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Social support (SS) predicts health outcomes among patients living with HIV. We administered a brief, validated measure of SS, the Multifactoral Assessment of Perceived Social Support, within a patient-reported outcomes assessment of health domains in HIV care at 4 U.S. clinics in English and Spanish (n = 708). In univariate analysis, low SS was associated with poorer engagement in care, antiretroviral adherence, and health-related quality of life; current methamphetamine/crystal use, depression, anxiety, and HIV stigma (all p

Background: Poor patient-provider communication is a clinic-based barrier to long-term adherence and retention in care among HIV patients. Objective assessments of this key metric of patient experience are lacking in [...]

Troy J Wood,1 Kimberly A Koester,2 Katerina A Christopoulos,3 John A Sauceda,1 Torsten B Neilands,1 Mallory O Johnson1 1Department of Medicine, University of California, San Francisco, CA, USA; 2AIDS Policy Research Center, Department of Medicine, University of California, San Francisco, CA, USA; 3Zuckerberg San Francisco General Hospital, Division of HIV, ID and Global Medicine, University of California, San Francisco, CA, USA Purpose: The patient–provider relationship is a central factor that can promote or hinder long-term engagement in care among people living with chronic illnesses. In this paper, we explore characteristics of the patient–provider relationship that facilitated or hindered engagement in care among patients receiving care at HIV specialty clinics.Patients and methods: We conducted 6 focus group discussions with a total of 43 well-retained and less well-retained HIV+ patients in San Francisco, Seattle, and Birmingham, to elicit a wide range of perspectives on engagement in HIV care. Borrowing from the field of psychotherapy, we examined patient–provider relationship characteristics through the lens of the therapeutic alliance, and with regard to their therapeutic efficacy and impact on patient engagement.Results: The majority of participants emphasized how a strong patient–provider relationship defined by trust, intimacy, and collaboration promoted engagement, while a weak patient–provider relationship impeded engagement.Conclusion: We discuss practical strategies and therapeutic techniques that may be helpful to providers in building strong patient–provider relationship and contend that a strong patient–provider relationship is crucial for patients to feel cared for during clinical encounters, which can promote long-term and sustained engagement in HIV care. Keywords: focus groups, engagement in care, therapeutic alliance, psychotherapy, HIV, HIV care

ABSTRACT Background Despite high rates of patient satisfaction with emergency department (ED) HIV testing, acceptance varies widely. It is thought that patients who decline may be at higher risk for HIV infection, thus we sought to better understand patient acceptance and refusal of ED HIV testing. Methods In-depth interviews with fifty ED patients (28 accepters and 22 decliners of HIV testing) in three ED HIV testing programs that serve vulnerable urban populations in northern California. Results Many factors influenced the decision to accept ED HIV testing, including curiosity, reassurance of negative status, convenience, and opportunity. Similarly, a number of factors influenced the decision to decline HIV testing, including having been tested recently, the perception of being at low risk for HIV infection due to monogamy, abstinence or condom use, and wanting to focus on the medical reason for the ED visit. Both accepters and decliners viewed ED HIV testing favorably and nearly all participants felt comfortable with the testing experience, including the absence of counseling. While many participants who declined an ED HIV test had logical reasons, some participants also made clear that they would prefer not to know their HIV status rather than face psychosocial consequences such as loss of trust in a relationship or disclosure of status in hospital or public health records. Conclusions Testing for HIV in the ED as for any other health problem reduces barriers to testing for some but not all patients. Patients who decline ED HIV testing may have rational reasons, but there are some patients who avoid HIV testing because of psychosocial ramifications. While ED HIV testing is generally acceptable, more targeted approaches to testing are necessary for this subgroup.

Abstract Background The 2006 Centers for Disease Control and Prevention (CDC) HIV testing guidelines recommend screening for HIV infection in all healthcare settings, including the emergency department (ED). In urban areas with a high background prevalence of HIV, the ED has become an increasingly important site for identifying HIV infection. However, this public health policy has been operationalized using different models. We sought to describe the development and implementation of HIV testing programs in three EDs, assess factors shaping the adoption and evolution of specific program elements, and identify barriers and facilitators to testing. Methods We performed a qualitative evaluation using in-depth interviews with fifteen 'key informants' involved in the development and implementation of HIV testing in three urban EDs serving sizable racial/ethnic minority and socioeconomically disadvantaged populations. Testing program HIV prevalence ranged from 0.4% to 3.0%. Results Three testing models were identified, reflecting differences in the use of existing ED staff to offer and perform the test and disclose results. Factors influencing the adoption of a particular model included: whether program developers were ED providers, HIV providers, or both; whether programs took a targeted or non-targeted approach to patient selection; and the extent to which linkage to care was viewed as the responsibility of the ED. A common barrier was discomfort among ED providers about disclosing a positive HIV test result. Common facilitators were a commitment to underserved populations, the perception that testing was an opportunity to re-engage previously HIV-infected patients in care, and the support and resources offered by the medical setting for HIV-infected patients. Conclusions ED HIV testing is occurring under a range of models that emerge from local realities and are tailored to institutional strengths to optimize implementation and overcome provider barriers.

Background: Doxycycline post-exposure prophylaxis (doxy-PEP) reduces chlamydia, gonorrhea, and syphilis infections among men who have sex with men (MSM) and transwomen (TW). Perspectives of health care providers (HCPs) regarding doxy-PEP can inform implementation efforts., Methods: From August 2022 to January 2023, HCPs were recruited from 13 cities with high sexually transmitted infection (STI) rates for semi-structured, in-depth interviews about their awareness of and attitudes towards doxy-PEP for STI prevention. HCPs were purposively sampled to include people with experience prescribing PrEP and provision of care to MSM. Interviews were conducted virtually via Zoom. Transcripts and debrief reports were analyzed using a directed content analysis approach to explore knowledge, attitudes, and beliefs about doxy-PEP., Results: Among 30 HCPs, almost half (47%) were between 31-40 years of age, 53% identified as male, and 47% reported their sexual orientation as gay or queer. Half (53%) of participants practiced in the South, 43% had >100 MSM in their clinic panel, and 17% had previously prescribed doxy-PEP. We identified four overarching themes: 1) HCPs expressed positive attitudes towards doxy-PEP; 2) antimicrobial resistance concerns limit enthusiasm for some HCPs; 3) additional data about the long-term safety of doxy-PEP would improve their confidence; and 4) development of guidelines would facilitate the prescription of doxy-PEP, including eligibility, dosing instructions, and treatment management., Conclusion: HCPs were motivated to prescribe doxy-PEP with almost 20% already having prescribed it. Guidelines and data about long-term safety, especially antimicrobial resistance, would facilitate introduction of doxy-PEP into clinical practice., (Copyright © 2024 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: We previously demonstrated at the Ward 86 HIV clinic in San Francisco that long-acting cabotegravir/rilpivirine (LA-CAB/RPV) can rapidly lead to viral suppression (VS) in people with HIV (PWH) with viremia due to adherence challenges. We now evaluate VS durability in this population., Methods: We conducted a retrospective cohort study of PWH who started LA-CAB/RPV with viremia (HIV RNA viral load [VL]≥50 copies/mL) before December 2022. Our primary outcome was VS (VL<50 copies/mL) with LA-CAB/RPV persistence (not discontinued or late by >14 days) at 48 weeks, using the closest VL to 48+/-8 weeks. We also describe viral failure (VF), defined as <2-log VL decline at 4 weeks or VL≥200 copies/mL after initial VS with emergent CAB- or RPV-associated resistance mutations; and overall 48-week VS including those switched to alternative ART., Results: Fifty nine PWH initiated LA-CAB/RPV with viremia and were included in analysis; 49% had CD4<200 cells/µL and median baseline VL was 42,900 copies/mL (Q1-Q3 5,272-139,038). At 48 weeks, 47 met the primary outcome of VS with LA-CAB/RPV persistence (80%; 95%CI 67-89%). Five had VF with resistance (three with RPV-associated mutations, two with CAB and RPV-associated mutations) and one was lost-to-follow-up. At week 48, two of those with VF were suppressed on alternative regimens (lenacapavir+BIC/TAF/FTC and CAB+lenacapavir). Overall week 48 VS on either LA-CAB/RPV or alternative ART was 92% (54/59)., Conclusions: In PWH initiating LA-CAB/RPV with initial viremia, 48-week VS (<50 copies/mL) was 92%. Long-acting ART can be an important tool for improving VS among patients who face adherence challenges to oral ART., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Purpose: Gun violence traumatizes communities and places a heavy burden on the mental health of those exposed. This ecological study examines the association between gun violence exposure and suicide mortality rates in US counties for the period 1999-2020 at various urbanicity levels., Methods: A Bayesian hierarchical Gamma-Poisson model with state random effects was employed to model the age-adjusted suicide mortality rates which adjusted for sex ratio, urbanicity, social vulnerability, gun ownership, culture of honor, and exposure spillovers from neighbouring counties., Results: Results indicate a small significant positive association between gun violence and suicide mortality rates. Urbanicity levels do not appear to modify this association, although the association may be slightly smaller for large urban metros., Conclusions: Gun violence exposure may be positively associated with suicide mortality in US counties., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

The purpose of this article is to describe a model of chronic disease self-management that incorporates the complexity of social and environmental interactions experienced by people who self-manage chronic conditions. This study combines quantitative data from a large national research cohort and qualitative interviews to test and refine a self-management model. The self-management within a syndemic model depicts the contextual, psychological, and social factors that predict self-management behaviors and clinical and long-term outcomes., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Few studies have examined which subgroups of people with HIV (PWH) carry the greatest burden of internalized HIV stigma (IHS), which may be important to care provision and interventions., Methods: PWH in the CFAR Network of Integrated Clinical Systems (CNICS) longitudinal, US-based, multisite, clinical care cohort completed tablet-based assessments during clinic visits including a four-item, Likert scale (low 1-5 high), IHS instrument. Associations between sociodemographic characteristics and IHS scores were assessed in adjusted linear regression models., Results: Twelve thousand six hundred and fifty-six PWH completed the IHS assessment at least once from February 2016 to November 2022, providing 28 559 IHS assessments. At baseline IHS assessment, the mean age was 49 years, 41% reported White, 38% Black/African American, and 16% Latine race/ethnicity, and 80% were cisgender men. The mean IHS score was 2.04, with all subgroups represented among those endorsing IHS. In regression analyses, younger PWH and those in care fewer years had higher IHS scores. In addition, cisgender women vs. cisgender men, PWH residing in the West vs. the Southeast, and those with sexual identities other than gay/lesbian had higher IHS scores. Compared with White-identifying PWH, those who identified with Black/African American or Latine race/ethnicity had lower IHS scores. Age stratification revealed patterns related to age category, including specific age-related differences by gender, geographic region and race/ethnicity., Discussion: IHS is prevalent among PWH, with differential burden by subgroups of PWH. These findings highlight the benefits of routine screening for IHS and suggest the need for targeting/tailoring interventions to reduce IHS among PWH., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Substance use in people with HIV (PWH) negatively impacts antiretroviral therapy (ART) adherence. However, less is known about this in the current treatment era and the impact of specific substances or severity of substance use. We examined the associations of alcohol, marijuana, and illicit drug use (methamphetamine/crystal, cocaine/crack, illicit opioids/heroin) and their severity of use with adherence using multivariable linear regression in adult PWH in care between 2016 and 2020 at 8 sites across the US. PWH completed assessments of alcohol use severity (AUDIT-C), drug use severity (modified ASSIST), and ART adherence (visual analogue scale). Among 9400 PWH, 16% reported current hazardous alcohol use, 31% current marijuana use, and 15% current use of ≥1 illicit drugs. In multivariable analysis, current methamphetamine/crystal use, particularly common among men who had sex with men, was associated with 10.1% lower mean ART adherence ( p  < 0.001) and 2.6% lower adherence per 5-point higher severity of use (ASSIST score) ( p  < 0.001). Current and more severe use of alcohol, marijuana, and other illicit drugs were also associated with lower adherence in a dose-dependent manner. In the current HIV treatment era, individualized substance use treatment, especially for methamphetamine/crystal, and ART adherence should be prioritized.

Doxycycline postexposure prophylaxis (doxy-PEP) reduces sexually transmitted infections (STIs) in men who have sex with men (MSM) and transgender women (TGW). In a clinical trial of doxy-PEP, we sought to assess acceptability, impact, and meaning of doxy-PEP use among MSM/TGW. We conducted semistructured, in-depth 1:1 interviews with MSM and TGW enrolled in the intervention arm of the Doxy-PEP study. We queried motivations for and meaning of use, attitudes, beliefs, adherence, effect on sexual behaviors, and partner, community, and structural factors related to use. We coded interview transcripts into content areas, followed by thematic analysis. We interviewed 44 participants (median age 38), 2% were TGW, 17% Black, 61% White, 30% Hispanic, and 45% persons with HIV. We identified three overarching themes. First, participants found doxy-PEP acceptable, and believed it was effective based on their history of STIs, easy to adhere to, and acceptable to sex partners. Second, doxy-PEP benefited their quality of life and mental health, offering "peace of mind" by reducing their anxiety about acquisition or unwitting transmission of STIs. Participants reported feeling more "in control" of preventing STIs, and positive about supporting their personal, partner, and community health. Third, impact on sexual behavior was variable, with most reporting no change or a brief initial change. Participants in a multi-site clinical trial of doxycycline for STI prevention perceived it to be efficacious, and that it provided quality-of-life benefits, including reduced anxiety and sense of control over sexual health. Doxy-PEP had limited impact on sexual behavior. Clinicaltrials.gov: NCT03980223.

Objective: Accurate estimation of kidney function is critical among persons with HIV (PWH) to avoid under-dosing of antiretroviral therapies and ensure timely referral for kidney transplantation. Existing estimation equations for kidney function include race, the appropriateness of which has been debated. Given advancements in understanding of race and the necessity of accuracy in kidney function estimation, this study aimed to examine whether race, or genetic factors, improved prediction of serum creatinine among PWH., Design: This cross-sectional study utilized data from the Center for AIDS Research Network of Integrated Clinical Systems cohort (2008-2018). The outcome was baseline serum creatinine., Methods: Ordinary least squares regression was used to examine whether inclusion of race or genetic factors [ apolipoprotein-L1 ( APOL1 ) variants and genetic African ancestry] improved serum creatinine prediction. A reduction in root mean squared error (RMSE) greater than 2% was a clinically relevant improvement in predictive ability., Results: There were 4183 PWH included. Among PWH whose serum creatinine was less than 1.7 mg/dl, race was significantly associated with serum creatinine ( β  = 0.06, SE = 0.01, P  < 0.001) but did not improve predictive ability. African ancestry and APOL1 variants similarly failed to improve predictive ability. Whereas, when serum creatinine was at least 1.7 mg/dl, inclusion of race reduced the RMSE by 2.1%, indicating improvement in predictive ability. APOL1 variants further improved predictive ability by reducing the RMSE by 2.9%., Conclusion: These data suggest that, among PWH, inclusion of race or genetic factors may only be warranted at higher serum creatinine levels. Work eliminating existing healthcare disparities while preserving the utility of estimating equations is needed., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Women involved in the carceral system (CS) experience several conditions that increase their risk for HIV (e.g. high rates of substance use, psychiatric disorders, histories of victimization). The purpose of this study is to explore perspectives on potential strategies to connect women in the CS to pre-exposure prophylaxis (PrEP) services., Design/methodology/approach: This study conducted in-depth interviews with 27 women involved in the CS eligible for PrEP. Using vignettes, interviews explored attitudes, barriers and facilitators toward PrEP screening, referral and linkage facilitated via a CS stakeholder, an mHealth application or providing PrEP service referrals during detention via a navigator., Findings: Most women were, on average, 41.3 years, from racial and ethnic minority groups (56% black/African American; 19% Latinx). Inductive thematic analysis revealed CS involved women expressed mostly positive attitudes toward CS-based PrEP implementation. Younger women were more accepting of and interested in mHealth interventions. Implementation facilitators included leveraging relationships with trusted allies (e.g. "peers") and existing systems collaborations. Recommended implementation strategies included providing HIV and PrEP-specific education and training for system stakeholders and addressing issues related to privacy, system mistrust and stigma., Originality/value: Results provide a critical foundation for the implementation of interventions to improve PrEP access for women involved in the CS and have important implications for implementation strategies for all adults involved in the CS. Improving access to PrEP among this population may also support progress toward addressing national disparities in PrEP uptake, where women, black and Latinx populations have substantial unmet need., (© Emerald Publishing Limited.)

Background: Exposure to birds has been linked with several lung pathologies and especially hypersensitivity pneumonitis, but discordant literature exist on the potential effects of this exposure on other respiratory pathologies., Aim: This study aims to examine the associations between bird ownership and asthma, lung cancer, and chronic obstructive pulmonary disease (COPD) in older European adults., Methods: A total of 28,109 participants from the Survey of Health, Ageing, and Retirement in Europe were employed and analyzed with multivariate logistic regressions., Results: No association was found with asthma or lung cancer. Bird ownership increased the odds for COPD diagnosis (OR=1.30; 95 % CI: 1.12-1.51) and more so in males (OR=1.53; 95 % CI: 1.25-1.87) after adjustment for demographic, respiratory, lifestyle, and socioeconomic factors. Male bird owners who smoke had an even more increased risk compared to non-smokers, as did those who lived in multi-person households compared to those living alone., Conclusion: Bird ownership may be positively associated with COPD in older European males., Competing Interests: Declaration of Competing Interest Author was a member of an animal welfare organization - K.C., (Copyright © 2023 SPLF and Elsevier Masson SAS. All rights reserved.)

The COVID-19 pandemic, along with oppressive government interventions, placed a heavy burden on mental health. Suicide mortality is an outcome that may have been affected by the stringency of these lockdown measures. The aim of this study is to examine the association between lockdown intensity, measured by the Stringency Index, and suicide mortality rates in US states from March 2020 to December 2021. To this end, Bayesian methods were used for the estimation of the association for the total population, as well as by gender, and by race. Results show a small negative association between lockdown intensity and suicide mortality rates which applies to most of the examined populations. Future research will determine if this relationship remains the same after the pandemic., Competing Interests: No competing interests., (© 2023 The Author.)

There are several pathways through which religion can affect longevity. Previous research, predominately from North America, has shown decreased mortality risk for participants that attended religious services. This study aims to examine the association between religion and all-cause mortality in a large sample of older European adults, comparing religious affiliations, and using prayer frequency as well as frequency of participation in a religious organisation as measures of religiousness. To this end, a total of 16,062 participants from the Survey of Health Ageing and Retirement in Europe were employed for a survival analysis (median follow-up 11.3 years; 3790 recorded deaths). Following a religion was negatively associated with mortality regardless of demographic and socioeconomic factors (HR = 0.81; 95% CI 0.74-0.89). Large differences in the median survival of participants from different religious affiliations can be mostly attributed to demographic and socioeconomic factors. Both frequency of prayer and religious participation exhibited a significant positive dose-response relationship with survival despite adjustments, although the results for religious participation were more profound. Changes on the religiosity levels of the European population will require additional research on the subject in the future., (© 2023. The Author(s).)

The United States combine high rates of firearm homicides with high gun prevalence. In the past, a significant positive association was found between the two. This study revisits the gun prevalence-gun homicide debate using more elaborate estimates of gun ownership for the 50 States. Longitudinal data (1999-2016) were analysed with Bayesian multilevel Gamma-Poisson models. The results demonstrated a very small positive association that diminished after adjusting for crime rates. Findings suggest that the association either attenuated in more recent years, or previous studies had overestimated this association., (© 2023. The Author(s).)

Introduction: Implementation of patient-centred care (PCC) practices in HIV treatment depends on healthcare workers' (HCWs) perceptions of the acceptability, appropriateness and feasibility of such practices (e.g. use of intentional, metric-driven activities to improve patient experiences)., Methods: We applied rapid, rigorous formative research methods to refine a PCC intervention for future trial. In 2018, we conducted focus group discussions (FGDs) with 46 HCWs purposefully selected from two pilot sites. We elicited HCW perceptions of HIV service delivery, HCW motivation and perceived value of patient experience measures intended to improve PCC. FGDs utilized participatory methods to understand HCW responses to patient-reported care engagement challenges and Scholl's PCC Framework principles (e.g. seeing a patient as a unique person), enablers (e.g. care coordination) and activities (e.g. patient involvement). Our rapid analysis used analytic memos, thematic analysis, research team debriefs and HCW feedback to inform time-sensitive trial implementation., Results: While HCWs nearly universally identified with and supported principles of PCC in both facilities, they raised practical barriers given the practice environment. HCWs described motivation to help patients, attached value to seeing positive health outcomes and the importance of teamwork. However, HCWs reported challenges with enablers needed to deliver PCC. HCWs cited a work culture characterized by differential power dynamics between cadres and departments restricting HCW autonomy and resource access. Barriers included inflexibility in accommodating individual patient needs due to high patient volumes, limited human resources, laboratory capacity, infrastructure and skills translating patient perspectives into practice. HCW motivation was negatively influenced by encounters with "difficult patients," and feeling "unappreciated" by management, resulting in cognitive dissonance between HCW beliefs and behaviours. However, the enactment of PCC values also occurred. Results suggested that PCC interventions should reduce practice barriers, highlighting the value of mentors who could help HCWs dynamically engage with health system constraints, to facilitate PCC., Conclusions: While HCWs perceived PCC principles as acceptable, they did not think it universally appropriate or feasible given the practice environment. Participatory and rapid methods provided timely insight that PCC interventions must provide clear and effective systems enabling PCC activities by measuring and mitigating relational and organizational constraints amenable to change such as inter-cadre coordination., (© 2023 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.)

Introduction: Poor client-provider communication is a critical barrier to long-term retention in care among people living with HIV. However, standardized assessments of this key metric are limited in Africa. We used the Roter Interaction Analysis System (RIAS) to quantitatively characterize patterns of person-centred communication (PCC) behaviours in Zambia., Methods: We enrolled pairs of people living with HIV making routine HIV follow-up visit and their providers at 24 Ministry of Health-facilities supported by the Centre for Infectious Disease Research in Zambia in Lusaka province between August 2019 and November 2021. Client-provider encounters were audio-recorded and coded using RIAS by trained research staff. We performed latent class analysis to identify interactions with distinctive patterns of provider PCC behaviours (i.e. rapport building, person-centred counselling, PCC micropractices [e.g. brief empathy statements], assessing barriers to care, shared decision-making and leveraging discretionary power) and compared their distribution across client, provider, interaction and facility characteristics., Results: We enrolled 478 people living with HIV and 139 providers (14% nurses, 73.6% clinical officers, 12.3% were medical officers). We identified four distinct profiles: (1) "Medically Oriented Interaction, Minimal PCC Behaviours" (47.6% of interactions) was characterized by medical discussion, minimal psychosocial/non-medical talk and low use of PCC behaviours; (2) "Balanced Medical/Non-medical Interaction, Low PCC Behaviours" (21.0%) was characterized by medical and non-medical discussion but limited use of other PCC behaviours; (3) "Medically Oriented Interaction, Good PCC Behaviours" (23.9%) was characterized by medically oriented discussion, more information-giving and increased use of PCC behaviours; and (4) "Highly person-centred Interaction" (7.5%) was characterized by both balanced medical/non-medical focus and the highest use of PCC behaviours. Nurse interactions were more likely to be characterized by more PCC behaviours (i.e. Class 3 or 4) (44.8%), followed by medical officers (33.9%) and clinical officers (27.3%) (p = 0.031). Longer interactions were also more likely to integrate more PCC behaviours (p < 0.001)., Conclusions: PCC behaviours are relatively uncommon in HIV care in Zambia, and often limited to brief rapport-building statements and PCC micropractices. Strengthening PCC, such as shared decision-making and leveraging discretionary power to better accommodate client needs and preferences, may be an important strategy for improving the quality in HIV treatment programmes., (© 2023 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.)

Describe health of transgender women (TW) with HIV vs. cisgender men and women (CM, CW) in a U.S. HIV care cohort. Data were from Centers for AIDS Research Network of Integrated Clinical Systems (CNICS), 2005-2022. TW were identified using clinical data/identity measures. PWH (n = 1285) were included in analyses (275 TW, 547 CM, 463 CW). Cross-sectional multivariable analyses compared HIV outcomes/co-morbidities between TW/CM and TW/CW, and adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) were estimated. TW had poorer adherence (> 90% adherent; aOR 0.57; 95%CI 0.38, 0.87) and were more likely to miss ≥ 3 visits in the past year than CM (aOR 1.50, 95%CI 1.06, 2.10); indicated more anxiety compared to both CM and CW (p ≤ 0.001, p = 0.02); hepatitis C infection (p = 0.03) and past-year/lifetime substance treatment (p = 0.004/p = 0.001) compared to CM; and substance use relative to CW. TW with HIV differed in HIV clinical outcomes and co-morbidities from CM and CW., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Alcohol use among people with HIV is associated with worse HIV treatment outcomes. Its impact on self-reported health status is unclear., Setting: Longitudinal cohort of people with HIV engaged in care across 7 clinics participating in the Centers for AIDS Research Network of Integrated Care Systems between January 2011 and June 2014., Methods: A total of 5046 participants were studied. A quantile regression model estimated the association of alcohol use levels with subsequent self-reported health status score, accounting for multiple covariates including depressive symptoms. Women, men who have sex with women, and men who have sex with men were analyzed separately., Results: Prevalence of heavy alcohol use was 21%, 31%, and 37% among women, men who have sex with women, and men who have sex with men, respectively. Women with heavy alcohol use had a subsequently decreased median self-reported health status score compared to women with no or moderate alcohol use (odds ratio [OR]: 0.76; 95% confidence interval [CI]: 0.58-0.99); this association was not explained by the presence of depressive symptoms. There was no observed association of alcohol use level on subsequent self-reported health status among men who have sex with women. Men who have sex with men reporting no alcohol use had a subsequently decreased median self-reported health status compared to moderate alcohol use (OR: 0.88; 95% CI: 0.80-0.97)., Conclusion: Heavy alcohol use is associated with worsened self-reported health status at subsequent visits among women with HIV and not men with HIV., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Objectives: People with HIV have a higher risk of myocardial infarction (MI) than the general population, with a greater proportion of type 2 MI (T2MI) due to oxygen demand-supply mismatch compared with type 1 (T1MI) resulting from atherothrombotic plaque disruption. People living with HIV report a greater prevalence of cigarette and alcohol use than do the general population. Alcohol use and smoking as risk factors for MI by type are not well studied among people living with HIV. We examined longitudinal associations between smoking and alcohol use patterns and MI by type among people living with HIV., Design and Methods: Using longitudinal data from the Centers for AIDS Research Network of Integrated Clinical Systems cohort, we conducted time-updated Cox proportional hazards models to determine the impact of smoking and alcohol consumption on adjudicated T1MI and T2MI., Results: Among 13 506 people living with HIV, with a median 4 years of follow-up, we observed 177 T1MI and 141 T2MI. Current smoking was associated with a 60% increase in risk of both T1MI and T2MI. In addition, every cigarette smoked per day was associated with a 4% increase in risk of T1MI, with a suggestive, but not significant, 2% increase for T2MI. Cigarette use had a greater impact on T1MI for men than for women and on T2MI for women than for men. Increasing alcohol use was associated with a lower risk of T1MI but not T2MI. Frequency of heavy episodic alcohol use was not associated with MI., Conclusions: Our findings reinforce the prioritization of smoking reduction, even without cessation, and cessation among people living with HIV for MI prevention and highlight the different impacts on MI type by gender., (© 2023 The Authors. HIV Medicine published by John Wiley & Sons Ltd on behalf of British HIV Association.)

Background: Antiretroviral therapy (ART) is recommended for people with HIV (PWH), irrespective of CD4 cell count, to improve their health and reduce the risk of transmission to sexual partners through long-term viral suppression. We identified risk factors for viral rebound among patients with a period of stable viral suppression to inform counseling and monitoring., Methods: We conducted a multisite, retrospective study of PWH with a 2-year period of sustained viral suppression in the United States using the Centers for AIDS Research Network of Integrated Clinical Systems cohort. We used multivariable logistic regression to identify characteristics independently associated with any viral rebound (viral load [VL] ≥200 copies/mL) and sustained viral rebound (VL ≥200 copies/mL followed by a VL that was also ≥200 copies/mL within 6 months), within 2 years of follow-up., Results: Among 3496 eligible patients with a 2-year period of sustained viral suppression, most (90%) continued to have viral suppression over 2 additional years; 10% experienced viral rebound, and 4% experienced sustained viral rebound. In multivariable analyses, Black race, current smoking, integrase strand transfer inhibitor use, and 5- to 9-year duration of ART were positively associated, and being age ≥50 years was negatively associated, with any viral rebound. Only current smoking and 5- to 9-year (vs 2- to 4-year) duration of ART were positively associated, and being age ≥60 years was negatively associated, with sustained viral rebound., Conclusions: Most people retained in clinical care and with HIV viral suppression on ART will have persistent viral suppression. However, some patients may benefit from additional treatment adherence support., Competing Interests: Potential conflicts of interest. E.R.C. received unrestricted research funds paid to UC Regents from Gilead Sciences, Inc., and Merck for unrelated research topics and served on advisory boards for Gilead Sciences, Inc., and Theratechnologies on unrelated medical topics. K.C. served as a medical advisory board member for Gilead Sciences, Inc. K.H.M. received unrestricted research grants from Gilead Sciences, Inc., and Merck. A.R. received research funding from Merck on an unrelated research topic. C.G.B. received research funding from Gilead Sciences, Inc., for unrelated research topics. All other authors report no potential conflicts., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: Vaporized nicotine (VN) use is increasing among people with HIV (PWH). We examined demographics, patterns of use, depression, and panic symptoms associated with VN and combustible cigarette (CC) use among PWH., Methods: We analyzed VN use among PWH in care at 7 US sites. PWH completed a set of patient-reported outcomes, including substance use and mental health. We categorized VN use as never vs. ever with the frequency of use (days/month) and CC use as never, former, or current. We used relative risk regression to associate VN and CC use, depression, and panic symptoms. Linear regression estimated each relationship with VN frequency. Models were adjusted for demographics., Results: Among 7431 PWH, 812 (11%) reported ever-using VN, and 264 (4%) reported daily use. Half (51%) of VN users concurrently used CC. VN users were more likely than those without use to be younger, to be White, and to report ever-using CC. PWH reporting former CC use reported ≥8.5 more days per month of VN use compared with never CC use [95% confidence interval (95% CI): 5.5 to 11.5 days/month] or current CC use (95% CI: 6.6 to 10.5 days/month). Depression (relative risk: 1.20 [95% CI: 1.02 to 1.42]) and panic disorder (1.71 [95% CI: 1.43 to 2.05]) were more common among PWH ever-using VN. Depression was common among PWH using VN (27%) and CC (22%), as was panic disorder (21% for VN and 16% for CC)., Conclusion: Our study elucidated demographic associations with VN use among PWH, revealed the overlap of VN and CC use, and associations with depression/panic symptoms, suggesting roles of VN in self-medication and CC substitution, warranting further longitudinal/qualitative research., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Despite the importance of physical exercise for older people, only a fraction of them receive advice to do so by primary care physicians. This study aims to examine whether gender disparities exist in primary care regarding General Practitioners' (GPs') advice for exercise in older European adults. A total of N=21,703 participants from 14 countries were employed from the Survey of Health, Ageing, and Retirement in Europe and analysed with the use of multivariate ordered logistic regressions. Being female reduced the odds of receiving advice from a primary care physician (OR=0.83; 95% CI: 0.78-0.88) irrespective of health, behavioural, demographic, and socioeconomic factors. In conclusion, older European women may have reduced odds of receiving advice for exercise because of their gender, which in turn may affect their frailty., Competing Interests: No conflicts of interest.

Background: The novel COVID-19 pandemic threatened to disrupt access to human immunodeficiency (HIV) treatment for persons living with HIV (PLHIV), two-thirds of whom live in sub-Saharan Africa. To inform a health system response supportive of continuity of care, we sought to understand clients' HIV care experiences and health priorities during the first wave of COVID-19 outbreak in Lusaka, Zambia., Methods: Leveraging a study cohort of those who completed periodic SMS surveys on HIV care, we purposefully sampled 25 PLHIV after first confirmed COVID-19 case was reported in Zambia on 18 th March 2020. We phone-interviewed participants, iteratively refining interview guide to capture emergent themes on COVID-19 awareness, health facility interactions, and social circumstances, which we analyzed using matrix analysis., Results: All participants were aware of COVID-19, and HIV care experiences and health priorities of clients were affected by associated changes at health system, household, and individual level. The health system instituted early clinic visits to provide 6-months of antiretroviral therapy (ART) for stable patients and 3-months for unstable patients to reduce clinic visits and wait times. Most patients welcomed this long-desired extended appointment spacing. Some reported feeling respected and engaged when health care workers telephoned requesting their early clinic visit. However, others felt discouraged by an absence of physical distancing during their clinic visit due to 'severe acute respiratory syndrome coronavirus 2' (SARS-CoV-2) infection concerns. Several expressed a lack of clarity regarding next viral load monitoring date and means for receiving results. Patients suggested regular patient-facility communication by telephone and SMS. Patients emphasized that COVID-19 restrictions led to loss of employment and household income, exacerbating poverty and difficulties in taking ART. At individual level, most participants felt motivated to stay healthy during COVID-19 by ART adherence and regular laboratory monitoring., Conclusions: Clients' HIV care and health priorities during the first wave of COVID-19 in Lusaka province were varied with a combination of positive and negative experiences that occurred especially at health system and individual levels, while at household level, the experiences were all negative. More research is needed to understand how patients practice resiliency in the widespread context of socio-economic instability. Governments and patients must work together to find local, health systems solutions to support ART adherence and monitoring. Additionally, the health system should consider how to build on changes for long-term HIV management and service delivery., (© 2022. The Author(s).)

With pet ownership on the rise, millions of individuals are exposed to this environmental exposure. Although the subject has been largely studied, more evidence is needed to clarify the potential association of pet ownership with human health. The aim of this research is to study the potential association of pet exposure (any pet, cat, dog, bird, fish) with all-cause, cardiovascular and cancer mortality of older ( ≥  50 years) European residents. To this end, a total of 23,274 participants from the Survey of Health Ageing and Retirement in Europe (SHARE) were employed (median follow-up 119 months). All-cause mortality (5163 events), as well as cardiovascular (CVD) (1832 events), and cancer mortality (1346 events) were examined using Cox Proportional Hazards models for their relation with pet exposure at baseline. Stratified analyses were also performed by gender and for single or multi-person households. No significant association was observed for any of the pets with all-cause mortality on the whole sample and the fully adjusted models. In stratified analyses, bird exposure significantly increased the risk of all-cause mortality in women [Hazard Ratio ( HR ) = 1.23 ; 95% CI 1.04-1.44] as well as women living alone ( HR = 1.38 ; 95% CI 1.02-1.85). Cause-specific models revealed an increased risk of death for women bird owners for causes other than cancer and CVD ( HR = 1.40 ; 95% CI 1.05-1.99). In conclusion, bird ownership may be negatively associated with survival of older women in Europe., Competing Interests: Conflict of interestCo-author was a proud dog owner and a member of an animal welfare organization - K.C. All other authors declare that they have no conflicts of interest., (© The Author(s) 2022.)

Objective: To examine associations between frailty and drug, alcohol, and tobacco use among a large diverse cohort of people with HIV (PWH) in clinical care in the current era., Methods: PWH at 7 sites across the United States completed clinical assessments of patient-reported measures and outcomes between 2016 and 2019 as part of routine care including drug and alcohol use, smoking, and other domains. Frailty was assessed using 4 of the 5 components of the Fried frailty phenotype and PWH were categorized as not frail, pre-frail, or frail. Associations of substance use with frailty were assessed with multivariate Poisson regression., Results: Among 9336 PWH, 43% were not frail, 44% were prefrail, and 13% were frail. Frailty was more prevalent among women, older PWH, and those reporting current use of drugs or cigarettes. Current methamphetamine use (1.26: 95% CI 1.07-1.48), current (1.65: 95% CI 1.39-1.97) and former (1.21:95% CI 1.06-1.36) illicit opioid use, and former cocaine/crack use (1.17: 95% CI 1.01-1.35) were associated with greater risk of being frail in adjusted analyses. Current smoking was associated with a 61% higher risk of being frail vs. not frail (1.61: 95% CI 1.41-1.85) in adjusted analyses., Conclusions: We found a high prevalence of prefrailty and frailty among a nationally distributed cohort of PWH in care. This study identified distinct risk factors that may be associated with frailty among PWH, many of which, such as cigarette smoking and drug use, are potentially modifiable., Competing Interests: Conflict of interest All authors report that they have no relevant conflicts of interest to disclose., (Copyright © 2022. Published by Elsevier B.V.)

Background: Women represent a meaningful proportion of new HIV diagnoses, with Black women comprising 58% of new diagnoses among women. As HIV infection also increases risk of chronic kidney disease (CKD), understanding CKD risk among women with HIV (WWH), particularly Black women, is critical., Methods: In this longitudinal cohort study of people with HIV (PWH) enrolled in CFAR Network of Integrated Clinical Systems (CNICS), a multicentre study comprised of eight academic medical centres across the United States from Jan 01, 1996 and Nov 01, 2019, adult PWH were excluded if they had ≤2 serum creatinine measurements, developed CKD prior to enrollment, or identified as intersex or transgendered, leaving a final cohort of 33,998 PWH. The outcome was CKD development, defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1·73 m 2 calculated using the CKD-EPI equation, for ≥90 days with no intervening higher values., Findings: Adjusting for demographic and clinical characteristics, WWH were 61% more likely to develop CKD than men (adjusted hazard ratio [aHR]: 1·61, 95% CI: 1·46-1·78, p<0·001). This difference persisted after further adjustment for APOL1 risk variants (aHR female sex: 1·92, 95% CI: 1·63-2·26, p<0·001) and substance abuse (aHR female sex: 1·70, 95% CI: 1·54-1·87, p<0·001)., Interpretation: WWH experienced increased risk of CKD. Given disparities in care among patients with end-stage kidney disease, efforts to engage WWH in nephrology care to improve chronic disease management are critical., Funding: US National Institutes of Health., Competing Interests: JEL reports grands and funding from Hansa, United Therapeutics, honoraria from Sanofi, and non-monetary support from the FDA and Davita, and reports support from the NIH for the present study. KC reports an investigator-initiated grant from Gilead Sciences and serves as a medical advisory board member for Gilead Sciences. GN reports R01-DK127139, R01-HL155915, R56-DK126930, and funding from Renalytix. GN also receives consulting fees from Renalytx (as well as royalties), Variant Bio, Qiming Capital, Cambridge Healthcare, Daiichi Sankyo (as well as honoraria). GN also has patent with Renalytx and participates in advisory boards for Renalytix and Pensieve Health. Finally, GN has stock/stock options in Renaltyx, Pensieve Health, Vierici Dx, Nexus I Connect, and Data2Wisdom LLC. SM reports honoraria from CareDx and serves on their advisory board, and reports NIH grants/contracts for use of CCR5 in HIV-positive transplant recipients and the prospective HOPE In-Action trial. DS has entered into a consulting agreement with IMS Consulting and Expert Services, has been elected as Councilor at Large to the American Society of Transplantation Board of Directors, and reports funding from the NIH for the present study. HC reports funding from the NIH (for the present study), AHRQ, Viiv, and serves on the Office of AIDS Advisory Council for the NIH. MS serves on the advisory or DSMB board for I-SPY, an NIH-funded study, and in a leadership role for IAS-USA. JJE reports financial support for the present study from the NIH; grants (outside the present study) from ViiV Healthcare, Gilead Science and Janssen; and consulting fees (outside the present study) from Merck, ViiV Healthcare, Gilead Sciences, and Jansssen. BJ and BAS report funding from the NIH. RM and IP report financial support from the NIH for the present study. All other authors declare no competing interests., (© 2022 The Author(s).)

Among 14 049 people with human immunodeficiency virus in care in 2019-2020, 96% were treated with antiretroviral therapy (ART). Current antiretroviral treatment patterns highlight high uptake of guideline-recommended ART regimens including second-generation integrase strand transfer inhibitors (dolutegravir and bictegravir) and tenofovir alafenamide, especially in antiretroviral-naive individuals initiating ART., Competing Interests: Potential conflicts of interest. K. C. is a member of the medical advisory board for Gilead Sciences and reports grants or contracts from Gilead Sciences to their institution, outside the submitted work. G. A. B. has received research grant support from Merck Foundation and Eli Lilly, consulting fees from Med IQ, and payment or honoraria from StateServ and the University of Kentucky. J. K. reports a past relationship with the American Board of Internal Medicine, as an infectious disease specialty board member. J. J. E. reports contracts to their institution from ViiV Healthcare, Gilead Sciences, and Janssen; is an ad hoc consultant to Merck, Gilead Sciences, ViiV, and Janssen; and is an investigator for clinical trials at the University of North Carolina, which receives funding from Gilead, ViiV, and Janssen. E. R. C. has received unrestricted research grants paid to UC Reagents from Gilead Sciences for an unrelated hepatitis C virus project and from Merck Sharp & Dohme for an unrelated project and has received payment or honoraria from Gilead Science. M. S. S. reports money paid to their institution from ViiV and Gilead for clinical trials that are now closed, outside the submitted work; reports participation on the data science monitoring board for the I-SPY COVID trial; and reports serving on the board of directors for International Antiviral Society-USA. H. M. C. has received research grant support from ViiV and the Agency for Healthcare Research and Quality paid to their institution, outside the submitted work, and reports participation on the National Institutes of Health Office of AIDS Research Advisory Council. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2022. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Background: Despite rising rates of syphilis among people with human immunodeficiency virus (HIV; PWH) in the United States, there is no optimal syphilis screening frequency or prioritization., Methods: We reviewed records of all PWH in care between 1 January 2014 and 16 November 2018 from 4 sites in the Centers for AIDS Research Network of Integrated Clinical Systems Cohort (CNICS; N = 8455). We calculated rates of syphilis testing and incident syphilis and used Cox proportional hazards models modified for recurrent events to examine demographic and clinical predictors of testing and diagnosis., Results: Participants contributed 29 568 person-years of follow-up. The rate of syphilis testing was 118 tests per 100 person-years (95% confidence interval [CI]: 117-119). The rate of incident syphilis was 4.7 cases per 100 person-years (95% CI: 4.5-5.0). Syphilis diagnosis rates were highest among younger cisgender men who have sex with men and transgender women, Hispanic individuals, people who inject drugs, and those with detectable HIV RNA, rectal infections, and hepatitis C., Conclusions: We identified PWH who may benefit from more frequent syphilis testing and interventions for syphilis prevention., Competing Interests: Potential conflicts of interest. K. C. reports investigator-initiated grant support from Gilead Sciences and serving on Gilead Sciences Medical Advisory Board, outside the submitted work. J. D. reports consulting fees from National Association of State and Territorial AIDS Directors and payment or honoraria for lectures, presentations, speaker’s bureaus, manuscript writing, or educational events from Planned Parenthood Federation of America, outside the submitted work. E. C. reports unrelated research grants, funding paid to UC Regents, from Merck Sharp and Dohme and Gilead Science, outside the submitted work. H. M. C. reports funding from the National Institutes of Health (NIH), the Agency for Healthcare Research and Quality, and ViiV and participation on the NIH Office of AIDS Research Advisory Council, outside the submitted work. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2021. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Background: Understanding the spectrum of COVID-19 in people with HIV (PWH) is critical to provide clinical guidance and risk reduction strategies., Setting: Centers for AIDS Research Network of Integrated Clinic System, a US multisite clinical cohort of PWH in care., Methods: We identified COVID-19 cases and severity (hospitalization, intensive care, and death) in a large, diverse HIV cohort during March 1, 2020-December 31, 2020. We determined predictors and relative risks of hospitalization among PWH with COVID-19, adjusted for disease risk scores., Results: Of 16,056 PWH in care, 649 were diagnosed with COVID-19 between March and December 2020. Case fatality was 2%; 106 (16.3%) were hospitalized, and 12 died. PWH with current CD4 count <350 cells/mm 3 [aRR 2.68; 95% confidence interval (CI): 1.93 to 3.71; P < 0.001] or lowest recorded CD4 count <200 cells/mm 3 (aRR 1.67; 95% CI: 1.18 to 2.36; P < 0.005) had greater risks of hospitalization. HIV viral load and antiretroviral therapy status were not associated with hospitalization, although most of the PWH were suppressed (86%). Black PWH were 51% more likely to be hospitalized with COVID-19 compared with other racial/ethnic groups (aRR 1.51; 95% CI: 1.04 to 2.19; P = 0.03). Chronic kidney disease, chronic obstructive pulmonary disease, diabetes, hypertension, obesity, and increased cardiovascular and hepatic fibrosis risk scores were associated with higher hospitalization risk. PWH who were older, not on antiretroviral therapy, and with current CD4 count <350 cells/mm 3 , diabetes, and chronic kidney disease were overrepresented among PWH who required intubation or died., Conclusions: PWH with CD4 count <350 cells/mm 3 , and a history of CD4 count <200 cells/mm 3 , have a clear excess risk of severe COVID-19, accounting for comorbidities associated with severe outcomes. PWH with these risk factors should be prioritized for COVID-19 vaccination and early treatment and monitored closely for worsening illness., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

The objective of this study was to test a self-management model for self-management in people living with HIV and type 2 diabetes (PLWH + T2DM). We conducted a predictive, longitudinal study of data from a national research cohort of PLWH using lag analysis to test short- and long-term health outcomes for PLWH + T2DM. We used a dataset from the Center for AIDS Research (CFAR) Network of Integrated Clinic Systems (CNICS), a nation-wide research network of 8 clinics that serves PLWH. Patient-reported outcomes, collected at clinic visit, included depression, adherence, CD4 cell count, and health-related quality of life (HRQoL). We computed summary statistics to describe the sample. Using lag analysis, we then modeled the three variables of adherence, CD4 count, and HRQoL as a function of their predecessors in our conceptual model. In the final model, an increase of in medication adherence corresponded to a small increase in HRQoL. An increase in CD4 count corresponded to a small increase in HRQoL. An increase in lagged depression was associated with a small decrease in HRQoL. The model was not sufficient to predict short- or long-term outcomes in PLWH + T2DM. Although depression had a moderate impact, the final model was not clinically significant. For people with a dual diagnosis of HIV and T2DM, variables other than those traditionally addressed in self-management interventions may be more important., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)