Introduction The COVID-19 pandemic has created substantial interruptions in healthcare presenting... more Introduction The COVID-19 pandemic has created substantial interruptions in healthcare presenting challenges for people with chronic illnesses to access care and treatment services. We aimed to assess the impact of the pandemic on HIV care delivery by characterizing the pandemic-related impact on HIV clinic-level services and the mitigation strategies that were developed to address them. Methods The data comes from a site assessment survey conducted in the DC Cohort, an observational clinical cohort of PWH receiving care at 14 HIV outpatient clinics in Washington, D.C. Frequency counts and prevalence estimates of clinic-level survey responses about the impact of care delivery, COVID-19 testing, and vaccinations and mitigation strategies are presented. Results Clinics reported an increase in temporary clinic closures (n = 2), reduction in clinic hours (n = 5), telehealth utilization (n = 10), adoption of multi-month dispensation of antiretroviral (ARV) medication (n = 11) and alterna...
The Ending the HIV Epidemic initiative aims to decrease new HIV infections and promote test-and-t... more The Ending the HIV Epidemic initiative aims to decrease new HIV infections and promote test-and-treat strategies. Our aims were to establish a baseline of HIV outcomes among newly diagnosed PWH in Washington, DC (DC), a ‘hotspot’ for the HIV epidemic. We also examined sociodemographic and clinical factors associated with retention in care (RIC), antiretroviral therapy (ART) initiation and viral suppression (VS) among newly diagnosed PWH in the DC Cohort from 2011–2016. Among 455 newly diagnosed participants, 92% were RIC at 12 months, ART was initiated in 65% at 3 months and 91% at 12 months, VS in at least 17% at 3 months and 82% at 12 months and 55% of those with VS at 12 months had sustained VS for an additional 12 months. AIDS diagnosis was associated with RIC (aOR 2.99; 1.13–2.28), ART initiation by 3 months (aOR 2.58; 1.61–4.12) and VS by 12 months (aOR4.87; 1.69–14.03). This analysis contributes to our understanding of the HIV treatment dynamics of persons with recently diagn...
Objective Women living with HIV (WLWH) experience psychosocial stress related to social-structura... more Objective Women living with HIV (WLWH) experience psychosocial stress related to social-structural vulnerabilities. To investigate neuroendocrine pathways linking stress and increased cardiovascular disease risk among WLWH, we evaluated associations between psychosocial stress (i.e., perceived stress, posttraumatic stress, and experiences of race- and gender-based harassment) and a composite neuroendocrine biomarker index among WLWH and women without HIV. Methods In 2019–2020, Women’s Interagency HIV Study participants in Washington, DC completed a questionnaire and provided blood and 12-hour overnight urine samples for testing of serum dehydroepiandrosterone sulfate (DHEA-S) and urinary free cortisol, epinephrine, and norepinephrine. Psychosocial stress was measured using the Perceived Stress Scale, PTSD Checklist-Civilian Version, and Racialized Sexual Harassment Scale. Latent profile analysis was used to classify participants into low (38%), moderate (44%), and high (18%) stress ...
We conducted a retrospective analysis of 38 children and youth with human immunodeficiency virus ... more We conducted a retrospective analysis of 38 children and youth with human immunodeficiency virus (aged 0–19 years) in the United States and report an increased rate of change of BMI-for-age z score after initiating integrase strand transfer inhibitors (+0.19 z score units/year [95% confidence interval, .01–.37]; P = .036) for a median follow-up of 527.5 days.
Background The U=U (Undetectable=Untransmittable) campaign advances the goal of ending the HIV ep... more Background The U=U (Undetectable=Untransmittable) campaign advances the goal of ending the HIV epidemic by promoting durable viral suppression and therefore reducing sexual transmission. We used geospatial analysis to assess the potential for sexual HIV transmission by ZIP code of residence in the District of Columbia (DC) using data from DC Cohort Longitudinal HIV Study (DC Cohort), a city-wide cohort of persons with HIV (PWH). Methods DC Cohort participants ages ≥13 were included in the study period between April 1, 2016 and March 31, 2018. Potential for sexual HIV transmission was defined as the proportion of participants with incident sexually transmitted infection (STI - gonorrhea, chlamydia, syphilis) and with HIV RNA ≥200 copies/mL from 9 months prior to 3 months after STI diagnosis. We performed geographic information system (GIS) analysis to determine the ZIP codes with the highest potential for sexual HIV transmission. Results Of 3,467 participants, 367 (10.6%) had at leas...
Background Two strategies of the US Ending the HIV Epidemic initiative are early diagnosis of inf... more Background Two strategies of the US Ending the HIV Epidemic initiative are early diagnosis of infections via widespread testing and prevention of new infections using pre-exposure prophylaxis (PrEP). These strategies are particularly important for adolescents and young adults (AYAs) who are disproportionately affected by HIV, particularly if they identify as Black and/or lesbian, gay, bisexual, transgender, queer or questioning, and others (LGBTQ+). This study will develop and test an interactive life-simulation game in which players can enact real-life behaviors and receive their HIV risk profile to improve HIV testing and PrEP access among AYAs aged 13-24 years in Washington, DC. Objective This mixed methods study aims to determine the acceptability of an interactive, enhanced life-simulation game prototype among AYAs, conduct a pilot test of the gaming intervention among a small cohort of AYAs to ensure game usability and acceptability, and evaluate the efficacy of the game in a ...
ObjectiveA rise in incidence of STIs has been noted in the USA and in the District of Columbia (D... more ObjectiveA rise in incidence of STIs has been noted in the USA and in the District of Columbia (DC). We aim to describe changes in incident STIs among persons in care for HIV in Washington, DC as well as trends in HIV viral load among those with incident STIs.MethodsWe conducted a retrospective DC Cohort analysis (n=7810) measuring STI incidence (syphilis, gonorrhoea and chlamydia) as well as incare viral load (ICVL) and percentage with all viral loads less than the limit of detection (%
This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Background Direct oral anticoagulants (DOACs) have become first-line treatment for venous thrombo... more Background Direct oral anticoagulants (DOACs) have become first-line treatment for venous thrombotic events. DOAC prescribing trends among people living with human immunodeficiency virus (PWH) are not well described. The coadministration of DOACs with the antiretroviral (ARV) pharmacokinetic boosters ritonavir (RTV) or cobicistat (COBI) may be complicated by pharmacokinetic interactions. Methods A longitudinal cohort study was conducted using the D.C. Cohort Database in Washington, D.C., from January 2011 to March 2017, to describe oral anticoagulant prescribing among PWH ≥ 18 years old and the prevalence of DOAC use with RTV or COBI. Data collection included demographic and clinical characteristics, ARV and anticoagulant prescriptions, and International Classification of Diseases Ninth and Tenth Edition diagnosis codes. Results Among 8315 PWH, there were 236 anticoagulant prescriptions (96 DOAC, 140 warfarin) for 206 persons. PWH prescribed anticoagulants were predominantly Black (...
Pre-exposure prophylaxis (PrEP) is a pillar of the US Department of Health and Human Services "En... more Pre-exposure prophylaxis (PrEP) is a pillar of the US Department of Health and Human Services "Ending the HIV Epidemic" (EHE) initiative in 50 EHE jurisdictions (48 U.S. counties and two U.S. cities) and seven U.S. states with high numbers of HIV diagnoses rates in rural areas. Current data systems do not provide data on PrEP uptake in counties or cities. Methods: We report on PrEP users at the county level. Data from a large, commercial pharmacy database were used; we applied the U.S. Census Bureau's method to allocate PrEP users within a ZIP3 into counties and validated the results. We report counts and rates of PrEP users in 2018 for all EHE jurisdictions. We used joinpoint regression to model the estimated annual percent change in PrEP use for each jurisdiction and state. Results: 93,156 people in the 50 EHE jurisdictions used PrEP in 2018; 94% were men and 39% were aged 25e34 years. There was more than an 80-fold difference in the range of rates of PrEP use per 100,000 population among the EHE jurisdictions (range: 8e644 per 100,000 population; median 93 per 100,000 population). PrEP use increased from 2012 to 2018 in all EHE counties and states. At current rates of growth of PrEP use, 94% of EHE counties and jurisdictions will reach their National HIV/AIDS Strategy goals of a 500% increase in PrEP use in 2020. EHE states had less variation in rates of PrEP use (range: 29 e51/100,000 population; median 32/100,000 population). Conclusions: At the outset of a major U.S. government program to reduce HIV infections, rates of PrEP use are highly variable among the 50 EHE jurisdictions. Data from commercial prescription databases will be a useful public resource to understand progress in promoting use of PrEP as part of the EHE initiative and evaluating progress in PrEP use across health jurisdictions.
Background Agents from the integrase inhibitor (INSTI) therapeutic class only are recommended as ... more Background Agents from the integrase inhibitor (INSTI) therapeutic class only are recommended as initial therapy for most patients with HIV. Clinicians now face a decision when treating ART-experienced patients on non-INSTI regimens: continue current therapy or switch to INSTI. Multiple factors may be considered in this decision: clinician/patient preference, comorbidities, tolerability, and resistance history. The objective of this analysis was to examine patient factors associated with currently taking an INSTI-based regimen. Methods We used data from the DC Cohort, a longitudinal observational cohort of patients receiving HIV care at 14 clinics between 2011–2018. Participants in the sample had ≥ 1 encounter between 4/1/17 and 3/1/18, were aged ≥ 18 years and were ART experienced. Participants were classified as currently, previously, or never on an INSTI. Independent variables included demographics, clinical characteristics, alcohol/tobacco use, HBV/HCV status and HIV-related var...
Background Among persons living with HIV (PLWH) with type 2 diabetes mellitus (DM) there is limit... more Background Among persons living with HIV (PLWH) with type 2 diabetes mellitus (DM) there is limited research on the effect of DM control on CD4 count. Current guidelines recommend that PLWH with DM maintain a hemoglobin A1c (HbA1c) <7%. This analysis examined the impact of HbA1c on trends in CD4 count among PLWH receiving care in Washington, DC. Methods We used data from the DC Cohort, a longitudinal observational cohort of patients receiving HIV care at 14 clinics between 2011–2018. Participants with DM on an ongoing antiretroviral regimen with ≥1 year of follow-up, ≥2 HbA1c results, and ≥2 CD4 count results were included. Participants were compared based on the most recent HbA1c result categorized into one of three control levels control: strict, HbA1c < 7.5%; moderate, HbA1c between 7.5–9.0%; and uncontrolled, HbA1c >9.0%. All statistical tests were performed within the framework of the linear mixed-effects (LME) model. The rates of increase in CD4 count by DM control we...
Background In 2019, the US Administration announced the Ending the HIV Epidemic plan to decrease ... more Background In 2019, the US Administration announced the Ending the HIV Epidemic plan to decrease new infections. A key component is the Test and Treat plan to diagnose early, treat rapidly and achieve viral suppression (VS) among persons living with HIV (PLWH). We assessed retention in care (RIC), antiretroviral therapy (ART) initiation and VS among newly diagnosed PLWH in Washington, DC. Methods We conducted a cross-sectional analysis using data from the DC Cohort, an observational longitudinal cohort of PLWH in care in 14 clinics in DC. We included participants enrolled from 2011 to 2016 whose HIV diagnosis was within 1 year of enrollment and with at least 12 months follow-up. RIC was defined as ≥2 visits or HIV lab results 90 days apart in the first year of follow-up. ART initiation was defined as being prescribed ART, VS was defined as HIV RNA <200 copies/mL, and both these outcomes were assessed at 2 time points: by 3 and 12 months. Adjusted multivariable logistic regression...
Objective: Adolescents and young adults (AYAs) account for >20% of new HIV diagnoses in the Unite... more Objective: Adolescents and young adults (AYAs) account for >20% of new HIV diagnoses in the United States, yet >50% are unaware of their infection. Digital gaming is widespread among youth and has proven efficacious in other disease areas; thus, we sought to determine whether a life-and-dating simulation game to increase HIV testing would be acceptable among AYAs. Materials and Methods: Focus groups and surveys were administered to health care providers and AYAs in Washington, DC. AYAs were shown a life-and-dating simulation game that incorporated the Centers for Disease Control and Prevention Risk Estimator tool to demonstrate the potential HIV risk of selected behaviors and a zipcode-level HIV testing locator. Thematic analysis was used to identify general gaming themes and game acceptance. Descriptive statistics were used to summarize response frequencies and Likert scales were used to evaluate game acceptability. Results: Providers, some of whom (38%, n = 5/13) had significant experience caring for youth living with or at increased risk for HIV, advised against the game forcing youth to disclose sexual identity or labeling youth ''at risk.'' AYAs (n = 46) found the initial and revised versions of the game to be highly acceptable: youth thought the game was interesting [mean (standard deviation, SD) = 4.8/5 (0.4)]; liked playing games about HIV-related behaviors [mean (SD) = 4.8/5 (0.5)]; and would share the game to help friends get tested for HIV [mean = 4.6/5 (0.8)]. Conclusions: This study suggests that a digital game to improve HIV testing is acceptable among youth. An efficacy trial is planned to determine the impact of the game on improving HIV testing.
Introduction: Prior studies found renal disease was common among HIV-infected outpatients. We upd... more Introduction: Prior studies found renal disease was common among HIV-infected outpatients. We updated incident renal disease estimates in this population, comparing those with and without tenofovir exposure. Methods: We conducted a retrospective analysis of the DC Cohort, a longitudinal study of HIV patients in Washington, DC, from 2011 to 2015. We included adults prescribed antiretroviral therapy (ART) with baseline glomerular filtration rate (GFR) $15 ml/min per 1.73 m 2. We defined renal disease as 50% decrease in GFR or doubled serum creatinine (Cr) within 3 months. We defined cumulative viral load as area under the curve (AUC) of log 10 transformed longitudinal HIV RNA viral load (VL). Correlates of time to incident renal disease were identified using Cox proportional hazard regression models, adjusted for demographics and known risk factors for kidney disease. Results: Among 6068 adults, 77% were Black and median age was 48 years. Incident renal disease rate was 0.77 per 100 person-years (95% confidence interval [
Pre-exposure prophylaxis (PrEP) with oral emtricitibine/tenofovir disoproxil fumarate (TDF/FTC) r... more Pre-exposure prophylaxis (PrEP) with oral emtricitibine/tenofovir disoproxil fumarate (TDF/FTC) reduces the risk of HIV infection by >90% when taken as prescribed. Trends in prevalence of PrEP use, which account for persons who have stopped PrEP, increased through 2016, but have not been described since. Annual prevalence estimates of unique, TDF/FTC PrEP users (individuals with ≥1 day of a filled PrEP prescription in a given year) in the United States (US) were generated for 2012-2017 from a national prescription database. A validated algorithm was used to distinguish users of TDF/FTC for HIV or chronic Hepatitis B treatment or postexposure prophylaxis from PrEP users. We calculated annual prevalence of PrEP use overall and by age, sex, and region. We used log-transformation to calculate estimated annual percent change (EAPC) in the prevalence of PrEP use. Annual prevalence of PrEP use increased from 3.3/100,000 population in 2012 to 36.7 in 2017 -a 56% annual increase from 2012...
Few HIV interventions have demonstrated efficacy in reducing HIV risk among adolescent men who ha... more Few HIV interventions have demonstrated efficacy in reducing HIV risk among adolescent men who have sex with men (AMSM), and fewer still have recognized the unique needs of AMSM based on race/ethnicity or geographical setting. Recognizing that youths' HIV vulnerability is intricately tied to their development and social context, delivering life skills training during adolescence might delay the onset or reduce the consequences of risk factors for HIV acquisition and equip AMSM with the skills to navigate HIV prevention. This protocol describes the development and testing of iREACH, an online multilevel life skills intervention for AMSM. This randomized controlled trial (RCT) aims to test the efficacy of an online-delivered life skills intervention, iREACH, on cognitive and behavioral HIV-related outcomes for AMSM. iREACH is a prospective RCT of approximately 600 cisgender adolescent males aged 13 to 18 years who report same-sex attractions. The intervention will be tested with a...
Washington DC has a high burden of HIV with a 2.0% HIV prevalence. The city is a national and int... more Washington DC has a high burden of HIV with a 2.0% HIV prevalence. The city is a national and international hub potentially containing a broad diversity of HIV variants; yet few sequences from DC are available on GenBank to assess the evolutionary history of HIV in the US capital. Towards this general goal, here we analyze extensive sequence data and investigate HIV diversity, phylodynamics, and drug resistant mutations (DRM) in DC. Molecular HIV-1 sequences were collected from participants infected through 2015 as part of the DC Cohort, a longitudinal observational study of HIV+ patients receiving care at 13 DC clinics. Sequences were paired with Cohort demographic, risk, and clinical data and analyzed using maximum likelihood, Bayesian and coalescent approaches of phylogenetic, network and population genetic inference. We analyzed 601 sequences from 223 participants for int (~864 bp) and 2,810 sequences from 1,659 participants for PR/RT (~1497 bp). Ninety-nine and 94% of the int a...
Journal of the American Medical Informatics Association, 2015
Objective Electronic medical records (EMRs) are being increasingly utilized to conduct clinical a... more Objective Electronic medical records (EMRs) are being increasingly utilized to conduct clinical and epidemiologic research in numerous fields. To monitor and improve care of HIV-infected patients in Washington, DC, one of the most severely affected urban areas in the United States, we developed a city-wide database across 13 clinical sites using electronic data abstraction and manual data entry from EMRs. Materials and Methods To develop this unique longitudinal cohort, a web-based electronic data capture system (Discovere®) was used. An Agile software development methodology was implemented across multiple EMR platforms. Clinical informatics staff worked with information technology specialists from each site to abstract data electronically from each respective site’s EMR through an extract, transform, and load process. Results Since enrollment began in 2011, more than 7000 patients have been enrolled, with longitudinal clinical data available on all patients. Data sets are produced...
Introduction The COVID-19 pandemic has created substantial interruptions in healthcare presenting... more Introduction The COVID-19 pandemic has created substantial interruptions in healthcare presenting challenges for people with chronic illnesses to access care and treatment services. We aimed to assess the impact of the pandemic on HIV care delivery by characterizing the pandemic-related impact on HIV clinic-level services and the mitigation strategies that were developed to address them. Methods The data comes from a site assessment survey conducted in the DC Cohort, an observational clinical cohort of PWH receiving care at 14 HIV outpatient clinics in Washington, D.C. Frequency counts and prevalence estimates of clinic-level survey responses about the impact of care delivery, COVID-19 testing, and vaccinations and mitigation strategies are presented. Results Clinics reported an increase in temporary clinic closures (n = 2), reduction in clinic hours (n = 5), telehealth utilization (n = 10), adoption of multi-month dispensation of antiretroviral (ARV) medication (n = 11) and alterna...
The Ending the HIV Epidemic initiative aims to decrease new HIV infections and promote test-and-t... more The Ending the HIV Epidemic initiative aims to decrease new HIV infections and promote test-and-treat strategies. Our aims were to establish a baseline of HIV outcomes among newly diagnosed PWH in Washington, DC (DC), a ‘hotspot’ for the HIV epidemic. We also examined sociodemographic and clinical factors associated with retention in care (RIC), antiretroviral therapy (ART) initiation and viral suppression (VS) among newly diagnosed PWH in the DC Cohort from 2011–2016. Among 455 newly diagnosed participants, 92% were RIC at 12 months, ART was initiated in 65% at 3 months and 91% at 12 months, VS in at least 17% at 3 months and 82% at 12 months and 55% of those with VS at 12 months had sustained VS for an additional 12 months. AIDS diagnosis was associated with RIC (aOR 2.99; 1.13–2.28), ART initiation by 3 months (aOR 2.58; 1.61–4.12) and VS by 12 months (aOR4.87; 1.69–14.03). This analysis contributes to our understanding of the HIV treatment dynamics of persons with recently diagn...
Objective Women living with HIV (WLWH) experience psychosocial stress related to social-structura... more Objective Women living with HIV (WLWH) experience psychosocial stress related to social-structural vulnerabilities. To investigate neuroendocrine pathways linking stress and increased cardiovascular disease risk among WLWH, we evaluated associations between psychosocial stress (i.e., perceived stress, posttraumatic stress, and experiences of race- and gender-based harassment) and a composite neuroendocrine biomarker index among WLWH and women without HIV. Methods In 2019–2020, Women’s Interagency HIV Study participants in Washington, DC completed a questionnaire and provided blood and 12-hour overnight urine samples for testing of serum dehydroepiandrosterone sulfate (DHEA-S) and urinary free cortisol, epinephrine, and norepinephrine. Psychosocial stress was measured using the Perceived Stress Scale, PTSD Checklist-Civilian Version, and Racialized Sexual Harassment Scale. Latent profile analysis was used to classify participants into low (38%), moderate (44%), and high (18%) stress ...
We conducted a retrospective analysis of 38 children and youth with human immunodeficiency virus ... more We conducted a retrospective analysis of 38 children and youth with human immunodeficiency virus (aged 0–19 years) in the United States and report an increased rate of change of BMI-for-age z score after initiating integrase strand transfer inhibitors (+0.19 z score units/year [95% confidence interval, .01–.37]; P = .036) for a median follow-up of 527.5 days.
Background The U=U (Undetectable=Untransmittable) campaign advances the goal of ending the HIV ep... more Background The U=U (Undetectable=Untransmittable) campaign advances the goal of ending the HIV epidemic by promoting durable viral suppression and therefore reducing sexual transmission. We used geospatial analysis to assess the potential for sexual HIV transmission by ZIP code of residence in the District of Columbia (DC) using data from DC Cohort Longitudinal HIV Study (DC Cohort), a city-wide cohort of persons with HIV (PWH). Methods DC Cohort participants ages ≥13 were included in the study period between April 1, 2016 and March 31, 2018. Potential for sexual HIV transmission was defined as the proportion of participants with incident sexually transmitted infection (STI - gonorrhea, chlamydia, syphilis) and with HIV RNA ≥200 copies/mL from 9 months prior to 3 months after STI diagnosis. We performed geographic information system (GIS) analysis to determine the ZIP codes with the highest potential for sexual HIV transmission. Results Of 3,467 participants, 367 (10.6%) had at leas...
Background Two strategies of the US Ending the HIV Epidemic initiative are early diagnosis of inf... more Background Two strategies of the US Ending the HIV Epidemic initiative are early diagnosis of infections via widespread testing and prevention of new infections using pre-exposure prophylaxis (PrEP). These strategies are particularly important for adolescents and young adults (AYAs) who are disproportionately affected by HIV, particularly if they identify as Black and/or lesbian, gay, bisexual, transgender, queer or questioning, and others (LGBTQ+). This study will develop and test an interactive life-simulation game in which players can enact real-life behaviors and receive their HIV risk profile to improve HIV testing and PrEP access among AYAs aged 13-24 years in Washington, DC. Objective This mixed methods study aims to determine the acceptability of an interactive, enhanced life-simulation game prototype among AYAs, conduct a pilot test of the gaming intervention among a small cohort of AYAs to ensure game usability and acceptability, and evaluate the efficacy of the game in a ...
ObjectiveA rise in incidence of STIs has been noted in the USA and in the District of Columbia (D... more ObjectiveA rise in incidence of STIs has been noted in the USA and in the District of Columbia (DC). We aim to describe changes in incident STIs among persons in care for HIV in Washington, DC as well as trends in HIV viral load among those with incident STIs.MethodsWe conducted a retrospective DC Cohort analysis (n=7810) measuring STI incidence (syphilis, gonorrhoea and chlamydia) as well as incare viral load (ICVL) and percentage with all viral loads less than the limit of detection (%
This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Background Direct oral anticoagulants (DOACs) have become first-line treatment for venous thrombo... more Background Direct oral anticoagulants (DOACs) have become first-line treatment for venous thrombotic events. DOAC prescribing trends among people living with human immunodeficiency virus (PWH) are not well described. The coadministration of DOACs with the antiretroviral (ARV) pharmacokinetic boosters ritonavir (RTV) or cobicistat (COBI) may be complicated by pharmacokinetic interactions. Methods A longitudinal cohort study was conducted using the D.C. Cohort Database in Washington, D.C., from January 2011 to March 2017, to describe oral anticoagulant prescribing among PWH ≥ 18 years old and the prevalence of DOAC use with RTV or COBI. Data collection included demographic and clinical characteristics, ARV and anticoagulant prescriptions, and International Classification of Diseases Ninth and Tenth Edition diagnosis codes. Results Among 8315 PWH, there were 236 anticoagulant prescriptions (96 DOAC, 140 warfarin) for 206 persons. PWH prescribed anticoagulants were predominantly Black (...
Pre-exposure prophylaxis (PrEP) is a pillar of the US Department of Health and Human Services "En... more Pre-exposure prophylaxis (PrEP) is a pillar of the US Department of Health and Human Services "Ending the HIV Epidemic" (EHE) initiative in 50 EHE jurisdictions (48 U.S. counties and two U.S. cities) and seven U.S. states with high numbers of HIV diagnoses rates in rural areas. Current data systems do not provide data on PrEP uptake in counties or cities. Methods: We report on PrEP users at the county level. Data from a large, commercial pharmacy database were used; we applied the U.S. Census Bureau's method to allocate PrEP users within a ZIP3 into counties and validated the results. We report counts and rates of PrEP users in 2018 for all EHE jurisdictions. We used joinpoint regression to model the estimated annual percent change in PrEP use for each jurisdiction and state. Results: 93,156 people in the 50 EHE jurisdictions used PrEP in 2018; 94% were men and 39% were aged 25e34 years. There was more than an 80-fold difference in the range of rates of PrEP use per 100,000 population among the EHE jurisdictions (range: 8e644 per 100,000 population; median 93 per 100,000 population). PrEP use increased from 2012 to 2018 in all EHE counties and states. At current rates of growth of PrEP use, 94% of EHE counties and jurisdictions will reach their National HIV/AIDS Strategy goals of a 500% increase in PrEP use in 2020. EHE states had less variation in rates of PrEP use (range: 29 e51/100,000 population; median 32/100,000 population). Conclusions: At the outset of a major U.S. government program to reduce HIV infections, rates of PrEP use are highly variable among the 50 EHE jurisdictions. Data from commercial prescription databases will be a useful public resource to understand progress in promoting use of PrEP as part of the EHE initiative and evaluating progress in PrEP use across health jurisdictions.
Background Agents from the integrase inhibitor (INSTI) therapeutic class only are recommended as ... more Background Agents from the integrase inhibitor (INSTI) therapeutic class only are recommended as initial therapy for most patients with HIV. Clinicians now face a decision when treating ART-experienced patients on non-INSTI regimens: continue current therapy or switch to INSTI. Multiple factors may be considered in this decision: clinician/patient preference, comorbidities, tolerability, and resistance history. The objective of this analysis was to examine patient factors associated with currently taking an INSTI-based regimen. Methods We used data from the DC Cohort, a longitudinal observational cohort of patients receiving HIV care at 14 clinics between 2011–2018. Participants in the sample had ≥ 1 encounter between 4/1/17 and 3/1/18, were aged ≥ 18 years and were ART experienced. Participants were classified as currently, previously, or never on an INSTI. Independent variables included demographics, clinical characteristics, alcohol/tobacco use, HBV/HCV status and HIV-related var...
Background Among persons living with HIV (PLWH) with type 2 diabetes mellitus (DM) there is limit... more Background Among persons living with HIV (PLWH) with type 2 diabetes mellitus (DM) there is limited research on the effect of DM control on CD4 count. Current guidelines recommend that PLWH with DM maintain a hemoglobin A1c (HbA1c) <7%. This analysis examined the impact of HbA1c on trends in CD4 count among PLWH receiving care in Washington, DC. Methods We used data from the DC Cohort, a longitudinal observational cohort of patients receiving HIV care at 14 clinics between 2011–2018. Participants with DM on an ongoing antiretroviral regimen with ≥1 year of follow-up, ≥2 HbA1c results, and ≥2 CD4 count results were included. Participants were compared based on the most recent HbA1c result categorized into one of three control levels control: strict, HbA1c < 7.5%; moderate, HbA1c between 7.5–9.0%; and uncontrolled, HbA1c >9.0%. All statistical tests were performed within the framework of the linear mixed-effects (LME) model. The rates of increase in CD4 count by DM control we...
Background In 2019, the US Administration announced the Ending the HIV Epidemic plan to decrease ... more Background In 2019, the US Administration announced the Ending the HIV Epidemic plan to decrease new infections. A key component is the Test and Treat plan to diagnose early, treat rapidly and achieve viral suppression (VS) among persons living with HIV (PLWH). We assessed retention in care (RIC), antiretroviral therapy (ART) initiation and VS among newly diagnosed PLWH in Washington, DC. Methods We conducted a cross-sectional analysis using data from the DC Cohort, an observational longitudinal cohort of PLWH in care in 14 clinics in DC. We included participants enrolled from 2011 to 2016 whose HIV diagnosis was within 1 year of enrollment and with at least 12 months follow-up. RIC was defined as ≥2 visits or HIV lab results 90 days apart in the first year of follow-up. ART initiation was defined as being prescribed ART, VS was defined as HIV RNA <200 copies/mL, and both these outcomes were assessed at 2 time points: by 3 and 12 months. Adjusted multivariable logistic regression...
Objective: Adolescents and young adults (AYAs) account for >20% of new HIV diagnoses in the Unite... more Objective: Adolescents and young adults (AYAs) account for >20% of new HIV diagnoses in the United States, yet >50% are unaware of their infection. Digital gaming is widespread among youth and has proven efficacious in other disease areas; thus, we sought to determine whether a life-and-dating simulation game to increase HIV testing would be acceptable among AYAs. Materials and Methods: Focus groups and surveys were administered to health care providers and AYAs in Washington, DC. AYAs were shown a life-and-dating simulation game that incorporated the Centers for Disease Control and Prevention Risk Estimator tool to demonstrate the potential HIV risk of selected behaviors and a zipcode-level HIV testing locator. Thematic analysis was used to identify general gaming themes and game acceptance. Descriptive statistics were used to summarize response frequencies and Likert scales were used to evaluate game acceptability. Results: Providers, some of whom (38%, n = 5/13) had significant experience caring for youth living with or at increased risk for HIV, advised against the game forcing youth to disclose sexual identity or labeling youth ''at risk.'' AYAs (n = 46) found the initial and revised versions of the game to be highly acceptable: youth thought the game was interesting [mean (standard deviation, SD) = 4.8/5 (0.4)]; liked playing games about HIV-related behaviors [mean (SD) = 4.8/5 (0.5)]; and would share the game to help friends get tested for HIV [mean = 4.6/5 (0.8)]. Conclusions: This study suggests that a digital game to improve HIV testing is acceptable among youth. An efficacy trial is planned to determine the impact of the game on improving HIV testing.
Introduction: Prior studies found renal disease was common among HIV-infected outpatients. We upd... more Introduction: Prior studies found renal disease was common among HIV-infected outpatients. We updated incident renal disease estimates in this population, comparing those with and without tenofovir exposure. Methods: We conducted a retrospective analysis of the DC Cohort, a longitudinal study of HIV patients in Washington, DC, from 2011 to 2015. We included adults prescribed antiretroviral therapy (ART) with baseline glomerular filtration rate (GFR) $15 ml/min per 1.73 m 2. We defined renal disease as 50% decrease in GFR or doubled serum creatinine (Cr) within 3 months. We defined cumulative viral load as area under the curve (AUC) of log 10 transformed longitudinal HIV RNA viral load (VL). Correlates of time to incident renal disease were identified using Cox proportional hazard regression models, adjusted for demographics and known risk factors for kidney disease. Results: Among 6068 adults, 77% were Black and median age was 48 years. Incident renal disease rate was 0.77 per 100 person-years (95% confidence interval [
Pre-exposure prophylaxis (PrEP) with oral emtricitibine/tenofovir disoproxil fumarate (TDF/FTC) r... more Pre-exposure prophylaxis (PrEP) with oral emtricitibine/tenofovir disoproxil fumarate (TDF/FTC) reduces the risk of HIV infection by >90% when taken as prescribed. Trends in prevalence of PrEP use, which account for persons who have stopped PrEP, increased through 2016, but have not been described since. Annual prevalence estimates of unique, TDF/FTC PrEP users (individuals with ≥1 day of a filled PrEP prescription in a given year) in the United States (US) were generated for 2012-2017 from a national prescription database. A validated algorithm was used to distinguish users of TDF/FTC for HIV or chronic Hepatitis B treatment or postexposure prophylaxis from PrEP users. We calculated annual prevalence of PrEP use overall and by age, sex, and region. We used log-transformation to calculate estimated annual percent change (EAPC) in the prevalence of PrEP use. Annual prevalence of PrEP use increased from 3.3/100,000 population in 2012 to 36.7 in 2017 -a 56% annual increase from 2012...
Few HIV interventions have demonstrated efficacy in reducing HIV risk among adolescent men who ha... more Few HIV interventions have demonstrated efficacy in reducing HIV risk among adolescent men who have sex with men (AMSM), and fewer still have recognized the unique needs of AMSM based on race/ethnicity or geographical setting. Recognizing that youths' HIV vulnerability is intricately tied to their development and social context, delivering life skills training during adolescence might delay the onset or reduce the consequences of risk factors for HIV acquisition and equip AMSM with the skills to navigate HIV prevention. This protocol describes the development and testing of iREACH, an online multilevel life skills intervention for AMSM. This randomized controlled trial (RCT) aims to test the efficacy of an online-delivered life skills intervention, iREACH, on cognitive and behavioral HIV-related outcomes for AMSM. iREACH is a prospective RCT of approximately 600 cisgender adolescent males aged 13 to 18 years who report same-sex attractions. The intervention will be tested with a...
Washington DC has a high burden of HIV with a 2.0% HIV prevalence. The city is a national and int... more Washington DC has a high burden of HIV with a 2.0% HIV prevalence. The city is a national and international hub potentially containing a broad diversity of HIV variants; yet few sequences from DC are available on GenBank to assess the evolutionary history of HIV in the US capital. Towards this general goal, here we analyze extensive sequence data and investigate HIV diversity, phylodynamics, and drug resistant mutations (DRM) in DC. Molecular HIV-1 sequences were collected from participants infected through 2015 as part of the DC Cohort, a longitudinal observational study of HIV+ patients receiving care at 13 DC clinics. Sequences were paired with Cohort demographic, risk, and clinical data and analyzed using maximum likelihood, Bayesian and coalescent approaches of phylogenetic, network and population genetic inference. We analyzed 601 sequences from 223 participants for int (~864 bp) and 2,810 sequences from 1,659 participants for PR/RT (~1497 bp). Ninety-nine and 94% of the int a...
Journal of the American Medical Informatics Association, 2015
Objective Electronic medical records (EMRs) are being increasingly utilized to conduct clinical a... more Objective Electronic medical records (EMRs) are being increasingly utilized to conduct clinical and epidemiologic research in numerous fields. To monitor and improve care of HIV-infected patients in Washington, DC, one of the most severely affected urban areas in the United States, we developed a city-wide database across 13 clinical sites using electronic data abstraction and manual data entry from EMRs. Materials and Methods To develop this unique longitudinal cohort, a web-based electronic data capture system (Discovere®) was used. An Agile software development methodology was implemented across multiple EMR platforms. Clinical informatics staff worked with information technology specialists from each site to abstract data electronically from each respective site’s EMR through an extract, transform, and load process. Results Since enrollment began in 2011, more than 7000 patients have been enrolled, with longitudinal clinical data available on all patients. Data sets are produced...
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Papers by Amanda Castel