Last data update: Apr 29, 2024. (Total: 46658 publications since 2009)
Records 1-28 (of 28 Records) |
Query Trace: Mugavero K [original query] |
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Advancing healthy food service in the United States: State food service guidelines policy adoption and implementation supports, 2015-2019
Lowry-Warnock A , Strombom N , Mugavero K , Harris D , Blanck HM , Onufrak S . Am J Health Promot 2022 37 (3) 8901171221123311 PURPOSE: Food service guidelines (FSG) policies can impact the nutritional quality of millions of meals sold or served to government employees, citizens in public places, or institutionalized persons. This study examines state FSG policies adopted January 1, 2015 to April 1, 2019, and uses a FSG Classification Tool (FSG Tool) to quantify alignment with nutrition recommendations for public health impact. DESIGN: Quantitative Content Analysis. SETTING: State Government Worksites and Facilities. PARTICIPANTS: 50 states and District of Columbia (D.C.) in the United States. MEASURES: Frequency of policies and percent alignment to FSG tool. ANALYSIS: FSG policies were identified using legal databases to assess state statutes, regulations, and executive orders. Content analysis and coding determined attributes of policies across 4 FSG Tool domains, (1) nutrition standards referenced; (2) behavioral design strategies encouraging selection of healthier offerings; (3) facility efficiency and environmental sustainability; and (4) FSG implementation supports. RESULTS: From 2015-2019, 5 FSG policies met study inclusion criteria. Four out of 5 policies earned a perfect nutrition score (100%) by referencing nutrition standards that align with the Dietary Guidelines for Americans (DGA) and are operationalized for use in food service venues. Four out of 5 policies included at least 1 implementation supports provision, such as naming an implementing agency, and 2 included provisions that encourage local food sourcing. CONCLUSION: From 2015-2019, overall FSG policy comprehensiveness scores ranged from 24% to 73%, with most policies referencing food and nutrition standards that align to national nutrition recommendations. Public health practitioners can educate decision makers on the potential impact of FSG policies on diet-related health outcomes and associated cost savings, as well as other important co-benefits that support locally grown products and environmental sustainability practices. |
Temporal and geographic variability in time from HIV diagnosis to viral suppression in Alabama, 2012-2014
Batey DS , Dong X , Rogers RP , Merriweather A , Elopre L , Rana AI , Hall HI , Mugavero MJ . JMIR Public Health Surveill 2020 6 (2) e17217 BACKGROUND: Evaluation of the time from HIV diagnosis to viral suppression (VS) captures the collective effectiveness of HIV prevention and treatment activities in a given locale and provides a more global estimate of how effectively the larger HIV care system is working in a given geographic area or jurisdiction. OBJECTIVE: To evaluate temporal and geographic variability in VS among persons with newly diagnosed HIV infection in Alabama in 2012-2014. METHODS: With data from the National HIV Surveillance System, we evaluated median time from HIV diagnosis to VS (<200 c/mL) overall and stratified by Alabama public health area (PHA) among persons with HIV diagnosed during 2012-2014 using the Kaplan-Meier approach. RESULTS: Among 1,979 newly diagnosed persons, 1,181 (59.7%) achieved VS within 12 months of diagnosis; 52.6% in 2012, 59.5% in 2013, and 66.9% in 2014. Median time from HIV diagnosis to VS was 8 months; 10 months in 2012, 8 months in 2013, and 6 months in 2014. Across 11 PHAs in Alabama, 12-month VS ranged from 45.8% to 83.9%, and median time from diagnosis to VS ranged from five to 13 months. CONCLUSIONS: Temporal improvement in persons achieving VS following HIV diagnosis statewide in Alabama is encouraging. However, considerable geographic variability warrants further evaluation to inform public health action. Time from HIV diagnosis to VS represents a meaningful indicator that can be incorporated into public health surveillance and programming. CLINICALTRIAL: |
Are missed- and kept-visit measures capturing different aspects of retention in HIV primary care
Batey DS , Kay ES , Westfall AO , Zinski A , Drainoni ML , Gardner LI , Giordano T , Keruly J , Rodriguez A , Wilson TE , Mugavero MJ . AIDS Care 2019 32 (1) 1-6 The literature recognizes six measures of retention in care, an integral component of the HIV Continuum of Care. Given prior research showing that different retention measures are differentially associated with HIV health outcomes (e.g., CD4 count and viral suppression), we hypothesized that different groups of people living with HIV (PLWH) would also have differential retention outcomes based on the retention measure applied. We conducted a cross-sectional analysis of multisite patient-level medical record data (n = 10,053) from six academically-affiliated HIV clinics using six different measures of retention. Principal component analysis indicated two distinct retention constructs: kept-visit-measures and missed-visit measures. Although black (compared to white) PLWH had significantly poorer retention on the three missed-visit measures, race was not significantly associated with any of the three kept-visit measures. Males performed significantly worse than females on all kept-visit measures, but sex differences were not observed for any missed-visit retention measures. IDU risk transmission group and younger age were associated with poorer retention on both missed- and kept-visit retention measures. Missed- and kept-visit measures may capture different aspects of retention, as indicated in the observed differential associations among race, sex, age, and risk transmission group. Multiple measures are needed to effectively assess retention across patient subgroups. |
Viral suppression among persons in HIV care in the United States during 2009-2013: sampling bias in Medical Monitoring Project surveillance estimates
Bradley H , Althoff KN , Buchacz K , Brooks JT , Gill MJ , Horberg MA , Kitahata MM , Marconi V , Mayer KH , Mayor A , Moore R , Mugavero M , Napravnik S , Paz-Bailey G , Prejean J , Rebeiro PF , Rentsch CT , Shouse RL , Silverberg MJ , Sullivan PS , Thorne JE , Yehia B , Rosenberg ES . Ann Epidemiol 2018 31 3-7 PURPOSE: To assess sampling bias in national viral suppression (VS) estimates derived from the Medical Monitoring Project (MMP) resulting from use of an abbreviated (four-month) annual sampling period. We aimed to improve VS estimates using cohort data from the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) and a novel cohort-adjustment method. METHODS: Using full calendar years of NA-ACCORD data, we assessed timing of HIV care attendance (inside vs. exclusively outside MMP's four-month sampling period), VS status at last test (<200 vs. >/=200 copies/mL), and associated demographics. These external estimates were used to standardize MMP to NA-ACCORD data with multivariable regression models of care attendance and VS, yielding adjusted 2009-2013 VS estimates with 95% confidence intervals. RESULTS: Weighted percentages of VS among persons in HIV care were 67% in 2009 and 77% in 2013. These estimates are slightly lower than previously published MMP estimates (72% and 80% in 2009 and 2013, respectively). The number of persons receiving HIV care was previously underestimated by 20%, because patients receiving care exclusively outside the MMP sampling period did not contribute toward the weighted population estimate. CONCLUSIONS: Careful examination of national surveillance estimates using data triangulation and novel methodologies can improve the robustness of VS estimates. |
Impact of abstinence and of reducing illicit drug use without abstinence on HIV viral load
Nance RM , Trejo MEP , Whitney BM , Delaney JAC , Altice F , Beckwith CG , Chander G , Chandler R , Christopoulous K , Cunningham C , Cunningham WE , Del Rio C , Donovan D , Eron JJ , Fredericksen RJ , Kahana S , Kitahata MM , Kronmal R , Kuo I , Kurth A , Mathews WC , Mayer KH , Moore RD , Mugavero MJ , Ouellet LJ , Quan VM , Saag MS , Simoni JM , Springer S , Strand L , Taxman F , Young JD , Crane HM . Clin Infect Dis 2019 70 (5) 867-874 BACKGROUND: Substance use is common among people living with HIV (PLWH) and a barrier to achieving viral suppression. OBJECTIVE: Among PLWH who report illicit drug use, we evaluated associations between HIV viral load (VL) and reduced use of illicit opioids, methamphetamine/crystal, cocaine/crack, and marijuana, regardless of whether or not abstinence was achieved. DESIGN: Longitudinal cohort studySetting/participantsPLWH in clinical care at 8 HIV clinics or 5 clinical studies. MEASUREMENTS: We used joint longitudinal and survival models to examine the impact of decreasing drug use and of abstinence for each drug on viral suppression. We repeated analyses using linear mixed models to examine associations between change in frequency of drug use and VL. RESULTS: The number of PLWH who were using each drug at baseline ranged from n=568 (illicit opioids) to n=4272 (marijuana). Abstinence was associated with higher odds of viral suppression (OR 1.4-2.2) and lower relative VL (ranging from 21-42% by drug) for all four drug categories. Reducing frequency of illicit opioid or methamphetamine/crystal use without abstinence was associated with VL suppression (OR 2.2, 1.6 respectively). Reducing frequency of illicit opioid or methamphetamine/crystal use without abstinence was associated with lower relative VL (47%, 38% respectively). LIMITATIONS: Observational data have limitations with causal inference. CONCLUSIONS: Abstinence was associated with viral suppression. In addition, reducing use of illicit opioids or methamphetamine/crystal, even without abstinence, was also associated with viral suppression. Findings highlight the impact of reducing substance use even when abstinence is not achieved and the potential benefits of medications, behavioral interventions, and harm-reduction interventions. |
Virologic suppression and CD4 cell count recovery after initiation of raltegravir- or efavirenz- containing HIV treatment regimens
Edwards JK , Cole SR , Hall HI , Mathews WC , Moore RD , Mugavero MJ , Eron JJ . AIDS 2017 32 (2) 261-266 OBJECTIVE: To explore the effectiveness of raltegravir-based antiretroviral therapy (ART) on treatment response among ART-naive patients seeking routine clinical care. DESIGN: Cohort study of adults enrolled in HIV care in the United States. METHODS: We compared virologic suppression and CD4 cell count recovery over a 2.5 year period after initiation of an ART regimen containing raltegravir or efavirenz using observational data from a US clinical cohort, generalized to the US population of people with diagnosed HIV. We accounted for nonrandom treatment assignment, informative censoring, and nonrandom selection from the US target population using inverse probability weights. RESULTS: Of the 2843 patients included in the study, 2476 initiated the efavirenz-containing regimen and 367 initiated the raltegravir-containing regimen. In the weighted intent-to-treat analysis, patients spent an average of 74 (95% CI: 41, 106) additional days alive with a suppressed viral load on the raltegravir regimen than on the efavirenz regimen over the 2.5-year study period. CD4 cell count recovery was also superior under the raltegravir regimen. CONCLUSIONS: Patients receiving raltegravir spent more time alive and suppressed than patients receiving efavirenz, but the probability of viral suppression by 2.5 years after treatment was similar between groups. Optimizing the amount of time spent in a state of viral suppression is important to improve survival among people living with HIV and to reduce onward transmission. |
Characterising HIV transmission risk among US patients with HIV in care: a cross-sectional study of sexual risk behaviour among individuals with viral load above 1500 copies/mL
Stirratt MJ , Marks G , O'Daniels C , Cachay ER , Sullivan M , Mugavero MJ , Dhanireddy S , Rodriguez AE , Giordano TP . Sex Transm Infect 2017 94 (3) 206-211 OBJECTIVES: Viral load and sexual risk behaviour contribute to HIV transmission risk. High HIV viral loads present greater transmission risk than transient viral 'blips' above an undetectable level. This paper therefore characterises sexual risk behaviour among patients with HIV in care with viral loads>1500 copies/mL and associated demographic characteristics. METHODS: This cross-sectional study was conducted at six HIV outpatient clinics in USA. The study sample comprises 1315 patients with HIV with a recent viral load >1500 copies/mL. This study sample was drawn from a larger sample of individuals with a recent viral load >1000 copies/mL who completed a computer-assisted self-interview (CASI) regarding sexual risk practices in the last 2 months. The study sample was 32% heterosexual men, 38% men who have sex with men (MSM) and 30% women. RESULTS: Ninety per cent of the sample had their viral load assay within 60 days of the CASI. Thirty-seven per cent reported being sexually active (vaginal or anal intercourse) in the last 2 months. Most of the sexually active participants reported always using condoms (56.9%) or limiting condomless sex to seroconcordant partners (serosorting; 29.2% overall and 42.9% among MSM). Among sexually active participants who reported condomless anal or vaginal sex with an at-risk partner (14%), most had viral loads>10 000 copies/mL (62%). CONCLUSIONS: A relatively small number of patients with HIV in care with viral loads above 1500 copies/mL reported concurrent sexual transmission risk behaviours. Most of the individuals in this small group had markedly elevated viral loads, increasing the probability of transmission. Directing interventions to patients in care with high viral loads and concurrent risk behaviour could strengthen HIV prevention and reduce HIV infections. TRIAL REGISTRATION NUMBER: NCT02044484, completed. |
Cancer-attributable mortality among people with treated human immunodeficiency virus infection in North America
Engels EA , Yanik EL , Wheeler W , Gill MJ , Shiels MS , Dubrow R , Althoff KN , Silverberg MJ , Brooks JT , Kitahata MM , Goedert JJ , Grover S , Mayor AM , Moore RD , Park LS , Rachlis A , Sigel K , Sterling TR , Thorne JE , Pfeiffer RM , Benson CA , Bosch RJ , Kirk GD , Boswell S , Mayer KH , Grasso C , Hogg RS , Harrigan PR , Montaner JSG , Yip B , Zhu J , Salters K , Gabler K , Buchacz K , Gebo KA , Carey JT , Rodriguez B , Horberg MA , Rabkin C , Jacobson LP , D'Souza G , Klein MB , Rourke SB , Rachlis AR , Globerman J , Kopansky-Giles M , Hunter-Mellado RF , Deeks SG , Martin JN , Patel P , Saag MS , Mugavero MJ , Willig J , Eron JJ , Napravnik S , Crane HM , Drozd DR , Haas D , Rebeiro P , Turner M , Bebawy S , Rogers B , Justice AC , Fiellin D , Gange SJ , Anastos K , McKaig RG , Freeman AM , Lent C , Van Rompaey SE , Morton L , McReynolds J , Lober WB , Abraham AG , Lau B , Zhang J , Jing J , Modur S , Wong C , Hogan B , Desir F , Liu B , You B . Clin Infect Dis 2017 65 (4) 636-643 Background Cancer remains an important cause of morbidity and mortality in people with human immunodeficiency virus (PWHIV) on effective antiretroviral therapy (ART). Estimates of cancer-attributable mortality can inform public health efforts. Methods We evaluated 46956 PWHIV receiving ART in North American HIV cohorts (1995-2009). Using information on incident cancers and deaths, we calculated population-attributable fractions (PAFs), estimating the proportion of deaths due to cancer. Calculations were based on proportional hazards models adjusted for age, sex, race, HIV risk group, calendar year, cohort, CD4 count, and viral load. Results There were 1997 incident cancers and 8956 deaths during 267145 person-years of follow-up, and 11.9% of decedents had a prior cancer. An estimated 9.8% of deaths were attributable to cancer (cancer-attributable mortality rate 327 per 100000 person-years). PAFs were 2.6% for AIDS-defining cancers (ADCs, including non-Hodgkin lymphoma, 2.0% of deaths) and 7.1% for non-AIDS-defining cancers (NADCs: lung cancer, 2.3%; liver cancer, 0.9%). PAFs for NADCs were higher in males and increased strongly with age, reaching 12.5% in PWHIV aged 55+ years. Mortality rates attributable to ADCs and NADCs were highest for PWHIV with CD4 counts <100 cells/mm 3. PAFs for NADCs increased during 1995-2009, reaching 10.1% in 2006-2009. Conclusions Approximately 10% of deaths in PWHIV prescribed ART during 1995-2009 were attributable to cancer, but this fraction increased over time. A large proportion of cancer-attributable deaths were associated with non-Hodgkin lymphoma, lung cancer, and liver cancer. Deaths due to NADCs will likely grow in importance as AIDS mortality declines and PWHIV age. |
Incident AIDS or death after initiation of human immunodeficiency virus treatment regimens including raltegravir or efavirenz among adults in the United States
Cole SR , Edwards JK , Hall HI , Brookhart MA , Mathews WC , Moore RD , Crane HM , Kitahata MM , Mugavero MJ , Saag MS , Eron JJ . Clin Infect Dis 2017 64 (11) 1591-1596 Background.: The long-term effectiveness of human immunodeficiency virus (HIV) treatments containing integrase inhibitors is unknown. Methods.: We use observational data from the Centers for AIDS Research Network of Integrated Clinical Systems and the Centers for Disease Control and Prevention to estimate 4-year risk of AIDS and all-cause mortality among 415 patients starting a raltegravir regimen compared to 2646 starting an efavirenz regimen (both regimens include emtricitabine and tenofovir disoproxil fumarate). We account for confounding and selection bias as well as generalizability by standardization for measured variables, and present both observational intent-to-treat and per-protocol estimates. Results.: At treatment initiation, 12% of patients were female, 36% black, 13% Hispanic; median age was 37 years, CD4 count 321 cells/microL, and viral load 4.5 log10 copies/mL. Two hundred thirty-five patients incurred an AIDS-defining illness or died, and 741 patients left follow-up. After accounting for measured differences, the 4-year risk was similar among those starting both regimens (ie, intent-to treat hazard ratio [HR], 0.96 [95% confidence interval {CI}, .63-1.45]; risk difference, -0.9 [95% CI, -4.5 to 2.7]), as well as among those remaining on regimens (ie, per-protocol HR, 0.95 [95% CI, .59-1.54]; risk difference, -0.5 [95% CI, -3.8 to 2.9]). Conclusions.: Raltegravir and efavirenz-based initial antiretroviral therapy have similar 4-year clinical effects. Vigilance regarding longer-term comparative effectiveness of HIV regimens using observational data is needed because large-scale experimental data are not forthcoming. |
Sodium intake among US school-aged children: National Health and Nutrition Examination Survey, 2011-2012
Quader ZS , Gillespie C , Sliwa SA , Ahuja JK , Burdg JP , Moshfegh A , Pehrsson PR , Gunn JP , Mugavero K , Cogswell ME . J Acad Nutr Diet 2017 117 (1) 39-47.e5 BACKGROUND: Identifying current major dietary sources of sodium can enhance strategies to reduce excess sodium intake, which occurs among 90% of US school-aged children. OBJECTIVE: To describe major food sources, places obtained, and eating occasions contributing to sodium intake among US school-aged children. DESIGN: Cross-sectional analysis of data from the 2011-2012 National Health and Nutrition Examination Survey. PARTICIPANTS/SETTING: A nationally representative sample of 2,142 US children aged 6 to 18 years who completed a 24-hour dietary recall. MAIN OUTCOME MEASURES: Population proportions of sodium intake from major food categories, places, and eating occasions. STATISTICAL ANALYSES PERFORMED: Statistical analyses accounted for the complex survey design and sampling. Wald F tests and t tests were used to examine differences between subgroups. RESULTS: Average daily sodium intake was highest among adolescents aged 14 to 18 years (3,565+/-120 mg), lowest among girls (2,919+/-74 mg). Little variation was seen in average intakes or the top five sodium contributors by sociodemographic characteristics or weight status. Ten food categories contributed to almost half (48%) of US school-aged children's sodium intake, and included pizza, Mexican-mixed dishes, sandwiches, breads, cold cuts, soups, savory snacks, cheese, plain milk, and poultry. More than 80 food categories contributed to the other half of children's sodium intake. Foods obtained from stores contributed 58% of sodium intake, fast-food/pizza restaurants contributed 16%, and school cafeterias contributed 10%. Thirty-nine percent of sodium intake was consumed at dinner, 31% at lunch, 16% from snacks, and 14% at breakfast. CONCLUSIONS: With the exception of plain milk, which naturally contains sodium, the top 10 food categories contributing to US schoolchildren's sodium intake during 2011-2012 comprised foods in which sodium is added during processing or preparation. Sodium is consumed throughout the day from multiple foods and locations, highlighting the importance of sodium reduction across the US food supply. |
Durable viral suppression and transmission risk potential among persons with diagnosed HIV infection: United States, 2012-2013
Crepaz N , Tang T , Marks G , Mugavero MJ , Espinoza L , Hall HI . Clin Infect Dis 2016 63 (7) 976-83 BACKGROUND: To examine durable viral suppression, cumulative viral load (VL) burden, and transmission risk potential among HIV-diagnosed persons in care. METHODS: Using data from the National HIV Surveillance System from 17 jurisdictions with complete reporting of VL test results, we determined the percentage of persons in HIV care who achieved durable viral suppression (all VL results <200 copies/mL) and examined viremia copy-years and time spent above VL levels that increase the risk of HIV transmission during 2012-2013. RESULTS: Of 265,264 persons in HIV care in 2011, 238,641 had at least two VLs in 2012-2013. The median number of VLs per individual during the 2-year period was five. Approximately 62% had durable viral suppression. The remaining 38% had high VL burden (geometric mean of viremia copy-years: 7,261) and spent an average of 438 days, 316 days, and 215 days (60%, 43.2%, and 29.5% of the 2-year time) above 200, 1,500, and 10,000 copies/mL. Women, blacks/African Americans, Hispanics/Latinos, persons with HIV infection attributed to transmission other than male-to-male sexual contact, younger age groups, and persons with gaps in care had higher viral burden and transmission risk potential. CONCLUSIONS: Two-thirds of persons in HIV care had durable viral suppression during a 2-year period. One-third had high VL burden and spent substantial time above VL levels with increased risk of onward transmission. More intervention efforts are needed to improve retention in care and medication adherence so that more persons in HIV care achieve durable viral suppression. |
Dietary sodium and cardiovascular disease risk - measurement matters
Cogswell ME , Mugavero K , Bowman BA , Frieden TR . N Engl J Med 2016 375 (6) 580-6 Hypertension is a common and major risk factor for the leading U.S. killer, cardiovascular disease. Reducing excess dietary sodium can lower blood pressure, with a greater response among persons with hypertension. Nine of 10 Americans consume excess dietary sodium, defined as more than 2300 mg per day. Many leading medical and public health organizations recommend reducing dietary sodium to a maximum of 2300 mg per day on the basis of evidence indicating a public health benefit. Yet this benefit has been questioned, mainly on the basis of studies suggesting that low sodium intake is also associated with an increased risk of cardiovascular disease. In science, conflicting evidence from studies with methods of different strengths is not uncommon. Studies that measure sodium intake vary widely in their methods and should be judged accordingly. Accurate measurement matters. Paradoxical findings based on inaccurate sodium measurements should not stall efforts to improve the food environment in ways that enable consumers to reduce excess sodium intake. Gradual, stepwise sodium reduction, as recommended by the Institute of Medicine, remains an achievable, effective, and important public health strategy to prevent tens of thousands of heart attacks and strokes and save billions of dollars in health care costs annually. |
Single Viral Load Measurements Overestimate Stable Viral Suppression among HIV Patients in Care: Clinical and Public Health Implications
Marks G , Patel U , Stirratt MJ , Mugavero MJ , Mathews WC , Giordano TP , Crepaz N , Gardner LI , Grossman C , Davila J , Sullivan M , Rose CE , O'Daniels C , Rodriguez A , Wawrzyniak AJ , Golden MR , Dhanireddy S , Ellison J , Drainoni ML , Metsch LR , Cachay ER . J Acquir Immune Defic Syndr 2016 73 (2) 205-12 BACKGROUND: The HIV continuum of care paradigm uses a single viral load test per patient to estimate the prevalence of viral suppression. We compared this single-value approach with approaches that used multiple viral load tests to examine stability of suppression. METHODS: The retrospective analysis included HIV patients who had at least two viral load tests during a 12-month observation period. We assessed (1) percent with suppressed viral load (<200 copies/ml) based on a single test during observation; (2) percent with suppressed viral loads on all tests during observation; (3) percent who maintained viral suppression among patients whose first observed viral load was suppressed; and (4) change in viral suppression status comparing first with last measurement occasions. Prevalence ratios compared demographic and clinical subgroups. RESULTS: Of 10,942 patients, 78.5% had a suppressed viral load based on a single test, whereas 65.9% were virally suppressed on all tests during observation. Of patients whose first observed viral load was suppressed, 87.5% were suppressed on all subsequent tests in next 12 months. More patients exhibited improving status (13.3% went from unsuppressed to suppressed) than worsening status (5.6% went from suppressed to unsuppressed). Stable suppression was less likely among women, younger patients, black patients, those recently diagnosed with HIV, and patients who missed ≥1 scheduled clinic visits. CONCLUSIONS: Using single viral load measurements overestimated the percent of HIV patients with stable suppressed viral load by 16% (relative difference). Targeted clinical interventions are needed to increase the percent of patients with stable suppression. |
The effect of antiretroviral therapy on all-cause mortality, generalized to persons diagnosed with HIV in the USA, 2009-11
Lesko CR , Cole SR , Hall HI , Westreich D , Miller WC , Eron JJ , Li J , Mugavero MJ . Int J Epidemiol 2016 45 (1) 140-50 BACKGROUND: Although antiretroviral therapy (ART) is known to be protective against HIV-related mortality, the expected magnitude of effect is unclear because existing estimates of the effect of ART may not directly generalize to recently HIV-diagnosed persons. METHODS: In this study, we estimated 5-year mortality risks for immediate versus no ART initiation among patients (n = 12 547) in the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) using the complement of adjusted Kaplan-Meier survival functions. We subsequently standardized estimates to persons diagnosed with HIV in the USA between 2009 and 2011, who were enumerated using national surveillance data. RESULTS: The 5-year mortality, had all patients in the CNICS immediately initiated ART, was 10.6% [95% confidence interval (CI): 9.3%, 11.9%] compared with 28.3% (95% CI: 19.1%, 37.5%) had ART initiation been delayed at least 5 years. The 5-year mortality risk difference due to ART among patients in the CNICS was -17.7% (95% CI: -27.0%, -8.4%). Based on methods for generalizing an estimate from a study sample to a different target population, the expected risk difference due to ART initiation among recently HIV-diagnosed persons in the USA was -19.1% (95% CI: -30.5%, -7.8%). CONCLUSIONS: Immediate ART initiation substantially lowers mortality among persons in the CNICS and this benefit is expected to be similar among persons recently diagnosed with HIV in the USA. We demonstrate a method by which concerns about generalizability can be addressed and evaluated quantitatively. |
School-level practices to increase availability of fruits, vegetables, and whole grains, and reduce sodium in school meals - United States, 2000, 2006, and 2014
Merlo C , Brener N , Kann L , McManus T , Harris D , Mugavero K . MMWR Morb Mortal Wkly Rep 2015 64 (33) 905-908 Students consume up to half of their daily calories at school, often through the federal school meal programs (e.g., National School Lunch Program) administered by the U.S. Department of Agriculture (USDA). In 2012, USDA published new required nutrition standards for school meals.* These standards were the first major revision to the school meal programs in >15 years and reflect current national dietary guidance and Institute of Medicine recommendations to meet students' nutrition needs. The standards require serving more fruits, vegetables, and whole grains and gradually reducing sodium content over 10 years. To examine the prevalence of school-level practices related to implementation of the nutrition standards, CDC analyzed data from the 2000, 2006, and 2014 School Health Policies and Practices Study (SHPPS) on school nutrition services practices related to fruits, vegetables, whole grains, and sodium. Almost all schools offered whole grain foods each day for breakfast and lunch, and most offered two or more vegetables and two or more fruits each day for lunch. The percentage of schools implementing practices to increase availability of fruits and vegetables and decrease sodium content in school meals increased from 2000-2014. However, opportunities exist to increase the percentage of schools nationwide implementing these practices. |
The contribution of missed clinic visits to disparities in HIV viral load outcomes
Zinski A , Westfall AO , Gardner LI , Giordano TP , Wilson TE , Drainoni ML , Keruly JC , Rodriguez AE , Malitz F , Batey DS , Mugavero MJ . Am J Public Health 2015 105 (10) e1-e8 OBJECTIVES: We explored the contribution of missed primary HIV care visits ("no-show") to observed disparities in virological failure (VF) among Black persons and persons with injection drug use (IDU) history. METHODS: We used patient-level data from 6 academic clinics, before the Centers for Disease Control and Prevention and Health Resources and Services Administration Retention in Care intervention. We employed staged multivariable logistic regression and multivariable models stratified by no-show visit frequency to evaluate the association of sociodemographic factors with VF. We used multiple imputations to assign missing viral load values. RESULTS: Among 10 053 patients (mean age = 46 years; 35% female; 64% Black; 15% with IDU history), 31% experienced VF. Although Black patients and patients with IDU history were significantly more likely to experience VF in initial analyses, race and IDU parameter estimates were attenuated after sequential addition of no-show frequency. In stratified models, race and IDU were not statistically significantly associated with VF at any no-show level. CONCLUSIONS: Because missed clinic visits contributed to observed differences in viral load outcomes among Black and IDU patients, achieving an improved understanding of differential visit attendance is imperative to reducing disparities in HIV. |
Estimating the cost of increasing retention in care for HIV-infected patients: results of the CDC/HRSA Retention in Care Trial
Shrestha RK , Gardner L , Marks G , Craw J , Malitz F , Giordano TP , Sullivan M , Keruly J , Rodriguez A , Wilson TE , Mugavero M . J Acquir Immune Defic Syndr 2014 68 (3) 345-50 BACKGROUND: Retaining HIV patients in medical care promotes access to antiretroviral therapy, viral load suppression, and reduced HIV transmission to partners. We estimate the programmatic costs of a U.S. multi-site randomized controlled trial of an intervention to retain HIV patients in care. METHODS: Six academically affiliated HIV clinics randomized patients to intervention (enhanced personal contact with patients across time coupled with basic HIV education) and control (standard of care (SOC)) arms. Retention in care was defined as 4-month visit constancy, i.e., at least one primary care visit in each four-month interval over a 12-month period. We used micro-costing methods to collect unit costs, and measure the quantity of resources used to implement the intervention in each clinic. All fixed and variable labor and non-labor costs of the intervention were included. RESULTS: Visit constancy was achieved by 45.7% (280/613) of patients in the SOC arm, and by 55.8% (343/615) of patients in the intervention arm, representing an increase of 63 patients (relative improvement 22.1%; 95% CI 9%-36%, P < 0.01). The total annual cost of the intervention at the six clinics was $241,565, the average cost per patient $393, and the estimated cost per additional patient retained in care beyond SOC was $3,834. CONCLUSION: Our analyses showed that a retention in care intervention consisting of enhanced personal contact coupled with basic HIV education may be delivered at fairly low cost. These results provide useful information for guiding decisions about planning or scaling-up retention in care interventions for HIV-infected patients. |
Enhanced personal contact with HIV patients improves retention in primary care: a randomized trial in six U.S. HIV clinics
Gardner LI , Giordano TP , Marks G , Wilson TE , Craw JA , Drainoni ML , Keruly JC , Rodriguez AE , Malitz F , Moore RD , Bradley-Springer LA , Holman S , Rose CE , Girde S , Sullivan M , Metsch LR , Saag M , Mugavero MJ . Clin Infect Dis 2014 59 (5) 725-34 BACKGROUND: To determine whether enhanced personal contact with HIV-infected patients across time improves retention in care compared with existing standard of care (SOC) practices, and whether brief skills training improves retention beyond enhanced contact. METHODS: The study, conducted at 6 US HIV clinics, included 1,838 patients with a recent history of inconsistent clinic attendance, and new patients. Each clinic randomized participants to one of three arms and continued to provide SOC practices to all enrollees: Enhanced contact with interventionist (EC; brief face-to-face meeting upon returning for care visit, interim visit call, appointment reminder calls, missed visit call); EC+skills (organization, problem solving, and communication skills); or SOC-only. The intervention was delivered by project staff for 12 months following randomization. The outcomes during that 12-month period were (1) percentage of participants attending at least one primary care visit in three consecutive 4-month intervals (visit constancy), and (2) proportion of kept/scheduled primary care visits (visit adherence). RESULTS: Log-binomial risk ratios comparing intervention arms against the SOC arm demonstrated better outcomes in both the EC and EC+skills arms (visit constancy: RRs=1.22 (1.09-1.36) and 1.22 (1.09-1.36); visit adherence: RR=1.08 (1.05-1.11) and 1.06 (1.02-1.09), all ps<0.01). Intervention effects were observed in numerous patient subgroups, although lower in patients reporting unmet needs or illicit drug use. CONCLUSION: Enhanced contact with patients improved retention in HIV primary care compared to existing SOC practices. A brief patient skill-building component did not improve retention further. Additional intervention elements may be needed for patients reporting illicit drug use or who have unmet needs. |
HIV care visits and time to viral suppression, 19 U.S. jurisdictions, and implications for treatment, prevention and the national HIV/AIDS strategy
Hall HI , Tang T , Westfall AO , Mugavero MJ . PLoS One 2013 8 (12) e84318 OBJECTIVE: Early and regular care and treatment for human immunodeficiency virus (HIV) infection are associated with viral suppression, reductions in transmission risk and improved health outcomes for persons with HIV. We determined, on a population level, the association of care visits with time from HIV diagnosis to viral suppression. METHODS: Using data from 19 areas reporting HIV-related tests to national HIV surveillance, we determined time from diagnosis to viral suppression among 17,028 persons diagnosed with HIV during 2009, followed through December 2011, using data reported through December 2012. Using Cox proportional hazards models, we assessed factors associated with viral suppression, including linkage to care within 3 months of diagnosis, a goal set forth by the National HIV/AIDS Strategy, and number of HIV care visits as determined by CD4 and viral load test results, while controlling for demographic, clinical, and risk characteristics. RESULTS: Of 17,028 persons diagnosed with HIV during 2009 in the 19 areas, 76.6% were linked to care within 3 months of diagnosis and 57.0% had a suppressed viral load during the observation period. Median time from diagnosis to viral suppression was 19 months overall, and 8 months among persons with an initial CD4 count ≤350 cells/microL. During the first 12 months after diagnosis, persons linked to care within 3 months experienced shorter times to viral suppression (higher rate of viral suppression per unit time, hazard ratio [HR] = 4.84 versus not linked within 3 months; 95% confidence interval [CI] 4.27, 5.48). Persons with a higher number of time-updated care visits also experienced a shorter time to viral suppression (HR = 1.51 per additional visit, 95% CI 1.49, 1.52). CONCLUSIONS: Timely linkage to care and greater frequency of care visits were associated with faster time to viral suppression with implications for individual health outcomes and for secondary prevention. |
Integrating sodium reduction strategies in the procurement process and contracting of food venues in the County of Los Angeles government, 2010-2012
Cummings PL , Kuo T , Gase LN , Mugavero K . J Public Health Manag Pract 2014 20 S16-22 Since sodium is ubiquitous in the food supply, recent approaches to sodium reduction have focused on increasing the availability of lower-sodium products through system-level and environmental changes. This article reviews integrated efforts by the Los Angeles County Sodium Reduction Initiative to implement these strategies at food venues in the County of Los Angeles government. The review used mixed methods, including a scan of the literature, key informant interviews, and lessons learned during 2010-2012 to assess program progress. Leveraging technical expertise and shared resources, the initiative strategically incorporated sodium reduction strategies into the overall work plan of a multipartnership food procurement program in Los Angeles County. To date, 3 County departments have incorporated new or updated nutrition requirements that included sodium limits and other strategies. The strategic coupling of sodium reduction to food procurement and general health promotion allowed for simultaneous advancement and acceleration of the County's sodium reduction agenda. |
Reducing sodium across the board: a pilot program in Schenectady County independent restaurants
Schuldt J , Levings JL , Kahn-Marshall J , Hunt G , Mugavero K , Gunn JP . J Public Health Manag Pract 2014 20 S31-7 Excess sodium intake can lead to increased blood pressure. Restaurant foods contribute nearly a quarter of the sodium consumed in the American diet. The objective of the pilot project was to develop and implement in collaboration with independent restaurants a tool, the Restaurant Assessment Tool and Evaluation (RATE), to assess efforts to reduce sodium in independent restaurants and measure changes over time in food preparation categories, including menu, cooking techniques, and products. Twelve independent restaurants in Schenectady County, New York, voluntarily participated. From initial assessment to a 6-month follow-up assessment using the RATE, 11 restaurants showed improvement in the cooking category, 9 showed improvement in the menu category, and 7 showed improvement in the product category. Menu analysis conducted by the Schenectady County Health Department staff suggested that reported sodium-reduction strategies might have affected approximately 25% of the restaurant menu items. The findings from this project suggest that a facilitated assessment, such as the RATE, can provide a useful platform for independent restaurant owners and public health practitioners to discuss and encourage sodium reduction. The RATE also provides opportunities to build and strengthen relationships between public health care practitioners and independent restaurant owners, which may help sustain the positive changes made. |
Sodium reduction: an important public health strategy for heart health
Mugavero KL , Gunn JP , Dunet DO , Bowman BA . J Public Health Manag Pract 2014 20 S1-5 High intake of dietary sodium is associated with elevated blood pressure, which increases the risk of heart disease and stroke.1 Heart disease and stroke are the first and fourth leading causes of death in the United States2; from a public health perspective, this makes control of hypertension an important issue. | To address this, the Million Hearts initiative (led by the US Department of Health and Human Services), Dietary Guidelines for Americans, Healthy People 2020, and guidelines from numerous health organizations recommend reducing the amount of sodium consumed in the diet.3 Most sodium consumed by Americans comes from processed and restaurant foods. Because these sources make up a large part of the American diet and because consumers have little control over the level of sodium in these foods, it is often difficult for consumers to reduce their sodium intake.4 Many of the ingredients and food products served in schools, work sites, and group meal sites such as senior citizen centers contain high levels of sodium. Even when food purchasers and food service staff try to offer healthier food options, lower-sodium ingredients and products may not be easily available and accessible. |
Retention among North American HIV-infected persons in clinical care, 2000-2008
Rebeiro P , Althoff KN , Buchacz K , Gill MJ , Horberg M , Krentz H , Brooks JT , Gebo KA , Sterling TR , Moore R , Mugavero M , Martin J , Klein M , Hogg R , Silverberg MJ , Rourke S , Thorne J , Gange SJ . J Acquir Immune Defic Syndr 2012 62 (3) 356-62 BACKGROUND: Retention in care is key to improving HIV outcomes. Our goal was to describe "churn" in patterns of entry, exit, and retention in HIV care in the US and Canada. METHODS: Adults contributing ≥1 CD4 count or HIV-1 RNA (HIV-lab) from 2000-2008 in North American Cohort Collaboration on Research and Design (NA-ACCORD) clinical cohorts were included. Incomplete retention was defined as lack of 2 HIV-labs (≥90 days apart) within 12 months, summarized by calendar year. We used beta-binomial regression models to estimate adjusted odds ratios (OR) and 95% confidence intervals (CI) of factors associated with incomplete retention. RESULTS: Among 61,438 participants, 15,360 (25%) with incomplete retention significantly differed in univariate analyses (p<0.001) from 46,078 (75%) consistently retained by age, race/ethnicity, HIV risk, CD4, ART use, and country of care (US vs. Canada). From 2000-2004, females (OR=0.82, CI:0.70-0.95), older individuals (OR=0.78, CI:0.74-0.83 per 10 years), and ART users (OR= 0.61, CI:0.54-0.68 vs all others) were less likely to have incomplete retention, while black individuals (OR=1.31, CI:1.16-1.49, vs. white), those with injection drug use (IDU) HIV risk (OR=1.68, CI:1.49-1.89, vs. non-IDU) and those in care longer (OR=1.09, CI:1.07-1.11 per year) were more likely to have incomplete retention. Results from 2005-2008 were similar. DISCUSSION: From 2000 to 2008, 75% of the NA-ACCORD population was consistently retained in care with 25% experiencing some change in status, or churn. In addition to the programmatic and policy implications, our findings identify patient groups who may benefit from focused retention efforts. |
Reducing sodium intake at the community level: the Sodium Reduction in Communities Program
Mugavero K , Losby JL , Gunn JP , Levings JL , Lane RI . Prev Chronic Dis 2012 9 E168 Approximately 90% of Americans aged 2 years or older consume too much sodium (1). The consumption of too much sodium increases blood pressure, which increases the risk for stroke, coronary heart disease, heart failure, and renal disease (2). Population-based strategies to reduce salt intake are cost-effective, can reduce blood pressure (3), and, according to the Institute of Medicine, are needed at national, state, and community levels (2). To improve food environments and reduce sodium intake at the community level, the Centers for Disease Control and Prevention (CDC) funds the Sodium Reduction in Communities Program (SRCP). This demonstration project supports communities in creating more healthful food environments and aims to expand the evidence base for effective community strategies to address sodium intake at the population level. In this article, we describe the role of communities and environments in influencing health and strategies being implemented and evaluated by SRCP communities. |
Measuring retention in HIV care: the elusive gold standard
Mugavero MJ , Westfall AO , Zinski A , Davila J , Drainoni ML , Gardner LI , Keruly JC , Malitz F , Marks G , Metsch L , Wilson TE , Giordano TP . J Acquir Immune Defic Syndr 2012 61 (5) 574-80 BACKGROUND: Measuring retention in HIV primary care is complex as care includes multiple visits scheduled at varying intervals over time. We evaluated six commonly used retention measures in predicting viral load (VL) suppression and the correlation among measures. METHODS: Clinic-wide patient-level data from six academic HIV clinics were used for 12-months preceding implementation of the CDC/HRSA Retention in Care intervention. Six retention measures were calculated for each patient based upon scheduled primary HIV provider visits: count and dichotomous missed visits, visit adherence, 6-month gap, 4-month visit constancy, and the HRSA HAB retention measure. Spearman correlation coefficients and separate unadjusted logistic regression models compared retention measures to one another and with 12-month VL suppression, respectively. The discriminatory capacity of each measure was assessed with the c-statistic. RESULTS: Among 10,053 patients, 8,235 (82%) had 12-month VL measures, with 6,304 (77%) achieving suppression (VL<400 c/mL). All six retention measures were significantly associated (P<0.0001) with VL suppression (OR;95%CI, c-statistic): missed visit count (0.73;0.71-0.75,0.67), missed visit dichotomous (3.2;2.8-3.6,0.62), visit adherence (3.9;3.5-4.3,0.69), gap (3.0;2.6-3.3,0.61), visit constancy (2.8;2.5-3.0,0.63), HRSA HAB (3.8;3.3-4.4,0.59). Measures incorporating "no show" visits were highly correlated (Spearman coefficient=0.83-0.85), as were measures based solely upon kept visits (Spearman coefficient=0.72-0.77). Correlation coefficients were lower across these two groups of measures (Range=0.16-0.57). CONCLUSIONS: Six retention measures displayed a wide range of correlation with one another, yet each measure had significant association and modest discrimination for VL suppression. These data suggest there is no clear gold standard, and that selection of a retention measure may be tailored to context. |
U.S. trends in antiretroviral therapy use, HIV RNA plasma viral loads, and CD4 T-lymphocyte cell counts among HIV-infected persons, 2000 to 2008
Althoff KN , Buchacz K , Hall HI , Zhang J , Hanna DB , Rebeiro P , Gange SJ , Moore RD , Kitahata MM , Gebo KA , Martin J , Justice AC , Horberg MA , Hogg RS , Sterling TR , Cescon A , Klein MB , Thorne JE , Crane HM , Mugavero MJ , Napravnik S , Kirk GD , Jacobson LP , Brooks JT . Ann Intern Med 2012 157 (5) 325-335 BACKGROUND: The U.S. National HIV/AIDS Strategy targets for 2015 include "increasing access to care and improving health outcomes for persons living with HIV in the United States" (PLWH-US). OBJECTIVE: To demonstrate the utility of the NA-ACCORD (North American AIDS Cohort Collaboration on Research and Design) for monitoring trends in the HIV epidemic in the United States and to present trends in HIV treatment and related health outcomes. DESIGN: Trends from annual cross-sectional analyses comparing patients from pooled, multicenter, prospective, clinical HIV cohort studies with PLWH-US, as reported to national surveillance systems in 40 states. SETTING: U.S. HIV outpatient clinics. PATIENTS: HIV-infected adults with 1 or more HIV RNA plasma viral load (HIV VL) or CD4 T-lymphocyte (CD4) cell count measured in any calendar year from 1 January 2000 to 31 December 2008. MEASUREMENTS: Annual rates of antiretroviral therapy use, HIV VL, and CD4 cell count at death. RESULTS: 45,529 HIV-infected persons received care in an NA-ACCORD-participating U.S. clinical cohort from 2000 to 2008. In 2008, the 26,030 NA-ACCORD participants in care and the 655,966 PLWH-US had qualitatively similar demographic characteristics. From 2000 to 2008, the proportion of participants prescribed highly active antiretroviral therapy increased by 9 percentage points to 83% (P < 0.001), whereas the proportion with suppressed HIV VL (≤2.7 log10 copies/mL) increased by 26 percentage points to 72% (P < 0.001). Median CD4 cell count at death more than tripled to 0.209 x 109 cells/L (P < 0.001). LIMITATION: The usual limitations of observational data apply. CONCLUSION: The NA-ACCORD is the largest cohort of HIV-infected adults in clinical care in the United States that is demographically similar to PLWH-US in 2008. From 2000 to 2008, increases were observed in the percentage of prescribed HAART, the percentage who achieved a suppressed HIV VL, and the median CD4 cell count at death. PRIMARY FUNDING SOURCE: National Institutes of Health; Centers for Disease Control and Prevention; Canadian Institutes of Health Research; Canadian HIV Trials Network; and the government of British Columbia, Canada. |
A low-effort clinic-wide intervention improves attendance for HIV primary care
Gardner L , Marks G , Craw J , Wilson T , Drainoni ML , Moore R , Mugavero M , Rodriguez A , Bradley-Springer L , Holman S , Keruly J , Sullivan M , Skolnik P , Malitz F , Metsch L , Raper J , Giordano T . Clin Infect Dis 2012 55 (8) 1124-34 BACKGROUND: Retention in care for HIV-infected patients is a National HIV/AIDS Strategy priority. We hypothesized that retention could be improved with coordinated messages to encourage patients' clinic attendance. We report here the results of the first phase of the CDC/HRSA Retention in Care project. METHODS: Six HIV-specialty clinics participated in a cross-sectionally sampled pre-post evaluation of brochures, posters and messages that conveyed the importance of regular clinic attendance. 10,018 patients in 2008-2009 (pre-intervention period) and 11,039 patients in 2009-2010 (intervention period) were followed for clinic attendance. Outcome variables were the percentage of patients who kept two consecutive primary care visits and the mean proportion of all primary care visits kept. Stratification variables were: new, re-engaging and active patients, HIV RNA viral load, CD4+ cell count, age, gender, race/ethnicity, risk group, number of scheduled visits and clinic site. Data were analyzed by multivariable log-binomial and linear models using generalized estimation equation methods. RESULTS: Clinic attendance for primary care was significantly higher in the intervention vs. pre-intervention year. Overall relative improvement was 7.0% for keeping two consecutive visits and 3.0% for the mean proportion of all visits kept (p<0.0001). Larger relative improvement for both outcomes was observed for new or re-engaging patients, young patients and patients with elevated viral loads. Improved attendance among the new or re-engaging patients was consistent across the six clinics, and less consistent across clinics for active patients. CONCLUSION: Targeted messages on staying in care, which were delivered at minimal effort and cost, improved clinic attendance, especially for new or re-engaging patients, young patients, and those with elevated viral loads. |
The spectrum of engagement in HIV care: do more than 19% of HIV-infected persons in the US have undetectable viral load?
Marks G , Gardner LI , Craw J , Giordano TP , Mugavero MJ , Keruly JC , Wilson TE , Metsch LR , Drainoni ML , Malitz F . Clin Infect Dis 2011 53 (11) 1168-9; author's reply 1169-70 The paper by Gardner et al [1] on the spectrum of engagement in human immunodeficiency virus (HIV) care provides an important heuristic for understanding the parameters and outcomes for a successful test-and-treat strategy to reduce HIV transmission. The spectrum begins with persons infected with HIV (unaware and aware) and progresses through diagnosed, linked to care, retained in care, needing antiretroviral therapy (ART), receiving ART, and having undetectable viral load. Gardner et al estimated that 19% of HIV-infected persons in the United States have undetectable HIV RNA. | We have data that we believe help refine this estimate. First, a recently published meta-analysis found that 59% of HIV-diagnosed persons are retained in care (multiple medical visits during specified time intervals) [2], which is somewhat higher than the estimate of Gardner et al [1] of 50% retained in care. Second, we are currently conducting a study at 6 HIV outpatient clinics in the United States (Baltimore, MD; Birmingham, AL; Boston, MA; Brooklyn, NY; Houston, TX; and Miami, FL). A total of 11468 HIV-infected patients had 1 or more primary care visits from 1 October 2009 through 30 September 2010 and had a viral load laboratory result within 90 days of their most recent visit in that interval. We calculated the percentage of these patients who had suppressed viral load, using 2 thresholds that were available at all 6 clinics (<400 copies/mL and <75 copies/mL). We found that 73% of the patients had viral load of <400 copies/mL, which is consistent with data from 13 clinical cohorts participating in the North American AIDS Cohort Collaboration on Research and Design [3]. If a cut-point of <75 copies/mL was used, then 62% of the patients had viral suppression. |
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