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Daily antiretroviral pre-exposure prophylaxis (PrEP) is a safe and effective method of preventing HIV. Clinicians' assumptions, biases, and judgments may impede access to PrEP. Specifically, concern that patients will engage in more condomless sex ("risk compensation") has been cited by clinicians as a reason for not prescribing PrEP.In this experimental study among medical students, we systematically varied race (White or Black) and condom-use behaviors (continued-use, planned-discontinuation, or continued-nonuse) of a fictional patient (all men with multiple male sex partners). Participants indicated the patients' assumed adherence to PrEP, patients' overall HIV risk, and willingness to prescribe PrEP. Participants completed an implicit association test to detect implicit racism and measures of heterosexism and attitudes toward nonmonogamy, which were examined as moderators of patient race and condom-use effects on participants' assumptions and ultimate willingness to prescribe PrEP.Participants ( N = 600) were most willing to prescribe PrEP to the continued-nonuse patient and least willing to prescribe to the planned-discontinuation patient. No differences were identified based on patient race. The continued-nonuse (vs. continued-use) patient was perceived as less likely to adhere to PrEP, which was associated with lower willingness to prescribe. Negative attitudes toward nonmonogamy exacerbated this effect. No effects of implicit racism or explicit heterosexism were identified.Participants were least willing to prescribe PrEP to patients who planned to discontinue condom use. Patients seeking PrEP are exhibiting agency over their sexual health, and clinicians should fulfill their role in ensuring access to this primary preventative therapy. Training and curricular reform regarding PrEP are needed.

Background The COVID-19 pandemic has exacerbated health inequities in the United States. People with unhealthy opioid use (UOU) may face disproportionate challenges with COVID-19 precautions, and the pandemic has disrupted access to opioids and UOU treatments. UOU impairs the immunological, cardiovascular, pulmonary, renal, and neurological systems and may increase severity of outcomes for COVID-19. Objective We applied machine learning techniques to explore clinical presentations of hospitalized patients with UOU and COVID-19 and to test the association between UOU and COVID-19 disease severity. Methods This retrospective, cross-sectional cohort study was conducted based on data from 4110 electronic health record patient encounters at an academic health center in Chicago between January 1, 2020, and December 31, 2020. The inclusion criterion was an unplanned admission of a patient aged ≥18 years; encounters were counted as COVID-19-positive if there was a positive test for COVID-19 or 2 COVID-19 International Classification of Disease, Tenth Revision codes. Using a predefined cutoff with optimal sensitivity and specificity to identify UOU, we ran a machine learning UOU classifier on the data for patients with COVID-19 to estimate the subcohort of patients with UOU. Topic modeling was used to explore and compare the clinical presentations documented for 2 subgroups: encounters with UOU and COVID-19 and those with no UOU and COVID-19. Mixed effects logistic regression accounted for multiple encounters for some patients and tested the association between UOU and COVID-19 outcome severity. Severity was measured with 3 utilization metrics: low-severity unplanned admission, medium-severity unplanned admission and receiving mechanical ventilation, and high-severity unplanned admission with in-hospital death. All models controlled for age, sex, race/ethnicity, insurance status, and BMI. Results Topic modeling yielded 10 topics per subgroup and highlighted unique comorbidities associated with UOU and COVID-19 (eg, HIV) and no UOU and COVID-19 (eg, diabetes). In the regression analysis, each incremental increase in the classifier’s predicted probability of UOU was associated with 1.16 higher odds of COVID-19 outcome severity (odds ratio 1.16, 95% CI 1.04-1.29; P=.009). Conclusions Among patients hospitalized with COVID-19, UOU is an independent risk factor associated with greater outcome severity, including in-hospital death. Social determinants of health and opioid-related overdose are unique comorbidities in the clinical presentation of the UOU patient subgroup. Additional research is needed on the role of COVID-19 therapeutics and inpatient management of acute COVID-19 pneumonia for patients with UOU. Further research is needed to test associations between expanded evidence-based harm reduction strategies for UOU and vaccination rates, hospitalizations, and risks for overdose and death among people with UOU and COVID-19. Machine learning techniques may offer more exhaustive means for cohort discovery and a novel mixed methods approach to population health.

To the Editor:The HIV epidemic in the United States has been a public health concern for over 40 years. In the past 20 years, we have witnessed significant progress in the treatment and prevention ...

BACKGROUND The COVID-19 pandemic has exacerbated health inequities in the United States. People with unhealthy opioid use (UOU) may face disproportionate challenges with COVID-19 precautions, and the pandemic has disrupted access to opioids and UOU treatments. Unhealthy opioid use impairs the immunological, cardiovascular, pulmonary, renal, and neurological systems and may increase severity of outcomes for COVID-19. OBJECTIVE To explore the clinical presentation of hospitalized patients with UOU and COVID-19 and to test the association between UOU and COVID-19 disease severity. METHODS This retrospective, cross-sectional cohort study was conducted based on data from 4,110 electronic health record patient encounters at an academic health center in Chicago between January 1, 2020, and December 31, 2020. Inclusion criteria were unplanned admissions for patients ≥18 years of age; encounters were counted as COVID-19-positive if there was a positive test for COVID-19 or two COVID-19 ICD-10 codes recorded in the encounter. Using a predefined cutoff with optimal sensitivity and specificity to identify UOU, we ran a digital machine learning UOU classifier on the data for patients with COVID-19 to estimate the subcohort of patients with UOU. Topic modeling was used to explore and compare the clinical presentations documented for two subgroups: encounters with UOU and COVID-19 and those with no-UOU and COVID-19. Mixed effects logistic regression accounted for multiple encounters for some patients and tested the association between UOU and COVID-19 outcome severity. Severity was measured with three utilization metrics: low - unplanned admission, medium - unplanned admission and receiving mechanical ventilation, and high - unplanned admission with in-hospital death. All models controlled for age, sex, race/ethnicity, insurance status, and body mass index (BMI). RESULTS Topic modeling yielded ten topics per subgroup and highlighted unique comorbidities associated with UOU and COVID-19 (e.g., HIV) and no-UOU and COVID-19 (e.g., diabetes). In regression analysis, each incremental increase in the classifier’s predicted probability of UOU was associated with 1.16 higher odds of COVID-19 outcome severity (odds ratio 1.16, 95% CI 1.04-1.29, P=.009). CONCLUSIONS Among patients hospitalized with COVID-19, UOU is an independent risk factor associated with greater outcome severity, including in-hospital death. Social determinants of health and opioid-related overdose are unique comorbidities in the clinical presentation of the UOU patient subgroup. Additional research is needed on the role of COVID-19 therapeutics and inpatient management of acute COVID-19 pneumonia for patients with UOU. Further research is needed to test associations between expanded evidence-based harm reduction strategies for UOU and vaccination rates, hospitalizations, and risks for overdose and death among people with UOU and COVID-19.

Introduction Daily pre-exposure prophylaxis (PrEP) for HIV-prevention is an essential component of national plans to end the HIV epidemic. Despite its well-documented safety and effectiveness, PrEP prescription has not met the public health need. Significant disparities between White and Black people exist with respect to PrEP prescription, as do disparities between men and women. One factor contributing to these disparities is clinicians’ assumptions about patients seeking PrEP. Methods The present study sought to investigate medical students’ assumptions about patients seeking PrEP (anticipated increased condomless sex, extra-relational sex, and adherence to PrEP), and assumed HIV risk when presenting with their sexual partner. We systematically varied the race (Black or White) and gender (man or woman) of a fictional patient and their sexual partner. All were in serodifferent relationships including men who have sex with men (MSM), women (MSW), and women who have sex with men (WSM). Participants also completed an implicit association test measuring implicit racism against Black people. We evaluated the moderation effects of patient and partner race on assumptions as well as the moderated moderation effects of implicit racism. Results A total of 1,472 students participated. For MSM patients, having a Black partner was associated with higher assumed patient non-adherence to PrEP compared to a White partner, however a White partner was associated with higher assumed HIV risk. For MSW patients, a White male patient was viewed as being more likely to engage in more extra-relational sex compared to a Black male patient. For WSM patients, White women were assumed to be more likely to have condomless and extra-relational sex, be nonadherent to PrEP, and were at higher HIV risk. Overall, implicit racism was not related to negative assumptions about Black patients as compared to White patients based on patient/partner race. Discussion Medical education about PrEP for HIV prevention must ensure future health professionals understand the full range of patients who are at risk for HIV, as well as how implicit racial biases may affect assumptions about patients in serodifferent couples seeking PrEP for HIV prevention. As gatekeepers for PrEP prescription, clinicians’ assumptions about patients seeking PrEP represent a barrier to access. Consistent with prior research, we identified minimal effects of race and implicit racism in an experimental setting.

Background Transgender medicine is an emergent subfield with clearly identified educational gaps. Aims This manuscript evaluates a gender-affirming healthcare curriculum for second-year medical (M2) students. Methods Students received a survey assessing Gender Identity Competency in terms of skills, knowledge and attitudes regarding transgender and gender non-conforming (TGNC) issues. The authors administered the survey before and after the delivery of the curriculum. The curriculum included five online modules, a quiz, a 3-hour case-based workshop and a 2-hour interactive patient-provider panel. Results Approximately 60% of M2 students (n=77) completed both preassessments and postassessments. The following showed a statistically significant improvement from preassessment to postassessment: student Gender Identity Competency, t(76) = −11.07, p Conclusions The curriculum improved students’ gender-affirming medical competency, knowledge and skills. The development of a sustained, longitudinal curriculum is recommended in addition to the continuing education of faculty to reinforce this expanding knowledge and skills base and to address discomfort working with this population.