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Youth with autism spectrum disorder often have complex medical needs. Disruptions of healthcare during the transition from pediatric to adult healthcare may put youth with autism spectrum disorder at higher risk of medical emergencies and high medical costs. We conducted a study among transition-age youth (14-25 years old) receiving healthcare at Kaiser Permanente Northern California during 2014-2015. We examined the differences in healthcare utilization and costs among youth with autism spectrum disorder (n = 4123), attention deficit and hyperactivity disorder (n = 20,6015), diabetes mellitus (n = 2156), and general population controls (n = 20,615). Analyses were also stratified by age and sex. Youth with autism spectrum disorder had the highest utilization of outpatient primary care, mental health, and psychotropic medications and the lowest utilization of obstetrics/gynecology and urgent care. Costs for youth with autism spectrum disorder were higher than those for attention deficit and hyperactivity disorder and general population peers and lower than for diabetes mellitus. Utilization patterns varied by age. Transition-age youth with autism spectrum disorder generally utilize healthcare at higher rates relative to attention deficit and hyperactivity disorder and general population peers but at similar or lower rates than diabetes mellitus peers, indicating this group's complex combination of psychiatric and medical healthcare needs. The relatively high utilization of psychiatric services and low utilization of women's health services in transition-age youth with autism spectrum disorder may have implications for long-term health and warrants additional research.

Some children in American schools have known and unknown communicable diseases, including herpes, cytomegalovirus, AIDS, mononucleosis, pinworms, and hepatitis. This article examines major public health issues, school responsibility, preventative measures (like basic hygiene), and the need for more effective community education programs. A disease chart and several informative insets are included. (MLH)

Objectives: Public health detailing is an intervention in which a public health professional visits health care providers to educate them about evidence-based approaches to improve health. The San Francisco Department of Public Health conducted a public health detailing program from 2016 to 2018 to improve sexual health care and preexposure prophylaxis services in the city. Methods: We conducted a mixed-methods study to understand the implementation of detailing and explore examples of changes to clinicians' clinical behaviors. We surveyed 203 clinicians, conducted 60-minute qualitative interviews with 7 clinicians and 4 detailers, and analyzed tracking forms. We used descriptive statistics to assess associations in the surveys. We used qualitative thematic analysis to understand facilitators and barriers to detailing and identify ways to improve the process and identify its potential benefits. Results: In interviews, both clinicians and detailers had a favorable view of detailing as a tool to connect health department expertise to clinicians. Detailers cited challenges such as limited clinic time, provider turnover, and policies that limit their access to clinicians. These challenges may attenuate the real-world benefits of detailing. Clinicians offered examples of how detailing altered their behaviors, such as taking sexual health histories, building knowledge and confidence about sexual health, and using health department services. Matched surveys (n = 21) showed preliminary changes to prescribing preexposure prophylaxis. Conclusions: Public health detailing is a promising approach to increase clinicians' knowledge and confidence to offer sexual health care services, build buy-in, and support connection to health departments. Detailing programs require sufficient investment and staff support to build lasting and collaborative relationships between clinicians and public health departments and to assess the impact of the intervention. [ABSTRACT FROM AUTHOR]

The location of parasites within individual hosts is often treated as a static trait, yet many parasite species can occur in multiple locations or organs within their hosts. Here, we apply distributional heat maps to study the within- and between-host infection patterns for four trematodes (Alaria marcianae, Cephalogonimus americanus, Echinostoma spp. and Ribeiroia ondatrae) within the amphibian hosts Pseudacris regilla and two species of Taricha. We developed heatmaps from 71 individual hosts from six locations in California, which illustrate stark differences among parasites both in their primary locations within amphibian hosts as well as their degree of location specificity. While metacercariae (i.e., cysts) of two parasites (C. americanus and A. marcianae) were relative generalists in habitat selection and often occurred throughout the host, two others (R. ondatrae and Echinostoma spp.) were highly localised to a specific organ or organ system. Comparing parasite distributions among these parasite taxa highlighted locations of overlap showing potential areas of interactions, such as the mandibular inner dermis region, chest and throat inner dermis and the tail reabsorption outer epidermis. Additionally, the within-host distribution of R. ondatrae differed between host species, with metacercariae aggregating in the anterior dermis areas of newts, compared with the posterior dermis area in frogs. The ability to measure fine-scale changes or alterations in parasite distributions has the potential to provide further insight about ecological questions concerning habitat preference, resource selection, host pathology and disease control. [ABSTRACT FROM AUTHOR]

The number and popularity of backyard poultry and livestock farming have rapidly increased in California as well as other states in the United States following consumers' preference for local and organic products in the last few years. This study aimed to investigate current on-farm management and farmers' understanding of Veterinary Feed Directive (VFD) and California Senate Bill (SB) 27 implications for disease prevention, biosecurity procedures, and antimicrobial use in small-scale and backyard farms in California. The survey consisted of 38 questions. The responses of 242 backyard and small-scale livestock owners were investigated in this study. Descriptive statistics summarized survey responses, and multivariable logistic regression evaluated the association of antibiotics purchase and use, and the impact of VFD and SB27 on antibiotic use with demographics and on-farm management. Backyard and small-scale farmers in California mostly raised chickens or small ruminants with small herd sizes kept for personal use. Antibiotics were generally used for individual treatment of a sick animal with the guidance of a veterinarian. VFD and SB27 implementation promoted the judicious use of antibiotics, specifically, by enhancing the relationship between backyard and small-scale farmers with veterinarians and treating fewer animals with antibiotics under veterinary oversight. Therefore, better access to veterinary service in backyard and small-scale farms will improve the farmer's knowledge of good husbandry practices with judicious antimicrobial use in livestock and finally contribute to reducing the risk of antimicrobial resistance in California. [ABSTRACT FROM AUTHOR]

Background: Harm reduction is an accumulation of strategies aimed at preventing adverse health outcomes associated with illicit substance use. Several harm reduction programs and services exist within Los Angeles County (LAC), however their success relies in part on the application of harm reduction principles by local primary care providers serving patients with substance use disorders. This study aims to assess the readiness of patient-centered medical homes in the San Fernando Valley to provide effective harm reduction to patients who use injection drugs and identify barriers to doing so.Methods: An online survey was distributed to primary care providers and social workers via email at federally qualified health centers and LAC Department of Health Services clinics in the San Fernando Valley between May and June 2019. It consisted of 22 multiple-choice, Likert scale, and short answer questions. The survey assessed knowledge of injection drug use (IDU), familiarity and utilization of harm-reduction and resources, and self-evaluation of attitudes and skills.Results: There were a total of 41 survey respondents across all clinics. Of respondents, 98% correctly identified heroin as a drug typically injected, and 93% identified Hepatitis C as an infectious risk of IDU. 63% of respondents use harm reduction strategies every few months or less. 34% prescribe buprenorphine routinely, and 76% prescribe pre-exposure prophylaxis to those at risk for Human Immunodeficiency Virus (HIV). 76% are comfortable discussing IDU with their patients, but 59% indicate that they lack the necessary skills, and 42% agree that they lack the time to address it.Conclusion: Knowledge of IDU was adequate among those surveyed, although overall utilization of harm reduction was infrequent. There is a perceived deficit in skills and time to effectively provide harm reduction to primary care patients in the San Fernando Valley. [ABSTRACT FROM AUTHOR]

Emergency general surgery (EGS) is a critical component of emergency care in the United States. Due to the time sensitiveness of EGS conditions, ensuring adequate spatial access to EGS services is paramount for reducing patient morbidity and mortality. Past studies have used travel time to measure spatial access to EGS services, which has its limitations. The major purpose of this paper is to evaluate the utility of a gravity-based spatial access model in measuring spatial access to EGS services in California. Our data sources include the American Hospital Association 2015 Annual Survey, the American Community Survey 2013–2017 five-year average dataset, and background geospatial datasets. We implemented both the gravity-based model and the shortest travel time method and compared them in measuring spatial access to EGS-capable hospitals in California at the census block group level. We analyzed each metric's ability to identify disparities in spatial access for the population as a whole, and subsequently to identify socio-demographic disparities. Overall, we found that both methods identified similar geographic and socio-demographic patterns of the spatial access. Native Americans and rural residents experienced the greatest disadvantage in spatial access to both general EGS services and advanced EGS services. However, the gravity-based model revealed more disparities in spatial access to EGS services than the travel time model, suggesting that using travel cost alone to measure spatial access to EGS services may underestimate the magnitude of disparities. These findings call for the use of gravity-based models that incorporate measures of population demand and hospital capacity when assessing spatial access to surgical services, and have implications for reallocating surgery resources to address disparities in spatial access. [ABSTRACT FROM AUTHOR]

This study employs the ecodevelopmental theory to examine the influence of mother and father bonding, family engagement in healthcare, and family support on PrEP stigma among BLMSM. We used a cross-sectional sample from wave five of the Healthy Young Men (HYM) study, with a survey sample of 399 participants aged 16–24 years. We conducted two-path analyses to test multiple hypotheses: (1) mother/father bonding is associated with an increase in family engagement in healthcare; (2) family engagement in healthcare is associated with family social support; and (3) family social support is associated with PrEP stigma. Family social support was negatively correlated with PrEP stigma (r = −0.15; p < 0.001). The findings show that families either led by a Black/Latino father or mother have a significant impact on the sexual health-seeking behavior of BLMSM and their perception of HIV and PrEP. [ABSTRACT FROM AUTHOR]

Objective  Severe maternal morbidity (SMM) has increased by 45% in the United States and is estimated to affect up to 1.5% of all deliveries. Research has not yet been conducted that demonstrates a benefit to multidisciplinary review of SMM. The aim of our study was to determine if standardized, routine review of the cases of SMM by a multidisciplinary committee results in a reduction of potentially preventable cases of SMM. Study Design  A retrospective cohort study of all women admitted for delivery at Cedars-Sinai Medical Center from March 1, 2012 to September 30, 2016. Our cohort was separated into two groups: a preintervention group composed of women admitted for delivery prior to the implementation of the obstetric Quality and Peer Review Committee (OBQPRC), and a postintervention group where the committee had been well established. Cases of confirmed SMM were presented to a multidisciplinary research committee, and the committee determined whether opportunities for improvement in care existed. The groups were compared with determine if there was a decreased incidence of preventable SMM following the implementation of the OBQPRC standardized review process. Results  There were 30,319 deliveries during the study period; 13,120 deliveries in the preintervention group; and 13,350 deliveries in the postintervention group (2,649 deliveries during the transition period). There was no difference in the rate of SMM between the preintervention (125; 0.95%) and postintervention (129; 0.97%) groups, (p  = 0.91). There was a significantly lower rate of opportunity for the improvement in care in the postintervention group (29.5%) compared with the preintervention group (46%; p  = 0.005). Conclusion  We demonstrated a significant reduction in the rate of potentially preventable SMM following the implementation of routine review of all SMM suggesting that this process plays an important role in improving maternal care and outcomes. Key Points Benefit to routine review of SMM has not been demonstrated. Routine review of SMM is associated with 36% reduction in potentially preventable SMM. This is the first study to demonstrate the benefit of routine review of SMM. [ABSTRACT FROM AUTHOR]

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Statin therapy is the cornerstone of preventing atherosclerotic cardiovascular disease (ASCVD), primarily by reducing low density lipoprotein cholesterol (LDL-C) levels. Optimal statin therapy decisions rely on shared decision making and may be uncertain for a given patient. In areas of clinical uncertainty, personalized approaches based on real-world data may help inform treatment decisions. We sought to develop a personalized statin recommendation approach for primary ASCVD prevention based on historical real-world outcomes in similar patients. Our retrospective cohort included adults from a large Northern California electronic health record (EHR) aged 40–79 years with no prior cardiovascular disease or statin use. The cohort was split into training and test sets. Weighted-K-nearest-neighbor (wKNN) regression models were used to identify historical EHR patients similar to a candidate patient. We modeled four statin decisions for each patient: none, low-intensity, moderate-intensity, and high-intensity. For each candidate patient, the algorithm recommended the statin decision that was associated with the greatest percentage reduction in LDL-C after 1 year in similar patients. The overall cohort consisted of 50,576 patients (age 54.6 ± 9.8 years) with 55% female, 48% non-Hispanic White, 32% Asian, and 7.4% Hispanic patients. Among 8383 test-set patients, 52%, 44%, and 4% were recommended high-, moderate-, and low-intensity statins, respectively, for a maximum predicted average 1-yr LDL-C reduction of 16.9%, 20.4%, and 14.9%, in each group, respectively. Overall, using aggregate EHR data, a personalized statin recommendation approach identified the statin intensity associated with the greatest LDL-C reduction in historical patients similar to a candidate patient. Recommendations included low- or moderate-intensity statins for maximum LDL-C lowering in nearly half the test set, which is discordant with their expected guideline-based efficacy. A data-driven personalized statin recommendation approach may inform shared decision making in areas of uncertainty, and highlight unexpected efficacy-effectiveness gaps. [ABSTRACT FROM AUTHOR]

For transgender (trans) women, community belonging may play an important role in shaping perceptions of HIV Pre-exposure Prophylaxis (PrEP). A cluster analysis was performed using data obtained from a survey administered to 128 trans women residing in Philadelphia, PA and the San Francisco Bay area, CA. Six items assessing feelings of community belongingness among trans women produced three distinct clusters. Associations were examined between cluster membership and perceptual items including beliefs about PrEP, experiences with healthcare, patient self-advocacy, and perceived trusted sources for PrEP information. Clusters were demographically comparable apart from age. There were significant differences noted between trust in various communication channels and perceptions of PrEP; the least community-connected cluster had less trust and more negative perceptions of PrEP. Analyses suggest that psychographic differences exist based on perceived community belongingness in this population, and this in turn may be consequential in determining how information about PrEP is communicated and diffused to trans women for whom PrEP may be indicated. [ABSTRACT FROM AUTHOR]

This study examined associations between transgender women's social network characteristics, perceived network member HIV risk/protective behaviors and HIV testing conversations between transgender women and their network members. From July 2015 to September 2016, 264 transgender women who nominated 2529 social network members completed surveys on sociodemographic characteristics, HIV risk/protective behaviors, and egocentric social networks. Mixed-effects logistic regression evaluated discussion of HIV testing with network member characteristics and perceived HIV risk/protective behaviors. HIV testing conversations were positively associated with being named as a trans "mother" (aOR 2.05; 95% CI 1.03–4.06) relationships of longer duration, and the following network member characteristics: perception as a confidant (3.09; 1.89–5.05), discussion of condom use (29.65; 16.75–52.49), knowledge of HIV pre-exposure prophylaxis (4.14; 2.11–8.15), and receipt of HIV testing (22.13; 11.47–42.69). HIV testing conversations were negatively associated with relationships where stimulants were used (aOR 0.32; 95% CI 0.12–0.84). These results indicate the importance of leveraging close relationship networks to increase HIV testing and the potential role for network-based HIV prevention strategies among transgender women. [ABSTRACT FROM AUTHOR]

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This paper explores how poor health outcomes in the HIV/AIDS and opioid epidemics in the United States are undergirded by iatrogenesis. Data are drawn from two projects in Southern California: one among men who have sex with men (MSM) engaging with pre-exposure prophylaxis to HIV (PrEP) and the other in a public hospital system encountering patients with chronic pain and opioid use disorder (OUD). Ethnographic evidence demonstrates how efforts to minimize risk via PrEP and opioid prescription regulation paradoxically generate new forms of risk. Biomedical risk management paradigms engaged across the paper's two ethnographic field sites hinge on the production and governance of deserving patienthood, which is defined by providers and experienced by patients through moral judgments about risk underlying both increased surveillance and abandonment. This paper argues that the logic of deservingness disconnects clinical evaluations of risk from patients' lived, intersectional experiences of race, class, gender, and sexuality. This paper's analysis thus re-locates patients in the context of broader historical and sociopolitical trajectories to highlight how notions of clinical risk designed to protect patients can in fact imperil them. Misalignment between official, clinical constructions of risk and the embodied experience of risk borne by patients produces iatrogenesis. [ABSTRACT FROM AUTHOR]

Pre-exposure prophylaxis (PrEP) is an effective daily prevention medicine to reduce the risks of HIV infections. Even though the number of PrEP users has been rapidly growing in the United States since 2012, only approximately 5% of the men who have sex with men (MSM) population is currently taking PrEP. This study examined PrEP uptake among MSM using the integrative model of behavioral prediction (IMBP) as the theoretical framework. The authors conducted formative elicitation interviews and a cross-sectional survey with MSM. Among the survey respondents, half of them were PrEP takers and half were not. The path modeling results showed that attitudes and norms predicted behavioral intention, and intention predicted PrEP uptake among MSM. The results also identified the strongest attitudinal predictors and normative referents of PrEP uptake. The study offers practical implications in helping professionals and scholars to understand PrEP uptake among MSM in a theoretically grounded way. [ABSTRACT FROM AUTHOR]

The purpose of this qualitative study was to identify barriers and motivators to PrEP uptake from the perspective of Black and Latina transgender women (TW) who are currently using PrEP to suggest intervention and outreach activities to increase PrEP uptake in this population. The Information-Motivation-Behavioral Skills Model guided the development of the semi-structured interview guide. A thematic analysis approach was used to analyze the data. Perceived barriers to PrEP uptake included structural and logistic barriers, language and cultural barriers to medical engagement, lack of transgender competent or gender-affirming care, and prioritizing hormone therapy over the use of PrEP. To increase PrEP uptake among BLTW, participants recommended disseminating PrEP information through a variety of methods, highlighting relationship and sexual health benefits of using PrEP, and developing effective patient-provider communication. Our findings highlight several ways to promote PrEP among BLTW. PrEP promotion should be integrated into gender-affirming care and supported by peer education and navigation services that reach BLTW in both clinic and community settings. [ABSTRACT FROM AUTHOR]

While transgender and gender non-binary (trans/nb) individuals are disproportionately affected by HIV, pre-exposure prophylaxis (PrEP) uptake remains low in this underserved population. We conducted four focus groups with 37 trans/nb individuals in San Diego and Los Angeles to assess barriers and facilitators of PrEP usage. Transcripts were coded for qualitative themes. Although overall PrEP awareness was high, participants reported limited knowledge and misinformation about PrEP. Barriers to PrEP use included: structural access (e.g., discrimination from health care providers, lack of trans-inclusive services, financial barriers), mental health struggles limiting ability to access PrEP, and concerns about potential side effects, drug-drug interactions with hormone therapy, and lack of other STI protection. Facilitators of PrEP usage included: increased PrEP availability, prior experience taking daily medications, and motivation to have active and healthy lives without fear of contracting HIV. Addressing both structural and psychosocial/behavioral factors in trans-affirming health care environments is crucial to designing inclusive, effective PrEP interventions. [ABSTRACT FROM AUTHOR]

The California Arbovirus Surveillance Program was initiated over 50 years ago to track endemic encephalitides and was enhanced in 2000 to include West Nile virus (WNV) infections in humans, mosquitoes, sentinel chickens, dead birds and horses. This comprehensive, statewide program is a function of strong partnerships among the California Department of Public Health (CDPH), the University of California, and local vector control and public health agencies. This manuscript summarizes WNV surveillance data in California since WNV was first detected in 2003 in southern California. From 2003 through 2018, 6,909 human cases of WNV disease, inclusive of 326 deaths, were reported to CDPH, as well as 730 asymptomatic WNV infections identified during screening of blood and organ donors. Of these, 4,073 (59.0%) were reported as West Nile neuroinvasive disease. California's WNV disease burden comprised 15% of all cases that were reported to the U.S. Centers for Disease Control and Prevention during this time, more than any other state. Additionally, 1,299 equine WNV cases were identified, along with detections of WNV in 23,322 dead birds, 31,695 mosquito pools, and 7,340 sentinel chickens. Annual enzootic detection of WNV typically preceded detection in humans and prompted enhanced intervention to reduce the risk of WNV transmission. Peak WNV activity occurred from July through October in the Central Valley and southern California. Less than five percent of WNV activity occurred in other regions of the state or outside of this time. WNV continues to be a major threat to public and wild avian health in California, particularly in Southern California and the Central Valley during summer and early fall months. Local and state public health partners must continue statewide human and mosquito surveillance and facilitate effective mosquito control and bite prevention measures. Author summary: West Nile virus (WNV) was first detected in the United States in 1999, and subsequently spread throughout the country. It is now the most commonly reported disease that is transmitted by mosquitoes in the United States. California has reported approximately 15% of all human WNV infections since the virus was first reported in the state in 2003. The California Department of Public Health works with partners throughout the state to conduct robust surveillance of WNV infections in mosquitoes, dead birds, and sentinel chickens, using these data to direct vector control activity and reduce the risk of WNV transmission to people. This article summarizes sixteen years of human, mosquito, chicken, equine, and dead wild bird surveillance for WNV in California, the most comprehensive description of WNV surveillance data to date. We found that WNV enzootic and human activity varied geographically and in intensity from year-to-year. Almost 95% of all WNV activity in California occurred in the Central Valley and southern California between April and November. [ABSTRACT FROM AUTHOR]

Pre-exposure prophylaxis (PrEP) for HIV prevention is indicated for people who inject drugs (PWID), yet most studies do not focus on PWID. This study examines factors associated with PrEP awareness and willingness, and identifies perceived barriers to PrEP among PWID. Methods: PWID were interviewed in Los Angeles and San Francisco, CA from 2016 to 2018. We analyzed data from self-reported HIV-negative participants who had injected drugs within the past 6 months (n = 469). Questions on PrEP included awareness, willingness, barriers, and uptake. Multiple logistic regression models of factors associated with awareness of, and willingness to, take PrEP were developed. Descriptive statistics on perceived PrEP barriers are reported. Results: Among HIV-negative PWID, 40% were aware of PrEP, 59% reported willingness to take PrEP, and 2% were currently taking PrEP. In multivariable analysis, PrEP awareness was associated with study site and sexual minority status, higher educational attainment, and HIV testing in the last 6 months. Willingness to take PrEP was associated with self-reported risk (paying sex partner in the last 6 months, sharing drug paraphernalia, and being injected by another PWID) and perceived HIV risk. The most common perceived barriers to PrEP were copays, concerns about increased HIV or sexually transmitted risk with PrEP, and concerns about reduction of medication efficacy without daily use. Conclusion: PrEP awareness among PWID remains inadequate. Willingness to take PrEP was moderate and was most desired by PWID who engaged in high-risk behaviors. Interventions to increase PrEP awareness and willingness, and to facilitate PrEP uptake among PWID are needed. [ABSTRACT FROM AUTHOR]

Young adults who experience homelessness have high rates of sexually transmitted infections (STIs) including HIV. Homelessness services programmes that provide housing to young adults have the capacity to reduce STI risk profiles. This study analysed data from 140 formerly homeless adults who moved into a housing programme in Los Angeles County between the ages of 18 and 25 years to investigate risk behaviour and access to HIV/AIDS prevention services. More than three quarters of participants reported sexual activity (vaginal or anal sex) in the prior 3 months, with 63% reporting any unprotected vaginal or anal sex, 29% reporting unprotected sex with a nonserious partner, 40% reporting multiple partners, and 11% reporting exchange sex. About three quarters reported a past-year HIV test. About half of the sample had never heard of pre-exposure prophylaxis (PrEP), 12% had heard of it but didn't know what it was, 25% reported knowing a little bit, and 15% said they knew a lot about PrEP. Slightly more than 4% of the overall sample reported being HIV positive. These findings suggest that housing programmes may be a prime location to implement HIV prevention services. [ABSTRACT FROM AUTHOR]

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Uptake of pre-exposure prophylaxis (PrEP) among Latino men who have sex with men (LMSM) remains low. We examined awareness, accessibility, acceptability and use of PrEP among LMSM. LMSM were recruited using social/sexual networking apps. Multiple Logistic regressions identified significant predictors of PrEP awareness, accessibility and acceptability. Among 276 participants, only 6% reported current PrEP use. Among non-PrEP users, 85% reported PrEP awareness, 71% indicated high likelihood of future PrEP use, but only 35% reported knowledge about accessing PrEP. In multiple logistic regressions, a lower likelihood of PrEP awareness was associated with lower level education, whereas a higher likelihood was associated with reporting 6–10 or over 10 sexual partners. A lower likelihood of PrEP accessibility was associated with lower level education and undocumented status. A lower likelihood of PrEP acceptability was associated with an income of $15,001–30,000, whereas a higher likelihood was associated with lower level education and reporting 6–10 or over 10 sexual partners. PrEP promotion targeting Latino MSM should be expanded for those with lower levels of education and those who are undocumented. [ABSTRACT FROM AUTHOR]

Understanding why clients stop taking pre-exposure prophylaxis (PrEP) is critical to improve PrEP delivery and ultimately reduce HIV incidence. We analyzed data from a programmatic evaluation conducted at the Los Angeles LGBT Center from February to May 2018. Of 180 respondents to the emailed survey, 91 had stopped taking PrEP and 11 never started. Among former PrEP users, most common reasons for stopping were entering a monogamous relationship (43%) and side effects (40%). Ten of 11 who never started PrEP reported access barriers (e.g., cost, insurance problems). A quarter of inactive clients re-engaged with PrEP services following the survey and 15% restarted PrEP by October 2018. Improving PrEP retention may require multifaceted interventions—e.g., tailored discussions about stopping and restarting PrEP safely as HIV risk changes, ensuring consistent access to affordable PrEP, and alternative dosing strategies. An emailed survey may be a simple, effective strategy to reengage some PrEP clients. [ABSTRACT FROM AUTHOR]

In this article the author talks about collective call to action for HIV/AIDS community based collaborative science in the era of COVID‑19. Topics discussed include COVID-19 is eroding already strained health systems in addition to further reducing its capacity to adequately address HIV/AIDS prevention and care and associated endemics of STIs, and physicians have reminded us that one cost to this tactic is that some health professionals will not be with us on the other side of this crisis.

Transgender women (TW) are disproportionately affected by HIV. Antiretroviral pre-exposure prophylaxis (PrEP) can reduce TW's vulnerability to HIV, but PrEP uptake has been limited among TW. To explore barriers to PrEP uptake, the study team conducted two semi-structured focus groups with TW in San Francisco at risk for HIV acquisition. A within-case, across-case approach was used to code and analyze emerging themes. Focus group participants were racially and ethnically diverse. A few participants in both groups had heard of PrEP, but some had not. Several said that their health care providers had not told them about PrEP. Participants in both groups had questions about side effects. They expressed medical mistrust and said poverty is an important context for their lives. They described a need for gender affirming health care services and raised concerns about interactions of PrEP with feminizing hormones. Information about side effects and interactions between gender affirming hormones and PrEP need to be explicitly addressed in PrEP education campaigns focusing on TW. Health care institutions and health departments should train clinical staff how to provide affirming care. Gender identity nondiscrimination laws and policies could improve transgender people's ability to earn a living and access health care. [ABSTRACT FROM AUTHOR]

We examined PrEP awareness and use among people who inject drugs (PWID) in San Francisco in 2018. Of 397 respondents not known to be HIV positive, 56.7% had heard of PrEP, 38.9% knew that PrEP can prevent HIV transmission from sharing injection equipment, 13.6% had discussed PrEP with a health care provider, and 3.0% had used PrEP in the last 12 months. All seven male PWID who had used PrEP were also men who had sex with men. There is urgent need to improve messaging on PrEP's effectiveness for PWID and to tailor ways of engaging PWID in PrEP programs. [ABSTRACT FROM AUTHOR]

This implementation and comparative effectiveness study compared an automated call system (ACS)-assisted method to enhance staff efficiency in panel management cancer screening outreach compared with standard outreach using manual calls. One panel manager assisted by the ACS at the intervention primary care practice completed outreach workflows for 43% more patients than 2 unassisted panel managers at comparison practices, with 78% more patients in the ACS-assisted panel management program ultimately having a preventive screening gap closed. Outreach cost per completion of 1 or more cancer screenings was $45.39 under standard procedures and $15.85 using the ACS-assisted method. [ABSTRACT FROM AUTHOR]

The CDC recommends PrEP for MSM at substantial risk of HIV acquisition, leaving clinicians unsure whether to prescribe PrEP to MSM who do not disclose HIV risk factors. A longitudinal cohort of MSM requesting PrEP despite reporting during a clinical visit either 100% condom use or participation in oral sex only and no other risk factors was followed over 13 months at a community clinic in San Francisco to assess the accuracy of their HIV risk perception. Participants completed a sexual and substance use behavior questionnaire at baseline, outside of the clinical visit and were followed by quarterly HIV/STI testing and condom use change questionnaires. Condomless sex increased from 0% at baseline to 12% at month 1, peaked at 34% at month 7, and then decreased again to 8% at month 13. Rates of pharyngeal GC/CT varied from 7% at baseline to 12% at month 13, while rectal GC/CT decreased from 6% at baseline to 0% at month 13. The rate of syphilis was 1% both at baseline and at month 13, however, 11% and 15% of clients tested positive for syphilis at months 1 and 7 respectively. [ABSTRACT FROM AUTHOR]

PrEP's potential benefit for men who have sex with men (MSM) who use stimulants may be limited by adherence or prescriber willingness to recommend PrEP due to concerns of non-compliance. Using data from PATH-PrEP, a 48-week study evaluating PrEP for MSM in Los Angeles, we modeled an interaction between stimulant use and condomless sex with multiple partners (CAS-MP) on prevention-effective dried blood spot tenofovir-diphosphate concentrations. At week 4, participants reporting stimulant use and CAS-MP had a decreased odds of prevention-effective adherence compared to non-stimulant use and non-CAS-MP (AOR 0.15, 95% CI 0.04–0.57). From week 4–48, participants reporting stimulant use and CAS-MP had increased odds of prevention-effective adherence (AOR 1.06 per week, 95%CI 1.01–1.12). Participants reporting CAS-MP without stimulant use had no significant change in prevention-effective adherence (AOR 0.99 per week, 95%CI 0.96–1.02). Stimulant use moderated the association of CAS-MP on prevention-effective PrEP adherence over time. [ABSTRACT FROM AUTHOR]

Latino men who have sex with men (LMSM) and Latina transgender women (LTGW) often lack access to HIV prevention information and strategies such as pre-exposure prophylaxis (PrEP). We explored knowledge gaps and culturally sensitive messaging about PrEP among HIV-negative LMSM and LTGW in Los Angeles. We recruited participants from a Latinx LGBT community-based organization. We conducted nine focus groups (n = 91 participants) with 52 LMSM and 39 LTGW. We used a rapid assessment process to create narrative reports that we analyzed using thematic analysis. Key quotes were transcribed verbatim; they were reviewed by the team, then uploaded to Dedoose to identify themes across sites and between groups. Three themes emerged for both LMSM and LTGW: knowledge gaps regarding PrEP remain; people who have knowledge about PrEP often served as its champions; highlighting positive aspects of culture could help improve PreP's uptake and sustained use. Only LMSM worried that PrEP could impact condom use. Some issues were more pronounced among LTGW (e.g., more limited access to PrEP); others were unique to LTGW (e.g., worry about drug-hormones interactions). Collaborative research, programs, and policies, informed by LMSM and LTGW themselves, are needed to narrow existing knowledge gaps and promote PrEP uptake and sustained utilization. [ABSTRACT FROM AUTHOR]

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Influenza and its bacterial complications are a leading cause of morbidity and mortality worldwide. The effect of combined immunization with live influenza vaccine and recombinant chimeric pneumococcal protein in dual infection caused by influenza H1N1 and S. pneumoniae (serotype 3) has been studied. The combined vaccine consisted of the strain A/California/2009/38 (H1N1) pdm and chimeric recombinant protein PSPF composed of immunodominant fragments of the surface virulence factors of S. pneumoniae—PsaA, PspA, and Shr1875—associated with modified salmonella flagellin. Vaccinated mice were infected with the influenza virus 24 hours before or 24 hours after the onset of pneumococcal infection. The protective effect of combined vaccination was shown on both models of viral-bacterial infection. [ABSTRACT FROM AUTHOR]

Objective: To assess the prevalence and risk of severe maternal morbidity among delivery hospitalization for stillbirth compared with live birth deliveries.Methods: Using data from the Office of Statewide Health Planning and Development in California, we performed a population-based cross-sectional study of 6,459,842 deliveries between 1999 and 2011. We identified severe maternal morbidity using an algorithm comprising diagnoses and procedures developed by the Centers for Disease Control and Prevention and used log-binomial regression models to examine the relative risk (RR) of severe maternal morbidity for stillbirth compared with live birth deliveries, adjusting for maternal demographic, medical, and obstetric characteristics. We also examined severe maternal morbidity prevalence by cause of fetal death among stillbirth deliveries.Results: The prevalence of severe maternal morbidity for stillbirth and live birth was 578 and 99 cases per 10,000 deliveries, respectively. After adjusting for maternal demographic, medical, and obstetric characteristics, the risk of severe maternal morbidity among stillbirth deliveries was more than fourfold higher (adjusted RR 4.77; 95% CI 4.53-5.02) compared with live birth deliveries. The severe maternal morbidity prevalence was highest among stillbirths caused by hypertensive disorders and placental conditions (24 and 19 cases/100 deliveries, respectively), and lowest among stillbirths caused by fetal malformations or genetic abnormalities (1 case per 100 deliveries).Conclusion: Women who have stillbirths are at substantially higher risk for severe maternal morbidity than women who have live births, regardless of cause of fetal death. The prevalence of severe maternal morbidity varies by cause of fetal death. [ABSTRACT FROM AUTHOR]

Analyses of the 2009 H1N1 influenza pandemic and post-pandemic years showed high attack rates and severity among indigenous populations. This study presents the characteristics of the first documented influenza outbreak in indigenous peoples in Brazil, that occurred from 30th March to 14th April 2016 in a Guarani village in Southeast Region. Acute respiratory infections were prospectively investigated. The majority of the 73 cases were influenza-like illness (ILI) (63.0%) or severe acute respiratory infection (SARI) (20.5%). The ILI+SARI attack rate (35.9%) decreased with increasing age. There was a high influenza vaccination rate (86.3%), but no statistically significant difference in vaccination rates between severe and non-severe cases was seen (p = 0.334). Molecular analyses of 19.2% of the cases showed 100% positivity for influenza A(H1N1)pdm09 and/or hRSV. Influenza A(H1N1)pdm09 was included in the 6B.1 genetic group, a distinct cluster with 13 amino acid substitutions of A/California/07/2009-like. The hRSV were clustered in the BA-like genetic group. The early arrival of the influenza season overlapping usual hRSV season, the circulation of a drifted influenza virus not covered by vaccine and the high prevalence of risk factors for infection and severity in the village jointly can explain the high attack rate of ARI, even with a high rate of influenza vaccination. The results reinforce the importance of surveillance of respiratory viruses, timely vaccination and controlling risk factors for infection and severity of in the indigenous populations in order to preventing disease and related deaths, particularly in children. [ABSTRACT FROM AUTHOR]

Using data from the National HIV Behavioral Surveillance of men who have sex with men (MSM), we estimated the prevalence of sexual behaviors among HIV-negative San Francisco MSM between 2004 and 2017. We estimate a recent increase in the 1-year prevalence of pre-exposure prophylaxis (PrEP) use, from 9.8% in 2014 to 44.9% in 2017. Over that same period, we estimate a decrease in the prevalence of consistent condom use, from 18.5 to 9.4%, and an increase in the percent of individuals with multiple condomless anal intercourse partners. We conclude that while risks for HIV infection may be decreasing among San Francisco MSM due, in part, to increases in PrEP use, the population faces increased risks for other sexually transmitted infections (STIs). Because PrEP alone does not protect against other STIs, we strongly recommend that PrEP users use condoms when possible, routinely screen for STIs, and disclose infections with sexual partners. [ABSTRACT FROM AUTHOR]

Laws and policies are vital tools in preventing outbreaks and limiting the further spread of disease, but they can vary in content and implementation. This manuscript provides insight into challenges in responding to recent vaccine-preventable disease outbreaks by examining legislative changes in California, policy changes on certain university campuses, and the laws implicated in a measles outbreak in Minnesota. [ABSTRACT FROM AUTHOR]

Barriers to HIV preexposure prophylaxis (PrEP) use have not been well-characterized in people who became HIV-infected, all of whom could have benefited from PrEP. We invited Kaiser Permanente Northern California members diagnosed with HIV during 2014-2016, following a negative HIV test in the prior year, to complete a survey assessing barriers to PrEP use before HIV diagnosis. Of 268 patients surveyed, 122 (46%) responded. Median age was 36, most (84%) were men who have sex with men, and 64% were of minority racial/ethnic background. Thirty-six (30%) had discussed PrEP with a provider, of whom 10 were diagnosed with HIV at PrEP intake. Overall, only 5 (4.1%) had used PrEP, and all 5 discontinued before diagnosis. Among all respondents, the most common barrier to PrEP use was lack of PrEP awareness (51%). Among those aware of PrEP, the most common barriers were cost/insurance concerns (36%) and perceived low risk for HIV (24%). Lack of PrEP awareness ranged from 39% among those aged 25-34 to 88% among those aged <25 (P = 0.011), and from 33% among Hispanics to 69% among Blacks (P = 0.055). Increasing awareness and affordability of PrEP, and facilitating accurate assessment of HIV risk, are critical to reducing missed opportunities for PrEP. [ABSTRACT FROM AUTHOR]

Increasing rates of sexually transmitted infections (STIs) in the United States among men who have sex with men (MSM) have raised concerns that pre-exposure prophylaxis (PrEP) has been associated with higher engagement in condomless anal intercourse (CAI). While partnership characteristics have previously been found to influence condom use, the extent to which PrEP use may modify their effect on CAI remains unknown. A secondary analysis of 535 sexual partnerships from a cross-sectional study in San Francisco was conducted to evaluate interactions between PrEP use and partnership characteristics on CAI. Bivariate and multivariate generalized estimating equation (GEE) logistic regression models were used to estimate relative measures of association, adjusted for confounding by seroconcordance and partnership type, as well as account for repeated partnerships per respondent. Partnerships where both partners used biomedical prevention had significantly greater odds of CAI [odds ratio (OR) = 5.19, 95% confidence interval (CI): 2.27–11.9] compared to those where only one partner used biomedical prevention, while those where neither partner used biomedical prevention had significantly lower odds of CAI (OR = 0.61, 95% CI: 0.40–0.93). There was no significant association between meeting place (online vs. offline) and sexual risk taking (OR = 1.03, p = 0.894). Having one partner disclose their HIV status (compared to neither partner having disclosed) was associated with significantly higher odds of CAI among partnerships of PrEP-using MSM [adjusted OR (aOR) = 5.28, 95% CI: 1.91–14.61], while the association was not significant among the partnerships of non-PrEP-using MSM (aOR = 1.29, 95% CI: 0.75–2.21). Differences in condom use among MSM using PrEP may not be well explained by differences in the effect of partnership characteristics. MSM using PrEP appear to commonly practice biomedical matching and high engagement in CAI with other biomedical prevention users, which could indicate relatively concentrated sexual networks and partly explain their disproportionate risk for STIs. Future studies should further investigate biomedical matching to develop interventions that further promote the sexual health of those using PrEP. [ABSTRACT FROM AUTHOR]

Youth experiencing homelessness (YEH) have a high risk of contracting HIV; however, they remain relatively unreached by pre-exposure prophylaxis (PrEP)-based HIV prevention initiatives. We used a cross-sectional mixed-methods study to explore PrEP knowledge, interest, facilitators, and barriers among YEH. Young adults were recruited from agencies serving YEH in Houston, TX (n = 30) and Los Angeles, CA (n = 15) to participate in an electronic self-report survey and a semistructured interview. Survey results indicate that 68.2% of YEH had low or no prior knowledge of PrEP, though 63.7% reported interest in taking PrEP. Qualitative results revealed facilitators of PrEP use, including high PrEP acceptability and awareness, and supportive social networks. Several barriers emerged, including medication-related barriers, adherence, cost, access barriers, low perceived HIV risk, perceived stigma of PrEP use, and low PrEP awareness. Despite high PrEP acceptability, PrEP use among YEH remains low partly due to low PrEP awareness, low perceived HIV risk, and medical mistrust. [ABSTRACT FROM AUTHOR]

Objectives. To determine the impact of the 2007–2009 economic crisis on tuberculosis (TB) trends among California residents. Methods. We analyzed available data from 4 different population-representative data sets. We used time charts, trend lines, and change-point detection tests during 2000 to 2016 to describe TB trends in California. Results. We found statistically significant changes in California TB trends with the time of the onset of the economic downturn based on age-adjusted TB case rates and TB mortality rates, crude rate of TB hospitalizations, and self-reported TB. Change on TB incidence was especially apparent among racial/ethnic minority groups. Conclusions. To our knowledge, changes in TB trends in the United States matching in time with the 2007–2009 economic crisis have not been previously reported. This study identified a slowdown in the decline of TB rates by 2007 to 2009 and provides new knowledge on TB trends that can be used to achieve California's goal of eliminating TB by 2040 and in the prevention and control of TB in the United States. [ABSTRACT FROM AUTHOR]

Background Pregnancy-related venous thromboembolism (VTE) is a leading preventable cause of maternal mortality in the United States; however, American guidelines for pharmacologic VTE prophylaxis remain less aggressive than other developed countries. The Safe Motherhood Initiative (SMI) combines aspects of American and international guidelines to increase utilization of prophylaxis and thereby decrease incidence of pregnancy-related VTE. Objectives To evaluate the prescribing and administration rates of pharmacologic VTE prophylaxis for women undergoing cesarean section (c-section) when retrospectively applying the SMI recommendations. Setting Large academic medical center in Sacramento, California, USA. Method This was a single-center retrospective cohort study of pregnant women undergoing c-section who would have met criteria for pharmacologic prophylaxis according to the SMI. Main outcome measures Prescribing and administration rates of mechanical and pharmacologic VTE prophylaxis. Secondary outcomes included incidence of thromboembolism within 6 weeks after c-section and thromboembolic associated mortality. Results A total of 616 charts were analyzed. When applying the SMI guidelines for VTE prophylaxis, the prescribing rates for mechanical and pharmacologic prophylaxis were 94.3% and 4.71% of patients, respectively, and 94.9% of ordered pharmacologic prophylaxis doses were administered. The incidence of 6-week post-partum VTE was 0.49%. There were no cases of VTE-associated mortality. Conclusion This study demonstrated that a large population of c-section patients fit the SMI criteria for pharmacologic VTE prophylaxis but did not receive it. We observed a 0.49% rate of VTE, which was slightly higher than the nationally reported average rate of 0.3%. With growing rates of pregnancy-associated VTE in the United States, perhaps a more aggressive guideline is warranted. [ABSTRACT FROM AUTHOR]

Background: The multiplier method is one of the most frequently used population size estimation (PSE) methods for key populations, yet estimates from this method are often inconsistent with each other, other PSE methods and local knowledge. We developed a novel Bayesian approach, the 'Anchored Multiplier', which synthesizes estimates from multipliers coupled to an a priori estimate to arrive at a single consensus estimate and credible range.Methods: Data for size estimation were collected from three cross-sectional bio-behavioural surveillance studies of people who inject drugs (PWID) in San Francisco, CA, USA (2005, 2009 and 2012). We demonstrate the application of the Anchored Multiplier and a Variance Adjusted-Anchored Multiplier using PSE produced by multipliers in the three surveys and the literature for the USA. Size estimates were compared with estimates from other available PSE methods.Results: Using the Anchored Multiplier, we estimated the PWID population made up 2.41% [95% credible interval (CI): 1.9-2.85] of the adult population in 2005, 2.1% (95% CI: 1.8-2.48) in 2009 and 2.3% (95% CI: 2.03-2.61) in 2012. The Variance Adjusted-Anchored Multiplier calculated similar point estimates, with wider 95% credible intervals. Credible intervals from both approaches were substantially narrower than from other standard PSE methods and, unlike other methods, indicated that the prevalence of PWID was stable over time.Conclusions: The Anchored Multiplier is a promising new approach to size estimation, which generates a single estimate to inform programmatic strategies to counter the HIV epidemic, and provides a robust denominator to quantify the burden of disease for key populations. [ABSTRACT FROM AUTHOR]

We assessed video directly observed therapy (VDOT) for monitoring tuberculosis treatment in 5 health districts in California, USA, to compare adherence between 174 patients using VDOT and 159 patients using in-person directly observed therapy (DOT). Multivariable linear regression analyses identified participant-reported sociodemographics, risk behaviors, and treatment experience associated with adherence. Median participant age was 44 (range 18-87) years; 61% of participants were male. Median fraction of expected doses observed (FEDO) among VDOT participants was higher (93.0% [interquartile range (IQR) 83.4%-97.1%]) than among patients receiving DOT (66.4% [IQR 55.1%-89.3%]). Most participants (96%) would recommend VDOT to others; 90% preferred VDOT over DOT. Lower FEDO was independently associated with US or Mexico birth, shorter VDOT duration, finding VDOT difficult, frequently taking medications while away from home, and having video-recording problems (p<0.05). VDOT cost 32% (range 6%-46%) less than DOT. VDOT was feasible, acceptable, and achieved high adherence at lower cost than DOT. [ABSTRACT FROM AUTHOR]