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Evidence-based HIV programming focused on populations at risk of HIV is critical for sustainable disease prevention. In response to the Tennessee Department of Health decision to reject federal HIV guidance, the present study examines the potential impact of Southern US states adopting policies that direct HIV prevention and testing efforts away from populations "disproportionately affected" (DA) by HIV toward populations "non-disproportionately affected" (NDA). Descriptive and projection analyses with publicly available data explored the influence of policies emphasizing NDA populations on HIV cases. Across the Southern US, DA populations (cisgender women, men who have sex with men, transgender persons, and people who inject drugs) represent the absolute majority (90%) of diagnosed HIV cases, whereas NDA populations (pregnant women, infants, first responders, and human trafficking victims) represent only a small proportion (2%) of diagnosed HIV cases. Estimated projections show avoidable HIV cases among DA populations in the Southern US alone could aggregate to over 32,000 by 2030 if prevention efforts exclusively concentrate on NDA populations, which approximates the current national annual incidence of 36,000 HIV cases. Prevention efforts aimed at DA populations compared with NDA populations could reduce new infections across the Southern US by 47% versus 1%, respectively, by 2030. Policies disregarding epidemiological data may hinder efforts to end the HIV epidemic, both regionally and nationally.

Introduction: The United States President's Emergency Plan for AIDS Relief (PEPFAR) is a large bilateral funder of the global HIV response whose policy decisions on key populations (KPs) programming determine the shape of the key populations' response in many countries. Understanding the size and relative share of PEPFAR funds going to KPs and the connection between PEPFAR's targets and resulting programming is crucial for successfully serving key populations., Methods: Publicly available PEPFAR budgets for key populations' services were assessed by country and geographical region for all 52 countries with budget data in fiscal year (FY) 2020. For the 23 countries which completed a full planning process in FY 2018 and 2019, PEPFAR targets for HIV testing and treatment initiation for key populations were assessed. Expenditures for KP programming were calculated to determine whether shifts in targets translated into programming. Implementing partners were characterized by the level of specialization using the share of assigned targets made up by KPs. The average target per year and implementing partner was calculated for each KP group and indicator., Results: PEPFAR country KP budgets ranged from US$35,000 to $15.2 million, and the proportion of funding to key populations varied by region, with Eastern and Southern African countries having the lowest proportion. Between FY 2018 and 2019, the KP targets for HIV testing and treatment among KPs increased, whereas expenditures on key populations decreased from US$115.4 to $111.0 million. Of the 11 countries with an increase in HIV testing targets, seven had a decrease in KP expenditures. Of the nine countries with an increase in treatment initiation targets, five had a decrease in KP expenditures. The proportion of targets assigned to partners which do not specialize in key populations increased from FY 2018 to 2019., Conclusions: Current key population policies have not resulted in a tight connection between targets and expenditures. This includes assigning a large proportion of key populations programming to partners who do not specialize in key populations, which may weaken the performance management role of the targets. These results signal that a new approach to key populations programming is needed., (© 2021 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of International AIDS Society.)

Emerging epidemiological data suggest that white Americans have a lower risk of acquiring COVID-19. Although many studies have pointed to the role of systemic racism in COVID-19 racial/ethnic disparities, few studies have examined the contribution of racial segregation. Residential segregation is associated with differing health outcomes by race/ethnicity for various diseases, including HIV. This commentary documents differing HIV and COVID-19 outcomes and service delivery by race/ethnicity and the crucial role of racial segregation. Using publicly available Census data, we divide US counties into quintiles by percentage of non-Hispanic white residents and examine HIV diagnoses and COVID-19 per 100,000 population. HIV diagnoses decrease as the proportion of white residents increase across US counties. COVID-19 diagnoses follow a similar pattern: Counties with the highest proportion of white residents have the fewest cases of COVID-19 irrespective of geographic region or state political party inclination (i.e., red or blue states). Moreover, comparatively fewer COVID-19 diagnoses have occurred in primarily white counties throughout the duration of the US COVID-19 pandemic. Systemic drivers place racial minorities at greater risk for COVID-19 and HIV. Individual-level characteristics (e.g., underlying health conditions for COVID-19 or risk behavior for HIV) do not fully explain excess disease burden in racial minority communities. Corresponding interventions must use structural- and policy-level solutions to address racial and ethnic health disparities.

Importance: Nonmedical prescription opioid use is a pressing public health issue in the United States. Transgender youth, including adolescent girls and young women who were assigned male at birth and currently identify as women, female, transgender women, or another diverse gender identity along the transfeminine gender spectrum, are more likely than their cisgender peers to report illicit substance use and meet diagnostic criteria for substance use disorders. However, relatively little is known about the experiences of these populations in the current era of opioid addiction and misuse., Objective: To report the prevalence of and risk factors associated with lifetime nonmedical prescription opioid use in a high-risk community sample of transgender adolescent girls and young women who are sexually active., Design, Setting, and Participants: This cross-sectional study used 2012 to 2015 baseline data from Project LifeSkills, a randomized clinical trial of a behavioral intervention to reduce the risk of HIV acquisition and transmission among a diverse sample of transgender adolescent girls and young women recruited from Boston, Massachusetts, and Chicago, Illinois. A total of 297 transgender girls and women aged 16 to 29 years who were sexually active were included in this analysis. Data were analyzed from June 2019 to August 2019., Exposures: Transgender woman identification., Main Outcomes and Measures: Self-reported lifetime nonmedical prescription opioid use., Results: Among 297 transgender adolescent girls and young women (mean [SD] age, 23.4 [3.5] years), 145 (48.8%) identified as non-Hispanic/Latinx black, 76 (25.6%) identified as non-Hispanic/Latinx white, 37 (12.5%) identified as Hispanic/Latinx, 7 (2.4%) identified as non-Hispanic/Latinx Asian, and 32 (10.8%) identified as multiracial or other race/ethnicity. Thirty-five participants (11.8%) reported lifetime nonmedical prescription opioid use. Young transgender women who smoked cigarettes monthly or less (adjusted odds ratio, 3.92; 95% CI, 1.10-13.89) and who smoked daily (adjusted odds ratio, 5.69; 95% CI, 1.87-17.33) had greater odds of nonmedical prescription opioid use compared with those who did not smoke. Additionally, participants who identified as a sexual orientation other than heterosexual, gay, lesbian, or bisexual had significantly greater odds of lifetime nonmedical prescription opioid use compared with those who identified as heterosexual (adjusted odds ratio, 3.69; 95% CI, 1.07-12.72)., Conclusions and Relevance: These findings suggest that transgender adolescent girls and young women have similar prevalence of lifetime nonmedical prescription opioid use compared with the US general population prevalence of 12.5%. These findings may serve as a call-to-action for public health surveillance studies and evidence-based interventions to be comprehensively tailored to examine and respond to specific trends of substance use, particularly opioid use disorder, among transgender populations.

Background: We previously reported the tolerability and immunogenicity 1 month after intramuscular administration of 2 bivalent virus-like particle (VLP)-based candidate norovirus vaccine formulations in adults. We now describe the persistence of immunity and responses to a memory probe vaccination 1 year later., Methods: A total of 454 healthy men and women aged 18-49 years in 3 equal groups received placebo (saline) or 15/50 or 50/50 vaccine formulations (ie, 15 or 50 µg of GI.1 genotype VLPs, respectively, and 50 µg of GII.4c VLPs) with MPL and Al(OH)3. Immunogenicity and safety were assessed up to day 365, when 351 participants received a memory probe vaccination of 15 µg each of GI.1 and GII.4c VLPs with Al(OH)3., Results: No safety signals were detected up to 1 year after the first vaccination. Pan-immunoglobulin, immunoglobulin A, and histo-blood group antigen-blocking (HBGA) antibody levels among vaccinees waned but remained higher than levels before vaccination and levels in placebo recipients on days 180 and 365. Memory probe vaccination increased all antibody titers. Levels of HBGA antibodies to GI.1 but not GII.4c were higher after the first vaccination in candidate vaccine groups, compared with those in the placebo group., Conclusion: Levels of antibodies to both candidate norovirus VLP formulations persisted above baseline levels for at least 1 year after primary vaccination. HBGA-blocking responses to the memory probe for GI.1 but not GII.4c displayed characteristics of immune memory., Clinical Trials Registration: NCT02142504., (© The Author(s) 2019. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Objective: To calculate a risk prediction model for hemangiosarcoma (HSA) diagnosis in dogs presenting with nontraumatic hemoabdomen., Design: Retrospective multicenter observational cohort study enrolling dogs presented 2003-2016., Setting: Five academic veterinary medical centers., Animals: A total of 406 dogs with nontraumatic hemoabdomen as the presenting complaint that underwent surgical exploration or necropsy and received a histological diagnosis. Overall, 219 dogs from 3 centers provided the data for model construction, and 187 dogs from 2 centers provided the population for external validation., Interventions: None., Measurements and Main Results: The risk score was modeled on 4 predictors: bodyweight (P = 0.01), total plasma protein (P < 0.01), platelet count (P < 0.01), and thoracic radiograph findings (P = 0.02). The incidence of HSA diagnosis was 36%, 76%, and 96% in the low risk (≤40), medium risk (41-55), and high risk (>55) score groups, respectively. The risk score AUROC was 0.85 (95% CI 0.79-0.90) on the construction population, and 0.77 (95% CI 0.70-0.84) on the validation population., Conclusions: The risk of HSA diagnosis in dogs presenting with nontraumatic hemoabdomen could be predicted using a simple risk score, which could aid in identification and treatment of dogs at lower risk for this diagnosis., (© Veterinary Emergency and Critical Care Society 2019.)

Objectives: To assess the impact of the expansion of Medicaid eligibility in the United States on the opioid epidemic, as measured through increased access to opioid analgesic medications and medication-assisted treatment., Methods: Using Medicaid enrollment and reimbursement data from 2011 to 2016 in all states, we evaluated prescribing patterns of opioids and the 3 Food and Drug Administration-approved medications used in treating opioid use disorders by using 2 statistical models. We used difference-in-differences and interrupted time series models to measure prescribing rates before and after state expansions., Results: Although opioid prescribing per Medicaid enrollee increased overall, we observed no statistical difference between expansion and nonexpansion states. By contrast, per-enrollee rates of buprenorphine and naltrexone prescribing increased more than 200% after states expanded eligibility, while increasing by less than 50% in states that did not expand. Methadone prescribing decreased in all states in this period, with larger decreases in expansion states., Conclusions: The Medicaid expansion enrolled a population no more likely to be prescribed opioids than the base Medicaid population while significantly increasing uptake of 2 drugs used in medication-assisted treatment.

Background: Disparities across a number of health indicators between the general population and particular racial and cultural minority groups including African Americans, Native Americans and Latino/a Americans have been well documented. Some evidence suggests that particular groups may receive poorer standards of care due to biased beliefs or attitudes held by health professionals. Less research has been conducted in specifically non-urban areas with smaller minority populations., Methods: This study explored the self-reported health care experiences for 117 racial and cultural minority Americans residing in a Mid-Western jurisdiction. Prior health care experiences (including perceived discrimination), attitudes towards cultural competence and satisfaction with health care interactions were ascertained and compared across for four sub-groups (African-American, Native American, Latino/a American, Asian American). A series of multiple regression models then explored relationships between a concert of independent variables (cultural strength, prior experiences of discrimination, education level) and health care service preferences and outcomes., Results: Overall, racial/cultural minority groups (African Americans, Native Americans, Latino/a Americans, and Asian Americans) reported general satisfaction with current healthcare providers, low levels of both health care provider racism and poor treatment, high levels of cultural strength and good access to health care services. Native American participants however, reported more frequent episodes of poor treatment compared to other groups. Incidentally, poor treatment predicted lower levels of treatment satisfaction and racist experiences predicted being afraid of attending conventional health care services. Cultural strength predicted a preference for consulting a health care professional from the same cultural background., Conclusions: This study provided a rare insight into minority health care expectations and experiences in a region with comparatively lower proportions of racial and cultural minorities. Additionally, the study explored the impact of cultural strength on health care interactions and outcomes. While the bulk of the sample reported satisfaction with treatment, the notable minority of participants reporting poor treatment is still of some concern. Cultural strength did not appear to impact health care behaviours although it predicted a desire for cultural matching. Implications for culturally competent health care provision are discussed within.

Background: USA300 methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of skin and soft-tissue infection (SSTI) in military personnel. USA300 MRSA has emerged as an important cause of healthcare-associated bloodstream infection (BSI) in metropolitan centers., Objective: To determine the prevalence, risk factors, and patient outcomes associated with USA300 MRSA BSI in military tertiary medical centers., Design: Retrospective case-control study., Patients: Patients admitted during the period 2001-2009 with MRSA BSI., Setting: Walter Reed Army Medical Center (Washington, DC) and National Naval Medical Center (Bethesda, MD) tertiary medical centers with 500 inpatient beds combined, which provide care to active duty service members and military beneficiaries., Methods: After identifying patients with MRSA BSI, we collected epidemiological data from electronic medical records and characterized bacterial isolates using pulsed-field gel electrophoresis (PFGE)., Results: A total of 245 MRSA BSI cases were identified, and 151 isolates were available for analysis. Epidemiological characteristics for the 151 patients with available isolates included the following: mean age, 61 years; male sex, 70%; white race, 62%; and combat-wounded service members, 11%. The crude in-hospital mortality rate was 17%. PFGE demonstrated that 30 (20%) of 151 MRSA BSI cases with isolates available for analysis were due to USA300, and 27 (87%) of these 30 cases were healthcare-associated infection. USA300 was associated with a significantly increasing proportion of MRSA BSI when examined over sequential time periods: 2 (4%) of 51 isolates during 2001-2003, 9 (19%) of 47 isolates during 2004-2006, and 19 (36%) of 53 isolates during 2007-2009 ([Formula: see text])., Conclusion: USA300 MRSA is emerging as a cause of healthcare-associated BSI in tertiary military medical centers.

Background: Invasive mucormycosis or aspergillosis is a life-threatening infection. The disease typically occurs in immunocompromised patients (e.g., those with diabetes mellitus or burns) but is rarely serious in otherwise-healthy young trauma patients., Methods: Case report and literature review., Results: A previously-healthy 22-year-old United States Marine who sustained large soft tissue injuries in support of Operation Enduring Freedom underwent multiple operations in theater to stabilize his wounds. He was evacuated first to Landstuhl Regional Medical Center in Germany and thence to the National Naval Medical Center in Maryland, where appropriate antifungal therapies were initiated and wide débridements were undertaken without success. His clinical status deteriorated, and he died. Tissue examination revealed systemic invasive mucormycosis and aspergillosis., Conclusion: The suspicion of invasive fungal infections must be tested early if intervention is to be curative.

Background: Defining centers of excellence for complex surgical procedures, including pulmonary resection, reveals lower mortality at high-volume centers. We postulate that short-term outcome after lung cancer resection is better at teaching hospitals (TH) compared with nonteaching hospitals (non-TH), independent of volume., Methods: Lung cancer resections in the Nationwide Inpatient Sample (NIS) dataset from 1998 to 2004 were stratified by resection type (segmentectomy, lobectomy, and pneumonectomy). The TH identified in the NIS include those with Accreditation Council for Graduate Medical Education-approved general surgery (GSTH) and thoracic surgery (TSTH) residency programs. The association of hospital teaching status with in-hospital mortality was assessed by multivariate logistic regression, adjusting for patient demographics and comorbidities., Results: Of 46,951 lung resections (5,651 segmentectomies, 37,027 lobectomies, 4,273 pneumonectomies), 56% were performed at TH. Overall mortality was significantly lower at TH versus non-TH (3.2% vs 4.0%; p < 0.001). Subgroup analysis for GSTH and TSTH confirmed this decrease. On multivariate regression, overall odds of death was independently reduced by 17% at TH versus non-TH (95% confidence interval: 0.73 to 0.93; p = 0.002). At TH, odds of death for pneumonectomy and lobectomy were significantly reduced independent of surgical volume, except for the latter at the highest hospital volume strata., Conclusions: In-hospital mortality is reduced for patients undergoing lung cancer resections at teaching hospitals, with results prominent at all but the highest volume institutions. Lower mortality rates persisted at GSTH and TSTH. Understanding and disseminating the processes of care associated with these settings may improve quality of care for lung cancer patients, and decrease patient bias against teaching hospitals.

A biological attack on U.S. crops, rangelands, or forests could reduce yield and quality, erode consumer confidence, affect economic health and the environment, and possibly impact human nutrition and international relations. Preparedness for a crop bioterror event requires a strong national security plan that includes steps for microbial forensics and criminal attribution. However, U.S. crop producers, consultants, and agricultural scientists have traditionally focused primarily on strategies for prevention and management of diseases introduced naturally or unintentionally rather than on responding appropriately to an intentional pathogen introduction. We assess currently available information, technologies, and resources that were developed originally to ensure plant health but also could be utilized for postintroduction plant pathogen forensics. Recommendations for prioritization of efforts and resource expenditures needed to enhance our plant pathogen forensics capabilities are presented.

Objective: To determine the effect of diabetes on long-term survival after acute myocardial infarction and to compare its effect with that of a previous myocardial infarction., Research Design and Methods: In a prospective cohort study, we followed 1,935 patients hospitalized with a confirmed acute myocardial infarction at 45 U.S. medical centers between 1989 and 1993, as part of the Determinants of Myocardial Infarction Onset Study. Trained interviewers performed chart reviews and face-to-face interviews with all patients. We analyzed survival using Cox proportional hazards regression to control for potentially confounding factors., Results: Of the 1,935 patients, 320 (17%) died during a mean follow-up of 3.7 years. A total of 399 patients (21%) had previously diagnosed diabetes. Diabetes was associated with markedly higher total mortality in unadjusted (hazard ratio [HR] 2.4; 95% CI 1.9-3.0) and adjusted (1.7; 1.3-2.1) analyses. The magnitude of the effect of diabetes was identical to that of a previous myocardial infarction. The effect of diabetes was not significantly modified by age, smoking, household income, use of thrombolytic therapy, type of hypoglycemic treatment, or duration of diabetes, but the risk associated with diabetes was higher among women than men (adjusted HRs 2.7 vs. 1.3, P = 0.01)., Conclusions: Diabetes is associated with markedly increased mortality after acute myocardial infarction, particularly in women. The increase in risk is of the same magnitude as a previous myocardial infarction and provides further support for aggressive treatment of coronary risk factors among diabetic patients.

A program of annual health examinations was expanded to include counseling based on a computerized appraisal of individual patients' specific health risk factors. Data obtained from a specially designed questionnaire, laboratory tests and a physical examination yielded a health hazard appraisal showing a number of weighted risk factors and their relation to ten leading causes of death as determined for that patient. From all of this information, a "risk age" was developed which could then be compared with the patient's "true age." The results were reviewed with each patient, and methods of correcting health hazards were stressed. The first annual retesting of a group of 107 examinees showed a net risk age reduction of 1.4 years (formerly reported in this journal). The longer term follow-up reported in this paper showed a net risk reduction of 2.38 years in a group of 26 examinees. The net risk age reduction in the two groups represented 32 and 40 percent, respectively, of the achievable risk age reduction when patients comply with suggestions made during risk reduction counseling. These findings indicate that health hazard appraisal counseling is an effective method of altering priorities of health practices.

A program of annual health examinations was expanded to include counseling based on a computerized appraisal of individual patients' specific health hazard factors. Data obtained from a specially designed questionnaire, laboratory tests and a physical examination yielded a printout showing a number of weighted risk factors and their relation to ten leading causes of death as determined for that patient. From all of this information, a risk ("apparent") age was developed for the patient. The results were reviewed with each patient, and methods of correcting health hazards were stressed. A total of 488 persons were appraised, and 107 were randomly reappraised in less than a year, with the finding that the net risk age was reduced by 1.4 years. Such a reduction in risk age is significant; it indicates that appraisal-based counseling is an effective method of altering priorities of health practices.