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BackgroundResearch investigating the efficacy of workplace wellness programmes to promote exercise, and by extension, reduce obesity and increase productivity has proliferated in recent years. Although preliminary work is encouraging, more work is needed.AimsTo evaluate the effects and overall cost of a workplace exercise programme on multiple physical outcomes, including body mass index, aerobic fitness and muscular fitness.MethodsData from the Bruin Health Improvement Programme .5 (BHIP) between August 2013 and July 2018 were analysed. BHIP is a 12-week workplace wellness programme that assesses multiple areas of physical and mental health. For this study, changes in weight, waist-to-hip ratio, aerobic fitness and muscular endurance were analysed using paired samples t-tests and chi-squared tests. Using results from a prior analysis of Medical Expenditure Panel Survey, the estimated medical expenditure savings associated with weight loss were also analysed.ResultsA total of 518 participants (84% female) took part in the BHIP programme (mean age = 41 years, SD = 1.17). There were significant decreases in all anthropometric indices and significant increases in all fitness outcomes (P < 0.01) from baseline to follow-up. Estimated programme cost per participant, per session was $473 US Dollars (USD), and weight loss is estimated to reduce annual medical care costs by ~$2200 USD.ConclusionsResults showed significant improvements in all physical outcomes of interest. Additionally, there appears to be an inverse relationship between improvements in employee health and employer healthcare costs. Strengths, limitations and future directions are discussed.

Background: Current guidelines recommend concurrent screening for HIV and syphilis with gonorrhea and chlamydia testing. Despite this, many patients are still not screened. This study describes trends in demographics and encounter locations associated with missed opportunities for HIV and syphilis screening among patients tested for gonorrhea or chlamydia., Methods: This is a retrospective review of all encounters with gonorrhea or chlamydia testing in a large, urban hospital from November 1, 2018, to July 31, 2021. Demographic information and encounter location were extracted from the medical record. Encounters were categorized as including both HIV and syphilis (complete) screening, HIV screening only, or neither. Logistic regression was used to examine associations between demographics and encounter location and likelihood of complete screening., Results: There were 42,791 patient encounters, of which 40.2% had complete screening, 6.2% had concurrent HIV screening only, and 53.6% had no concurrent screening. Increasing age, female sex (adjusted odds ratio [aOR], 0.58; 95% confidence interval [CI], 0.55-0.61; P < 0.01), non-Hispanic Black race (aOR, 0.52; 95% CI, 0.49-0.55; P < 0.01), and public insurance (aOR, 0.72; 95% CI, 0.69-0.75; P < 0.01) were associated with lower odds of complete screening. Emergency department (ED) encounters were most likely to include complete screening (aOR, 3.11; 95% CI, 2.96-3.26; P < 0.01)., Conclusions: This study found that a large proportion of patients tested for gonorrhea and chlamydia had missed opportunities for HIV and syphilis screening. Significant demographic disparities were found. The emergency department was most likely to screen for both HIV and syphilis. Decreasing disparities in screening could have profound effects on the HIV and syphilis epidemics., Competing Interests: Conflict of Interest and Sources of Funding: Dr. McNulty has served on an advisory board for Gilead Sciences, Inc. Dr. Hazra has served on an advisory board for Gilead Sciences, Inc, and ViiV Healthcare. All other authors have no conflicts of interest to disclose., (Copyright © 2024 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Rates of congenital syphilis (CS) in the United States have risen sharply in recent years. There has been sparse research centering the voices and experiences of birthing parents who have delivered infants with CS and prenatal providers in Chicago or the surrounding Midwestern United States to date. Additionally, there has been little research on the role of extrinsic factors, such as stigma and attitudes surrounding CS in an individual's community, in their entry into and retention in the CS prevention cascade., Methods: Semistructured interviews seeking to gather perspectives and factors related to the rise of CS were conducted with birthing parents who delivered infants with CS at a major academic medical institution (AMI) and the prenatal providers who served them. This was supplemented by retrospective data of birthing parent outcomes., Results: Barriers elicited during the interviews included insufficient penicillin uptake, limited transportation, poor communication between providers and patients, gaps in patient understanding or knowledge around CS contraction and treatment, missed appointments, appointment burden for patients, life stressors of patients, housing instability, childcare difficulties, and stigma related to the CS diagnosis. The quantitative data revealed differing proportions of CS outcomes and care between those with care within the AMI, those with care outside the AMI, and those who had no prenatal care., Conclusions: This study found numerous perspectives and factors that may explain the rise of CS along various stages of the syphilis care continuum through in-depth interviews of prenatal providers and birthing parents., Competing Interests: Potential conflicts of interest. All authors: No reported conflicts of interest., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

HIV and substance abuse are common among young men, associated with a cluster of risk behaviors. Yet, most services addressing these challenges are delivered in setting underutilized by men and are often inconsistent with male identity. This cluster randomized controlled trial aimed to reduce multiple risk behaviors found among young men township areas on the outskirts of Cape Town, South Africa. Young men aged 18-29 years (N = 1193) across 27 neighborhoods were randomized by area to receive HIV-related skills training during either: (1) a 12-month soccer league (SL) intervention; (2) 6-month SL followed by 6 months of vocational training (VT) intervention (SL/VT, n = 9); or 3) a control condition (CC). Bayesian longitudinal mixture models were used to evaluate behaviors over time. Because we targeted multiple outcomes as our primary outcome, we analyzed if the number of significantly different outcomes between conditions exceeded chance for 13 measures over 18 months (with 83%, 76%, and 61% follow-up). Only if there were three significant benefits favoring the SL/VT over the SL would benefits be significant. Outcome measures included substance use, HIV-testing, protective sexual behaviors, violence, community engagement and mental health. Consistent participation in the SL was typically around 45% over time across conditions, however, only 17% of men completed SL/VT. There were no significant differences between conditions over time based on the number of study outcomes. These structural interventions were ineffective in addressing young men's substance abuse and risk for HIV.Clinical Trial Registration: This trial was prospectively registered on 24 November 2014 with ClinicalTrials.gov (NCT02358226)., (© 2024. The Author(s).)

Background: With recent increases in syphilis, there is growing interest in expanding screening; however, treatment rates have historically been low., Objectives: This study examines demographic and clinical factors that may contribute to non-completion of syphilis treatment., Design: This is a retrospective comparative cohort study of all patients with syphilis from January through November 2018 at an urban, tertiary care hospital., Methods: Demographics and clinical information were extracted from the electronic medical record. Descriptive statistics and odds ratios (ORs) were calculated., Results: Of 171 patients with syphilis, 89 (52.0%) completed treatment. Patients ages 40-49 were least likely to complete treatment (OR 0.14; 95% CI 0.03-0.72, p = 0.02) compared to those ages 18-24. Non-heterosexual patients were significantly more likely to complete treatment (OR 3.60; 95% CI 1.13-11.49, p = 0.03) compared to heterosexual patients. Patients diagnosed in the emergency department completed treatment at the lowest rate., Conclusion: A major gap in syphilis treatment still exists, which must be addressed to achieve optimal impact from syphilis screening programs., Competing Interests: The authors declare that there is no conflict of interest., (© The Author(s), 2024.)

Introduction: To expand access to naloxone, the state of Illinois implemented a standing order allowing registered pharmacies to dispense the drug without an individual prescription. To participate under the standing order, pharmacies were required to opt in through a formal registration process. In our study we aimed to evaluate the availability and price of naloxone at registered pharmacies., Methods: This was a prospective, de-identified, cross-sectional telephone survey. Trained interviewers posed as potential customers and used a standardized script to determine the availability of naloxone between February-December, 2019. The primary outcome was defined as a pharmacy indicating it carried naloxone, currently had naloxone in stock, and was able to dispense it without an individual prescription., Results: Of 948 registered pharmacies, 886 (93.5%) were successfully contacted. Of those, 792 (83.4%) carried naloxone, 659 (74.4%) had naloxone in stock, and 472 (53.3%) allowed purchase without a prescription. Naloxone nasal spray (86.4%) was the formulation most commonly stocked. Chain pharmacies were more likely to carry naloxone (adjusted odds ratio [aOR] 3.16, 95% confidence interval [CI] 1.97-5.01, P  < 0.01) and have naloxone in stock (aOR 2.72, 95% CI 1.76-4.20, P  < 0.01), but no more likely to dispense it without a prescription. Pharmacies in higher population areas (aOR 0.99, 95% CI 0.99-0.99, P  < 0.05) and rural areas adjacent to metropolitan areas (aOR 0.5, 95% CI 025-0.98, P  < 0.05) were less likely to have naloxone available without a prescription. Associations of naloxone availability based on other urbanicity designations, overdose count, and overdose rate were not significant., Conclusion: Among pharmacies in Illinois that formally registered to dispense naloxone without a prescription, the availability of naloxone remains limited. Additional interventions may be needed to maximize the potential impact of a statewide standing order., Competing Interests: Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

Background: There is increasing interest in improving routine HIV screening in emergency departments and increasing HIV cotesting rates among patients tested for sexually transmitted infections (STIs), who are considered at elevated risk of acquiring HIV., Methods: This is a retrospective review of all ED encounters at a large, urban emergency departments with an existing HIV screening program for seven months before (November 1, 2018, to May 30, 2019) and after (June 1 to December 31, 2019) the implementation of a best practice advisory prompting universal HIV and syphilis screening., Results: The study included 14,767 unique encounters, with 3,982 pre-implementation encounters and 10,785 post-implementation. After implementation, HIV testing increased 242%, from 2,851 tests to 9,757, and syphilis testing increased 326%, from 2,191 tests to 9,330. The proportion of encounters for urogenital STI testing without HIV cotesting decreased by 10.3%, from 43.6% to 33.3%., Discussion: An automated electronic medical record (EMR) prompt can have a huge impact on both HIV and syphilis testing rates, as well as the rate of missed opportunities for cotesting among patients undergoing STI testing., Conclusions: Hospitals should support screening with automated alerts to help meet quality metrics, improve screening rates, and reduce missed opportunities for screening in vulnerable patients., (Copyright © 2024 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

While rare in the larger population, anal cancer incidence is significantly higher in groups such as sexual minority men and people living with HIV. This qualitative analysis examined participants' experiences and perceptions of barriers to anal self-examination and anal companion examination through interviews completed as a part of a larger clinical trial. Interviews were conducted online with participants ( n  = 131) within a week of their baseline appointment between January 2020 and October 2021. Content analysis denoted participants' thoughts and perceptions about anal self-examination and anal companion examinations. Of the 131 cisgender men interviewed (mean age 49.9 years, SD 12.7), 92.4% identified as gay, 54.9% identified as white, 22.1% identified as Black, 19.9% identified as Latino, and 44.3% of participants were living with HIV. Participants did not report feelings of excessive anxiety when an abnormality was detected. However, three salient themes emerged as to why participants may not perform an anal self-examination or anal companion examination: (1) physical limitation(s), (2) potential sexualisation of the examination, and (3) level of comfort discussing anal health. Future work must continue to explore methods that not only decrease stigma surrounding anal health but also bolster feelings of accessibility to perform self and couple examinations.

Background: Squamous cell carcinoma of the anus (SCCA) annual incidence among sexual minority men with and without HIV is 85/100,000 and 19/100,000 persons, respectively, which is significantly higher than the overall incidence (2/100,000). Incidence may also be higher in transgender women. Since SCCA tumours average ≥30 mm at diagnosis, we assessed the accuracy of individuals to self-detect smaller anal abnormalities., Methods: Using convenience sampling, the study enrolled sexual minority men and transgender women, aged 25-81 years, in Chicago, Illinois and Houston, Texas, USA, during 2020-2022. Individuals were taught the anal self-examination and anal companion examination (ASE/ACE). Then, a clinician performed a digital anal rectal examination (DARE) before participants conducted the ASE or ACE. The sensitivity, specificity and concordance of the ASE/ACE to detect an abnormality were measured along with factors associated with ASE/ACE and DARE concordance., Findings: Among 714 enrolled individuals, the median age was 40 years (interquartile range, 32-54), 36.8% (259/703) were living with HIV, and 47.0% (334/710), 23.4% (166/710), and 23.0% (163/710) were non-Hispanic white, non-Hispanic Black, and Hispanic, respectively. A total of 94.1% (671/713) identified as cisgendered men, and 5.9% (42/713) as gender minorities. A total of 658 participants completed an ASE and 28 couples (56 partners) completed an ACE. Clinicians detected abnormalities in 34.3% (245/714) of individuals. The abnormalities were a median of 3 mm in diameter. Sensitivity and specificity of the ASE/ACE was 59.6% (95% CI 53.5-65.7%) and 80.2% (95% CI 76.6-83.8%), respectively. Overall concordance was 0.73 (95% CI 0.70-0.76) between ASE/ACE and DARE and increased with increasing anal canal lesion size (p = 0.02). Concordance was lower when participants were older and received ASE/ACE training from a lay person rather than a clinician., Interpretation: Sexual minority men/transgender women may self-detect SCCA when malignant lesions are much smaller than the current mean dimension at presentation of ≥30 mm., Funding: National Cancer Institute., Competing Interests: Aniruddha Hazra declared receiving consulting fees from Gilead Sciences, ViiV Healthcare, and Abbott Technologies; Ashish A. Deshmukh declared receiving consulting fees from Merck Inc., Value Analytics Lab, support to attend EUROGIN, and payment or honoraria for giving talks/conferences at the NIH and Mt. Sinai; Elizabeth Y. Chiao has a leadership or fiduciary role as Chair, solid Tumour Working Group, AIDS Malignancy Consortium; Michael D. Swartz received funding from the NIH., (© 2024 The Author(s).)

Background: Black cisgender gay, bisexual, and other sexual minority men (SMM) and transgender women (TW) continue to be heavily affected by HIV. Further research is needed to better understand HIV prevention and care outcomes in this population. In particular, there is a need for research examining the impact of substance use and sleep health on HIV prevention and treatment outcomes among Black SMM and TW., Objective: This paper outlines the study methods being used in the recently launched follow-up study to the Neighborhoods and Networks (N2) study, which we refer to as N2 Part 2 (N2P2). N2P2 aims to address this gap in the literature, build off the findings of the original N2 study, and identify socioenvironmental determinants of health, including whether neighborhood and network factors mediate and moderate these relationships., Methods: Building on the N2 cohort study in Chicago from 2018 to 2022, N2P2 used a prospective longitudinal cohort design and an observational-implementation hybrid approach. With sustained high levels of community engagement, we aim to recruit a new sample of 600 Black SMM and TW participants residing in the Chicago metropolitan statistical area. Participants are asked to participate in 3 study visits across an 18-month study period (1 visit every 9 months). Four different forms of data are collected per wave: (1) an in-person survey, (2) biological specimen collection, (3) a daily remote ecological momentary assessment for 14 days after each study visit, and (4) data from electronic health records. These forms of data collection continue to assess neighborhood and network factors and specifically explore substance use, sleep, immune function, obesity, and the implementation of potential interventions that address relevant constructs (eg, alcohol use and pre-exposure prophylaxis adherence)., Results: The N2P2 study was funded in August 2021 by the National Institute of Drug Abuse (R01DA054553 and R21DA053156) and National Heart, Lung, and Blood Institute (R01HL160325). This study was launched in November 2022. Recruitment and enrollment for the first wave of data collection are currently ongoing., Conclusions: The N2P2 study is applying innovative methods to comprehensively explore the impacts of substance use and sleep health on HIV-related outcomes among an HIV status-neutral cohort of Black SMM and TW in Chicago. This study is applying an observational-implementation hybrid design to help us achieve findings that support rapid translation, a critical priority among populations such as Black SMM and TW that experience long-standing inequities with regard to HIV and other health-related outcomes. N2P2 will directly build off the findings that have resulted from the original N2 study among Black SMM and TW in Chicago. These findings provide a better understanding of multilevel (eg, individual, network, and neighborhood) factors that contribute to HIV-related outcomes and viral suppression among Black SMM and TW., International Registered Report Identifier (irrid): DERR1-10.2196/48548., (©Justin R Knox, Brett Dolotina, Tyrone Moline, Isabella Matthews, Mainza Durrell, Hillary Hanson, Ellen Almirol, Anna Hotton, Jade Pagkas-Bather, Yen-Tyng Chen, Devin English, Jennifer Manuzak, Joseph E Rower, Caleb Miles, Brett Millar, Girardin Jean-Louis, H Jonathon Rendina, Silvia S Martins, Christian Grov, Deborah S Hasin, Adam W Carrico, Steve Shoptaw, John A Schneider, Dustin T Duncan. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 01.12.2023.)

Black and Latino sexual minority men (SMM) continue to be disproportionately impacted by HIV. We utilized eight components of the Meaningful Involvement of People Living with HIV/AIDS (MIPA) framework to assess the engagement of Black and Latino SMM. Thirty-six (36) studies were included in the literature review. Forty-two percent of studies were Black SMM-specific, followed by Latino SMM-specific (31%) studies. Twenty-eight percent of studies were conducted among both groups. Most studies (72%) were intervention-related and focused on HIV prevention. The top five most common methods of community engagement were focus groups (39%), followed by interviews (36%), community-based participatory research (14%), the utilization of community advisory boards or peer mentorship (11%), and the establishment of multi-stakeholder coalitions, observations, or surveys (8%). We documented at least 7 MIPA components in 47% of the included studies. Community-based participatory research was more commonly utilized to engage Latino SMM. Researchers were more likely to initiate the engagement across all included studies. Few studies documented how Black and Latino SMM perceived the engagement. Engagement responsiveness was a well-documented MIPA component. In terms of engagement power dynamics, there were several examples of power imbalances, especially among Black SMM-specific studies. The inclusion of Black and Latino SMM had robust impacts on HIV research and interventions. There were limited examples of engagement capacity and maintenance. This is one of the first studies focused on utilizing MIPA to document the engagement of SMM of color. MIPA served as a useful framework for understanding the engagement of SMM of color in the US HIV response. The engagement of SMM of color is critical to reducing health inequities., (© 2022. W. Montague Cobb-NMA Health Institute.)

Introduction: Sexual Assault Nurse Examiners (SANE), who are trained to provide comprehensive and compassionate specialty care to sexual assault survivors, are increasingly used in the emergency department (ED), but there is little published literature to support their benefit. In this study we aimed to compare services offered and received by sexual assault survivors in the ED when care was provided by a SANE vs those with traditional care teams, hypothesizing that SANE utilization will be associated with improved uptake of recommended services. Methods: This was a retrospective review examining all patient encounters in which a sexual assault was disclosed in a large, urban, adult ED between June 1, 2019-June 30, 2022. We extracted timeline information from the ED encounter, demographic information, resources offered to and accepted by the patient, clinical care data, and continuity of care data from the medical record. We used unadjusted and adjusted analyses to compare patient demographics and services offered and accepted between SANE and non-SANE encounters. Results: We included a total of 182 encounters in the analysis, of which 130 (71.4%) involved SANEs. Demographics were similar between groups, except there was a larger proportion of cisgender men in the non-SANE group (14.0% vs 5.5%), and the timing of visits differed, with non-SANE visits more common during the overnight shift. All recommended testing, prophylaxis, and resources were offered more frequently during SANE visits, and all but one were more frequently accepted by patients during SANE visits, although not all comparisons reached statistical significance. Conclusion: Patients who received care from a SANE were more often offered recommended services and resources and more frequently accepted them. Making SANE care available at all times to these vulnerable patients would both improve patient outcomes and allow hospitals to meet required quality metrics. States should consider expanding legislation to encourage and fund SANE coverage for all hospitals to support access to vital resources in the ED for survivors of sexual assault., Competing Interests: Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

Background: Many people vulnerable to HIV do not perceive themselves at risk or consider preexposure prophylaxis (PrEP). This study hypothesizes that syphilis diagnosis through universal, emergency department (ED) screening would increase PrEP uptake., Methods: This prospective cohort study enrolled patients tested for syphilis through ED screening between July 2019 and July 2021. Participants completed a survey about behaviors, HIV and PrEP knowledge, and opinions at the time of enrollment. All were offered PrEP if they met Centers for Disease Control and Prevention guidelines for PrEP use. Information about PrEP use and HIV status was collected 6 months later. Bivariate analysis was used to compare outcomes between groups testing positive versus negative for syphilis., Results: The study enrolled 97 participants, 49 with syphilis and 48 testing negative. Overall, 11 (11.3%) started PrEP, all in the syphilis group, despite 28 (58.3%) in the negative group having indications for PrEP. Participants with syphilis less frequently reported low perceived HIV risk than syphilis-negative participants who reported HIV transmission behaviors (83.7% vs. 92.9%). Participants reporting moderate to high HIV risk perception were significantly more likely to start PrEP (odds ratio, 10.5; 95% confidence interval, 1.41-78.1; P = 0.02). At 6 months, 3 participants remained on PrEP (follow-up data available for 63.5% of PrEP-eligible participants)., Conclusions: Syphilis diagnosis was associated with increased perception of HIV risk and increased PrEP initiation. Individuals who otherwise might not seek testing for syphilis because of perceived low risk may be identified through routine screening, thus providing an important opportunity to link more people to HIV prevention and PrEP services., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

Black sexual minority men (BSMM) and Black transgender women (BTW) are disproportionately impacted by HIV and incarceration in the United States. In-depth interviews (N=34) and ongoing thematic analysis guided by the Exploration Phase of the Exploration, Preparation, Implementation, Sustainment framework were conducted to uncover key themes focused on the awareness, acceptability, and early adoption of conventional (i.e., daily oral pill) and non-conventional forms of PrEP (i.e., long-acting injectable, e-prescription for pick up post release) among jail-involved BSMM and BTW in Chicago, Illinois and Baton Rouge, Louisiana. The majority of participants were cisgender BSMM (88%) and were enrolled in Chicago (65%). There was greater awareness, availability, and adoption of conventional PrEP and non-conventional PrEP e-prescription for pick up post release among Chicago participants compared with Baton Rouge participants. Participants were largely receptive to all three forms of PrEP and stated a high need for HIV prevention in jails and immediately following release. PrEP stigma emerged as a major barrier to conventional daily PrEP adoption while incarcerated; potential misuse (e.g., pill selling) as a potential barrier to PrEP eprescription; and needle aversion and added clinic time as potential barriers to longacting injectable (LAI)-PrEP. Participants indicated that PrEP e-prescription could help support continuity of care post release and highlighted reduced stigma, convenience, and longer-term HIV protection as benefits for LAI-PrEP. Study findings provided context-specific information to inform the implementation of future PrEP interventions for jail-involved BSMM and BTW in two highly HIV-impacted jurisdictions., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Young men in South Africa face the intersecting epidemics of HIV, substance use and endemic poverty. We tested the effectiveness of a behavioral intervention using soccer training to reduce the cluster of risks associated with HIV and substance use. This cluster randomized controlled trial was conducted with men aged 18-29 years old in 27 neighborhoods in the townships of Cape Town, South Africa. Neighborhoods were randomized to receive for 6 months either: (1) Soccer League (SL; n = 18 neighborhoods, n = 778 men) who attended soccer three times weekly (72 sessions; 94% uptake, 45.5% weekly attendance rate), combined with an HIV/substance use, cognitive-behavioral intervention; or (2) a Control Condition (CC; n = 9; 415 men) who received educational materials and referrals at 3 month intervals. The primary outcome was the number of significant changes in a cluster of outcomes including HIV-related risks, substance abuse, employment/income, mental health, violence, and community engagement. There was only one significant difference on the rapid diagnostic tests for mandrax at 6 months, an insufficient number of changes to indicate a successful intervention. A group-based behavioral intervention was ineffective in addressing multiple risk behaviors among at-risk young men, similar to the findings of several recent soccer-related interventions. Early adulthood may be too late to alter well-established patterns of risk behaviors.Clinical Trial Registration This trial was prospectively registered on 24 November 2014 with ClinicalTrials.gov NCT02358226., (© 2022. The Author(s).)

Background: Drug overdose rates in the United States have been steadily increasing, particularly in rural areas. The COVID-19 pandemic and associated mitigation strategies may have increased overdose risk for people who use drugs by impacting social, community, and structural factors., Methods: The study included a quantitative survey focused on COVID-19 administered to 50 people who use drugs and semi-structured qualitative interviews with 17 people who use drugs, 12 of whom also participated in the quantitative survey. Descriptive statistics were run for the quantitative data. Qualitative coding was line-by-line then grouped thematically. Quantitative and qualitative data were integrated during analysis., Results: Findings demonstrate how COVID-19 disruptions at the structural and community level affected outcomes related to mental health and drug use at the individual level. Themes that emerged from the qualitative interviews were (1) lack of employment opportunities, (2) food and housing insecurity, (3) community stigma impacting health service use, (4) mental health strains, and (5) drug market disruptions. Structural and community changes increased anxiety, depression, and loneliness on the individual level, as well as changes in drug use patterns, all of which are likely to increase overdose risk., Conclusion: The COVID-19 pandemic, and mitigation strategies aimed at curbing infection, disrupted communities and lives of people who use drugs. These disruptions altered individual drug use and mental health outcomes, which could increase risk for overdose. We recommend addressing structural and community factors, including developing multi-level interventions, to combat overdose. Trial registration Clinicaltrails.gov: NCT04427202. Registered June 11, 2020: https://clinicaltrials.gov/ct2/show/NCT04427202?term=pho+mai&draw=2&rank=3., (© 2022. The Author(s).)

Objective: This is a secondary analysis examining neighborhood factors predicting high rates of child resilience in South African Township neighborhoods., Methods: A population cohort of South African pregnant women (98%; n = 1238), were recruited and assessed across five years with high follow-up rates (83-96%). Resilient children were identified based on consistently meeting global standards for growth, cognitive functioning, and behavior. Community infrastructure, maternal risks, and caretaking behaviors were examined based on neighborhood as predictors of childhood resilience., Results: The rate of resilient children varied significantly by neighborhood (9.5% to 27%). Mothers living in high prevalence neighborhoods (HPN) compared to low prevalence neighborhoods (LPN) were older and more likely be living with three or more people in formal housing with access to water and electricity. In the HPN, resilient children had more food security and were less likely to have mothers with depressed mood. Migration to rural areas occurred more frequently among resilient compared to non-resilient children in the HPN., Conclusion: This study applies a novel measure of resilience that is multidimensional and longitudinally defined. Living in formal housing with consistent access to food was associated with resilience. Migration to rural areas among families living in HPN suggests that rural areas could be protective., Trial Registration: ClinicalTrials.gov registration #NCT00996528., (Copyright © 2022. Published by Elsevier Inc.)

Background: The COVID-19 pandemic has worsened the opioid overdose crisis in the US. Rural communities have been disproportionately affected by opioid use and people who use drugs in these settings may be acutely vulnerable to pandemic-related disruptions due to high rates of poverty, social isolation, and pervasive resource limitations., Methods: We performed a mixed-methods study to assess the impact of the pandemic in a convenience sample of people who use drugs in rural Illinois. We conducted 50 surveys capturing demographics, drug availability, drug use, sharing practices, and mental health symptoms. In total, 19 qualitative interviews were performed to further explore COVID-19 knowledge, impact on personal and community life, drug acquisition and use, overdose, and protective substance use adaptations., Results: Drug use increased during the pandemic, including the use of fentanyl products such as gel encapsulated "beans" and "buttons". Disruptions in supply, including the decreased availability of heroin, increased methamphetamine costs and a concomitant rise in local methamphetamine production, and possible fentanyl contamination of methamphetamine was reported. Participants reported increased drug use alone, experience and/or witness of overdose, depression, anxiety, and loneliness. Consistent access to harm reduction services, including naloxone and fentanyl test strips, was highlighted as a source of hope and community resiliency., Conclusions: The COVID-19 pandemic period was characterized by changing drug availability, increased overdose risk, and other drug-related harms faced by people who use drugs in rural areas. Our findings emphasize the importance of ensuring access to harm reduction services, including overdose prevention and drug checking for this vulnerable population.

Home visiting by community health workers (CHW) improves child outcomes in efficacy trials, there is however limited evidence of impact evaluating CHW programmes when operating outside of a research project. A CHW programme, previously demonstrated efficacious in a peri-urban township, was evaluated in a deeply rural context in a non-randomised comparative cohort study. Two non-contiguous, rural areas in the Eastern Cape of South Africa of about equal size and density were identified and 1469 mother-infant pairs were recruited over 33 months. In one area, CHWs conducted perinatal home visits (intervention group). Mothers in the comparison group received standard clinic care. Maternal and child outcomes were compared between the groups at one year. Mothers in the intervention group had significantly fewer depressive symptoms than mothers in the comparison group. Children of intervention mothers attained a higher proportion of their developmental milestones, compared to children in the comparison group. There were no other significant differences between mothers and children in the two groups. It is important to establish key parameters for implementing efficacious CHW programmes, especially as the numbers of CHWs are rapidly increased and are becoming critical components of task-shifting strategies of health departments in low and middle income countries (LMIC).

Machine learning creates new opportunities to design digital health interventions for youth at risk for acquiring HIV (YARH), capitalizing on YARH's health information seeking on the internet. To date, researchers have focused on descriptive analyses that associate individual factors with health-seeking behaviors, without estimating of the strength of these predictive models. We developed predictive models by applying machine learning methods (i.e., elastic net and lasso regression models) to YARH's self-reports of internet use. The YARH were aged 14-24 years old (N = 1287) from Los Angeles and New Orleans. Models were fit to three binary indicators of YARH's lifetime internet searches for general health, sexual and reproductive health (SRH), and social service information. YARH responses regarding internet health information seeking were fed into machine learning models with potential predictor variables based on findings from previous research, including sociodemographic characteristics, sexual and gender minority identity, healthcare access and engagement, sexual behavior, substance use, and mental health. About half of the YARH reported seeking general health and SRH information and 26% sought social service information. Areas under the ROC curve (≥ .75) indicated strong predictive models and results were consistent with the existing literature. For example, higher education and sexual minority identification was associated with seeking general health, SRH, and social service information. New findings also emerged. Cisgender identity versus transgender and non-binary identities was associated with lower odds of general health, SRH, and social service information seeking. Experiencing intimate partner violence was associated with higher odds of seeking general health, SRH, and social service information. Findings demonstrate the ability to develop predictive models to inform targeted health information dissemination strategies but underscore the need to better understand health disparities that can be operationalized as predictors in machine learning algorithms., (© 2021. Society for Prevention Research.)

Households experiencing intimate partner violence (IPV) and food insecurity are at high risk of lifelong physical and behavioral difficulties. Longitudinal data from a perinatal home-visiting cluster-randomized controlled intervention trial in South Africa townships were used to examine the relationships between household settings and mothers' histories of risk and children's behavior problems at 3 and 5 years of age. IPV, food insecurity, maternal depressed mood, and geriatric pregnancy (at age of 35 or older) were consistently associated with children's internalizing and externalizing behavior problems. Aggressive behavior was more prevalent among 3- and 5-year olds boys, and was associated with maternal alcohol use. The effects of these factors on child behavior were more prominent than maternal HIV status. There is a continuing need to reduce IPV and household food insecurity, as well as supporting older, depressed, alcohol using mothers in order to address children's behavioral needs.

Abstract: The impact of the COVID-19 pandemic on syphilis rates is unknown. A retrospective chart review was performed of all patients screened for syphilis through universal screening in a large, urban emergency department from June 2019 to June 2020. During the early pandemic (April through June 2020), screening rates remained similar, but the rate of presumed active infection increased from 1.2% to 1.8% (prevalence ratio, 1.54; 95% confidence interval, 1.17-2.00; P < 0.01), with significant increases among adolescents and women. Only 19.2% of patients with presumed active infection presented for STI-related complaints. Universal screening represents a valuable tool for achieving syphilis control within high-prevalence communities., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2021 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Mental illness and substance use are prevalent among people living with HIV and often lead to poor health outcomes. Electronic medical record (EMR) data are increasingly being utilized for HIV-related clinical research and care, but mental illness and substance use are often underdocumented in structured EMR fields. Natural language processing (NLP) of unstructured text of clinical notes in the EMR may more accurately identify mental illness and substance use among people living with HIV than structured EMR fields alone., Objective: The aim of this study was to utilize NLP of clinical notes to detect mental illness and substance use among people living with HIV and to determine how often these factors are documented in structured EMR fields., Methods: We collected both structured EMR data (diagnosis codes, social history, Problem List) as well as the unstructured text of clinical HIV care notes for adults living with HIV. We developed NLP algorithms to identify words and phrases associated with mental illness and substance use in the clinical notes. The algorithms were validated based on chart review. We compared numbers of patients with documentation of mental illness or substance use identified by structured EMR fields with those identified by the NLP algorithms., Results: The NLP algorithm for detecting mental illness had a positive predictive value (PPV) of 98% and a negative predictive value (NPV) of 98%. The NLP algorithm for detecting substance use had a PPV of 92% and an NPV of 98%. The NLP algorithm for mental illness identified 54.0% (420/778) of patients as having documentation of mental illness in the text of clinical notes. Among the patients with mental illness detected by NLP, 58.6% (246/420) had documentation of mental illness in at least one structured EMR field. Sixty-three patients had documentation of mental illness in structured EMR fields that was not detected by NLP of clinical notes. The NLP algorithm for substance use detected substance use in the text of clinical notes in 18.1% (141/778) of patients. Among patients with substance use detected by NLP, 73.8% (104/141) had documentation of substance use in at least one structured EMR field. Seventy-six patients had documentation of substance use in structured EMR fields that was not detected by NLP of clinical notes., Conclusions: Among patients in an urban HIV care clinic, NLP of clinical notes identified high rates of mental illness and substance use that were often not documented in structured EMR fields. This finding has important implications for epidemiologic research and clinical care for people living with HIV., (©Jessica P Ridgway, Arno Uvin, Jessica Schmitt, Tomasz Oliwa, Ellen Almirol, Samantha Devlin, John Schneider. Originally published in JMIR Medical Informatics (http://medinform.jmir.org), 10.03.2021.)

Background: Fetal Alcohol Spectrum Disorders (FASD) are a global health concern. Early intervention mitigates deficits, yet early diagnosis remains challenging. We examined whether children can be screened and meet diagnoses for FASD at 1.5 years compared to 5 years post-birth., Methods: A population cohort of pregnant women in 24 neighborhoods (N = 1258) was recruited and 84.5 %-96 % were reassessed at two weeks post-birth, 0.5 years, 1.5 years, 3 years, and 5 years later. A two-step process was followed to diagnose FASD; first, a paraprofessional screened the children and then a physician evaluated the child. We evaluated FASD symptoms at 1.5 vs. 5 years. We also examined maternal differences in children receiving a positive FASD screening (n = 160) with those who received a negative FASD screening., Results: Screening positive for FASD more than doubled from 1.5 years to 5 years (from 6.8 % to 14.8 %). About one quarter of children who screened positive and were evaluated by a physician, were diagnosed as having a FASD. However, half did not complete the 2nd stage screening. Compared to mothers of children with a negative FASD screening, mothers of children with a positive FASD screening were less likely to have a high school education and more likely to have lower incomes, have experienced interpersonal partner violence, and have a depressed mood. Mothers of children who did not follow up for a 2nd stage physician evaluation were more like to live in informal housing compared to those who followed-up (81.3 % vs. 62.5 %, p = 0.014)., Conclusions: We found that children can be screened and diagnosed for FASD at 1.5 and 5 years. As FASD characteristics develop over time, repeated screenings are necessary to identify all affected children and launch preventive interventions. Referrals for children to see a physician to confirm diagnosis and link children to care remains a challenge. Integration with the primary healthcare system might mitigate some of those difficulties., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Home visits by paraprofessional community health workers (CHWs) has been shown to improve maternal and child health outcomes in research studies in many countries. Yet, when these are scaled or replicated, efficacy disappears. An effective CHW home visiting program in peri-urban Cape Town found maternal and child health benefits over the 5 years point but this study examines if these benefits occur in deeply rural communities., Methods: A non-randomized, two-group comparison study evaluated the impact of CHW in the rural Eastern Cape from August 2014 to May 2017, with 1310 mother-infant pairs recruited in pregnancy and 89% were reassessed at 6 months post-birth., Results: Home visiting had limited, but important effects on child health, maternal wellbeing and health behaviors. Mothers reported fewer depressive symptoms, attended more antenatal visits and had better baby-feeding practices. Intervention mothers were significantly more likely to exclusively breastfeed for 6 months (OR: 1.8; 95% CI: 1.1, 2.9), had lower odds of mixing formula with baby porridge (regarded as detrimental) (OR: 0.4; 95% CI: 0.2, 0.8) and were less likely to consult traditional healers. Mothers living with HIV were more adherent with co-trimoxazole prophylaxis (p < 0.01). Intervention-group children were significantly less likely to be wasted (OR: 0.5; 95% CI 0.3-0.9) and had significantly fewer symptoms of common childhood illnesses in the preceding two weeks (OR: 0.8; 95% CI: 0.7,0.9)., Conclusion: The impact of CHWs in a rural area was less pronounced than in peri-urban areas. CHWs are likely to need enhanced support and supervision in the challenging rural context.

Background: Engaging and retaining young men in community-based interventions is highly challenging. The purpose of this study was to investigate the individual factors that predict intervention engagement and adherence in a sample of at-risk South African men., Methods: Baseline data were collected as a part of a cluster randomised control trial (RCT) situated in Khayelitsha and Mfuleni, two peri-urban settlements situated on the outskirts of Cape Town, South Africa. Neighbourhoods were randomised to one of three intervention conditions. We performed univariate descriptive statistics to report neighbourhood and individual socio-demographic factors, and ran multivariate models, adjusting for entry of study, to determine if high adherence and consistency of engagement with the intervention were associated with socio-behavioural demographics and risk behaviours, such as hazardous substance use, gangsterism, and criminal activity., Results: Total of 729 men were on average 22.5 years old (SD 2.8), with a mean of 10 years of education. More than half of the sample were single (94%), lived with their parents (66%) and had an income below ~$30 (52%). The overall mean of adherence is 0.41 (SD 0.24) and mean of consistency of engagement is 0.61 (SD 0.30). Our data indicated that completing more years of education, living with parents, and having higher socioeconomic status were significantly associated with higher rates of engagement and adherence. Men with a history of gang membership demonstrated higher levels of adherence and consistent engagement with the intervention, compared with other men who were recruited to the intervention. Crucially, our data show that young men with a history of substance use, and young men who report symptoms of depression and high levels of perceived stress are equally likely as other young men to adhere to the intervention and attend intervention sessions consistently., Conclusion: Our results may contribute to a better understanding of young men's patterns of engagement and adherence to public health interventions. The results may have important implications for policy and practice, as they may be useful in planning more effective interventions and could potentially be used to predict which young men can be reached through community-based interventions., Trial Registration: ClinicalTrials.gov registration, NCT02358226. Prospectively registered 24 November 2014.

Despite empirical support for "Self-control theory" in criminology, there is controversy about how self-control should be operationalized. Working within the framework of "self-control theory," we investigated if violence and criminal behaviors are associated with nine distinct dimensions of cognitive control in a community sample of young men (n = 654) living in peri-urban townships in South Africa. Cognitive control was assessed using the Behavior Rating Inventory of Executive Function. Multivariate statistical analysis was used, to identify associations between violence and criminality, and deaggregated measures of nine distinct components of cognitive control. Fifteen percent of the sample reported recent violence, 27% had been in physical fights with family/friends in the preceding 6 months, 10% reported being arrested, 4% reported forced sexual contact, and 26% reported intimate partner violence (IPV). Controlling for substance use and sociodemographic variables, contact with the criminal justice system and violence were associated with deficits in all domains of cognitive control. Forced sexual contact was associated with behavioral dysregulation. IPV was associated with behavior dysregulation and executive control dysfunction. Future studies might utilize deaggregated measures of self-control to provide further insight into links between particular components of cognitive control and various forms of offending and violence., (© 2019 Wiley Periodicals, Inc.)

Alcohol, depression, and intimate partner violence (IPV) are endemic in sub-Saharan Africa. This article examines whether and how these conditions affect mothers living with HIV (MLH), compared to mothers without HIV (MWOH). In particular, we assess the influence of these comorbidities on engagement in HIV care and adherence to antiretroviral therapies (ARV) among MLH. Data on maternal HIV care are typically based on clinic samples, with substantial loss to follow-up. This study fills that gap by including all mothers in specified areas. A cohort study examines MLH in Cape Town, South Africa recruited in pregnancy and followed repeatedly for 5 years, compared to MWOH. Almost all (98%) pregnant women in 12 neighborhoods (N = 594) were recruited in pregnancy. Mothers and children were reassessed five times over 5 years with high retention rates at each of the six assessments, from 98.7% at 2 weeks to 82.8% at 5 years post-birth. MLH's uptake and adherence to HIV care was evaluated over time associated with maternal comorbidities of alcohol use, depressed mood, and IPV using mixed effects logistic regression. MLH have fewer resources (income, food, education) and are more likely to face challenges from alcohol, depression, and having seropositive partners over time than MWOH. Only 22.6% of MLH were consistently engaged in HIV care from 6 months to 5 years post-birth. At 5 years, 86.7% self-reported engaged in HIV care, 76.9% were receiving ARVs and 87% of those on ARV reported consistent ARV adherence. However, data on viral suppression are unavailable. Alcohol use, but not depressed mood or IPV, was significantly related to reduced uptake of HIV care and adherence to ARV over time. Adherence to lifelong ARV by MLH requires a combination of structural and behaviorally-focused interventions. Alcohol abuse is not typically addressed in low and middle-income countries, but is critical to support MLH.

Objective: Examine resiliency among a South African population cohort of children of mothers living with HIV (MLH) and mothers without HIV (MWOH) in low-income townships over the first 5 years of life., Design: A cluster randomized controlled intervention trial evaluating child resiliency and the effects of home visiting in township neighborhoods from pregnancy through 5 years postbirth., Methods: The population of pregnant women in 24 matched neighborhoods were recruited and randomized by neighborhood to a standard care condition (n = 594) or a paraprofessional home visiting intervention condition (n = 644). Mothers and children were assessed at 2 weeks, 6, 18, 36, and 60 months postbirth (92-84% follow-up; 10.2% mortality). Resilient children were identified based on consistently meeting global standards for growth, cognitive functioning, and behavior. Maternal HIV status (n = 354 MLH; n = 723 mothers without HIV MWOH), intervention condition, maternal risks, caretaking, sociodemographic characteristics, and neighborhood were examined as predictors of child resiliency over time using analysis of variance, chi-square analyses, and Fisher's exact tests, where appropriate., Results: None of HIV-seropositive children (n = 17) were resilient; 19% of 345 HIV-exposed but uninfected children of MLH were resilient, a rate very similar to the 16% among MWOH. Resiliency was significantly associated with lower income, food security, not having a live-in partner, and the absence of maternal risk (i.e., not being depressed, using alcohol, or being a victim of intimate partner violence). Being randomized to a home visiting intervention, maternal breastfeeding for at least 3 months and attending a preschool crèche were also unrelated to resiliency. Although matched pairs of neighborhoods had similar rates of resilient children, resiliency varied significantly by neighborhood with rates ranging from 9.5 to 27%., Conclusion: We set a new standard to define resiliency, as consistently recommended by theoreticians. Although seropositive children are not resilient, uninfected children of MLH are as resilient as their peers of MWOH. Typical protective factors (e.g., home visiting, breastfeeding, preschool) were unrelated to resiliency over the first 5 years of life., Trial Registration: ClinicalTrials.gov registration #NCT00996528.

Emergency department visits provide an opportunity to reengage people living with HIV (PLWH) who are out of care. We developed an electronic medical record-based algorithm to identify PLWH in the emergency department and inpatient settings and utilized a trained HIV care navigator to reengage PLWH in these settings. The algorithm identified 420 PLWH during the 14-month observation period. Of these, 56 patients were out of care. Out-of-care individuals were significantly younger than those in care (mean age: 38.6 ± 15.5 vs 46.3 ±14.8 years, P < .001) and more likely to be uninsured (7.1% [4/56] vs 1.8% [6/337], P = .02). Among out-of-care patients, 66.1% (37/56) were reengaged in care. Only 21.4% (12/56) of out-of-care patients had previously received outpatient HIV care at our institution. This project demonstrates the feasibility of using an electronic medical record alert and HIV care navigator to reengage PLWH seeking emergency medical care.

PrEP is greater than 90% effective at preventing HIV infection, but many people who are vulnerable to HIV choose not to take PrEP. Among women, men who have sex with women (MSW) and men who have sex with men (MSM) who tested HIV negative in our emergency department, we assessed behavioral risk factors, self-perception of HIV risk, and interest in PrEP linkage. Women had lower odds of perceiving any HIV risk versus no risk than MSM, while Whites had greater odds of perceiving themselves as high risk than Blacks. Age and self-perception of risk were not associated with PrEP interest, but patients who were objectively classified as "at risk" had greater odds of interest in PrEP than those not at risk (p < .01). Discordance between HIV risk self-perception and objective risk demonstrates the limitation of relying on patient self-referral for PrEP based on their own subjective risk perception.

Background: Identification of clients at greatest risk of acquiring HIV is critical for preexposure prophylaxi (PrEP) implementation. Young black MSM (YBMSM) have high incidence of HIV. We examined published guidelines in identifying eligible PrEP candidates, including seroconverters, in a representative cohort of YBMSM., Methods: The uConnect cohort included YBMSM aged 16-29 years during PrEP roll-out in Chicago from 2013 and 2016. YBMSM with indications for PrEP were determined using Center for Disease Control and Prevention (CDC) guidelines, the HIV incidence risk index for MSM (HIRI-MSM) scoring tool, and Gilead recommendations with calculation of sensitivities, specificities, and area under the curve (AUC) for HIV seroconversion over 18 months. Incidence rate ratios (IRRs) using Poisson regression were modeled to compare individual and network factors associated with seroconversion., Results: In the study cohort, 300 HIV uninfected YBMSM contributed 390.4 person-years of follow-up [mean age (SD), 22.3 years (3.07)]. HIV incidence was 8.5 cases per 100 person-years (95% confidence interval, 6.0-11.9). One network factor was associated with seroconversion: having partners more than 10 years older (IRR = 4.4, 95% confidence interval, 1.6-11.8). Overall, 49% of the cohort had an indication for PrEP using CDC guidelines; 72% using HIRI-MSM, and 86% using Gilead recommendations. HIV seroconverters (n = 33) were identified as PrEP eligible prior to seroconversion with sensitivities/AUCs for CDC (52%/0.51), HIRI-MSM (85%/0.57), and Gilead guidelines (94%/0.54)., Conclusion: Low sensitivity of CDC guidelines and limited AUC of HIRI-MSM and Gilead screening tools are of concern for PrEP implementation among most at risk populations such as YBMSM. Consideration of demographics, local epidemiology, and network factors may better guide identification of clients who could benefit most from PrEP.