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Purpose A high daily census may hinder the ability of physicians to deliver quality care in the intensive care unit (ICU). We sought to determine the relationship between intensivist-to-patient ratios and mortality among ICU patients. Methods We performed a retrospective cohort study of intensivist-to-patient ratios in 29 ICUs in 10 hospitals in the United States from 2018 to 2020. We used meta-data from progress notes in the electronic health record to determine an intensivist-specific caseload for each ICU day. We then fit a multivariable proportional hazards model with time-varying covariates to estimate the relationship between the daily intensivist-to-patient ratio and ICU mortality at 28 days. Results The final analysis included 51,656 patients, 210,698 patient days, and 248 intensivist physicians. The average caseload per day was 11.8 (standard deviation: 5.7). There was no association between the intensivist-to-patient ratio and mortality (hazard ratio for each additional patient: 0.987, 95% confidence interval: 0.968-1.007, p = 0.2). This relationship persisted when we defined the ratio as caseload over the sample-wide average (hazard ratio: 0.907, 95% confidence interval: 0.763-1.077, p = 0.26) and cumulative days with a caseload over the sample-wide average (hazard ratio: 0.991, 95% confidence interval: 0.966-1.018, p = 0.52). The relationship was not modified by the presence of physicians-in-training, nurse practitioners, and physician assistants (p value for interaction term: 0.14). Conclusions Mortality for ICU patients appears resistant to high intensivist caseloads. These results may not generalize to ICUs organized differently than those in this sample, such as ICUs outside the United States., Author(s): Jeremy M. Kahn [sup.1] [sup.2], Jonathan G. Yabes [sup.3] [sup.4], Leigh A. Bukowski [sup.1], Billie S. Davis [sup.1] Author Affiliations: (1) grid.21925.3d, 0000 0004 1936 9000, CRISMA Center, Department [...]

Rationale: Little is known about how physicians develop their beliefs about new treatments or update their beliefs in the face of new clinical evidence. These issues are particularly salient in the context of the coronavirus disease (COVID-19) pandemic, which created rapid demand for novel therapies in the absence of robust evidence. Objectives: To identify psychological traits associated with physicians' willingness to treat with unproven therapies and willingness to update their treatment preferences in the setting of new evidence in the context of COVID-19. Methods: We administered a longitudinal e-mail survey to United States physicians board certified in intensive care medicine in April and May 2020 (phase one) and October and November 2020 (phase two). We assessed five psychological traits potentially related to evidence uptake: need for cognition, evidence skepticism, need for closure, risk tolerance, and research engagement. We then examined the relationship between these traits and physician preferences for pharmacological treatment for a hypothetical patient with severe COVID-19 pneumonia. Results: There were 592 responses to the phase one survey, conducted prior to publication of trial data. At this time physicians were most willing to treat with macrolide antibiotics (50.5%), followed by antimalaria agents (36.1%), corticosteroids (24.5%), antiretroviral agents (22.6%), and angiotensin inhibitors (4.4%). Greater evidence skepticism (relative risk [RR], 1.40; 95% confidence interval [CI], 1.30-1.52; P < 0.001), greater need for closure (RR, 1.19; 95% CI, 1.06-1.34; P = 0.003), and greater risk tolerance (RR, 1.17; 95% CI, 1.08-1.26; P < 0.001) were associated with an increased willingness to treat, whereas greater need for cognition (RR, 0.85; 95% CI, 0.75-0.96, P = 0.010) and greater research engagement (RR, 0.91; 95% CI, 0.88-0.95; P < 0.0001) were associated with decreased willingness to treat. In phase two, most physicians updated their beliefs after publication of trial data about antimalarial agents and corticosteroids. Physicians with greater evidence skepticism were more likely to persist in their beliefs. Conclusions: Psychological traits associated with clinical decisions in the setting of uncertain evidence may provide insight into strategies to better align clinical practice with published evidence. [ABSTRACT FROM AUTHOR]

HIV Pre-Exposure Prophylaxis (PrEP) has shown great promise in reducing HIV transmission among affected populations; however, PrEP uptake among Black men who have sex with men (BMSM) has stalled. This study compares BMSM using PrEP and BMSM at risk for HIV not using PrEP based on differences in behavior, psychosocial conditions and the presence of a syndemic (n = 1,411). BMSM reporting PrEP use were significantly more likely to report three of five HIV risk behaviors and three of four psychosocial conditions. Odds of reporting PrEP use increased as the number of psychosocial conditions increased such that BMSM with three psychosocial conditions (AOR = 5.65, 95% CI: 3.17, 10.08) and four conditions (AOR = 18.34, 95% CI: 5.01, 67.20) demonstrated significantly greater odds of PrEP use compared to BMSM reporting one or less conditions. While BMSM at greatest risk are using PrEP, strategies are still needed for men at varying risk levels. [ABSTRACT FROM AUTHOR]

Black men who have sex with men (BMSM) have the highest HIV incidence rates among all men who have sex with men (MSM) and have been less likely than other MSM to be diagnosed, linked or retained in care for HIV. The Promoting Our Worth, Equality, and Resilience (POWER) study administered a behavioral health survey and HIV test to BMSM to estimate the HIV continuum of care among a community-derived sample. Of the N = 1,680 BMSM living with HIV, n = 956 (56.9%) were aware of their HIV-positive status. BMSM who had been previously diagnosed reported progression through the care continuum at greater than 80% for linkage to medical care (97.6%), retention in medical care (97.3%), prescription of antiretroviral therapy (93.6%) and viral suppression (86.4%). Results of this analysis reveal the urgent need to ensure BMSM are being screened and diagnosed. Additionally, community-driven samples are a promising method offering the opportunity to build on the resilience of BMSM progressing though the continuum as well as engage BMSM not yet in care. Lastly, such methods can assist in communicating with those lost to retention. [ABSTRACT FROM AUTHOR]

Black men who have sex with men (BMSM) have elevated risk for depression compared to the general population. BMSM's capacity to cope with these experiences is not well understood. Increased understanding of how multiple forms of discrimination contribute to depression and how BMSM cope with discrimination can better inform interventions. Data come from 3,510 BMSM who attended Black Pride events in six U.S. cities from 2015-2017. Participants completed a health survey that ascertained their psychosocial health and resiliency profiles. Using multivariable logistic regression models, we tested the associations between type-specific discrimination (race, sexuality, HIV status) and depression. We then conducted sub-analyses to determine if coping attenuated the association between type-specific discrimination and depression. Our findings indicated that increased odds of depression among BMSM were associated with discrimination based on race (aOR=1.38, 95% CI = 1.08-1.76), sexual orientation (aOR=1.32, 95% CI = 1.01- 1.72), and HIV status (aOR=1.53, 95% CI = 1.08-2.17). Sub-analyses indicated coping had inconsistent moderation effects between type-specific discrimination and depression. Our findings demonstrate that impact of various forms of discrimination on BMSM's mental health and the mitigating role of coping. Interventions should seek to address depression by reducing experiences of discrimination and building coping resiliency. [ABSTRACT FROM AUTHOR]

Background: Although black transgender women (BTW) experience high prevalence of HIV in the United States, no characterization of the HIV care continuum exists for this population. This study addresses this gap by (1) characterizing the HIV care continuum, and (2) exploring correlates of HIV diagnosis and viral suppression among a community-based sample of BTW., Methods: Data came from Promoting Our Worth, Equality, and Resilience (POWER). From 2014 to 2017, POWER recruited BTW who attended Black Pride events in 6 U.S. cities. Participants completed a behavioral health survey and were offered onsite HIV testing. Simple frequencies were used to characterize the HIV care continuum, and multivariable logistic regression analysis was used to identify correlates of HIV diagnosis and viral suppression., Results: A total of 422 BTW provided completed data for our analysis, 45.0% of whom were living with HIV. Over half of the HIV-positive BTW (51.4%) reported being undiagnosed at the time of survey, and 24.5% reported viral suppression. Incarceration and a lack of access to medical care were significantly and positively associated with an undiagnosed HIV-positive status in multivariable models. Incarceration, homelessness, polydrug use, physical assault, intimate partner violence, and current hormone use were significantly and negatively associated with viral suppression in multivariable models., Conclusions: Developing and implementing interventions that address timely HIV diagnosis may assist in informing the HIV disparity among BTW in the United States. Interventions should address the fundamental causes of poor health in this population.

Background: The HIV epidemic among black men who have sex with men (BMSM) demands urgent public health attention. Pre-exposure prophylaxis (PrEP) is a highly efficacious option for preventing HIV, but characteristics of PrEP use among community samples of BMSM are not well-understood., Methods: A serial cross-sectional survey assessment (N = 4184 BMSM reporting HIV-negative/unsure status) and HIV testing were conducted at Black Gay Pride events in 6 US cities in 2014, 2015, 2016, and 2017., Results: HIV prevalence was higher among BMSM self-reporting current PrEP use (1 of 3 participants) than BMSM not self-reporting current PrEP use (1 of 5 participants) [32.3%, N = 103/319 vs. 20.0%, N = 639/3,193, adjusted odds ratio (aOR) = 1.68, 95% confidence interval (CI): 1.31 to 2.15]. BMSM reporting current PrEP use (N = 380) were more likely to report having a greater number of male sex partners (aOR = 1.02, 95% CI: 1.01 to 1.03), a sexually transmitted infection diagnosis (aOR = 2.44, 95% CI: 1.88 to 3.16), and stimulant drug use (aOR = 2.05, 95% CI, 1.21 to 3.47) when compared with BMSM not reporting current PrEP use (N = 3804). PrEP use increased from 4.7% (2014) to 15.5% (2017) (aOR = 1.19, 95% CI: 1.13 to 1.25). Among PrEP users, inability to afford health care coverage was associated with testing HIV-positive (aOR = 2.10, 95% CI: 1.24 to 3.56)., Conclusions: The high prevalence of HIV infection among BMSM reporting PrEP use is concerning. It does not, however, challenge the efficacy of PrEP itself but rather the uptake of the surrounding preventative package including behavioral risk reduction support, sexually transmitted infection treatment, and medication adherence counseling. Further research to understand barriers to fully effective PrEP is needed to guide operational and behavioral interventions that close the gap on incident infection.

Introduction: Differences across the HIV care continuum between men who have sex with men and women (MSMW) and men who have sex with men only (MSMO) are emerging in recent literature but have not been comprehensively documented among black MSM. Although MSMW have lower HIV prevalence than MSMO, they are more likely to be HIV-positive unaware and be virally unsuppressed. Explanatory factors for these differences have not previously been assessed., Methods: Between 2014 and 2016, we surveyed sexually active black MSM 18 years or older at Black Gay Pride events in 6 U.S. cities (n = 3881), 1229 of whom either self-reported HIV-positive status or tested HIV-positive onsite. We compared HIV-positive MSMW (n = 196) with HIV-positive MSMO (n = 1033) by HIV-positive unaware status, HIV care uptake, and viral load suppression. We conducted multivariable logistic regressions and built a structural equation model assessing mediating effects of psychosocial comorbidities (violence victimization, depression, and polydrug use) on the relationship between MSMW status and unsuppressed virus., Results: MSMW were more likely than MSMO to be HIV-positive unaware [adjusted odds ratio (aOR) = 2.17; 95% confidence interval (CI): 1.58 to 3.00]. Among those who were HIV-positive aware (n = 720), MSMW were more likely to report never receiving HIV care (aOR = 2.74; 95% CI: 1.05 to 7.16) and to report detectable viral loads (aOR = 2.34; 95% CI: 1.31 to 4.19). Psychosocial comorbidities significantly mediated (P = 0.01) the relationship between MSMW status and unsuppressed virus., Discussion: Black MSMW were less likely than black MSMO to uptake biomedical care and secondary prevention. Biobehavioral intervention development specific to HIV-positive black MSMW will be most successful if psychosocial comorbidities are also addressed.