (SDH) are associated with the burden of hepatitis B virus (HBV) infection among foreign-born persons residing in the United States. METHODS: Multivariate logistic regression was used to examine the Racial and Ethnic Approaches to Community Health (REACH) 2010 Risk Factor Survey data to investigate the independent relationship between SDH and HBV testing and access to care. RESULTS: HBV infected persons with insurance were more likely to see a physician than those without. Respondents worried about money to pay rent or mortgage were more likely to report HBV infection than individuals who reported they never worry. Compared to English speakers, Spanish-speakers were less likely to report HBV infection, Vietnamese-speakers were more likely to see a physician for HBV infection, and Khmer-speakers were less likely to be tested. CONCLUSIONS: Health insurance coverage, worries about paying rent, and language of interview all differentially affect HBV testing and linkages to care among foreign-born persons. Multi-sectorial stakeholder collaborative efforts should integrate resources to provide culturally sensitive health promotion campaigns which may improve HBV related outcomes.

HIV community viral load trends in South Carolina.

Community viral load is an aggregate measure of HIV viral load in a particular geographic location, community, or subgroup. Community viral load provides a measure of disease burden in a community and community transmission risk. This study aims to examine community viral load trend in South Carolina and identify differences in community viral load trends between selected population subgroups using a state-wide surveillance dataset that maintains electronic records of all HIV viral load measurements reported to the state health department. Community viral load trends were examined using random mixed effects models, adjusting for age, race, gender, residence, CD4 counts, HIV risk group, and initial antiretroviral regimen during the study period, and time. The community viral load gradually decreased from 2004 to 2013 ( p < 0.0001). The number of new infections also decreased ( p = 0.0001) over time. A faster rate of decrease was seen among men compared to women ( p < 0.0001), men who have sex with men ( p = 0.0001) compared to heterosexuals, patients diagnosed in urban areas compared to that in rural areas ( p = 0.0004), and patients prescribed single-tablet regimen compared to multiple-tablet regimen ( p < 0.0001). While the state-wide community viral load decreased over time, the decline was not uniform among residence at diagnosis, HIV risk group, and single-tablet regimen versus multiple-tablet regimen subgroups. Slower declines in community viral load among females, those in rural areas, and heterosexuals suggest possible disparities in care that require further exploration. The association between using single-tablet regimen and faster community viral load decline is noteworthy.

Chronic health conditions in Medicare beneficiaries 65 years old, and older with HIV infection.

OBJECTIVES: To examine sociodemographic factors and chronic health conditions of people living with HIV (PLWHIV/HIV+) at least 65 years old and compare their chronic disease prevalence with beneficiaries without HIV. DESIGN: National fee-for-service Medicare claims data (parts A and B) from 2006 to 2009 were used to create a retrospective cohort of beneficiaries at least 65 years old. METHODS: Beneficiaries with an inpatient or skilled nursing facility claim, or outpatient claims with HIV diagnosis codes were considered HIV+. HIV+ beneficiaries were compared with uninfected beneficiaries on demographic factors and on the prevalence of hypertension, hyperlipidemia, ischemic heart disease, rheumatoid arthritis/osteoarthritis, and diabetes. Odds ratios (OR), 95% confidence intervals (CIs), and P values were calculated. Adjustment variables included age, sex, race/ethnicity, end stage renal disease (ESRD), and dual Medicare-Medicaid enrollment. Chronic conditions were examined individually and as an index from zero to all five conditions. RESULTS: Of 29 060 418 eligible beneficiaries, 24 735 (0.09%) were HIV+. HIV+ beneficiaries were more likely to be Hispanic, African-American, male, and younger (P > 0.0001) and were 1.5-2.1 times as likely to have a chronic disease [diabetes (adjusted OR) 1.51, 95% CI (1.47, 1.55): rheumatoid arthritis/osteoarthritis 2.14, 95% CI (2.08, 2.19)], and 2.4-7 times as likely to have 1-5 comorbid chronic conditions [1 condition (adjusted OR) 2.38, 95% CI (2.21, 2.57): 5 conditions 7.07, 95% CI (6.61, 7.56)]. CONCLUSION: Our results show that PLWHIV at least 65 years old are at higher risk of comorbidities than other fee-for-service Medicare beneficiaries. This finding has implications for the cost and health management of PLWHIV 65 years and older.

Rural-urban differences in HIV viral loads and progression to AIDS among new HIV cases.

OBJECTIVE: The human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic in the United States has shifted to the South, where an increasing proportion is occurring in rural areas. We sought to gain a better understanding of the affected rural population in this region. METHODS: The statewide HIV/AIDS Electronic Reporting System database was used to examine the epidemiological characteristics of newly diagnosed HIV cases in South Carolina from 2005 to 2011. Rural-urban differences were examined in sociodemographic and clinical characteristics, including progression to AIDS and a decline in HIV viral load (VL) to undetectable levels within 1 year of diagnosis. RESULTS: Of the 5336 individuals newly diagnosed as having HIV, 1433 (26.9%) were from rural areas. Compared with urban residents, a higher proportion of rural residents were black, non-Hispanic (80.1% vs 68.5%; P ≤ 0.0001) and reported heterosexual risk (28.8% vs 22.9%; P = 0.0007). The proportion of female patients was higher in rural areas (29.7% vs 26.4%; P = 0.016). No significant rural-urban differences were found in initial CD4(+) T-cell and VL counts or proportion obtaining an undetectable VL at 1 year. Rural residents were significantly more likely than urban residents to have AIDS at diagnosis or within 1 year of the HIV diagnosis (adjusted odds ratio 1.15; 95% confidence interval 1.007-1.326). CONCLUSIONS: The reasons behind differences in proportions of rural and urban residents who were diagnosed as having AIDS or progressed to AIDS despite similar initial CD4(+) T-cell counts and VL suppression at 1 year are unclear and should be explored in future studies. Future prevention and treatment efforts may need to consider the unique characteristics of rural populations in the South.

Incidence of primary hypertension in a population-based cohort of HIV-infected compared with non-HIV-infected persons and the effect of combined antiretroviral therapy.

Literature remains scarce on the impact of antiretroviral medications on hypertension in the HIV population. We used the South Carolina Medicaid database linked with the enhanced HIV/AIDS system surveillance database for 1994-2011 to evaluate incident hypertension and the impact of combination antiretroviral therapy (cART) in HIV/AIDS population compared with a propensity- matched non-HIV control group. Multivariable, time-dependent survival analysis suggested no significant difference in incidence of hypertension between the HIV group and the non-HIV control group. However, subgroup analysis suggested that among the HIV-infected group, months of exposure to both non-nucleoside reverse transcriptase inhibitors (adjusted hazard ratio, 1.52; 95% confidence interval, 1.3-1.75) and protease inhibitors (adjusted hazard ratio, 1.26; 95% confidence interval, 1.11-1.44) were associated with an increased risk of incident hypertension after adjusting for traditional demographic and metabolic risk factors. In people with HIV/AIDS, prolonged exposure to both protease inhibitor-based and non-nucleoside reverse transcriptase inhibitor-based cART may increase the risk of incident hypertension.

Disparities in viral load and CD4 count trends among HIV-infected adults in South Carolina.

On a population level, trends in viral load (VL) and CD4 cell counts can provide a marker of infectivity and an indirect measure of retention in care. Thus, observing the trend of CD4/VL over time can provide useful information on disparities in populations across the HIV care continuum when stratified by demography. South Carolina (SC) maintains electronic records of all CD4 cell counts and HIV VL measurements reported to the state health department. We examined temporal trends in individual HIV VLs reported in SC between January 1, 2005 and December 31, 2012 by using mixed effects models adjusting for gender, race/ethnicity, age, baseline CD4 count, HIV risk category, and residence. Overall VL levels gradually decreased over the observation period. There were significant differences in the VL decline by gender, age groups, rural/urban residence, and HIV risk exposure group. There were significant differences in CD4 increases by race/ethnicity, age groups, and HIV risk exposure group. However, the population VL declines were slower among individuals aged 13-19 years compared to older age groups (p<0.0001), among men compared to women (p=0.002), and among people living with HIV/AIDS (PLWHA) with CD4 count ≤200 cell/mm(3) compared to those with higher CD4 counts (p<0.0001). Significant disparities were observed in VL decline by gender, age, and CD4 counts among PLWHA in SC. Population based data such as these can help streamline and better target local resources to facilitate retention in care and adherence to medications among PLWHA.

Training racial and ethnic minority students for careers in public health sciences.

BACKGROUND: A workforce that resembles the society it serves is likely to be more effective in improving health equity for racial and ethnic minorities in the U.S. Racial and ethnic minorities are underrepresented in the U.S. public health professions. Project Imhotep is operated by Morehouse College with funding and technical assistance from CDC. Imhotep trains racial and ethnic minority students for entry into graduate and professional training programs for careers in the public health sciences. The curriculum focuses on biostatistics, epidemiology, and occupational safety and health with practical training in statistical data analysis, scientific writing, and oral presentation skills. PURPOSE: To describe the Imhotep program and highlight some of its outcomes. METHODS: Data were collected every year by self-administered questionnaire or follow-up telephone and e-mail interviews of students who participated in Imhotep during 1982-2010 and were followed through December 2013. RESULTS: Findings demonstrated that 100% of the 481 trained students earned bachelor's degrees; 73.2% earned graduate degrees (53% earned master's degrees, 11.1% earned medical degrees, and 7.3% earned other doctoral degrees); and 60% entered public health careers. CONCLUSIONS: The Imhotep program has improved the representation of racial and ethnic minorities among public health professionals in the U.S. A diverse workforce involving Imhotep graduates could augment the pool of pubic health professionals who make strategic and tactical decisions around program design and resource allocation that impact health in the most affected communities.

Impact of clinical and therapeutic factors on incident cardiovascular and cerebrovascular events in a population-based cohort of HIV-infected and non-HIV-infected adults.

BACKGROUND: Cardiovascular and cerebrovascular (CVD) events/diseases are a common cause of non-acquired immunodeficiency syndrome (AIDS)-related mortality in the aging human immunodeficiency virus (HIV)-infected population. The incidence rate and clinical correlates of CVD in people living with HIV/AIDS compared to the general population warrants further investigation. HYPOTHESIS: HIV/AIDS is associated with increased risk CVD compared to general population. METHODS: CVD events in a matched cohort of HIV-infected and non-HIV-infected adults, ≥18 years old, served through the South Carolina Medicaid program during 1994 to 2011 were examined using time-dependent proportional hazards regression and marginal structural modeling. RESULTS: A retrospective cohort of 13,632 adults was followed longitudinally for an average of 51 months. The adjusted hazard ratio (aHR) of incident CVD events was higher among HIV-infected individuals exposed to combination antiretroviral therapy (cART) (aHR = 1.15) compared to the non-HIV-infected group, but did not differ from the subgroup of cART-naïve HIV-infected adults. A higher aHR of incident CVD was associated with comorbid hypertension (aHR = 2.18), diabetes (aHR = 1.38), obesity (aHR = 1.30), tobacco use (aHR = 1.47), and hepatitis C coinfection (aHR = 1.32), and older age (aHR = 1.26), but with a lower risk among females (aHR = 0.86). A higher risk of incident CVD events was also apparent in HIV-infected individuals with exposure to both protease inhibitors (adjusted risk ratio [aRR] = 1.99) and non-nucleoside reverse transcriptase inhibitors (aRR = 2.19) compared to those with no exposure. Sustained viral load suppression was associated with a lower risk of incident CVD events (aRR = 0.74). CONCLUSIONS: After adjusting for traditional risk factors and sociodemographic differences, there is higher risk of incident cardiovascular events among HIV-infected individuals exposed to combined antiretroviral medications compared to the general population.

Relationship of HIV care engagement to emergency department utilization.

To determine if HIV primary care engagement (PCE) is associated with Emergency Department (ED) utilization, a retrospective cohort study using the South Carolina HIV surveillance data from January 1986 to December 2006 linked to the hospital discharge data-set was used to assess utilization at statewide EDs during January 2007-December 2010. Suboptimal PCE was defined as <2 reports of a CD4 + T-cell count or viral load value to surveillance in each calendar year from January 2007 to December 2010. Multivariable logistic regression explored associations of HIV PCE with ED utilization after accounting for sociodemographic characteristics and disease stage. Poisson and negative binominal regression examined PCE, sociodemographic characteristics, and disease stage on the frequency of ED utilization. Suboptimal PCE was associated with increased odds of ED utilization for NIR/NRR (no identified risk/no risk reported; aOR [adjusted odds ratio] = 2.25; CI = 1.69-2.99), self-payers (aOR = 1.81; CI = 1.38-2.39), and those diagnosed with an AIDS-defining illness (ADI; aOR = 1.51; CI = 1.14-2.00), who also had the most median ED visits (six). More ED visits were associated with young age, female (incidence rate ratio [IRR] = 1.16; CI = 1.06-1.27), ADI (IRR = 2.17; CI = 1.93-2.45), Medicaid recipients (IRR = 1.34; CI = 1.21-1.49), indigent/charity recipients (IRR = 1.86; CI = 1.57-2.21), or AIDS > 1 year (IRR = 1.23; CI = 1.13-1.35). Fewer visits to the ED were associated with MSM (males having sex with males IRR = 0.81; CI = 0.72-0.90), NIR/NRR (IRR = 0.86; CI = 0.78-0.95), self-payers (IRR = 0.56; CI = 0.50-0.62), or Medicare recipients (IRR = 0.85; CI = 0.77-0.95). Disease stage and insurance type were differentially associated with primary care and ED utilization. There is a need to evaluate HIV primary care systems to increase access and develop interventions to reduce preventable ED visits.