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To summarize the broad impact of the coronavirus disease 2019 (COVID-19) pandemic on HIV prevention and care in the United States with a focus on the status-neutral HIV care continuum.We conducted an editorial review of peer-reviewed literature on the topics of HIV-risk behaviors, sexually transmitted illness (STI) and HIV prevalence, HIV prevention and treatment trends, and evolving practices during the COVID-19 pandemic.For relevant literature, we reviewed, summarized, and categorized into themes that span the HIV prevention and care continua, including sexual risk behaviors, mental health, and substance use.We identified important changes within each component of the HIV care continuum across the United States during the COVID-19 pandemic. Shifts in prevention practices, engagement with care, care provision, medication adherence, testing, and prevalence rates were observed during the pandemic.Although heightened disparities for people at risk for, and living with, HIV were seen during the COVID-19 pandemic, many health systems and clinics have achieved and maintained engagement in HIV prevention and care. This review highlights barriers and innovative solutions that can support durable and accessible health systems through future public health crises.

ImportanceRecent advances in treatment and prevention of HIV warrant updated recommendations to guide optimal practice.ObjectiveBased on a critical evaluation of new data, to provide clinicians with recommendations on use of antiretroviral drugs for the treatment and prevention of HIV, laboratory monitoring, care of people aging with HIV, substance use disorder and HIV, and new challenges in people with HIV, including COVID-19 and monkeypox virus infection.Evidence ReviewA panel of volunteer expert physician scientists were appointed to update the 2020 consensus recommendations. Relevant evidence in the literature (PubMed and Embase searches, which initially yielded 7891 unique citations, of which 834 were considered relevant) and studies presented at peer-reviewed scientific conferences between January 2020 and October 2022 were considered.FindingsInitiation of antiretroviral therapy (ART) is recommended as soon as possible after diagnosis of HIV. Barriers to care should be addressed, including ensuring access to ART and adherence support. Integrase strand transfer inhibitor–containing regimens remain the mainstay of initial therapy. For people who have achieved viral suppression with a daily oral regimen, long-acting injectable therapy with cabotegravir plus rilpivirine given as infrequently as every 2 months is now an option. Weight gain and metabolic complications have been linked to certain antiretroviral medications; novel strategies to ameliorate these complications are needed. Management of comorbidities throughout the life span is increasingly important, because people with HIV are living longer and confronting the health challenges of aging. In addition, management of substance use disorder in people with HIV requires an evidence-based, integrated approach. Options for preexposure prophylaxis include oral medications (tenofovir disoproxil fumarate or tenofovir alafenamide plus emtricitabine) and, for the first time, a long-acting injectable agent, cabotegravir. Recent global health emergencies, like the SARS-CoV-2 pandemic and monkeypox virus outbreak, continue to have a major effect on people with HIV and the delivery of services. To address these and other challenges, an equity-based approach is essential.Conclusions and RelevanceAdvances in treatment and prevention of HIV continue to improve outcomes, but challenges and opportunities remain.

PURPOSE: Little is known regarding HIV/STI testing preferences for location, staffing, and hours of operation among young black men who have sex with men (YBMSM) in the Southeastern U.S, a population at high risk for HIV/STIs. We used a discrete choice experiment to explore these preferences. METHODS: YBMSM ages 16-35 in Birmingham, Alabama and Jackson, Mississippi completed online surveys evaluating their preferences (best/worst) for HIV/STI testing locations, staffing, hours, method of results notification, and cost. They also selected preferred combinations of these variables through choice tasks. Results were analyzed using joint best/worst and discrete choice experiment models. RESULTS: Between June 2018-December 2019, participants in Alabama (n = 54) and Mississippi (n = 159) completed online surveys. Both groups preferred stationary testing locations over mobile testing vans, with the most significant difference favoring STI testing-only clinics in Mississippi and local health departments in Alabama (p < 0.001). Technician-performed tests or self-testing were significantly less preferred compared to clinician-performed testing for both groups (p < 0.0001 and p < 0.0001, respectively). Free testing and phone results notification (versus text) were preferred by both groups. The most desirable combination among all participants was weekday clinician-performed testing at the health department for $5. CONCLUSION: YBMSM in the Southeastern U.S. prefer traditional testing locations staffed by experienced personnel. Combination choices are influenced by services that are low- or no-cost. More research is needed to inform the best way(s) to provide affordable, high-quality HIV/STI testing services for YBMSM, particularly in the post-COVID-19 era when sexual healthcare delivery models are evolving toward home-based and remote-health focused strategies.

In an analysis of randomized trials, use of efavirenz for treatment of human immunodeficiency virus (HIV) infection was associated with increased suicidal thoughts/behaviors. However, analyses of observational data have found no evidence of increased risk. To assess whether population differences might explain this divergence, we transported the effect of efavirenz use from these trials to a specific target population. Using inverse odds weights and multiple imputation, we transported the effect of efavirenz on suicidal thoughts/behaviors in these randomized trials (participants were enrolled in 2001–2007) to a trials-eligible cohort of US adults initiating antiretroviral therapy while receiving HIV clinical care at medical centers between 1999 and 2015. Overall, 8,291 cohort participants and 3,949 trial participants were eligible. Prescription of antidepressants (19% vs. 13%) and injection drug history (16% vs. 10%) were more frequent in the cohort than in the trial participants. Compared with the effect in trials, the estimated hazard ratio for efavirenz on suicidal thoughts/behaviors was attenuated in our target population (trials: hazard ratio (HR) = 2.3 (95% confidence interval (CI): 1.2, 4.4); transported: HR = 1.8 (95% CI: 0.9, 4.4)), whereas the incidence rate difference was similar (trials: HR = 5.1 (95% CI: 1.6, 8.7); transported: HR = 5.4 (95% CI: −0.4, 11.4)). In our target population, there was greater than 20% attenuation of the hazard ratio estimate as compared with the trials-only estimate. Transporting results from trials to a target population is informative for addressing external validity.

Objective Historically, a high burden of resistance to antiretroviral therapy (ART) in heavily treatment-experienced (HTE) persons with HIV (PWH) resulted in limited treatment options (LTOs). We evaluated the prevalence, risk factors, and virologic control of HTE PWH with LTO throughout the modern ART era. Design We examined all ART-experienced PWH in care between 2000 and 2017 in the Centers for AIDS Research Network of Integrated Clinical Systems cohort. Methods We computed the annual prevalence of HTE PWH with LTO defined as having two or less available classes with two or less active drugs per class based on genotypic data and cumulative antiretroviral resistance. We used multivariable Cox proportional hazards models to examine risk of LTO by 3-year study entry periods adjusting for demographic and clinical characteristics. Results Among 27 133 ART-experienced PWH, 916 were classified as having LTO. The prevalence of PWH with LTO was 5.2-7.5% in 2000-2006, decreased to 1.8% in 2007, and remained less than 1% after 2012. Persons entering the study in 2009-2011 had an 80% lower risk of LTO compared with those entering in 2006-2008 (adjusted hazard ratio 0.20; 95% confidence interval: 0.09-0.42). We found a significant increase in undetectable HIV viral loads among PWH ever classified as having LTO from less than 30% in 2001 to more than 80% in 2011, comparable with persons who never had LTO. Conclusion Results of this large multicenter study show a dramatic decline in the prevalence of PWH with LTO to less than 1% with the availability of more potent drugs and a marked increase in virologic suppression in the current ART era.

Acute bacterial infections such as endocarditis and skin and soft tissue infections are a common cause of hospitalization among persons with opioid use disorder (OUD). These interactions with acute care physicians provide an opportunity to diagnose OUD and treat patients with medications for OUD, including buprenorphine. When available, Addiction Medicine Consultation can be effective at linking patients to addiction treatment and also engaging patients in care for acute bacterial infections. In health systems without access to addiction medicine experts, infectious diseases providers, hospitalists, and other clinicians serve a valuable role in the diagnosis and treatment of OUD.

HIV pre-exposure prophylaxis (PrEP) effectively prevents HIV acquisition among men who have sex with men (MSM), but PrEP uptake has been associated with sexually transmitted infections (STIs). The effect of PrEP on STIs in MSM in the Deep South of the United States is unknown. We performed a retrospective analysis of adult MSM at an American Deep South PrEP clinic to calculate the prevalence and incidence rate of bacterial STIs (chlamydia, gonorrhea, and syphilis) and identify associated risk factors by linking incident STI to patient-reported outcomes; 139 MSM accessed the clinic between 2014 and 2018 with baseline bacterial STI prevalence of 11%. Twenty-six of 81 eligible MSM on PrEP had incident STIs with an incidence rate of 33.1 cases per 100 person-years. Significantly higher proportions of high PrEP adherence, multiple sexual partners, and inconsistent condom use were seen in those with incident STI, and we identified MSM with both high PrEP adherence and multiple sexual partners as being at especially high risk for bacterial STIs (hazard ratio: 7.57, 95% confidence interval: 1.75–32.74). Bacterial STIs are common after initiating PrEP in this clinic, and MSM reporting high PrEP adherence and multiple sexual partners have a significant risk for incident STI. High-risk sexual behaviors persisted after starting PrEP, highlighting the importance of ongoing, intensive sexual health screening and interventions.

Hospitalizations for drug-use associated infective endocarditis (DUA-IE) have led to increasing surgical consultation for valve replacement. Cardiothoracic surgeons' perspectives about the process of decision making around operation for people with DUA-IE are largely unknown.This multisite semiqualitative study sought to gather the perspectives of cardiothoracic surgeons on initial and repeat valve surgery for people with DUA-IE through purposeful sampling of surgeons at 7 hospitals: University of Alabama, Tufts Medical Center, Boston Medical Center, Massachusetts General Hospital, University of North Carolina-Chapel Hill, Vanderbilt University Medical Center, and Rhode Island Hospital-Brown University.Nineteen cardiothoracic surgeons (53% acceptance) were interviewed. Perceptions of the drivers of addiction varied as well as approaches to repeat valve operations. There were mixed views on multidisciplinary meetings, although many surgeons expressed an interest in more efficient meetings and more intensive postoperative and posthospitalization multidisciplinary care.Cardiothoracic surgeons are emotionally and professionally impacted by making decisions about whether to perform valve operation for people with DUA-IE. The use of efficient, agenda-based multidisciplinary care teams is an actionable solution to improve cross-disciplinary partnerships and outcomes for people with DUA-IE.

In 2017 alone, 783,000 children aged 12 to 17 years misused opioids with 14,000 using heroin. Opioid misuse and opioid use disorder (OUD) in adolescents and young adults are significant barriers to ending the human immunodeficiency virus (HIV) epidemic. To address these synergistic scourges requires dedicated practitioners and improved access to life-saving evidence based treatment. Adolescents and young adults make up over 1 in 5 new HIV diagnoses even though they are less likely to be tested or know they are infected. Adolescents and young adults living with HIV are less likely to be retained in care or achieve virological suppression. OUD further leads to increased rates of risky behaviors (like sex without condoms), deceased retention in HIV care, and decreased rates of viral suppression in this vulnerable population. Medications for opioid use disorder (MOUD) are recommended for adolescents and young adults with severe OUD and help retain youth in HIV treatment and decrease risk of death. However, due to stigma and lack of experience prescribing MOUD in adolescents, MOUD is often perceived as a last line option. MOUD remains difficult to access for adolescents with a shortage of providers and decreased options for treatment as compared to adults. Addiction treatment is infection prevention, and integrated addiction and HIV services are recommended to improve health outcomes. A multipronged approach including patient education, provider training, and policy changes to improve access to treatment and harm reduction are urgently needed confront the drug use epidemic in youth.

The objective of this systematic review is to examine the relationship between opioid use disorder (OUD) and its related biomarkers, as well as the effects of pharmacotherapy for OUD on biomarkers. The eligibility criteria are the inclusion of human population studies focusing on biomarkers, including the immune system, related to OUD or opioid-related disorders. English, peer reviewed, original research, case studies or case series, and clinical trials were included in this review. Papers were excluded if they met one or more of the following criteria: animal studies, review articles, studies focusing only on OUD or opioid-related disorders without mention of potential biomarkers, studies focusing only on biomarkers and/or the immune system without relating to OUD or opioid-related disorders, and studies that focused on other substance use disorders other than OUD specifically. A PubMed, PsycINFO, and Cochrane databases search on August 25, 2020, yielded 101 results; only 14 articles met inclusion criteria that were included in this review. However, heterogeneity of study definitions and measurements should be noted. Various potential biomarkers indicated systemic, peripheral, and chronic inflammation in patients with OUD or opioid-related disorders. Medications, including buprenorphine and methadone, significantly decreased chronic inflammation in this population. Our results suggest that patients with OUD or opioid-related disorders have potential biomarkers that can be targeted to provide optimal treatment options for this population. A better understanding of potential biomarkers may assist to identify at-risk populations, monitor disease progression and treatment response, and develop therapeutic strategies for OUD.Systematic Review Registration:This review has been registered in PROSPERO (CRD42020202014).

BackgroundAntiretroviral therapy (ART) durability, time to modification or cessation, has declined. The study objective was to determine whether kidney dysfunction is contributing to reduced durability.MethodsThis retrospective follow-up study of CNICS evaluated treatment-naive PLWH initiating ART between 2007 and 2014. Regimen modification was defined as cessation/modification of any part of the 3-drug ART regimen. We evaluated the role of kidney dysfunction in initial regimen modification as both a mediator and effect measure modifier. Associations of the variables with the ART modification were examined using univariable and multivariable Cox proportional hazard models.ResultsOf 4515 PLWH included in the analysis, 1967 modified their ART. Of those receiving TDF-based ART (n = 3888), 1580 (41%) modified their regimen compared with 387 (62%) receiving other regimens. Overall, the median eGFR decreased by 5 mL/min/1.73 m (quartiles: first = -16, third = 0) from baseline to follow-up. Of the 128 patients with low baseline eGFR (

Background The global COVID-19 pandemic has the potential to indirectly impact transmission dynamics and prevention of HIV and other sexually transmitted infections (STI). It is unknown what combined impact reductions in sexual activity and interruptions in HIV/STI services will have on HIV/STI epidemic trajectories. Methods We adapted a model of HIV, gonorrhea, and chlamydia for a population of approximately 103 000 men who have sex with men (MSM) in the Atlanta area. Model scenarios varied the timing, overlap, and relative extent of COVID-19–related sexual distancing and service interruption within 4 service categories (HIV screening, preexposure prophylaxis, antiretroviral therapy, and STI treatment). Results A 50% relative decrease in sexual partnerships and interruption of all clinical services, both lasting 18 months, would generally offset each other for HIV (total 5-year population impact for Atlanta MSM, −227 cases), but have net protective effect for STIs (−23 800 cases). If distancing lasted only 3 months but service interruption lasted 18 months, the total 5-year population impact would be an additional 890 HIV cases and 57 500 STI cases. Conclusions Immediate action to limit the impact of service interruptions is needed to address the indirect effects of the global COVID-19 pandemic on the HIV/STI epidemic., The transmission model of HIV, gonorrhea, and chlamydia among men who have sex with men in the Atlanta area demonstrates the impact of changes to sexual behavior and disruptions to HIV/STI clinical services in response to the COVID-19 pandemic.

The infectious disease (ID) physician can play an important role in the evidence-based treatment of both opioid use disorder (OUD) and addiction-related infections. A comprehensive ID consultation will include substance-related screening, diagnosis, and initiation of medications for OUD—extended-release naltrexone, buprenorphine, and methadone. This care can be integrated into the treatment of common and uncommon OUD-related infections. Providers should understand patient-centered concepts for persons who use drugs such as acute pain, opioid-related conditions, and reduction of unplanned disposition. Team-based integration of ID and OUD management can improve care and reduce treatment interruptions.

Background The opioid epidemic has led to increases in injection drug use (IDU)-associated infectious diseases; however, little is known about how more recent increases in stimulant use have affected the incidence and outcomes of hospitalizations for infections among people who inject drugs (PWID). Methods All hospitalizations of PWID for IDU-associated infections in Florida were identified using administrative diagnostic codes and were grouped by substance used (opioids, stimulants, or both) and site of infection. We evaluated the association between substance used and the outcomes: patient-directed discharge (PDD, or “against medical advice”) and in-hospital mortality. Results There were 22 856 hospitalizations for infections among PWID. Opioid use was present in 73%, any stimulants in 43%, and stimulants-only in 27%. Skin and soft tissue infection was present in 50%, sepsis/bacteremia in 52%, osteomyelitis in 10%, and endocarditis in 10%. PWID using opioids/stimulants were youngest, most uninsured, and had the highest rates of endocarditis (16%) and hepatitis C (44%). Additionally, 25% of patients with opioid/stimulant use had PDD versus 12% for those using opioids-only. In adjusted models, opioid/stimulant use was associated with PDD compared to opioid-only use (aRR 1.28, 95% CI 1.17–1.40). Younger age and endocarditis were also associated with PDD. Compared to opioid-only use, stimulant-only use had higher risk of in-hospital mortality (aRR 1.26, 95% CI 1.03–1.46). Conclusions While opioid use contributed to most IDU-associated infections, many hospitalizations also involved stimulants. Increasing access to harm reduction interventions could help prevent these infections, while further research on the acute management of stimulant use disorder-associated infections is needed., Among people hospitalized with injection drug use-associated infections in Florida, those with both stimulant and opioid use were more likely to have endocarditis and to have patient-directed discharge compared to those using opioids-only. Stimulant-only use was associated with in-hospital mortality.

Background Hospital-based strategies that link persons with infectious complications of opioid use disorder (OUD) to medications for OUD (MOUD) are of great interest. The objective of this study is to determine whether a hospital-based protocol would increase the use of MOUD and to identify barriers to MOUD during admission and at the time of discharge. Methods This study included participants with a documented or suspected history of injection drug usage receiving care for an infection at the University of Alabama at Birmingham Hospital from 2015 to 2018. The protocol, the intravenous antibiotic and addiction team (IVAT), included Addiction Medicine and Infectious Diseases consultation and a 9-item risk assessment. We quantified MOUD use before and after IVAT and used logistic regression to determine factors associated with MOUD. We explored barriers to MOUD uptake using chart review. Results A total of 37 and 98 patients met criteria in the pre- and post-IVAT periods, respectively. With IVAT, the percentage with OUD receiving MOUD significantly increased (29% pre-IVAT and 37% post-IVAT; P = .026) and MOUD use was higher in “high risk” participants (62%). Clinical and sociodemographic factors were not associated with MOUD receipt. Conclusions A hospital-based protocol may increase the use of MOUD; however, the uptake of MOUD remains suboptimal (

Background Hospitalized persons who inject drugs are at a greater risk of adverse hospital outcomes including discharge against medical advice, inpatient illicit drug use, overdose, and death. However, there are limited data on the frequency and outcomes of these events in the United States. Methods This retrospective analysis included patients with injection-related infections receiving a protocol for injection drug use (IDU) at University of Alabama at Birmingham Hospital from 2016 to 2017. In-hospital IDU was suspected or reported drug usage plus confirmatory drug screen, and documented discharges “against medical advice” were deemed patient-directed discharges (PDD). We analyzed the frequency of and associations between in-hospital IDU, PDD, 30-day readmission, and deaths (between 2016 and 2019) using McNemar’s tests. Logistic regression models evaluated the association between PDD, in-hospital IDU, readmission, and death. Results Overall, 83 patients met inclusion criteria: 28 (34%) with in-hospital IDU, 12 (14%) PDD, 9 (11%) died, and 12 (14%) 30-day readmission. In-hospital IDU was significantly associated with PDD (P = .003), 30-day readmission (P = .005), and death (P = .0003). Patient-directed discharges and 30-day readmission were not significantly associated with death nor with each other. Conclusions In a cohort of patients receiving inpatient care for injection-related infections, illicit drug use, PDD, 30-day readmissions, and death were common. Furthermore, patients who use illicit drugs while hospitalized are significantly more likely to leave early, be readmitted, and/or die. We must design models of care that prevent adverse outcomes, including drug use and PDD, to reduce barriers to evidence-based treatment of infections., In hospitalized patients with injection related infections, we found that illicit drug use, premature discharge, readmissions and death were common. Further, those who use illicit drugs while hospitalized are significantly more likely to leave early, be readmitted and die.

Endocarditis, once predominately found in older adults, is increasingly common among younger persons who inject drugs. Untreated opioid use disorder (OUD) complicates endocarditis management. We aimed to determine if rates of overdose and rehospitalization differ between persons with OUD with endocarditis who are initiated on medications for OUD (MOUDs) within 30 days of hospital discharge and those who are not.We performed a retrospective cohort study using a large commercial health insurance claims database of persons ≥18 years between July 1, 2010, and June 30, 2016. Primary outcomes included opioid-related overdoses and 1-year all-cause rehospitalization. We calculated incidence rates for the primary outcomes and developed Cox hazards models to predict time from discharge to each primary outcome as a function of receipt of MOUDs.The cohort included 768 individuals (mean age 39 years, 51% male). Only 5.7% of people received MOUDs in the 30 days following hospitalization. The opioid-related overdose rate among those who did receive MOUDs in the 30 days following hospitalization was lower than among those who did not (5.8 per 100 person-years [95% confidence interval [CI], 5.1-6.4] vs 7.3 per 100-person years [95% CI, 7.1-7.5], respectively). The rate of 1-year rehospitalization among those who received MOUDs was also lower than those who did not (162.0 per 100 person-years [95% CI, 157.4-166.6] vs 255.4 per 100 person-years [95% CI, 254.0-256.8], respectively). In the Cox hazards models, the receipt of MOUDs was not associated with either of the outcomes.MOUD receipt following endocarditis may improve important health-related outcomes in commercially insured persons with OUD.

Rural, poor, persons with HIV (PWH) and substance use are among the most vulnerable to SARS-CoV-2 and related health service disruptions. The objective of the study was to evaluate the health outcomes and utilization of PWH at an Outpatient-based Opioid Treatment (OBOT) Clinic.We evaluated a clinic-based cohort at the University of Alabama at Birmingham HIV clinic from November 2018 to May 2021. We compared HIV outcomes of OBOT patients, who are highly vulnerable, to the overall clinic. We stratified OBOT patients according to comorbid stimulant use disorder and compared clinic utilization and viral load suppression in the 6 months before and after the safer at home mandate (May 2020) in Alabama.Of 3857 PWH, 57 were referred to OBOT, 48 attended, 45 were initiated on buprenorphine, and 35 had a VL 200 in the last 6 months. Relative to the overall HIV clinic, OBOT patients were significantly less likely to remain VL suppressed (90% vs 78%, p = 0.01). More patients were suppressed after OBOT linkage (81%) than prior (73%). For those referred before May 2020, there was no change in viral suppression before and after the safer at home order (75%). Although new OBOT referrals did not increase during the pandemic, the number of visits attended per month did increase from a median of 3-4 per patient.Unlike many PWH who faced access barriers, PWH receiving care at OBOT did not fall out of care but increased healthcare utilization and maintained viral suppression despite the public health emergency.

PURPOSE OF REVIEW The antiviral agent tenofovir is highly effective for the treatment of HIV and hepatitis B virus infections, and the older prodrug tenofovir disoproxil fumarate (TDF) is also a component of daily preexposure prophylaxis (PrEP) to reduce the risk of HIV infection in high-risk populations. Although TDF is well tolerated, the potential for kidney and bone toxicity has important implications for public health given the large number of individuals exposed to TDF worldwide. This review summarizes the recent literature on kidney and bone health in individuals treated with TDF and the newer prodrug tenofovir alafenamide (TAF). RECENT FINDINGS Risk factors for TDF toxicity appear to be similar in patients treated for HIV or hepatitis B virus and in HIV-uninfected PrEP users, although drug-drug interactions are a more important concern in HIV-positive individuals. The risk of toxicity appears to be lower with TAF, but further studies are needed to confirm the safety of long-term use and to evaluate the efficacy of TAF-based PrEP. SUMMARY Nephrologists should be aware of the potential kidney and bone toxicity of TDF, as well as unique situations in which the newer prodrug TAF may contribute to kidney injury.

148 Background: The World Health Organization cited vaccine hesitancy as one of 2019’s top ten threats to global health, a threat that has been further exacerbated by COVID-19 pandemic. Existing COVID-19 vaccine hesitancy research focuses on the general population, but less is known about the specific concerns of medically vulnerable populations, including individuals with cancer. Methods: This cross-sectional analysis used data that assessed likelihood of COVID-19 vaccination (likely vs unlikely/unsure) among past or current patients with cancer from a nationwide survey administered in December 2020 by the Patient Advocate Foundation (PAF), a non-profit organization that provides case management and financial aid to patients diagnosed with a chronic illness. Inclusion criteria included previous or current cancer treatment, aged ≥ 19, and a valid e-mail address. Age, sex, race/ethnicity, and urban/rural residence were abstracted from the PAF database. Respondents self-reported education level, employment status, trust in media regarding COVID-19 pandemic, and media viewership on COVID-19 vaccine development. The Group-Based Medical Mistrust Scale assessed respondents’ level of mistrust in medical providers based on ethnicity. Likelihood of COVID-19 vaccine acceptance was evaluated using risk ratios (RR) and 95% confidence intervals (CI) from modified Poisson regression models with robust error variance. All variables were included in our model. Results: Of 429 respondents, 48% were unlikely/unsure about accepting the COVID-19 vaccine, primarily due to concerns about vaccine safety (32%) and worry about health conditions (12%). When compared to those likely to accept COVID-19 vaccine, respondents who were unlikely/unsure were more often Black, Indigenous, or People of Color (40% vs. 23%), aged 36-55 (40% vs. 29%), and female (80% vs. 65%). In adjusted analysis, Black respondents were 55% less likely to accept a COVID-19 vaccine, when compared to White respondents (RR 0.55; 95% CI 0.4-0.8). When compared to those who did not follow the media regarding COVID-19 vaccine development, those who followed the media very closely were 4.5 times more likely to accept a COVID-19 vaccine (RR 4.5; 95% CI 1.6-13.2). Respondents who reported below average trust in the media were 60% less likely to accept a COVID-19 vaccine (RR 0.6; 95% CI 0.5-0.8), compared to those who reported above average trust in the media. Conclusions: Despite being at high risk of COVID-19 morbidity and mortality, a substantial proportion of under-resourced individuals with cancer were unlikely/unsure about vaccination, exposing a significant disconnect between risk of severe disease and vaccine acceptance. Our analysis also reveals a need to assess for and debunk misinformation to increase vaccine enthusiasm among medically vulnerable populations.

Background Efavirenz has been a mainstay of antiretroviral therapy (ART) for over 15 years in the US. Its association with neuropsychiatric side effects may influence clinical prescribing and management. Methods We included HIV-infected adults enrolled in care at seven sites across the US, who initiated combination ART between 1999 and 2015. We examined the proportion initiating and continuing on efavirenz, overall and by mental health status. Log binomial and Cox models were used to estimate associations between mental health, clinical and sociodemographic characteristics and initiating or switching from efavirenz as first-line ART. Results Of the 8,230 participants included, 3,710 (45%) initiated efavirenz. In multivariable analyses, prior mono-or dual-ART, ART initiation after 2006, being female, intravenous drug use, antidepressant prescription, previous mental health diagnosis and baseline CD4+ T-cell count >350 cells/mm3 were inversely associated with initiating efavirenz. Participants initiating efavirenz had a faster time to a regimen switch, compared with those initiating an efavirenz-free regimen ( P-value Conclusions Multiple clinical factors, including mental health diagnoses, appeared to influence efavirenz use. While mental health diagnosis status and more recent treatment starts were associated with shorter duration of efavirenz therapy, a previous mental health diagnosis did not preclude efavirenz initiation or continuation in many participants.

In this retrospective study of treatment-naive PLWH initiating antiretroviral therapy, the score for the depression scale of the Patient Health Questionnaire (PHQ-9) was significantly higher at baseline (median, 6.0; interquartile range, 2-11) than at 12 months (3.0; 0-8; P < .001). Baseline depression and lack of insurance are associated with 12-month depression, but receipt of efavirenz-based antiretroviral therapy is not.

Infections are a common cause of hospitalization for patients with opioid use disorder (OUD), and hospital admissions are rising in the context of the worsening US opioid crisis. Infectious disease (ID) physicians are frequently the first point of medical contact for these patients. In this article, we discuss the integration of evidence-based management of OUD and patient-centered care of hospitalized persons with acute injection-related infections. We describe the following components of a comprehensive approach for OUD with inpatient ID consultations: (1) how to screen for OUD; (2) how to initiate the 3 US Food and Drug Administration-approved medications for OUD (buprenorphine, methadone, and extended-release naltrexone); (3) how to manage acute pain and opioid-related conditions; and (4) how to link and integrate ID and OUD treatment after hospital discharge. These strategies reduce unplanned discharges and increase completion of recommended antimicrobial regimens.

Background We have previously identified PrEP adherence as a risk factor for STIs in an academically affiliated Deep South PrEP clinic. In this analysis of a community-based Deep South PrEP clinic, we hypothesized that PrEP adherence and high risk sexual behaviors would be associated with STI. Methods This was a retrospective analysis of men who have sex with men (MSM) aged ≥18 years receiving PrEP at a community-based clinic in Birmingham, AL from 2016 to 2018. HIV negative patients were included if they completed ≥1 sexual behavior and PrEP adherence survey and were prescribed PrEP. Screening for gonorrhea, chlamydia, and syphilis and patient-reported outcomes (PROs) were performed at quarterly clinic visits. The outcome of interest was incident bacterial STI. We evaluated the association of sexual behavior and PrEP adherence PROs with STI using logistic regression. Results Of 119 eligible participants, 48% were ≥35 years, 21% reported no condom use, and 75% reported ≥2 sexual partners. Over the study period, 29 cases of STI were detected including 18 chlamydia, 10 gonorrhea and 1 syphilis case. However, 14 participants declined STI testing. Of 85 patients who completed ≥1 PRO (initial visit plus follow-up), 74% reported excellent PrEP adherence. By univariate and multivariable analysis neither condom use, number of sexual partners, or PrEP adherence were significantly associated with STIs, though consistent condom use approached significance. Conclusion In a community-based PrEP clinic in the Deep South, adherence was high and high-risk sexual behaviors were common. Neither adherence nor sexual behaviors were associated with STIs. Although it did not meet statistical significance, there was a trend toward STI for those reporting condomless anal sex. Surprisingly, many patients declined recommended STI testing, leaving missing data and suggesting an overall lack of awareness of STI risk in this community. These results highlight the need for vigorous STI screening and education Disclosure No significant relationships.

Background Technology, such as text messaging and mobile apps, has been integrated into health care. Technology preferences of underrepresented young black men who have sex with men (YB MSM) remain unknown but likely influence the use of health care services. The objective was to query the preferences of YB MSM related to technology regarding sexual health care and research. We hypothesized that YB MSM would prefer the use of social media and mobile applications (apps). Methods We recruited YB MSM in Birmingham, Alabama to participate in a discrete choice analysis of sexual health preferences. Participants were given a link to an electronic survey, which queried their sociodemographic status and preferences for STI testing and research. We specifically queried the use of technology to notify of STI results and recruit for research in addition to privacy concerns. Results 33 YB MSM met criteria: median age was 28, most were homosexual (n=27, 82%) and the remaining bisexual, 17 (52%) had HIV, 24 (73%) reported a prior STI, 16 (48%) live below the state federal poverty level, and 11 (33%) were uninsured. When asked, the best and worst way to be contacted with STI testing results, 21/33 (64%) preferred phone notification. Further, (52%) and (39%) said texting and email were the worst option, respectively. When asked the best way to recruit YB MSM for sexual health research, 16/33 (48%) reported social media. The most frequently recommended social media sites were Facebook (33%) and Instagram (27%). When asked their greatest concern about STI testing, 8/33 (24%) reported privacy concerns. None expressed concerns about limited access to technology. Conclusion YB MSM in the Southern U.S. prefer social media and mobile apps for research recruitment but not for communication about personal health. When it comes to STI testing, privacy remains a significant concern for YB MSM. Disclosure No significant relationships.

Background Approximately 15% of persons with HIV (PWH) have opioid use disorder (OUD) over their lifetime. Due to substance use-related behaviors, untreated OUD is an obstacle to ending the HIV epidemic, especially in rural states with limited treatment options. In November, 2019, The UAB 1917 HIV Clinic opened an outpatient based opioid treatment (OBOT) clinic one half day a week. The objective of this study is to evaluate clinical outcomes and utilization over 8 months. We hypothesized that approximately 200 PWD would have OUD, many with comorbid stimulant use, and that new referrals would increase over time. Methods This is a retrospective study PWH at the 1917 clinic from OBOT start until June 2020. Opioid misuse was identified by patient reported illicit use using validated tools and/or ICD9 code in the last 12 months. We stratified PWH to determine the OUD continuum of care for all versus those with comorbid stimulant disorder: OBOT referral, attendance, buprenorphine initiation, and HIV suppression (viral load < 20). We explored changes in clinic utilization following COVID19. Results A total of 3,580 patients receive care in the UAB 1917 HIV clinic of whom 40 were identified as having opioid misuse (Fig 1, blue). Overall, 30 patients were referred to OBOT, 25 attended any OBOT visit, 19 were initiated on buprenorphine and 14 (74%) had a VL < 20 in the last 3 months. Over half of patients had comorbid stimulant use disorder (orange). Patients received an average of 3.7 visits (range 1–10) over the study period. Although the number of new referrals did not increase (average 3.8 per month), the overall number of OBOT appointments increased from an average of 12 per month before COVID to 26 per month after March 1. Figure 1. The Opioid Continuum of Care for PWH at the UAB Outpatient Opioid Treatment Clinic (blue) including those with comorbid Stimulant Use Disorder (orange) Conclusion A surprisingly low percentage of patients report opioid misuse, which likely underestimates the true OUD burden in the Deep South. Stimulant Use Disorder affects over half: an added barrier to HIV suppression. In this small and early assessment, there are multiple missed opportunities for progress along the OUD continuum starting with diagnosis and referral. Yet, even this small clinic has rapidly reached clinical capacity (1/2 day weekly) accelerated by psychosocial needs in the context of COVID19. Disclosures All Authors: No reported disclosures

Background Young Black men who have sex with men (YBMSM) in the Deep South are at increased risk of sexually transmissible infections (STIs) and HIV. The present two-phase study evaluated the recruitment of YBMSM, both HIV infected and uninfected, for a sexual health study in Birmingham (AL, USA) from 2017 to 2019 and explored alternative patient-centred recruitment methods. Methods: In Phase 1, YBMSM were recruited to participate in focus groups related to STI testing. To recruit participants, flyers were displayed in businesses, clinics and lesbian, gay, bisexual and transgender (LGBT)-friendly organisations. In addition, research staff at an HIV clinic referred participants and a recruiter attended community events. In Phase 2, YB men were asked, in an electronic survey, ‘What is the best way to recruit young, Black men for surveys about sexual health?’ and ‘If you selected ‘social media’, which social media sites or ‘apps’ do you think are best to recruit young, Black men?’. Results: In Phase 1, 38 YBMSM participated in focus groups. Twelve (32%) were recruited by referral, 9 (24%) were recruited from an HIV clinic and 11 (29%) were recruited from an LGBT organisation. The recruiter was unable to recruit any participants. In Phase 2, 55 YBMSM completed the electronic survey. Twenty-six (48%) selected social media as the best way to recruit young Black men for surveys about sexual health, and their suggested platforms included Instagram, Facebook, Twitter, Snapchat, Kik and dating apps. Seventeen (31%) selected ‘Having young gay black men recruit from their friends and acquaintances’ as the ideal recruitment strategy. Conclusion: Challenges persist when recruiting YBMSM for sexual health research. Social media may provide better access to this vulnerable population.

Trichomonas vaginalis infection contributes to HIV transmission. The study objective was to determine the incidence and predictors of T. vaginalis reinfection among HIV-infected women in Birmingham, Alabama. A retrospective cohort study of women at an urban HIV clinic from August 2014 to March 2016 with T. vaginalis by nucleic acid amplification test (NAAT) was conducted. Time to first episode of reinfection was evaluated using Kaplan–Meier survival curves. The association of various predictors was evaluated by univariate and multivariable Cox proportional hazards analyses. Of 612 HIV-infected women at the UAB HIV clinic tested for T. vaginalis by the Aptima TV assay, 110 (18.0%) were identified with prevalent T. vaginalis infection. Overall, 25/110 (22.7%) had a first episode of T. vaginalis reinfection by NAAT with a rate of 3.7 reinfections per 100 person-months (95% confidence interval [CI]: 2.3, 5.2). In univariate analysis, only an HIV viral load (VL) ≥200 copies/ml approached statistical significance (hazard ratio = 2.26; 95% CI: 0.97, 5.29, p = 0.06). After adjusting for age and race, the association of HIV VL ≥200 copies/ml remained strong (adjusted hazard ratio = 2.49; 95% CI: 0.99, 6.27, p = 0.05). T. vaginalis reinfection was high among HIV-infected women in this sample, necessitating enhanced disease control efforts in this high-risk population.

A 9-point risk assessment identified persons with a history of injection drug use who were safe for discharge. "Low-risk" patients were discharged with outpatient antibiotics; others continued inpatient treatment. Use of the assessment reduced the mean length of stay by 20 days and total direct cost by 33%, creating capacity for an additional 333 patients.

Purpose: We examined the association of psychosocial stressors (depressive symptoms, incarceration, and intimate partner violence [IPV]) with sexual behaviors, sexually transmitted infection (STI) history, and STI diagnoses among African American women who have sex with women (AAWSW). Methods: This was a secondary analysis from a study of AAWSW ≥16 years. Multivariable Poisson regression estimated risk ratios (RRs) for the association between depressive symptoms, incarceration, and IPV and sexual behaviors, STI history, and STI diagnosis at enrollment, adjusting for age and sexual orientation identity. Results: Of 165 AAWSW, the mean depressive symptom score was 1.0 (SD ±0.8); 22.4% reported incarceration and 62.4% reported IPV. Depressive symptoms were associated with alcohol/drug use at last sexual encounter (RR = 1.52, 95% confidence interval [CI]: 1.18–1.95) and STI diagnosis (RR = 1.19; 95% CI: 1.05–1.34). Incarceration was associated with STI history (RR = 1.28; 95% CI: 1.07–1.53). IPV was associated with alcohol/drug use during sex with women (RR = 1.42; 95% CI: 1.05–1.92) and STI history (RR = 1.42, 95% CI: 1.13–1.78), particularly trichomoniasis (RR 2.50; 95% CI: 1.52–4.12). Among AAWSW reporting sex with men (n = 144), depressive symptoms were associated with sex in exchange for money/drugs (RR = 1.98; 95% CI: 1.17–3.34) and alcohol/drug use during sex with men (RR = 1.24; 95% CI: 1.05–1.46). Incarceration was associated with sex in exchange for money/drugs with men (RR = 5.21; 95% CI: 1.86–14.57); IPV was associated with sex in exchange for money/drugs (RR = 5.04; 95% CI: 1.18–21.50) and alcohol/drug use during sex with men (RR = 1.66; 95% CI: 1.14–2.41). Conclusion: Providers and public health programs should address both psychosocial stressors and STI risk among AAWSW.

BackgroundHigh sexually transmitted infection (STI) rates in the South, especially among young black men who have sex with men (YB MSM), make STI testing imperative for public health.PurposeTo identify STI testing preferences in this population to improve testing delivery and utilization.MethodsYB MSM ages 16-35 in Birmingham, Alabama participated in focus groups (FG). A trained qualitative researcher coded transcripts after each FG and added questions to explore emerging themes.ResultsBetween September 2017 and January 2018, 36 YB MSM participated in 5 focus groups. Median age was 25.5 (Interquartile range 22-30). Participants preferred STI testing at doctors' offices conducted by physicians but they also preferred having options related to testing locations, frequency, and timing to address diverse needs. Participants did not prefer testing by non-physician staff or home self-testing.ConclusionA variety of options, including varied locations, personnel, and methods (self-collected and provider collected) are needed to make patient-preferred STI testing a reality among YB MSM in the Deep South. Further, the desire to be tested by a trusted physician highlights the need for access to primary care providers. Results suggest that newer home-based tests and self-collected tests are less preferable to YB MSM in the South, which deserves further study as these tests are rapidly integrated into clinical care.

Background In the context of the opioid epidemic, infective endocarditis (IE) poses an economic challenge in Alabama. The objective of this proposal is to analyze the outcomes and financial burden of IE in persons who inject drugs (PWID) at The University of Alabama at Birmingham (UAB) Hospital, the largest tertiary referral center in this rural, Southern state. We hypothesized that those with the most severe substance use disorder would be most costly. Methods This is a retrospective study of PWID receiving care for IE at UAB Hospital from October 1, 2016 to March 1, 2019. IE was defined by Infectious Diseases consultation. Clinical data were obtained from the electronic medical record (EMR). Deaths were obtained from both the EMR and the regional medical examiner. Hospital costs (direct costs, overall charges) were obtained from financial accounts. To stratify patients by severity of substance use disorder, we used a 9-item risk assessment for PWID (see table). We then evaluated the association between clinical factors and outcomes (death, cost) using parametric and nonparametric tests when appropriate. A P-value < 0.05 was considered significant. Results A total of 69 persons met criteria (Table 1). The average length of stay was 30.8 days. Thirty-four (52%) had documentation of antibiotic completion (in or outpatient). Seventeen received surgery: 16 with valve replacement and one device removal. Overall, 14 (20%) died over the study period. There was no significant association between antibiotic completion or 9-item risk and death. When stratified into low risk ( Conclusion PWID with IE at a hospital serving a rural, Southern population have a greater length of stay, discharges against advice, surgical interventions, and costs than other regions, relative to existing literature. The lack of association between 9-item risk and outcomes suggests that death and high costs are attributable to factors beyond substance use. Costs of providing care for this population are exorbitant and likely devastating for rural county hospitals within the context of the current public health and payment framework, including Medicaid non-expansion. Disclosures All authors: No reported disclosures.

Currently, HIV treatment is recommended for all persons living with HIV (PLWH) regardless of their immune status in order to prevent HIV-related morbidity, mortality and reduce transmission to others[1, 2]. There are multiple first line antiretroviral therapy (ART) regimens recommended for treatment-naive PLWH based on efficacy and tolerability data obtained in randomized controlled trials[3, 4]. Each contains 3 or more antiretroviral agents, and most contain an Integrase Strand Transfer Inhibitor (InSTI). A majority of these ART regimens contain an antiretroviral agent that was approved by the Food and Drug Administration (FDA) in the last 3 years based on short-term surrogate endpoints including achieving viral suppression[5–7]. Further, these first line regimens have demonstrated relatively little toxicity, like neurologic disturbances, in select samples and controlled settings[8, 9]. Due to their novelty, many of these contemporary ART regimens have not been studied in observational cohorts. Because participants in a randomized control trial (RCT) may vary greatly from real world populations (race/ethnicity, comorbidities, and adherence rates), and additional supports are afforded by the RCT environment, it is important to study ART outcomes as a part of routine care to demonstrate the comparative effectiveness of novel ART[10, 11]. Real world ART durability may reflect more subjective treatment outcomes like quality of life or mild side effects that affect adherence in routine care and are likely of greater importance in clinic-based samples consisting of more diverse and heterogeneous PLWH in routine HIV care[12]. Provider and patient decisions also contribute to real world durability[13]. Recently, two national multi-site cohorts have demonstrated improved durability of ART [14, 15]. Notably, these studies extended to 2009 and 2011, respectively, precluding the study of novel antiretroviral agents, like elvitegravir, and dolutegravir, which are now included in first line treatment guidelines[3]. In our single-site clinic population we found that, in treatment naive individuals, ART durability was decreasing in recent years (2010–2012 vs. 2007–2009); largely due to the availability of newer ART regimens, which afford improved tolerability and dosing convenience[13, 16]. This trend emerged when patients and providers selected novel ART to replace older ART, abbreviating the durability of older regimens in the current treatment era. Yet, these findings are already dated by the dynamic ART treatment landscape in which several novel regimens have been FDA-approved and increasingly adopted as first-line ART since the conclusion of this study. The objective of this study was to evaluate the durability, defined as time to regimen modification (including discontinuation), of novel ART regimens, including those released since 2012, as part of routine care in a multi-site cohort in the U.S. We examined various socio-demographic and clinical characteristics associated with the initial regimen modification. We hypothesized that novel InSTI-based regimens would be more durable than older regimens and that overall durability would decrease in more recent years, reflective of a treatment landscape that now includes multiple well tolerated co-formulated and single tablet ART regimens, based on prior research in our clinic cohort and elsewhere[13, 16].

Although the reverse syphilis screening algorithm is more efficient than the traditional algorithm, it may lead to exorbitant costs for health systems serving persons living with HIV needing annual syphilis screening. Alternatively, the traditional screening algorithm is cost saving in many scenarios.

BackgroundEvidence about the effect of initiating efavirenz-containing combination antiretroviral therapy (ART) as the first-line therapy on suicidal thoughts remains conflicting.MethodsUsing data from a cohort of HIV-infected adults enrolled in routine care across 5 sites in the United States, we included participants with a baseline patient-reported outcome measure and detectable viral load who initiated ART between 2011 and 2014. Participants were followed until the earliest of the following: first suicidal thoughts, discontinuation of initial ART regimen, death, loss to care (>12 months with no HIV appointments), or administrative censoring (2014-2015). Suicidal thoughts were measured using a Patient Health Questionnaire-9 item. We used weighted marginal structural Cox models to estimate the effect of initiating efavirenz-containing ART, versus efavirenz-free ART, on the hazard of active or passive suicidal thoughts after ART initiation, accounting for confounding by channeling bias.ResultsOverall, 597 participants were followed for a median of 19 months (13,132 total person-months); 147 (25%) initiated efavirenz-containing ART. At ART initiation, 38% of participants reported suicidal thoughts or depressive symptoms. Initiating efavirenz-based ART was associated with a hazard ratio (HR) for suicidal thoughts below the null in the crude analysis [HR, 0.88; 95% confidence interval (CI): 0.53 to 1.45] and above the null in the weighted analysis (HR, 1.21; 95% CI: 0.66 to 2.28). Among those with a prior mental health issue, the weighted HR was 1.76 (95% CI: 0.45 to 6.86).ConclusionsAfter accounting for measured channeling bias, we observed no strong evidence that initiating efavirenz-containing ART increased the hazard of suicidal thoughts.

Condoms remain the most effective barrier against the sexual transmission of the human immunodeficiency virus (HIV). Male condoms have proven to be 80% to 90% effective, and female condoms have similar results. Poor adherence and improper use limit their effectiveness. In addition to condoms, microbicides are a promising barrier against HIV transmission. More than 50 candidate topical microbicide compounds have undergone preclinical or clinical testing in the last 10 years, but there are currently no US Food and Drug Administration (FDA)-approved compounds. Rectal microbicides are also being developed, as anal receptive sex is an effective mode of HIV transmission.

Effective human immunodeficiency virus (HIV) care in the modern antiretroviral therapy (ART) era requires early entry into and retention in care. Early initiation and adherence to ART therapy improves outcomes. Many evidence-based tools and behavioral interventions are available to optimize adherence to care and ART and can be implemented in clinical settings. Monitoring care engagement and ART adherence creates the opportunity to intervene and prevent virologic failure or loss to follow up. Special HIV-infected populations, such as pregnant and mentally ill patients, require enhanced surveillance and care.

Background We implemented an Intravenous Antibiotics and Addiction Team (IVAT) intervention to identify hospitalized persons with a history of injection drug use (IDU) that are safe for discharge with IV antibiotics based on a 9-point risk assessment. IVAT has been shown to reduce average length of stay (ALOS) without increasing readmissions. We analyzed the cost savings of the IVAT to the health system. Methods PWID at the University of Alabama at Birmingham (UAB) hospital with indications for prolonged IV antibiotics received IVAT to determine risk of continued IDU. “Low-risk” patients were discharged for outpatient antibiotics and addiction care; others continued inpatient antibiotics, group therapy, opioid agonist therapy (if applicable), and weekly assessment for discharge readiness. Cost of care was defined by direct costs and was obtained by querying financial accounts. Results A total of 37 pre-IVAT and 111 post-IVAT admissions (including 25 “low risk”) met study criteria. IVAT reduced ALOS by 20 days. Total direct costs per admission in the post-IVAT period were 33% lower: $26,014 versus $38,716 (Table 1). Because ALOS at UAB for all patients is 6.58 days, a 20-day ALOS reduction following IVAT creates capacity for an additional 333 patients (n = 20/6.58 × 111). Conclusion IVAT for PWID allows health systems to focus inpatient resources on those at greatest risk of ongoing IVDU, creates additional inpatient capacity, and may cut hospital direct costs by one-third. Table 1: Hospital Utilization Before and After IVAT Implementation Inpatient Costs Pre-Intervention January 2015–February 2016 Post-Intervention October 2016–January 2018 Number of admissions N = 37 N = 111 Risk group Low N/A 25 (27%) Medium 56 (61%) High 56 (61%) 11 (12%) Total direct costs $1,432,497 $2,887,515 Average LOS 42 22 Uninsured patients 20 (54%) 53 (48%) Medicaid beneficiaries 13 (35%) 31 (28%) Medicare beneficiaries 3 (8%) 9 (8%) Commercially insured patients 1 (3%) 18 (16%) Inpatient costs per admission Total direct costs $38,716 $26,014 Direct costs/day $922 $1,182 Inpatient costs per admission categorized by service Nursing costs $16,305 $9,139 Pharmacy costs $8,829 $5,720 Surgery costs $4,986 $3,474 ICU costs $2,568 $2,081 Disclosures J. M. Rodriguez, finch: Research Contractor, Research support. seres: Research Contractor, Research support.