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The Ending the HIV Epidemic initiative aims to decrease new HIV infections and promote test-and-treat strategies. Our aims were to establish a baseline of HIV outcomes among newly diagnosed PWH in Washington, DC (DC), a ‘hotspot’ for the HIV epidemic. We also examined sociodemographic and clinical factors associated with retention in care (RIC), antiretroviral therapy (ART) initiation and viral suppression (VS) among newly diagnosed PWH in the DC Cohort from 2011–2016. Among 455 newly diagnosed participants, 92% were RIC at 12 months, ART was initiated in 65% at 3 months and 91% at 12 months, VS in at least 17% at 3 months and 82% at 12 months and 55% of those with VS at 12 months had sustained VS for an additional 12 months. AIDS diagnosis was associated with RIC (aOR 2.99; 1.13–2.28), ART initiation by 3 months (aOR 2.58; 1.61–4.12) and VS by 12 months (aOR4.87; 1.69–14.03). This analysis contributes to our understanding of the HIV treatment dynamics of persons with recently diagnosed HIV infection in a city with a severe HIV epidemic.

Introduction The COVID-19 pandemic has created substantial interruptions in healthcare presenting challenges for people with chronic illnesses to access care and treatment services. We assessed the impact that the pandemic has had on the care of people with HIV (PWH) by characterizing the pandemic-related impact on HIV clinic-level services and the mitigation strategies that were developed to address them. Methods The data comes from a site assessment conducted in the DC Cohort, an observational clinical cohort of PWH receiving care at 14 HIV outpatient clinics in Washington, D.C. Frequency counts and prevalence estimates of clinic-level survey responses about the impact of care delivery, COVID-19 testing, and vaccinations and mitigation strategies are presented. Results Clinics reported an increase in temporary clinic closures (n = 2), reduction in clinic hours (n = 5), telehealth utilization (n = 10), adoption of multi-month dispensation of antiretroviral medication (n = 11) and alternative drug delivery via postal/courier service, home/community delivery or pick-up (n = 11). Clinics utilized support strategies for PWH who were lost to follow-up during the pandemic including offering care to persons with any income level and insurance status (n = 9), utilizing e-prescribing for auto refills even if the patient missed visits (n = 8), and utilization of the regional health information exchange to check for hospitalizations of PWH lost to follow-up (n = 8). Most social services offered before the pandemic remained available during the pandemic; however, some support services were modified. Conclusions Our findings demonstrate the extent of pandemic-era disruptions and the use of clinic-level mitigation strategies among urban HIV clinics. These results may help prepare for future pandemic or public health emergencies that disrupt healthcare delivery and access.

BACKGROUND COVID-19 isolation recommendations have evolved over the course of the pandemic. Initially, the US Centers for Disease Control and Prevention required 10 days of isolation after a positive test result. In December 2021, this was reduced to a minimum of 5 days with symptom improvement, followed by 5 days of mask wearing. As a result, several institutions of higher education, including the George Washington University, required persons testing positive for COVID-19 to either submit a negative rapid antigen test (RAT) with symptom resolution to leave isolation after 5 days or to maintain a 10-day isolation period in the absence of a negative RAT and the presence of continued symptoms. RATs are tools that can be used both to shorten isolation periods and to ensure that persons testing positive for COVID-19 remain in isolation if infectious. OBJECTIVE The purpose of this analysis is to report on the experience of implementing RAT policies, examine the number of days that isolation was reduced via RAT testing, determine the factors that predicted uploading a RAT, and determine RAT positivity percentages to illustrate the utility of using RATs to end isolation. METHODS In this study, 880 individuals in COVID-19 isolation at a university in Washington, DC, uploaded 887 RATs between February 21 and April 14, 2022. Daily positivity percentages were calculated, and multiple logistic regression analyses examined the odds of uploading a RAT by campus residential living status (ie, on or off campus), student or employee designation, age, and days in isolation. RESULTS A total of 76% (669/880) of individuals in isolation uploaded a RAT during the study period. Overall, 38.6% (342/887) of uploaded RATs were positive. Uploaded RATs were positive 45.6% (118/259) of the time on day 5; 45.4% (55/121) on day 6; 47.1% (99/210) on day 7; and 11.1% (7/63) on day 10 or beyond. Adjusted logistic regression modeling indicated cases living on campus had increased odds of uploading a RAT (odds ratio [OR] 2.54, 95% CI 1.64-3.92), whereas primary student affiliation (OR 0.29, 95% CI 0.12-0.69) and days in isolation (OR 0.45, 95% CI 0.39-0.52) had decreased odds of uploading a RAT. Of the 545 cases with a negative RAT, 477 were cleared prior to day 10 of their isolation due to lack of symptoms and timely submission, resulting in a total of 1547 days of lost productivity saved compared to all being in isolation for 10 days. CONCLUSIONS RATs are beneficial, as they can support a decision to release individuals from isolation when they have recovered and maintain isolation for people who may still be infectious. Future isolation policies should be guided by similar protocols and research to reduce the spread of COVID-19 and minimize lost productivity and disruption to individuals’ lives.

Housing instability can hinder the ability of people with HIV (PWH) to maintain engagement in care, adhere to antiretroviral (ART) regimens, and achieve viral suppression. This analysis examined the association between housing instability and HIV outcomes, as well as the association between housing status and substance use disorders, mental health disorders, and sexually transmitted infections. Multivariable logistic regressions were performed using data from the DC Cohort, a longitudinal cohort of PWH. Among 8622 PWH, unstably housed PWH were significantly more likely to be prescribed ART (aOR: 1.4; 95%CI: 1.1, 1.8) yet were significantly less likely to be virally suppressed (aOR: 0.6; 95%CI: 0.5, 0.8). Unstably housed PWH were also significantly more likely to have a substance use or mental health disorder, which may inhibit PWH's ability to achieve viral suppression. Efforts to end the HIV epidemic should address housing to ensure treatment is optimized for key populations.

Pre-exposure prophylaxis (PrEP) for HIV is highly effective, yet uptake has been limited. We measured PrEP knowledge, eligibility, and referral willingness among patients receiving emergency or acute care in Washington, DC. We surveyed HIV-negative patients with STI-related complaints on HIV risk behaviors, PrEP knowledge, eligibility, and willingness for PrEP referral. Among 174 participants, 70% were PrEP unaware and 33% were PrEP eligible. Most participants (81%) supported learning more, 64% would consider taking PrEP, and 28% agreed to immediate referral. Willingness to learn more about PrEP suggests referral from non-traditional settings may increase uptake. Further evaluation of this approach is warranted.

Unmet needs can impede optimal care engagement, impacting the health and well-being of people living with HIV (PLWH); yet, whether unmet needs differ by care engagement status is not well understood. Using surveys and qualitative interviews, we examined and compared unmet needs for PLWH (n = 172) at different levels of care engagement. Unmet needs varied only slightly by care status. Survey findings revealed that provision of housing, emergency financial assistance, employment assistance, and food security were the greatest unmet need; for those in care, housing was the greatest unmet need, whereas for those sporadically in care or out of care, employment assistance was the greatest unmet needs. Qualitative interviews likewise illustrated that a lack of financial resources including insurance, housing, employment, and transportation presented barriers to care engagement across all care groups. Our findings indicate that unmet needs among PLWH are complex and multi-faceted across care engagement status.

Pre-exposure prophylaxis (PrEP) is an effective method to prevent HIV acquisition in high-risk individuals. This cross-sectional survey study estimated the proportion of patients who were PrEP eligible among a targeted sample of emergency department (ED) patients with chief complaints indicative of HIV risk. Research assistants screened a convenience sample of adult patients who presented to two hospital EDs in Washington, DC, during a 6-month period with genitourinary, substance use, or intentional injury-related complaints. Patients with these complaints who reported being sexually active within the past 6 months and HIV negative completed a computer-assisted survey that included questions on sexual practices and partners, substance use, and attitudes and knowledge about PrEP. We used the Centers for Disease Control and Prevention (CDC) clinical guidelines to determine whether PrEP use was indicated. We report differences in PrEP eligibility by demographic characteristics, knowledge, and attitudes. Of the 410 participants, the majority were black (85%), and heterosexual females (72%). PrEP use was indicated in 20% (N = 84), most commonly because of condomless sex with a person of unknown HIV status (82%) and/or a sexually transmitted infection (STI) diagnosis (41%). One-third (34%) of participants had heard of PrEP. Overall, 36% of the sample (N = 148) wanted to learn more about PrEP while in the ED. The percentage who wanted to learn more about PrEP was higher among PrEP-eligible patients (52%) compared with PrEP-ineligible patients (32%). Using CDC criteria, targeted screening identified that a substantial proportion of ED patients are PrEP eligible based on their self-reported behaviors.

Purpose Oral emtricitabine (FTC)/tenofovir disoproxil fumarate (TDF) was approved for use as pre-exposure prophylaxis (PrEP) by the United States Food and Drug Administration (FDA) in 2012. We used national pharmacy data to examine trends of PrEP use in U.S. counties from 2012-2018. Methods Using multi-level small-area spatial temporal modelling, we calculated the estimated annual percent change (EAPC) in prevalence of PrEP use in the general population from 2012 to 2018. We also used a proxy measure for prevalence of PrEP use among men who have sex with men (MSM) to evaluate trends of use among MSM, the PrEP use-to-MSM ratio (PmR) or number of male PrEP users per 1,000 MSM population. Results The prevalence of PrEP use and PmR increased (EAPC range:(+26.9%, +71.0%) and (+28.4%, +158.7%), respectively) in all counties with varying magnitude of increase. Counties of the Midwest and the upper South and upper West had the slowest increase in prevalence of PrEP use (EAPC range: (+26.9%; +52.9%)). Counties of the northern part of the South had the lowest PmR (EAPC range: (+28.4%; +76.0%)). Counties of the most populous Core-based Statistical Areas (CBSAs) had a relatively faster increase in population prevalence of PrEP use but slower increase in PmR. Conclusion All counties in the U.S. have witnessed an increase in PrEP use with important geographic variabilities. Identifying areas with slow improvement in PrEP use, as well as ‘model counties’ with the fastest pace of progress in PrEP coverage, is critical to inform local and state-level policies and program evaluation for PrEP scale up, particularly among MSM at higher risk for HIV.

With more effective antiretroviral therapy (ART), people with HIV (PWH) are living longer and have more chronic diseases, including diabetes mellitus (DM). The prevalence of DM has been estimated in PWH previously, however there is less research regarding DM control. Our objectives were to determine the prevalence of DM and DM control and determine factors associated with DM control in a large urban cohort of PWH in care. We examined DC Cohort participants aged ≥18 years old to determine DM prevalence and to assess DM control (HbA1c measurement

BACKGROUND: In this era of effective combination antiretroviral therapy (cART) the incidence of AIDS defining cancers (ADCs) is projected to decline while the incidence of certain non-AIDS defining cancers (NADCs) increases. Some of these NADCs are potentially preventable with appropriate cancer screening. SETTING: We examined cancer incidence, screening eligibility, and receipt of screening among persons actively enrolled in the DC Cohort, a longitudinal observational cohort of PLWH, between 2011-2017. METHODS: Cancer screening eligibility was determined based on age, sex, smoking history and comorbidity data available and published national guidelines. RESULTS: The incidence rate of NADCs was 12.1 (95% CI 10.7, 13.8) and ADCs 1.6 (95% CI 0.6, 4.6) per 1000 person-years. The most common incident NADCs were breast 2.6 (95% CI 0.5,1 2.1), prostate 2.3 (95% CI 1.2, 4.3), and non-melanoma skin 1.2 (95% CI 0.6, 2.3) incident diagnoses/cases per 1000 person-years. Among cohort sites where receipt of cancer screening was assessed, less than 60% of eligible participants had any ascertained anal HPV, breast, cervical, colorectal, hepatocellular carcinoma, or lung cancer screening. CONCLUSIONS: In this cohort of PLWH, there were more incident NADCs versus ADCs in contrast to earlier cohort studies where ADCs predominated. Despite a large eligible population there were low rates of screening. Implementation of cancer screening is an important component of care among PLWH.

Washington, DC continues to experience a generalized HIV-1 epidemic. We characterized the local phylodynamics of HIV-1 in DC using next-generation sequencing (NGS) data. Viral samples from 68 participants from 2016 through 2017 were sequenced and paired with epidemiological data. Phylogenetic and network inferences, drug resistant mutations (DRMs), subtypes and HIV-1 diversity estimations were completed. Haplotypes were reconstructed to infer transmission clusters. Phylodynamic inferences based on the HIV-1 polymerase (pol) and envelope genes (env) were compared. Higher HIV-1 diversity (n.s.) was seen in men who have sex with men, heterosexual, and male participants in DC. 54.0% of the participants contained at least one DRM. The 40–49 year-olds showed the highest prevalence of DRMs (22.9%). Phylogenetic analysis of pol and env sequences grouped 31.9–33.8% of the participants into clusters. HIV-TRACE grouped 2.9–12.8% of participants when using consensus sequences and 9.0–64.2% when using haplotypes. NGS allowed us to characterize the local phylodynamics of HIV-1 in DC more broadly and accurately, given a better representation of its diversity and dynamics. Reconstructed haplotypes provided novel and deeper phylodynamic insights, which led to networks linking a higher number of participants. Our understanding of the HIV-1 epidemic was expanded with the powerful coupling of HIV-1 NGS data with epidemiological data.

People with HIV (PWH) have a high burden of medical comorbidities, potentially putting them at increased risk for severe COVID-19. Additionally, during the COVID-19 pandemic, HIV care delivery has been restructured and the impact on HIV outcomes is unknown. The objectives of this study were first, to examine the risk of severe COVID-19 among PWH, using a definition incorporating clinical risk factors, and second, to examine the pandemic's impact on HIV care. We used data from the DC Cohort, a large cohort of people receiving HIV care in Washington, DC. We found that a high proportion of participants across all age groups qualified as increased (58%) or high risk (34%) for severe COVID-19. Between 2019 and 2020, encounters increased (17.7%, increasing to 23.5% of active DC Cohort participants had an encounter) while laboratory utilization decreased (14.4%, decreasing to 11.4% of active DC Cohort participants had an HIV RNA test performed). Implications of our work include the importance of protecting vulnerable people with HIV from acquiring COVID-19 and potentially manifesting severe complications through strategies including vaccination. Additionally, acknowledging that HIV service delivery will likely be changed long-term by the pandemic, adaptation is required to ensure continued progress towards 90-90-90 goals.

Background The Undetectable = Untransmittable (U = U) campaign advances the goal of ending the HIV epidemic by promoting durable viral suppression and therefore reducing sexual transmission. We used geospatial analysis to assess the potential for sexual HIV transmission by ZIP code of residence in the District of Columbia (DC) using data from the DC Cohort Longitudinal HIV Study (DC Cohort), a city-wide cohort of persons with HIV (PWH). Methods DC Cohort participants aged ≥13 years were included in the study period between April 1, 2016, and March 31, 2018. Potential for sexual HIV transmission was defined as the proportion of participants with incident sexually transmitted infection (STI; gonorrhea, chlamydia, syphilis) and with HIV RNA ≥200 copies/mL from 9 months before to 3 months after STI diagnosis. We performed geographic information system (GIS) analysis to determine the ZIP codes with the highest potential for sexual HIV transmission. Results Of 3467 participants, 367 (10.6%) had at least 1 incident STI, with 89.4% residing in 11 of the 20 residential ZIP codes in DC. Of the 367 participants with an incident STI, at least 1 HIV RNA was available for 348 (94.8%). Ninety-seven (27.9%) individuals with an incident STI had HIV RNA ≥200 copies/mL in the defined time window. Of these 97, 66 (68.0%) resided in 5 of the 20 DC ZIP codes. Conclusions In DC, 5 ZIP codes of residence accounted for the majority of the estimated potential for HIV transmission among participants in the DC Cohort. These results support focused neighborhood-level interventions to help end the HIV epidemic.

The George Washington University (GW) in Washington, D.C., USA established the Public Health Laboratory and Campus COVID-19 Support Team (CCST) to develop and implement its SARS-CoV-2 surveillance testing and outbreak response for the 2020-2021 academic year.Approximately 4,000 GW members had access to campus for living accommodations, limited in-person instruction, athletics, research, and university operations. The outbreak response included daily risk assessment surveys, weekly surveillance testing, symptomatic and voluntary testing, case investigation, and contact tracing.Between August 17 - November 24, 2020, 42,350 SARS-CoV-2 PCR tests were performed, and 194 (0.46%) of tests were positive. Surveillance testing identified 59 (30.4%); voluntary testing 97 (50%); and symptomatic testing 30 (15.5%) of the cases, respectively.Robust testing of asymptomatic people and rapid isolation and quarantine of members who are exposed or infected effectively limited the spread of SARS-CoV-2 during the Fall 2020 semester.

Background Using the results of a site assessment survey performed at clinics throughout Washington, DC, we studied the impact of clinic-level factors on antiretroviral therapy (ART) initiation and viral suppression (VS) among people living with human immunodeficiency virus (HIV; PLWH). Methods This was a retrospective analysis from the District of Columbia (DC) Cohort, an observational, clinical cohort of PLWH from 2011–2018. We included data from PLWH not on ART and not virally suppressed at enrollment. Outcomes were ART initiation and VS (HIV RNA < 200 copies/mL). A clinic survey captured information on care delivery (eg, clinical services, adherence services, patient monitoring services) and clinic characteristics (eg, types of providers, availability of evenings/weekends sessions). Multivariate marginal Cox regression models were generated to identify those factors associated with the time to ART initiation and VS. Results Multiple clinic-level factors were associated with ART initiation, including retention in care monitoring and medication dispensing reviews (adjusted hazard ratios [aHRs], 1.34 to 1.40; P values < .05 for both). Furthermore, multiple factors were associated with VS, including retention in HIV care monitoring, medication dispensing reviews, and the presence of a peer interventionist (aHRs, 1.35 to 1.72; P values < .05 for all). In multivariable models evaluating different combinations of clinic-level factors, enhanced adherence services (aHR, 1.37; 95% confidence interval [CI], 1.18–1.58), medication dispensing reviews (aHR, 1.22; 95% CI, 1.10–1.36), and the availability of opioid treatment (aHR, 1.26; 95% CI, 1.01–1.57) were all associated with the time to VS. Conclusions The observed association between clinic-level factors and ART initiation/VS suggests that the presence of specific clinic services may facilitate the achievement of HIV treatment goals.

Re-engaging people living with HIV (PLWH) who are out of care (OOC) is of utmost importance to ending the HIV epidemic in the U.S. We used DC Department of Health (DCDOH) HIV surveillance data to determine whether re-engaging PLWH results in improved long-term clinical outcomes. PLWH identified as OOC for 6-12 months at both the clinic-level and using DCDOH data were targeted for re-engagement efforts through Recapture Blitz (RB). Uni- and bivariate analyses were conducted comparing engagement in care (EIC), CD4 counts, and viral suppression (VS) at 6, 12, and 18-months post-re-engagement between persons re-engaged through RB and those not re-engaged via RB. Of the 569 PLWH contacted; 57 were re-engaged through RB, 46 were not but may have reengaged on their own. Compared to those not re-engaged via RB, at 18-months of follow-up, more PLWH re-engaged through RB were EIC (71.9% vs. 56.5%) and VS (52.6% vs. 30.4%). Higher proportions of PLWH re-engaged through RB were virally suppressed at 6, 12, and 18-months (

Introduction Prior studies found renal disease was common among HIV-infected outpatients. We updated incident renal disease estimates in this population, comparing those with and without tenofovir exposure. Methods We conducted a retrospective analysis of the DC Cohort, a longitudinal study of HIV patients in Washington, DC, from 2011 to 2015. We included adults prescribed antiretroviral therapy (ART) with baseline glomerular filtration rate (GFR) ≥15 ml/min per 1.73 m2. We defined renal disease as 50% decrease in GFR or doubled serum creatinine (Cr) within 3 months. We defined cumulative viral load as area under the curve (AUC) of log10 transformed longitudinal HIV RNA viral load (VL). Correlates of time to incident renal disease were identified using Cox proportional hazard regression models, adjusted for demographics and known risk factors for kidney disease. Results Among 6068 adults, 77% were Black and median age was 48 years. Incident renal disease rate was 0.77 per 100 person-years (95% confidence interval [CI]: 0.65–0.9). Factors associated with renal disease were age (adjusted hazard ratio [aHR]: 1.4; CI 1.1–1.7 per 10 years), public non-Medicaid, non-Medicare insurance (aHR: 3.4; CI: 1.9–6.4), AUC VL (aHR: 1.1; CI: 1.1–1.2), diabetes mellitus (aHR: 1.6; CI: 1.0–2.4), and mildly reduced GFR (60–89 ml/min per 1.73 m2) (aHR: 1.5; CI: 1.0–2.3); recent tenofovir exposure was not associated with renal disease (aHR: 0.7; CI: 0.5–1.1). Conclusion Our study revealed a substantial burden of renal disease among HIV patients. Cumulative VL was associated with renal disease, suggesting that early VL suppression may decrease its incidence., Graphical abstract

Integrase inhibitors (INSTIs) are recommended by expert panels as initial therapy for people with HIV. Because there can be disparities in prescribing and uptake of novel and/or recommended therapies, this analysis assessed potential INSTI prescribing disparities using a combined data set from the Johns Hopkins HIV Clinical Cohort and the DC Cohort. We performed multivariable logistic regression to identify factors associated with ever being prescribed an INSTI. Disparities were noted, including clinic location, age, and being transgender. Identifying disparities may allow clinicians to focus their attention on these individuals and ensure that therapy decisions are grounded in valid clinical reasons., We assessed INSTI prescribing disparities using Johns Hopkins HIV Clinical Cohort/DC Cohort data. Disparities were noted, including clinic location, age, and being transgender. Clinicians should focus their attention on these individuals and make therapy decisions grounded in valid clinical reasons.

We conducted a retrospective analysis of 38 children and youth with human immunodeficiency virus (aged 0–19 years) in the United States and report an increased rate of change of BMI-for-age z score after initiating integrase strand transfer inhibitors (+0.19 z score units/year [95% confidence interval, .01–.37]; P = .036) for a median follow-up of 527.5 days., Children and youth with HIV in the United States (n=38) have an increased rate of change of BMI-for-age z-score (+0.19 z-score units/year) after initiating integrase strand transfer inhibitors for a median follow-up of 527.5 days.

Molecular epidemiology (ME) is one tool used to end the HIV epidemic in the United States. We combined clinical and behavioral data with HIV sequence data to identify any overlap in clusters generated from different sequence datasets; to characterize HIV transmission clusters; and to identify correlates of clustering among people living with HIV (PLWH) in Washington, District of Columbia (DC). First, Sanger sequences from DC Cohort participants, a longitudinal HIV study, were combined with next-generation sequences (NGS) from participants in a ME substudy to identify clusters. Next, demographic and self-reported behavioral data from ME substudy participants were used to identify risks of secondary transmission. Finally, we combined NGS from ME substudy participants with Sanger sequences in the DC Molecular HIV Surveillance database to identify clusters. Cluster analyses used HIV-Transmission Cluster Engine to identify linked pairs of sequences (defined as distance ≤1.5%). Twenty-eight clusters of ≥3 sequences (size range: 3–12) representing 108 (3%) participants were identified. None of the five largest clusters (size range: 5–12) included newly diagnosed PLWH. Thirty-four percent of ME substudy participants (n = 213) reported condomless sex during their last sexual encounter and 14% reported a Syphilis diagnosis in the past year. Seven transmission clusters (size range: 2–19) were identified in the final analysis, each containing at least one ME substudy participant. Substudy participants in clusters from the third analysis were present in clusters from the first analysis. Combining HIV sequence, clinical and behavioral data provided insights into HIV transmission that may not be identified using traditional epidemiological methods alone. Specifically, the sexual risk behaviors and STI diagnoses reported in the substudy survey may not have been disclosed during Partner Services activities and the survey data complemented clinical data to fully characterize transmission clusters. These findings can be used to enhance local efforts to interrupt transmission and avert new infections.

The COVID-19 pandemic has greatly impacted US colleges and universities. As The George Washington University (GWU), a large urban university, prepared to reopen for the Fall 2020 semester, GWU established protocols to protect the health and wellness of all members of campus community. Reopening efforts included a cadre of COVID-19 surveillance systems including development of a public health COVID-19 laboratory, weekly and symptomatic SARS-CoV-2 testing and daily risk screening and symptom monitoring. Other activities included completion of a mandatory COVID-19 training and influenza vaccination for the on-campus population, quarantining of students returning to campus, campus-focused case investigations and quarantining of suspected close contacts, clinical follow-up of infected persons, and regular communication and monitoring. A smaller on-campus population of 4,435 students, faculty and staff returned to campus with later expansion of testing to accommodate GWU students living in the surrounding area. Between August 17 and December 4, 2020, 38,288 tests were performed; 220 were positive. The surveillance program demonstrated a relatively low positivity rate, with temporal clustering of infected persons mirroring community spread, and little evidence for transmission among the GWU on-campus population. These efforts demonstrate the feasibility of safely partially reopening a large urban college campus by applying core principles of public health surveillance, infectious disease epidemiology, behavioral measures, and increased testing capacity, while continuing to promote educational and research opportunities. GWU will continue to monitor the program as the pandemic evolves and periodically reassess to determine if these strategies will be successful upon a full return to in-person learning.Summary BoxWhat is the current understanding of this subject? When the COVID-19 pandemic began, generally universities were not prepared and it was unclear how to safely reopen colleges and universities given the uncertain risks of transmission among students, faculty and staff.What does this report add to the literature? This case report highlights the successful approaches employed, including applying the core principles of public health surveillance and increasing testing capacity, to mitigate the spread of SARS-CoV-2 on a densely populated urban college campus resulting in a safe reopening.What are the implications for public health practice? This experience can provide a roadmap for other universities to consider as they plan for the safe reopening of their campuses.

Background Two strategies of the US Ending the HIV Epidemic initiative are early diagnosis of infections via widespread testing and prevention of new infections using pre-exposure prophylaxis (PrEP). These strategies are particularly important for adolescents and young adults (AYAs) who are disproportionately affected by HIV, particularly if they identify as Black and/or lesbian, gay, bisexual, transgender, queer or questioning, and others (LGBTQ+). This study will develop and test an interactive life-simulation game in which players can enact real-life behaviors and receive their HIV risk profile to improve HIV testing and PrEP access among AYAs aged 13-24 years in Washington, DC. Objective This mixed methods study aims to determine the acceptability of an interactive, enhanced life-simulation game prototype among AYAs, conduct a pilot test of the gaming intervention among a small cohort of AYAs to ensure game usability and acceptability, and evaluate the efficacy of the game in a randomized controlled study with AYAs at risk for HIV in Washington, DC. Methods This research protocol will be conducted in 3 phases. A formative phase will involve surveys and focus groups (n=64) with AYAs living in the DC area. These focus groups will allow researchers to understand youth preferences for game enhancement. The second phase will consist of a pilot test (n=10) of the gaming intervention. This pilot test will allow researchers to modify the game based on formative results and test the planned recruitment and data collection strategy with intended end users. The third phase will consist of a randomized controlled study among 300 AYAs to examine the efficacy of the life-simulation game compared with app-based HIV educational materials on HIV and PrEP in changing HIV testing, knowledge, risk behaviors, and PrEP access. Participants will have unlimited access to either the life-simulation game or the educational app for 3 months from the time of enrollment. Study assessments will occur at enrollment and at 1, 3, and 6 months post enrollment via e-surveys. At 6 months, a subset of intervention participants (n=25) will participate in in-depth exit interviews regarding their experience being in the study. Results Institutional review board approval was received on February 5, 2020. This project is currently recruiting participants for the formative phase. Conclusions This interactive life-simulation intervention aims to increase HIV testing and PrEP access among AYAs in the DC area. In this intervention, players can enact real-life behaviors and receive their HIV risk profile to promote HIV testing and PrEP seeking. Such an intervention has great potential to improve knowledge of HIV and PrEP among AYAs, increase motivation and self-efficacy related to HIV testing and PrEP use, and decrease individual and structural barriers that often preclude engagement in HIV prevention services. Trial Registration ClinicalTrials.gov NCT04917575; https://clinicaltrials.gov/ct2/show/NCT04917575 International Registered Report Identifier (IRRID) PRR1-10.2196/29792

BACKGROUND Two strategies of the US Ending the HIV Epidemic initiative are early diagnosis of infections via widespread testing and prevention of new infections using pre-exposure prophylaxis (PrEP). These strategies are particularly important for adolescents and young adults (AYAs) who are disproportionately affected by HIV, particularly if they identify as Black and/or lesbian, gay, bisexual, transgender, queer or questioning, and others (LGBTQ+). This study will develop and test an interactive life-simulation game in which players can enact real-life behaviors and receive their HIV risk profile to improve HIV testing and PrEP access among AYAs aged 13-24 years in Washington, DC. OBJECTIVE This mixed methods study aims to determine the acceptability of an interactive, enhanced life-simulation game prototype among AYAs, conduct a pilot test of the gaming intervention among a small cohort of AYAs to ensure game usability and acceptability, and evaluate the efficacy of the game in a randomized controlled study with AYAs at risk for HIV in Washington, DC. METHODS This research protocol will be conducted in 3 phases. A formative phase will involve surveys and focus groups (n=64) with AYAs living in the DC area. These focus groups will allow researchers to understand youth preferences for game enhancement. The second phase will consist of a pilot test (n=10) of the gaming intervention. This pilot test will allow researchers to modify the game based on formative results and test the planned recruitment and data collection strategy with intended end users. The third phase will consist of a randomized controlled study among 300 AYAs to examine the efficacy of the life-simulation game compared with app-based HIV educational materials on HIV and PrEP in changing HIV testing, knowledge, risk behaviors, and PrEP access. Participants will have unlimited access to either the life-simulation game or the educational app for 3 months from the time of enrollment. Study assessments will occur at enrollment and at 1, 3, and 6 months post enrollment via e-surveys. At 6 months, a subset of intervention participants (n=25) will participate in in-depth exit interviews regarding their experience being in the study. RESULTS Institutional review board approval was received on February 5, 2020. This project is currently recruiting participants for the formative phase. CONCLUSIONS This interactive life-simulation intervention aims to increase HIV testing and PrEP access among AYAs in the DC area. In this intervention, players can enact real-life behaviors and receive their HIV risk profile to promote HIV testing and PrEP seeking. Such an intervention has great potential to improve knowledge of HIV and PrEP among AYAs, increase motivation and self-efficacy related to HIV testing and PrEP use, and decrease individual and structural barriers that often preclude engagement in HIV prevention services. CLINICALTRIAL ClinicalTrials.gov NCT04917575; https://clinicaltrials.gov/ct2/show/NCT04917575 INTERNATIONAL REGISTERED REPORT PRR1-10.2196/29792

Substance use disorders (SUDs) are common among people with HIV and can prevent achievement of optimal health outcomes. Using data from a longitudinal HIV cohort study in the District of Columbia (2011-2018), we calculated the prevalence and correlates of SUD (alcohol, stimulant, and/or opioid use disorders) and determined the association of SUD with engagement in HIV care, ART prescription, viral suppression, and mortality. Of 8420 adults, 3168 (37.6%) had a history of any SUD, most commonly history of alcohol use disorder (29.6%). SUDs disproportionately affected Black individuals (aOR 1.33) and heterosexuals (aOR 1.18), and women had a lower risk of SUD (aOR 0.65). SUD was not associated with engagement in care, ART prescription, or viral suppression. SUD was associated with mortality (aHR 1.31). Addressing alcohol use disorder and preventable causes of death among people with HIV and substance use disorders should be priorities for clinical care and public health.Los trastornos por uso de sustancias (TUS) son comunes entre las personas con VIH y pueden impedir el logro de resultados óptimos de salud. Utilizando datos de un estudio sobre VIH de cohorte longitudinal en el Distrito de Columbia (2011–2018), calculamos la prevalencia y los correlatos de TUS (trastornos por consumo de alcohol, estimulantes y/o opioides) y determinamos la asociación de los TUS con la vinculación a cuidado de VIH, prescripción de terapia antirretroviral, supresión viral y mortalidad. De 8420 adultos, 3168 (37.6%) tenían historial de algún TUS, más comúnmente historial de trastorno por consumo de alcohol (29.6%). Los TUS afectaron de manera desproporcionada a las personas negras (aOR 1.33) y a los heterosexuales (aOR 1.18) y las mujeres tenían un riesgo menor de TUS (aOR 0.65). TUS no tuvo asociación estadísticamente significativa con la vinculación a cuidado de VIH, la prescripción de terapia antirretroviral o la supresión viral. TUS se asoció con mortalidad (aHR 1.31). Abordar el trastorno por consumo de alcohol y las causas prevenibles de muerte entre personas con VIH y trastornos por consumo de sustancias debe ser una prioridad para el cuidado clínico y la salud pública.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the cause of COVID-19, was first detected in China in December 2019 and has rapidly spread throughout the world. Globally, the impact of COVID-19 has been severe with more than half a million deaths over 6 months; in contrast, the HIV pandemic has resulted in over 32 million deaths worldwide over 40 years. This paper reviews the current epidemiology of COVID-19, summarizes its relationship to HIV, identifies synergies in our response, and suggests actions that can be taken to curtail the spread of COVID-19 among persons living with HIV (PLWH). Our understanding of the epidemiology, clinical presentation, prevention, and treatment of COVID-19 has evolved rapidly as they did with HIV. Epidemiologically, there are similarities between the two viruses including asymptomatic spread, disproportionate impact on persons of color, need for rapid diagnostic testing, and lack of a cure or vaccine. PLWH do not appear generally to have an increased incidence of COVID-19 infection or a more severe course of disease. Clinical trials to identify potential treatment and prevention options for COVID-19 have included antiretrovirals used to treat HIV that have not been efficacious. Public health responses overlap between the two pandemics including the need for behavior change and containment strategies such as contact tracing. As the SARS-CoV-2 pandemic evolves, the path forward to controlling, preventing, and treating COVID-19 can be informed by lessons learned from HIV as we seek to control the spread of both viral pandemics.

Washington, DC, and sub-Saharan Africa are both affected by generalized HIV epidemics. However, care for persons living with HIV (PLWH) and clinical outcomes may differ in these geographically and culturally diverse areas. We compared patient and clinical site characteristics among adult persons living with HIV (PLWH) enrolled in two longitudinal HIV cohort studies-the African Cohort Study (AFRICOS) and the DC Cohort.The DC Cohort is a clinic-based city-wide longitudinal cohort comprised of PLWH attending 15 HIV clinics in Washington, DC. Patients' socio-demographic characteristics, clinical evaluations, and laboratory data are retrospectively collected from electronic medical records and limited manual chart abstraction. AFRICOS is a prospective observational cohort of PLWH and uninfected volunteers attending 12 select HIV care and treatment facilities in Nigeria, Kenya, Uganda and Tanzania. AFRICOS study participants are a subset of clinic patients who complete protocol-specific visits every 6 months with history and physical examination, questionnaire administration, and blood/sputum collection for ascertainment of HIV outcomes and comorbidities, and neurocognitive and functional assessments. Among participants aged ≥ 18 years, we generated descriptive statistics for demographic and clinical characteristics at enrollment and follow up and compared them using bivariable analyses.The study sample included 2,774 AFRICOS and 8,420 DC Cohort participants who enrolled from January 2013 (AFRICOS)/January 2011 (DC Cohort) through March 2018. AFRICOS participants were significantly more likely to be women (58.8% vs 27.1%) and younger (83.3% vs 61.1% aged50 years old) and significantly less likely to be MSM (only 0.1% of AFRICOS population reported MSM risk factor) than DC Cohort. Similar rates of current viral suppression (about 75% of both samples), hypertension, hepatitis B coinfection and alcohol use were observed. However, AFRICOS participants had significantly higher rates of CD4200 and tuberculosis and significantly lower rates of obesity, DM, hepatitis C coinfection and syphilis.With similar viral suppression outcomes, but many differences between our cohorts noted, the combined sample provides unique opportunities to assess and compare HIV care and treatment outcomes in the U.S. and sub-Saharan Africa. Comparing these two cohorts may inform care and treatment practices and may pave the way for future pathophysiologic analyses.

The process of recruiting racial and ethnic minority persons living with HIV (PLWH) is important for research studies to ensure inclusivity of underrepresented groups. To understand factors associated with recruitment of minority PLWH, this study examined the recruitment process of PLWH for an observational study of their routine medical care at 14 clinics in Washington, DC. Research assistant (RA) recruiters were interviewed to assess their consenting processes and strategies. Data were collected on clinic services, patient demographics, and recruitment logs of patient approaches for obtaining informed consent resulting in agreement or refusal. A median of 96% of eligible patients was approached to obtain consent, yielding a median consent rate of 78% across all sites. A total of 8438 patients consented and 1326 refused study participation. Clinical sites with more comprehensive services had higher consent rates. black/African American and Hispanic/Latinx PLWH consented or refused study participation in similar proportions, while significantly more white patients enrolled than refused. More men, compared with women, enrolled than refused study participation. The most frequent reasons for refusing study participation were the lack of interest in research (33.2%) and no specific reason provided (28%). RAs identified that effective recruitment strategies used culturally sensitive approaches, built rapport with patients, and obtained provider support for the study. Recruitment strategies that are gender sensitive to address the disparity of underrepresentation of women, address perceived barriers, and examine clinic-specific services are needed to maximize research participation for minority PLWH to improve prevention and health outcomes.

BACKGROUND AIDSVu is a public resource for visualizing HIV surveillance data and other population-based information relevant to HIV prevention, care, policy, and impact assessment. OBJECTIVE The site, AIDSVu.org, aims to make data about the US HIV epidemic widely available, easily accessible, and locally relevant to inform public health decision making. METHODS AIDSVu develops visualizations, maps, and downloadable datasets using results from HIV surveillance systems, other population-based sources of information (eg, US Census and national probability surveys), and other data developed specifically for display and dissemination through the website (eg, pre-exposure prophylaxis [PrEP] prescriptions). Other types of content are developed to translate surveillance data into summarized content for diverse audiences using infographic panels, interactive maps, local and state fact sheets, and narrative blog posts. RESULTS Over 10 years, AIDSVu.org has used an expanded number of data sources and has progressively provided HIV surveillance and related data at finer geographic levels, with current data resources providing HIV prevalence data down to the census tract level in many of the largest US cities. Data are available at the county level in 48 US states and at the ZIP Code level in more than 50 US cities. In 2019, over 500,000 unique users consumed AIDSVu data and resources, and HIV-related data and insights were disseminated through nearly 4,000,000 social media posts. Since AIDSVu’s inception, at least 249 peer-reviewed publications have used AIDSVu data for analyses or referenced AIDSVu resources. Data uses have included targeting of HIV testing programs, identifying areas with inequitable PrEP uptake, including maps and data in academic and community grant applications, and strategically selecting locations for new HIV treatment and care facilities to serve high-need areas. CONCLUSIONS Surveillance data should be actively used to guide and evaluate public health programs; AIDSVu translates high-quality, population-based data about the US HIV epidemic and makes that information available in formats that are not consistently available in surveillance reports. Bringing public health surveillance data to an online resource is a democratization of data, and presenting information about the HIV epidemic in more visual formats allows diverse stakeholders to engage with, understand, and use these important public health data to inform public health decision making.