Last data update: May 06, 2024. (Total: 46732 publications since 2009)
Records 1-30 (of 41 Records) |
Query Trace: McGowan E[original query] |
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A systematic review and meta-analysis of chemical exposures and attention-deficit/hyperactivity disorder in children
Dimitrov LV , Kaminski JW , Holbrook JR , Bitsko RH , Yeh M , Courtney JG , O'Masta B , Maher B , Cerles A , McGowan K , Rush M . Prev Sci 2023 Exposure to certain chemicals prenatally and in childhood can impact development and may increase risk for attention-deficit/hyperactivity disorder (ADHD). Leveraging a larger set of literature searches conducted to synthesize results from longitudinal studies of potentially modifiable risk factors for childhood ADHD, we present meta-analytic results from 66 studies that examined the associations between early chemical exposures and later ADHD diagnosis or symptoms. Studies were eligible for inclusion if the chemical exposure occurred at least 6 months prior to measurement of ADHD diagnosis or symptomatology. Included papers were published between 1975 and 2019 on exposure to anesthetics (n = 5), cadmium (n = 3), hexachlorobenzene (n = 4), lead (n = 22), mercury (n = 12), organophosphates (n = 7), and polychlorinated biphenyls (n = 13). Analyses are presented for each chemical exposure by type of ADHD outcome reported (categorical vs. continuous), type of ADHD measurement (overall measures of ADHD, ADHD symptoms only, ADHD diagnosis only, inattention only, hyperactivity/impulsivity only), and timing of exposure (prenatal vs. childhood vs. cumulative), whenever at least 3 relevant effect sizes were available. Childhood lead exposure was positively associated with ADHD diagnosis and symptoms in all analyses except for the prenatal analyses (odds ratios (ORs) ranging from 1.60 to 2.62, correlation coefficients (CCs) ranging from 0.14 to 0.16). Other statistically significant associations were limited to organophosphates (CC = 0.11, 95% confidence interval (CI): 0.03-0.19 for continuous measures of ADHD outcomes overall), polychlorinated biphenyls (CC = 0.08, 95% CI: 0.02-0.14 for continuous measures of inattention as the outcome), and both prenatal and childhood mercury exposure (CC = 0.02, 95% CI: 0.00-0.04 for continuous measures of ADHD outcomes overall for either exposure window). Our findings provide further support for negative impacts of prenatal and/or childhood exposure to certain chemicals and raise the possibility that primary prevention and targeted screening could prevent or mitigate ADHD symptomatology. Furthermore, these findings support the need for regular review of regulations as our scientific understanding of the risks posed by these chemicals evolves. |
Assessment of school staff knowledge and perceptions of student e-cigarette use and resource needs, and e-cigarettes confiscated at 12 North Carolina high schools-2019
Tanz LJ , Heck C , Herzig CTA , Ranney LM , Herndon S , Martin J , Hast M , McGowan E , Baler G , Shamout M , King BA , Tynan MA , Kansagra SM . NC Med J 2023 84 (6) 49-57 Background E-cigarettes are the most commonly used tobacco product among US youth and are regularly used on school grounds. We assessed school staff’s awareness of students’ e-cigarette use, response by schools, and resources needed to address use, and examined e-cigarettes confiscated by school staff in North Carolina to guide prevention and identify needed resources. methods In May 2019, staff from a random sample of 25 of 451 North Carolina public and charter high schools were invited to complete an online survey and semistructured interview; 12 schools consented to ≥ 1 component (survey, N = 514; interviews, N = 35). Staff knowledge and perceptions of students’ e-cigarette use and school tobacco policies were assessed, including school efforts to address e-cigarette use. E-cigarette products confiscated by nine schools from students during the 2018-2019 school year were collected. limitations Only 12 public high schools participated, and these schools might not be representative of all North Carolina high schools. Quantitative surveys were not collected from all staff at participating schools; however, the response rate was 62% and included different staff positions and both urban and rural schools. Finally, e-cigarette products collected by schools might not be representative of all devices used by students. Results Among surveyed staff, 33% observed students using e-cigarettes on school grounds; 86% believed e-cigarette use somewhat or largely contributes to learning disruptions. Overall, 94% of respondents knew their school’s policy prohibits student e-cigarette use on school grounds, and 57% were not confident their school has resources to help students quit. From 35 interviews, themes included concern that schools’ tobacco-free policies do not deter use and additional resources are needed to address e-cigarette use in schools. Of 336 collected devices, there were different e-cigarette types and most (65%) e-liquid bottles were flavored. conclusion Efforts are warranted to incorporate evidence-based curricula; educate staff, parents, and youth regarding health risks of ecigarette use; and help youth quit e-cigarettes. © 2023 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved. |
Oral tenofovir disoproxil fumarate/emtricitabine for HIV pre-exposure prophylaxis increases expression of type I/III interferon-stimulated factors in the gastrointestinal tract but not in the blood (preprint)
Hughes SM , Levy CN , Calienes FL , Stekler JD , Pandey U , Vojtech L , Berard AR , Birse K , Noël-Romas L , Richardson B , Golden JB , Cartwright M , Collier AC , Stevens CE , Curlin ME , Holtz TH , Mugo N , Irungu E , Katabira E , Muwonge T , Lama JR , Baeten JM , Burgener A , Lingappa JR , McElrath MJ , Mackelprang R , McGowan I , Cranston RD , Cameron MJ , Hladik F . bioRxiv 2019 701961 Tenofovir disoproxil fumarate and emtricitabine are used for HIV treatment and pre-exposure prophylaxis. Previously, we found that topical rectal application of tenofovir 1% gel caused many gene expression changes. Here, we measured RNA and protein expression in several clinical trials of oral administration in HIV-uninfected individuals (using microarrays, RNAseq, droplet digital PCR, mass spectrometry, and microscopy). We found tens to hundreds of differentially expressed genes in the gastrointestinal tract, but none in the blood or female reproductive tract. In rectal samples from one trial, most of the 13 upregulated genes were related to type I/III interferon signaling. Similar changes were seen at the protein level in the same trial and in the duodenum and rectum in another trial. We conclude that tenofovir disoproxil fumarate and emtricitabine have little effect on gene expression in the blood or female reproductive tract but increase type I/III interferon signaling in the gut. This effect may enhance their anti-viral efficacy when used as pre-exposure prophylaxis, in particular to prevent rectal HIV transmission. However, it may also contribute to chronic immune activation and HIV reservoir maintenance in chronically treated people living with HIV. |
A Collaborative Multi-Model Ensemble for Real-Time Influenza Season Forecasting in the U.S (preprint)
Reich NG , McGowan CJ , Yamana TK , Tushar A , Ray EL , Osthus D , Kandula S , Brooks LC , Crawford-Crudell W , Gibson GC , Moore E , Silva R , Biggerstaff M , Johansson MA , Rosenfeld R , Shaman J . bioRxiv 2019 566604 Seasonal influenza results in substantial annual morbidity and mortality in the United States and worldwide. Accurate forecasts of key features of influenza epidemics, such as the timing and severity of the peak incidence in a given season, can inform public health response to outbreaks. As part of ongoing efforts to incorporate data and advanced analytical methods into public health decision-making, the United States Centers for Disease Control and Prevention (CDC) has organized seasonal influenza forecasting challenges since the 2013/2014 season. In the 2017/2018 season, 22 teams participated. A subset of four teams created a research consortium called the FluSight Network in early 2017. During the 2017/2018 season they worked together to produce a collaborative multi-model ensemble that combined 21 separate component models into a single model using a machine learning technique called stacking. This approach creates a weighted average of predictive densities where the weight for each component is based on that component’s forecast accuracy in past seasons. In the 2017/2018 influenza season, one of the largest seasonal outbreaks in the last 15 years, this multi-model ensemble performed better on average than all individual component models and placed second overall in the CDC challenge. It also outperformed the baseline multi-model ensemble created by the CDC that took a simple average of all models submitted to the forecasting challenge. This project shows that collaborative efforts between research teams to develop ensemble forecasting approaches can bring measurable improvements in forecast accuracy and important reductions in the variability of performance from year to year. Efforts such as this, that emphasize real-time testing and evaluation of forecasting models and facilitate the close collaboration between public health officials and modeling researchers, are essential to improving our understanding of how best to use forecasts to improve public health response to seasonal and emerging epidemic threats. |
Forecasting seasonal influenza in the U.S.: A collaborative multi-year, multi-model assessment of forecast performance (preprint)
Reich NG , Brooks LC , Fox SJ , Kandula S , McGowan CJ , Moore E , Osthus D , Ray EL , Tushar A , Yamana TK , Biggerstaff M , Johansson MA , Rosenfeld R , Shaman J . bioRxiv 2018 397190 Influenza infects an estimated 9 to 35 million individuals each year in the United States and is a contributing cause for between 12,000 and 56,000 deaths annually. Seasonal outbreaks of influenza are common in temperate regions of the world, with highest incidence typically occurring in colder and drier months of the year. Real-time forecasts of influenza transmission can inform public health response to outbreaks. We present the results of a multi-institution collaborative effort to standardize the collection and evaluation of forecasting models for influenza in the US for the 2010/2011 through 2016/2017 influenza seasons. For these seven seasons, we assembled weekly real-time forecasts of 7 targets of public health interest from 22 different models. We compared forecast accuracy of each model relative to a historical baseline seasonal average. Across all regions of the US, over half of the models showed consistently better performance than the historical baseline when forecasting incidence of influenza-like illness 1, 2 and 3 weeks ahead of available data and when forecasting the timing and magnitude of the seasonal peak. In some regions, delays in data reporting were strongly and negatively associated with forecast accuracy. More timely reporting and an improved overall accessibility to novel and traditional data sources are needed to improve forecasting accuracy and its integration with real-time public health decision-making. |
Video telemedicine experiences in COVID-19 were positive, but physicians and patients prefer in-person care for the future
SteelFisher GK , McMurtry CL , Caporello H , Lubell KM , Koonin LM , Neri AJ , Ben-Porath EN , Mehrotra A , McGowan E , Espino LC , Barnett ML . Health Aff (Millwood) 2023 42 (4) 575-584 To help inform policy discussions about postpandemic telemedicine reimbursement and regulations, we conducted dual nationally representative surveys among primary care physicians and patients. Although majorities of both populations reported satisfaction with video visits during the pandemic, 80 percent of physicians would prefer to provide only a small share of care or no care via telemedicine in the future, and only 36 percent of patients would prefer to seek care by video or phone. Most physicians (60 percent) felt that the quality of video telemedicine care was generally inferior to the quality of in-person care, and both patients and physicians cited the lack of physical exam as a key reason (90 percent and 92 percent, respectively). Patients who were older, had less education, or were Asian were less likely to want to use video for future care. Although improvements to home-based diagnostic tools could improve both the quality of and the desire to use telemedicine, virtual primary care will likely be limited in the immediate future. Policies to enhance quality, sustain virtual care, and address inequities in the online setting may be needed. |
Prevalence and predictors of breastfeeding duration of 24 or more months
McGowan A , Li R , Marks KJ , Hamner HC . Pediatrics 2023 151 (2) Breastfeeding is associated with reductions in morbidity and mortality among mothers and children.1–4 The Dietary Guidelines for Americans, American Academy of Pediatrics, and World Health Organization recommend exclusive breastfeeding for 6 months, with continued breastfeeding for at least 1 (Dietary Guidelines for Americans5 ) or 2 years (American Academy of Pediatrics,6 World Health Organization3 ), while complementary foods are introduced. | | Benefits of longer breastfeeding durations have been documented3,4 ; however, limited studies describe US breastfeeding duration past 18 months.7 Using data from a nationally representative survey, we examined the prevalence and predictors of breastfeeding duration ≥24 months. |
Human milk expression in first year postpartum among persons with low incomes
Nakayama JY , Marks KJ , McGowan A , Li R , Hamner HC . J Hum Nutr Diet 2023 36 (4) 1261-1269 BACKGROUND: Expressing milk (i.e., human milk) is common in the United States, but practices are unknown among families in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). This study of a WIC population explores the practice of and reasons for expressing milk in the first year postpartum. METHODS: We analyzed data from a longitudinal study to examine milk expression at 1, 3, 5, 7, 9, 11, and 13 months postpartum among breastfeeding persons enrolled in WIC with term singletons. We cross-sectionally analyzed the weighted prevalence of milk expression at each survey month and report reasons for milk expression in the first 7 months. RESULTS: Among study participants who reported feeding human milk at month 1, 70.4% expressed milk in the first 13 months postpartum. The prevalence of milk expression was 56.8% at month 1 and decreased to 13.9% at month 13 among those feeding any human milk that month. Reasons for expressing milk changed over time; in the first month, increasing milk supply, relieving engorgement, and having an emergency supply of milk were common. In later months, having a supply of milk available so that someone else could feed their infant was common. CONCLUSIONS: Clinicians, health educators, WIC staff, and others working with WIC families can promote optimal expressed milk feeding and storage practices. Extra attention and support may be especially important in the first months postpartum when milk expression is common. Support for persons who are expressing milk can be tailored for reasons of milk expression. This article is protected by copyright. All rights reserved. |
Patterns in mothers' recollection of health care providers' young child feeding recommendations
McGowan A , Boundy EO , Nelson JM , Hamner HC . J Nutr Educ Behav 2022 54 (11) 1024-1033 OBJECTIVE: Characterize feeding guidance mothers recall receiving from their child's health care provider (HCP). DESIGN: Cross-sectional study of mothers participating in the 2017-2019 National Survey of Family Growth. PARTICIPANTS: US mothers reporting (n = 1,302) information about their youngest child (aged 6 months to 5 years). VARIABLES MEASURED: Weighted percentage of mothers who recalled their child's HCP discussing 6 different feeding topics by demographic characteristics. ANALYSIS: Logistic regression assessing the relationship between recall of feeding guidance and demographics. RESULTS: In this sample, 36.9% of mothers (95% confidence interval, 32.3-41.4) recalled HCPs recommending solid food before 6 months old (34.6% at 4-5 months, and 2.3% before 4 months). Mothers who were older or had a higher education level were more likely than their counterparts to recall their HCP discussing several of the feeding topics examined. CONCLUSION AND IMPLICATIONS: Mothers reported high recollection of early childhood nutrition guidance from their HCP; however, certain topics (eg, appropriate timing of solid food introduction) could be prioritized, and some subpopulations may need additional focus to improve receipt of messages. A better understanding of variability in recall of feeding guidance could provide information for interventions to address barriers to receiving and retaining guidance. |
SARS-CoV-2 B.1.1.529 (Omicron) Variant Transmission Within Households - Four U.S. Jurisdictions, November 2021-February 2022.
Baker JM , Nakayama JY , O'Hegarty M , McGowan A , Teran RA , Bart SM , Mosack K , Roberts N , Campos B , Paegle A , McGee J , Herrera R , English K , Barrios C , Davis A , Roloff C , Sosa LE , Brockmeyer J , Page L , Bauer A , Weiner JJ , Khubbar M , Bhattacharyya S , Kirking HL , Tate JE . MMWR Morb Mortal Wkly Rep 2022 71 (9) 341-346 The B.1.1.529 (Omicron) variant, first detected in November 2021, was responsible for a surge in U.S. infections with SARS-CoV-2, the virus that causes COVID-19, during December 2021-January 2022 (1). To investigate the effectiveness of prevention strategies in household settings, CDC partnered with four U.S. jurisdictions to describe Omicron household transmission during November 2021-February 2022. Persons with sequence-confirmed Omicron infection and their household contacts were interviewed. Omicron transmission occurred in 124 (67.8%) of 183 households. Among 431 household contacts, 227 were classified as having a case of COVID-19 (attack rate [AR] = 52.7%).(†) The ARs among household contacts of index patients who had received a COVID-19 booster dose, of fully vaccinated index patients who completed their COVID-19 primary series within the previous 5 months, and of unvaccinated index patients were 42.7% (47 of 110), 43.6% (17 of 39), and 63.9% (69 of 108), respectively. The AR was lower among household contacts of index patients who isolated (41.2%, 99 of 240) compared with those of index patients who did not isolate (67.5%, 112 of 166) (p-value <0.01). Similarly, the AR was lower among household contacts of index patients who ever wore a mask at home during their potentially infectious period (39.5%, 88 of 223) compared with those of index patients who never wore a mask at home (68.9%, 124 of 180) (p-value <0.01). Multicomponent COVID-19 prevention strategies, including up-to-date vaccination, isolation of infected persons, and mask use at home, are critical to reducing Omicron transmission in household settings. |
Acceptability of a Dapivirine/Placebo Gel Administered Rectally to HIV-1 Seronegative Adults (MTN-026)
Bauermeister JA , Tingler RC , Dominguez C , Dunne EF , Hoesley C , Ho K , Johnson S , Lucas J , Macagna N , Brown E , Gundacker H , Peda M , Jacobson CE , Kramzer L , Singh D , Dezzutti CS , Ayudhya Rpkn , Marzinke MA , Piper J , Devlin B , Nuttall J , McGowan I , Hendrix CW , Cranston RD . AIDS Behav 2021 26 (5) 1333-1346 This study describes the acceptability of a rectal microbicide gel formulation using dapivirine (DPV) among men and women from two countries (United States and Thailand) participating in the Microbicide Trials Network-026 trial. We evaluated participants' acceptability of a rectal DPV/placebo gel as part of a Phase I trial (N = 26; 18 male, 8 female). Participants reported favorable acceptability of the study gel, with most participants reporting that they liked the gel the same (n = 14; 53.8%) or more (n = 11; 42.4%) than when they started the trial. Over half of participants noted that they would prefer the gel over condoms (n = 13; 50%) or that they liked condoms and the gel equally (n = 8; 30.8%). Side effects across products included leakage (n = 8; 30.8%), diarrhea (n = 4; 15.4%), or soiling (n = 1; 3.8%). The high acceptability of a rectal gel underscores its promise as a short-acting biomedical prevention, warranting future research for HIV prevention.Trial Registration: NCT03239483. |
An open-label pharmacokinetic and pharmacodynamic assessment of tenofovir gel and oral emtricitabine / tenofovir disoproxil fumarate
McGowan IM , Kunjara Na Ayudhya RP , Brand RM , Marzinke MA , Hendrix CW , Johnson S , Piper J , Holtz TH , Curlin ME , Chitwarakorn A , Raengsakulrach B , Doncel G , Schwartz Icloud Com J , Rooney JF , Cranston RD . AIDS Res Hum Retroviruses 2021 38 (4) 279-287 The MTN-017 study was undertaken to characterize the safety, acceptability, pharmacokinetic, and pharmacodynamic profile of the reduced-glycerin (RG) 1% tenofovir (RG-TFV) gel compared to oral emtricitabine / tenofovir disoproxil fumarate (FTC/TDF). The study was a Phase 2, three-period, randomized sequence, open-label, expanded safety and acceptability crossover study. In each 8-week study period, HIV-1 uninfected participants were randomized to RG-TFV rectal gel daily; or RG-TFV rectal gel before and after receptive anal intercourse (RAI) (or at least twice weekly in the event of no RAI); or daily oral FTC/TDF. A mucosal substudy was conducted at sites in the USA and Thailand. Samples were collected to evaluate PK and ex vivo biopsy challenge with HIV-1. A total of 195 MSM and transgender women (TW) were enrolled in the parent study and 37 in the mucosal substudy. As previously reported, both products were found to be safe and acceptable. Systemic TFV concentrations were significantly higher following oral exposure and daily rectal administration compared to RAI-associated product use (p<0.001). All three routes of PrEP administration resulted in inhibition of explant infection (p<0.05) and there was a significant inverse correlation between explant HIV-1 p24 and tissue concentrations of TFV and FTC (p<0.0001). Despite significant differences in systemic and mucosal drug concentrations, all three PrEP regimens were able to protect rectal explants from ex vivo HIV infection. These data suggest that there is a rationale for co-development of oral and topical antiretroviral PrEP for HIV prevention. |
A randomized, double blind, placebo-controlled, phase 1 safety and pharmacokinetic study of dapivirine gel (0.05%) administered rectally to HIV-1 seronegative adults (MTN-026)
Cranston RD , Brown E , Bauermeister J , Dunne EF , Hoesley C , Ho K , Johnson S , Lucas J , Dominguez-Islas C , Gundacker H , Peda M , Jacobson CE , Kramzer L , Singh D , Dezzutti CS , Kunjara Na Ayudhya RP , Brand RM , Wang L , Marzinke MA , Piper J , Devlin B , Nuttall J , McGowan I , Hendrix CW . AIDS Res Hum Retroviruses 2021 38 (4) 257-268 INTRODUCTION: Dapivirine (DPV), formulated as vaginal ring, demonstrated HIV risk reduction. MTN-026 explored DPV, formulated as rectal gel, for safety, pharmacokinetics, and acceptability. METHODS: HIV-uninfected men and women aged 18-45 years were enrolled at United States and Thailand sites and randomized 2:1 to receive DPV 0.05% or placebo gel via rectal applicator. A single dose phase was followed by 7 observed daily doses. Plasma, and fluid and tissue from both rectum and cervix were collected at baseline and after the final dose over 72 hours for pharmacokinetics, ex-vivo HIV-1 biopsy challenge, histology, and flow cytometry. RESULTS: 28 participants were randomized; 2 terminated early; 9 were female and 19 male; 12 were white, 11 Asian, 4 black and 1 other race/ethnicity. Mean age was 28.5 and 34.2 years in the DPV and placebo arms, respectively. Thirty adverse events occurred (all Grade 1 or 2, except one unrelated Grade 3) without study arm differences. DPV rectal tissue concentrations (median [interquartile range]) 0.5-1 and 2 hours after a single dose were 256 ng/gm (below limit of quantitation [BLQ], 666) and BLQ (BLQ, 600), respectively, then BLQ (BLQ, BLQ) from 24-72 hours; concentrations following multiple doses were similar. The largest median DPV plasma concentrations were 0.33 ng/mL (0.15, 0.48) after one dose and 0.40 (0.33, 0.49) after seven doses. CONCLUSIONS: The DPV rectal gel was acceptable and without safety concerns. While DPV plasma concentrations were similar to the vaginal ring, rectal tissue concentrations were well below vaginal ring tissue concentrations, suggesting need for reformulation. |
Experiences and Views of Domestic Summer Travelers During the COVID-19 Pandemic: Findings from a National Survey.
SteelFisher GK , McMurtry CL , Caporello HL , McGowan E , Schafer TJ , Lubell KM , Friedman AL , Allen J , Shockey C , Grady A , Ben-Porath EN . Health Secur 2021 19 (3) 338-348 Domestic travel creates a serious risk of spreading COVID-19, including novel strains of the virus. Motivating potential travelers to take precautions is critical, especially for those at higher risk for severe illness. To provide an evidence base for communication efforts, we examined the experiences and views of travelers during the summer of 2020 through a telephone survey of 1,968 US adults, conducted in English and Spanish, July 2 through July 16, 2020. The survey found that more than one-quarter (28%) of adults had traveled domestically in the prior 30 days, most commonly for "vacation" (43%), and less than half wore masks (46%) or practiced social distancing (47%) "all of the time." Although high-risk adults were significantly less likely to travel than non-high-risk adults (23% vs 31%; P < .001), they were no more likely to take precautions. Many travelers did not wear a mask or practice social distancing because they felt such actions were unnecessary (eg, they were outside or with friends and family). Although a substantial share of travelers (43% to 53%) trusted public health agencies "a great deal" for information about reducing risks while traveling, more travelers (73%) trusted their own healthcare providers. Findings suggest that outreach may be improved by partnering with providers to emphasize the benefits of layering precautions and provide targeted education to high-risk individuals. Messages that are empathetic to the need to reduce stress and convey how precautions can protect loved ones may be particularly resonant after more than a year of pandemic-related restrictions. |
Notes from the field: Characteristics of e-cigarette, or vaping, products confiscated in public high schools in California and North Carolina - March and May 2019
Shamout M , Tanz L , Herzig C , Oakley LP , Peak CM , Heinzerling A , Hast M , McGowan E , Williams RJ , Hess C , Wang C , Planche S , Herndon S , Martin J , Kansagra SM , Al-Shawaf M , Melstrom P , Marynak K , Tynan MA , Agaku IT , King BA . MMWR Morb Mortal Wkly Rep 2020 69 (42) 1552-1554 E-cigarette, or vaping, products are electronic devices that produce an inhalable aerosol by heating an e-liquid that typically contains nicotine and other additives (1). Nicotine is highly addictive, can harm adolescent brain development, and can prime the brain for addiction to other drugs (1). In 2019, 27.5% of U.S. high school students currently used e-cigarettes (2), and 73.4% of high school students had observed e-cigarette use on school grounds (3). E-cigarette use among U.S. youths increased considerably during 2017–2019 (2). This rise coincided with the increased popularity of “pod mods,” which are products with a prefilled or refillable pod cartridge (pod) and a modifiable (mod) system. Pod mods typically use nicotine salts rather than the freebase nicotine used in most other e-cigarette, or vaping, products and conventional tobacco products (e.g., cigarettes).* Nicotine salts, which have a lower pH than freebase nicotine, allow particularly high levels of nicotine to be inhaled more easily and with less irritation to the throat than freebase nicotine.† The most commonly sold pod mod brand is JUUL, which accounted for 75% of all U.S. e-cigarettes sales by the end of 2018.§ A majority (59.1%) of U.S. high school student e-cigarette users report JUUL is their usual brand (2). |
Treatment with commonly used antiretroviral drugs induces a type I/III interferon signature in the gut in the absence of HIV infection
Hughes SM , Levy CN , Calienes FL , Stekler JD , Pandey U , Vojtech L , Berard AR , Birse K , Noël-Romas L , Richardson B , Golden JB , Cartwright M , Collier AC , Stevens CE , Curlin ME , Holtz TH , Mugo N , Irungu E , Katabira E , Muwonge T , Lama JR , Baeten JM , Burgener A , Lingappa JR , McElrath MJ , Mackelprang R , McGowan I , Cranston RD , Cameron MJ , Hladik F . Cell Rep Med 2020 1 (6) 100096 Tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC) are used for HIV treatment and prevention. Previously, we found that topical rectal tenofovir gel caused immunological changes in the mucosa. Here, we assess the effect of oral TDF/FTC in three HIV pre-exposure prophylaxis trials, two with gastrointestinal and one with cervicovaginal biopsies. TDF/FTC induces type I/III interferon-related (IFN I/III) genes in the gastrointestinal tract, but not blood, with strong correlations between the two independent rectal biopsy groups (Spearman r = 0.91) and between the rectum and duodenum (r = 0.81). Gene set testing also indicates stimulation of the type I/III pathways in the ectocervix and of cellular proliferation in the duodenum. mRNA sequencing, digital droplet PCR, proteomics, and immunofluorescence confirm IFN I/III pathway stimulation in the gastrointestinal tract. Thus, oral TDF/FTC stimulates an IFN I/III signature throughout the gut, which could increase antiviral efficacy but also cause chronic immune activation in HIV prevention and treatment settings. |
Receptive anal sex contributes substantially to heterosexually-acquired HIV infections among at-risk women in twenty US cities: results from a modelling analysis
Elmes J , Silhol R , Hess KL , Gedge LM , Nordsletten A , Staunton R , Anton P , Shacklett B , McGowan I , Dang Q , Adimora AA , Dimitrov DT , Aral S , Handanagic S , Paz-Bailey G , Boily MC . Am J Reprod Immunol 2020 84 (2) e13263 PROBLEM: Receptive anal intercourse (RAI) is more efficient than receptive vaginal intercourse (RVI) at transmitting HIV, but its contribution to heterosexually-acquired HIV infections among at-risk women in the US is unclear. METHOD OF STUDY: We analysed sexual behaviour data from surveys of 9,152 low-income heterosexual women living in 20 cities with high rates of HIV conducted in 2010 and 2013 as part of US National HIV Behavioral Surveillance. We estimated RAI prevalence (past-year RAI) and RAI fraction (fraction of all sex acts (RVI and RAI) at the last sexual episode that were RAI among those reporting past-year RAI) overall and by key demographic characteristics. These results and HIV incidence were used to calibrate a risk-equation model to estimate the population attributable fraction of new HIV infections due to RAI (PAFRAI ) accounting for uncertainty in parameter assumptions. RESULTS: RAI prevalence (overall: 32%, city range: 19-60%) and RAI fraction (overall: 27%, city-range: 18-34%) were high overall and across cities, and positively associated with exchange sex. RAI accounted for an estimated 41% (uncertainty range: 18-55%) of new infections overall (city range: 21-57%). Variability in PAFRAI estimates was most influenced by uncertainty in the estimate of the per-act increased risk of RAI relative to RVI and the number of sex acts. CONCLUSIONS: RAI may contribute disproportionately to new heterosexually-acquired HIV infections among at-risk low-income women in the US, meaning that tools to prevent HIV transmission during RAI are warranted. Number of RVI and RAI acts should also be collected to monitor heterosexually-acquired HIV infections. |
Accuracy of real-time multi-model ensemble forecasts for seasonal influenza in the U.S
Reich NG , McGowan CJ , Yamana TK , Tushar A , Ray EL , Osthus D , Kandula S , Brooks LC , Crawford-Crudell W , Gibson GC , Moore E , Silva R , Biggerstaff M , Johansson MA , Rosenfeld R , Shaman J . PLoS Comput Biol 2019 15 (11) e1007486 Seasonal influenza results in substantial annual morbidity and mortality in the United States and worldwide. Accurate forecasts of key features of influenza epidemics, such as the timing and severity of the peak incidence in a given season, can inform public health response to outbreaks. As part of ongoing efforts to incorporate data and advanced analytical methods into public health decision-making, the United States Centers for Disease Control and Prevention (CDC) has organized seasonal influenza forecasting challenges since the 2013/2014 season. In the 2017/2018 season, 22 teams participated. A subset of four teams created a research consortium called the FluSight Network in early 2017. During the 2017/2018 season they worked together to produce a collaborative multi-model ensemble that combined 21 separate component models into a single model using a machine learning technique called stacking. This approach creates a weighted average of predictive densities where the weight for each component is determined by maximizing overall ensemble accuracy over past seasons. In the 2017/2018 influenza season, one of the largest seasonal outbreaks in the last 15 years, this multi-model ensemble performed better on average than all individual component models and placed second overall in the CDC challenge. It also outperformed the baseline multi-model ensemble created by the CDC that took a simple average of all models submitted to the forecasting challenge. This project shows that collaborative efforts between research teams to develop ensemble forecasting approaches can bring measurable improvements in forecast accuracy and important reductions in the variability of performance from year to year. Efforts such as this, that emphasize real-time testing and evaluation of forecasting models and facilitate the close collaboration between public health officials and modeling researchers, are essential to improving our understanding of how best to use forecasts to improve public health response to seasonal and emerging epidemic threats. |
Views and experiences of travelers from US states to Zika-affected areas
SteelFisher GK , Caporello H , Blendon RJ , Ben-Porath EN , Lubell K , Friedman AL , Holton K , Smith BJ , McGowan E , Schafer T . Health Secur 2019 17 (4) 307-323 Travelers to areas with Zika virus transmission are at risk of infection and of transmitting the virus after returning home. While protective behaviors during and after travel can reduce these risks, information about traveler practices or underlying views is limited. We examined these issues using data from the first representative poll of travelers from US states to Zika-affected areas, including US territories and Miami, Florida, conducted December 1 to 23, 2016. We analyzed results among all travelers (n = 1,285) and 2 subgroups at risk for pregnancy-related complications: (1) travelers in households where someone was pregnant or considering pregnancy (n = 72), and (2) other travelers of reproductive age (n = 631). We also examined results among those with different levels of awareness and knowledge about Zika virus. Results show that in households where someone was pregnant or considering pregnancy, awareness of Zika in the destination, concern about infection, and adoption of protective behaviors was relatively high. That said, sizable shares of travelers as a whole did not know information about asymptomatic and sexual transmission or post-travel behaviors. Further, concern about getting infected during travel was low among travelers as a whole, including other travelers of reproductive age. Few travelers consistently adopted protective behaviors during or after travel. Even among travelers who were aware of Zika in their destination and knew how to protect themselves, adoption of protective behaviors was only slightly higher. Findings from this poll suggest communications may be more effective if tailored to different levels of true and perceived risk. To address gaps in knowledge about transmission and post-travel protective behaviors, messaging should include facts and acknowledge the complexities of novel information and social context. Consideration should also be given to emphasizing other benefits of Zika protective behaviors or prioritizing behaviors that are most feasible. |
Healthy People: The role of law and policy in the nation's public health agenda
McGowan AK , Kramer KT , Teitelbaum JB . J Law Med Ethics 2019 47 63-67 Each decade since 1979, the Healthy People initiative establishes the national prevention agenda and provides the foundation for disease prevention and health promotion policies and programs. Law and policy have been included in Healthy People objectives from the start, but not integrated into the overall initiative as well as possible to potentially leverage change to meet Healthy People targets and goals. This article provides background on the Healthy People initiative and its use among various stakeholder groups, describes the work of a project aiming to better integrate law and policy into this initiative, and discusses the development of Healthy People 2030 - the next iteration of health goals for the nation. Lessons from the preliminary stages of developing Healthy People by the HHS Secretary's Advisory Committee (Committee) on National Health Promotion and Disease Prevention Objectives for 2030 and a Federal Interagency Workgroup will be included. Efforts by the Committee focused on the role of law and policy as determinants of health and valuable resources around health equity are also shared. Finally, the article discusses ways that law and policy can potentially be tools to help meet Healthy People targets and to attain national health goals. |
Collaborative efforts to forecast seasonal influenza in the United States, 2015-2016
McGowan CJ , Biggerstaff M , Johansson M , Apfeldorf KM , Ben-Nun M , Brooks L , Convertino M , Erraguntla M , Farrow DC , Freeze J , Ghosh S , Hyun S , Kandula S , Lega J , Liu Y , Michaud N , Morita H , Niemi J , Ramakrishnan N , Ray EL , Reich NG , Riley P , Shaman J , Tibshirani R , Vespignani A , Zhang Q , Reed C . Sci Rep 2019 9 (1) 683 Since 2013, the Centers for Disease Control and Prevention (CDC) has hosted an annual influenza season forecasting challenge. The 2015-2016 challenge consisted of weekly probabilistic forecasts of multiple targets, including fourteen models submitted by eleven teams. Forecast skill was evaluated using a modified logarithmic score. We averaged submitted forecasts into a mean ensemble model and compared them against predictions based on historical trends. Forecast skill was highest for seasonal peak intensity and short-term forecasts, while forecast skill for timing of season onset and peak week was generally low. Higher forecast skill was associated with team participation in previous influenza forecasting challenges and utilization of ensemble forecasting techniques. The mean ensemble consistently performed well and outperformed historical trend predictions. CDC and contributing teams will continue to advance influenza forecasting and work to improve the accuracy and reliability of forecasts to facilitate increased incorporation into public health response efforts. |
A collaborative multiyear, multimodel assessment of seasonal influenza forecasting in the United States
Reich NG , Brooks LC , Fox SJ , Kandula S , McGowan CJ , Moore E , Osthus D , Ray EL , Tushar A , Yamana TK , Biggerstaff M , Johansson MA , Rosenfeld R , Shaman J . Proc Natl Acad Sci U S A 2019 116 (8) 3146-3154 Influenza infects an estimated 9-35 million individuals each year in the United States and is a contributing cause for between 12,000 and 56,000 deaths annually. Seasonal outbreaks of influenza are common in temperate regions of the world, with highest incidence typically occurring in colder and drier months of the year. Real-time forecasts of influenza transmission can inform public health response to outbreaks. We present the results of a multiinstitution collaborative effort to standardize the collection and evaluation of forecasting models for influenza in the United States for the 2010/2011 through 2016/2017 influenza seasons. For these seven seasons, we assembled weekly real-time forecasts of seven targets of public health interest from 22 different models. We compared forecast accuracy of each model relative to a historical baseline seasonal average. Across all regions of the United States, over half of the models showed consistently better performance than the historical baseline when forecasting incidence of influenza-like illness 1 wk, 2 wk, and 3 wk ahead of available data and when forecasting the timing and magnitude of the seasonal peak. In some regions, delays in data reporting were strongly and negatively associated with forecast accuracy. More timely reporting and an improved overall accessibility to novel and traditional data sources are needed to improve forecasting accuracy and its integration with real-time public health decision making. |
Considering disability and health: Reflections on the Healthy People 2020 Midcourse Review
Sinclair LB , Fox MH , Jonas BS , Berry HG , Quatrano LA , McGowan AK , Peacock G . Disabil Health J 2018 11 (3) 333-338 The Healthy People 2020 (HP2020) Midcourse Review (MCR) presents an opportunity for professionals in the disability and health field to contemplate preliminary progress toward achieving specific health objectives. The MCR showed notable progress in access to primary care, appropriate services for complex conditions associated with disability, expansion of health promotion programs focusing on disability, improving mental health, and reducing the unemployment rate among job seekers with disabilities. This commentary presents potential considerations, at least in part, for such progress including increased access to health care, greater awareness of appropriate services for complex conditions, and opportunities for societal participation. Additional considerations are provided to address the lack of progress in employment among this population -- a somewhat different measure than that for unemployment. Continuing to monitor these objectives will help inform programs, policies, and practices that promote the health of people with disabilities as measured by HP2020. |
Epigenetic impacts of stress priming of the neuroinflammatory response to sarin surrogate in mice: a model of Gulf War illness.
Ashbrook DG , Hing B , Michalovicz LT , Kelly KA , Miller JV , de Vega WC , Miller DB , Broderick G , O'Callaghan JP , McGowan PO . J Neuroinflammation 2018 15 (1) 86 BACKGROUND: Gulf War illness (GWI) is an archetypal, medically unexplained, chronic condition characterised by persistent sickness behaviour and neuroimmune and neuroinflammatory components. An estimated 25-32% of the over 900,000 veterans of the 1991 Gulf War fulfil the requirements of a GWI diagnosis. It has been hypothesised that the high physical and psychological stress of combat may have increased vulnerability to irreversible acetylcholinesterase (AChE) inhibitors leading to a priming of the neuroimmune system. A number of studies have linked high levels of psychophysiological stress and toxicant exposures to epigenetic modifications that regulate gene expression. Recent research in a mouse model of GWI has shown that pre-exposure with the stress hormone corticosterone (CORT) causes an increase in expression of specific chemokines and cytokines in response to diisopropyl fluorophosphate (DFP), a sarin surrogate and irreversible AChE inhibitor. METHODS: C57BL/6J mice were exposed to CORT for 4 days, and exposed to DFP on day 5, before sacrifice 6 h later. The transcriptome was examined using RNA-seq, and the epigenome was examined using reduced representation bisulfite sequencing and H3K27ac ChIP-seq. RESULTS: We show transcriptional, histone modification (H3K27ac) and DNA methylation changes in genes related to the immune and neuronal system, potentially relevant to neuroinflammatory and cognitive symptoms of GWI. Further evidence suggests altered proportions of myelinating oligodendrocytes in the frontal cortex, perhaps connected to white matter deficits seen in GWI sufferers. CONCLUSIONS: Our findings may reflect the early changes which occurred in GWI veterans, and we observe alterations in several pathways altered in GWI sufferers. These close links to changes seen in veterans with GWI indicates that this model reflects the environmental exposures related to GWI and may provide a model for biomarker development and testing future treatments. |
Results from the second year of a collaborative effort to forecast influenza seasons in the United States
Biggerstaff M , Johansson M , Alper D , Brooks LC , Chakraborty P , Farrow DC , Hyun S , Kandula S , McGowan C , Ramakrishnan N , Rosenfeld R , Shaman J , Tibshirani R , Tibshirani RJ , Vespignani A , Yang W , Zhang Q , Reed C . Epidemics 2018 24 26-33 Accurate forecasts could enable more informed public health decisions. Since 2013, CDC has worked with external researchers to improve influenza forecasts by coordinating seasonal challenges for the United States and the 10 Health and Human Service Regions. Forecasted targets for the 2014-15 challenge were the onset week, peak week, and peak intensity of the season and the weekly percent of outpatient visits due to influenza-like illness (ILI) 1-4 weeks in advance. We used a logarithmic scoring rule to score the weekly forecasts, averaged the scores over an evaluation period, and then exponentiated the resulting logarithmic score. Poor forecasts had a score near 0, and perfect forecasts a score of 1. Five teams submitted forecasts from seven different models. At the national level, the team scores for onset week ranged from <0.01 to 0.41, peak week ranged from 0.08 to 0.49, and peak intensity ranged from <0.01 to 0.17. The scores for predictions of ILI 1-4 weeks in advance ranged from 0.02-0.38 and was highest 1 week ahead. Forecast skill varied by HHS region. Forecasts can predict epidemic characteristics that inform public health actions. CDC, state and local health officials, and researchers are working together to improve forecasts. |
Preference of oral tenofovir disoproxil fumarate/emtricitabine versus rectal tenofovir reduced-glycerin 1% gel regimens for HIV prevention among cisgender men and transgender women who engage in receptive anal intercourse with men
Carballo-Dieguez A , Giguere R , Dolezal C , Leu CS , Balan IC , Brown W 3rd , Rael C , Richardson BA , Piper JM , Bekker LG , Chariyalertsak S , Chitwarakorn A , Gonzales P , Holtz TH , Liu A , Mayer KH , Zorrilla CD , Lama JR , McGowan I , Cranston RD . AIDS Behav 2017 21 (12) 3336-3345 Oral pre-exposure prophylaxis (PrEP) can prevent HIV transmission. Yet, some may prefer not to take systemic daily medication. MTN-017 was a 3-period, phase 2 safety and acceptability study of microbicide gel applied rectally either daily or before and after receptive anal intercourse (RAI), compared to daily oral tablet. At baseline, cisgender men and transgender women who reported RAI (N = 187) rated the daily oral regimen higher in overall liking, ease of use, and likelihood of future use than the gel regimens. After trying all three, 28% liked daily oral the least. Gel did not affect sexual enjoyment (88%) or improved it (7-8%). Most partners had no reaction to gel use. Ease of gel use improved significantly between the first and the last few times of daily use. A rectal gel used before and after RAI may constitute an attractive alternative to daily tablet. Experience with product use may increase acceptability. |
High levels of adherence to a rectal microbicide gel and to oral Pre-Exposure Prophylaxis (PrEP) achieved in MTN-017 among men who have sex with men (MSM) and transgender women
Carballo-Dieguez A , Balan IC , Brown W 3rd , Giguere R , Dolezal C , Leu CS , Marzinke MA , Hendrix CW , Piper JM , Richardson BA , Grossman C , Johnson S , Gomez K , Horn S , Kunjara Na Ayudhya RP , Patterson K , Jacobson C , Bekker LG , Chariyalertsak S , Chitwarakorn A , Gonzales P , Holtz TH , Liu A , Mayer KH , Zorrilla C , Lama J , McGowan I , Cranston RD . PLoS One 2017 12 (7) e0181607 Trials to assess microbicide safety require strict adherence to prescribed regimens. If adherence is suboptimal, safety cannot be adequately assessed. MTN-017 was a phase 2, randomized sequence, open-label, expanded safety and acceptability crossover study comparing 1) daily oral emtricitabine/tenofovir disoproxil fumarate (FTC/TDF), 2) daily use of reduced-glycerin 1% tenofovir (RG-TFV) gel applied rectally, and 3) RG-TFV gel applied before and after receptive anal intercourse (RAI)-if participants had no RAI in a week, they were asked to use two doses of gel within 24 hours. Product use was assessed by mixed methods including unused product return count, text messaging reports, and qualitative plasma TFV pharmacokinetic (PK) results. Convergence interviews engaged participants in determining the most accurate number of doses used based on product count and text messaging reports. Client-centered adherence counseling was also used. Participants (N = 187) were men who have sex with men and transgender women enrolled in the United States (42%), Thailand (29%), Peru (19%) and South Africa (10%). Mean age was 31.4 years (range 18-64 years). Based on convergence interviews, over an 8-week period, 94% of participants had ≥80% adherence to daily tablet, 41% having perfect adherence; 83% had ≥80% adherence to daily gel, 29% having perfect adherence; and 93% had ≥80% adherence to twice-weekly use during the RAI-associated gel regimen, 75% having perfect adherence and 77% having ≥80% adherence to gel use before and after RAI. Only 4.4% of all daily product PK results were undetectable and unexpected (TFV concentrations <0.31 ng/mL) given self-reported product use near sampling date. The mixed methods adherence measurement indicated high adherence to product use in all three regimens. Adherence to RAI-associated rectal gel use was as high as adherence to daily oral PrEP. A rectal microbicide gel, if efficacious, could be an alternative for individuals uninterested in daily oral PrEP. |
Improving patient safety through antibiotic stewardship: The Veterans Health Administration leads the way, again
Srinivasan A , Davidson LE . Infect Control Hosp Epidemiol 2017 38 (5) 521-523 The Veterans Health Administration (VHA) has demonstrated national leadership in infection control, achieving impressive reductions in methicillin-resistant Staphylococcus aureus Reference Jain, Kralovic and Evans1 and Clostridium difficile infection.Reference Evans, Kralovic and Simbartl 2 Now the VHA has done it again, this time for antibiotic stewardship. | The critical importance of improving antibiotic use is not a subject of debate. The United Nations discussed antibiotic use and resistance during its General Assembly meeting in September 2015; it was only the fourth time that the full General Assembly has discussed a health issue. 3 In 2014, the United States issued a National Strategy and National Action Plan for Combating Antibiotic Resistant Bacteria. These documents lay out aggressive efforts to stem the tide of antibiotic resistance, and they feature improved antibiotic use as a core approach. 4 | For too long, however, antibiotic stewardship has been viewed as a means to promote a societal good—the reduction of resistance. While the societal good from reducing antibiotic resistance is both real and important, the discussion loses sight of the fact that improving antibiotic use through stewardship has benefits to individual patients at the point of care. Published studies demonstrate that hospital-based antibiotic stewardship programs protect patients from Clostridium difficile infections, adverse drug events, and antibiotic-resistant superinfections during a hospital stay.Reference Dellit, Owens and McGowan 5 Most importantly, in an era of antibiotic resistance and a patient population that is sicker and more complex than ever, antibiotic stewardship programs can help providers choose the optimal treatments to improve the chance of a cure.Reference Gross, Morgan and Kinky 6 |
MTN-017: A rectal phase 2 extended safety and acceptability study of tenofovir reduced-glycerin 1% gel
Cranston RD , Lama JR , Richardson BA , Carballo-Dieguez A , Kunjara Na Ayudhya RP , Liu K , Patterson KB , Leu CS , Galaska B , Jacobson CE , Parikh UM , Marzinke MA , Hendrix CW , Johnson S , Piper JM , Grossman C , Ho KS , Lucas J , Pickett J , Bekker LG , Chariyalertsak S , Chitwarakorn A , Gonzales P , Holtz TH , Liu AY , Mayer KH , Zorrilla C , Schwartz JL , Rooney J , McGowan I . Clin Infect Dis 2016 64 (5) 614-620 BACKGROUND: HIV disproportionately affects men who have sex with men (MSM) and transgender women (TGW). Safe and acceptable topical HIV prevention methods that target the rectum are needed. METHODS: MTN-017 was a Phase 2, three-period, randomized sequence, open-label, expanded safety and acceptability crossover study comparing rectally applied reduced-glycerin (RG) 1% tenofovir (TFV) and oral emtricitabine/TFV disoproxil fumarate (FTC/TDF). In each 8-week study period participants were randomized to RG-TFV rectal gel daily; or RG-TFV rectal gel before and after receptive anal intercourse (RAI) (or at least twice weekly in the event of no RAI); or daily oral FTC/TDF. RESULTS: MSM and TGW (n=195) were enrolled from 8 sites in the United States, Thailand, Peru, and South Africa with mean age of 31.1 years (range 18-64). There were no differences in Grade 2 or higher adverse event rates in participants using daily gel (Incidence Rate Ratio (IRR): 1.09, p=0.59) or RAI gel (IRR: 0.90, p=0.51) compared to FTC/TDF. High adherence (≥80% of prescribed doses as assessed by unused product return and SMS reports) was less likely in the daily gel regimen (Odds Ratio (OR): 0.35, p<0.001) and participants reported less likelihood of future daily gel use for HIV protection compared to FTC/TDF (OR: 0.38, p<0.001). CONCLUSIONS: Rectal application of RG TFV gel was safe in MSM and TGW. Adherence and product use likelihood were similar for the intermittent gel and daily oral FTC/TDF regimens, but lower for the daily gel regimen. |
A picture is worth a thousand words: maps of HIV indicators to inform research, programs, and policy from NA-ACCORD and CCASAnet clinical cohorts
Althoff KN , Rebeiro PF , Hanna DB , Padgett D , Horberg MA , Grinsztejn B , Abraham AG , Hogg R , Gill MJ , Wolff MJ , Mayor A , Rachlis A , Williams C , Sterling TR , Kitahata MM , Buchacz K , Thorne JE , Cesar C , Cordero FM , Rourke SB , Sierra-Madero J , Pape JW , Cahn P , McGowan C . J Int AIDS Soc 2016 19 (1) 20707 INTRODUCTION: Maps are powerful tools for visualization of differences in health indicators by geographical region, but multi-country maps of HIV indicators do not exist, perhaps due to lack of consistent data across countries. Our objective was to create maps of four HIV indicators in North, Central, and South American countries. METHODS: Using data from the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) and the Caribbean, Central, and South America network for HIV epidemiology (CCASAnet), we mapped median CD4 at presentation for HIV clinical care, proportion retained in HIV primary care, proportion prescribed antiretroviral therapy (ART), and the proportion with suppressed plasma HIV viral load (VL) from 2010 to 2012 for North, Central, and South America. The 15 Canadian and US clinical cohorts and 7 clinical cohorts in Argentina, Brazil, Chile, Haiti, Honduras, Mexico, and Peru represented approximately 2-7% of persons known to be living with HIV in these countries. RESULTS: Study populations were selected for each indicator: median CD4 at presentation for care was estimated among 14,811 adults; retention was estimated among 87,979 adults; ART use was estimated among 84,757 adults; and suppressed VL was estimated among 51,118 adults. Only three US states and the District of Columbia had a median CD4 at presentation >350 cells/mm3. Haiti, Mexico, and several states had >85% retention in care; lower (50-74%) retention in care was observed in the US West, South, and Mid-Atlantic, and in Argentina, Brazil, and Peru. ART use was highest (90%) in Mexico. The percentages of patients with suppressed VL in the US South and Northeast were lower than in most of Central and South America. CONCLUSIONS: These maps provide visualization of gaps in the quality of HIV care and allow for comparison between and within countries as well as monitoring policy and programme goals within geographical boundaries. |
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