Last data update: May 20, 2024. (Total: 46824 publications since 2009)
Records 1-30 (of 76 Records) |
Query Trace: Skarbinski J [original query] |
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SARS-CoV-2 Delta variant genomic variation associated with breakthrough infection in Northern California: A retrospective cohort study
Skarbinski J , Nugent JR , Wood MS , Liu L , Bullick T , Schapiro JM , Arunleung P , Morales C , Amsden LB , Hsiao CA , Wadford DA , Chai SJ , Reingold A , Wyman SK . J Infect Dis 2023 228 (7) 878-888 BACKGROUND: The association between SARS-CoV-2 genomic variation and breakthrough infection is not well-defined among persons with Delta variant SARS-CoV-2 infection. METHODS: In a retrospective cohort we assessed whether individual non-lineage defining mutations and overall genomic variation (including low frequency alleles) were associated with breakthrough infection defined as SARS-CoV-2 infection after COVID-19 primary vaccine series. We identified all non-synonymous single nucleotide polymorphisms, insertions and deletions in SARS-CoV-2 genomes with ≥5% allelic frequency and population frequency of ≥5% and ≤95%. Using Poisson regression, we assessed the association with breakthrough infection for each individual mutation and a viral genomic risk score. RESULTS: Thirty-six mutations met our inclusion criteria. Among 12,744 persons infected with Delta variant SARS-CoV-2, 5,949 (47%) were vaccinated and 6,795 (53%) were unvaccinated. Viruses with a viral genomic risk score in the highest quintile were 9% more likely to be associated with breakthrough infection than viruses in the lowest quintile, but including the risk score improved overall predictive model performance (measured by c-statistic) by only +0.0006. CONCLUSIONS: Genomic variation within SARS-CoV-2 Delta variant was weakly associated with breakthrough infection, however several potential non-lineage defining mutations were identified that might contribute to immune evasion by SARS-CoV-2. |
Natural Language Processing for Improved Characterization of COVID-19 Symptoms: An Observational Study of 350,000 Patients in a Large Integrated Healthcare System.
Malden DE , Tartof SY , Ackerson BK , Hong V , Skarbinski J , Yau V , Qian L , Fischer H , Shaw S , Caparosa S , Xie F . JMIR Public Health Surveill 2022 8 (12) e41529 BACKGROUND: Natural language processing (NLP) of unstructured text from Electronic Medical Records (EMR) can improve characterization of COVID-19 signs and symptoms, but large-scale studies demonstrating the real-world application and validation of NLP for this purpose are limited. OBJECTIVE: To assess the contribution of NLP when identifying COVID-19 signs and symptoms from EMR. METHODS: This study was conducted in Kaiser Permanente Southern California, a large integrated healthcare system using data from all patients with positive SARS-CoV-2 laboratory tests from March 2020 to May 2021. An NLP algorithm was developed to extract free text from EMR on 12 established signs and symptoms of COVID-19, including fever, cough, headache, fatigue, dyspnea, chills, sore throat, myalgia, anosmia, diarrhea, vomiting/nausea and abdominal pain. The proportion of patients reporting each symptom and the corresponding onset dates were described before and after supplementing structured EMR data with NLP-extracted signs and symptoms. A random sample of 100 chart-reviewed and adjudicated SARS-CoV-2 positive cases were used to validate the algorithm performance. RESULTS: A total of 359,938 patients (mean age: 40.4 years; 53% female) with confirmed SARS-CoV-2 infection were identified over the study period. The most common signs and symptoms identified through NLP-supplemented analyses were cough (61%), fever (52%), myalgia (43%), and headache (40%). The NLP algorithm identified an additional 55,568 (15%) symptomatic cases that were previously defined as asymptomatic using structured data alone. The proportion of additional cases with each selected symptom identified in NLP-supplemented analysis varied across the selected symptoms, from 29% of all records for cough, to 61% of all records with nausea or vomiting. Of 295,305 symptomatic patients, the median time from symptom onset to testing was 3 days using structured data alone, whereas the NLP-algorithm identified signs or symptoms approximately one day earlier. When validated against chart-reviewed cases, the NLP algorithm successfully identified most signs and symptoms with consistently high sensitivity (ranging from 87% to 100%) and specificity (94% to 100%). CONCLUSIONS: These findings demonstrate that NLP can identify and characterize a broad set of COVID-19 signs and symptoms from unstructured data within the EMR, with enhanced detail and timeliness compared with structured data alone. |
Population-based assessment of risks for severe COVID-19 disease outcomes.
Zerbo O , Lewis N , Fireman B , Goddard K , Skarbinski J , Sejvar JJ , Azziz-Baumgartner E , Klein NP . Influenza Other Respir Viruses 2021 16 (1) 159-165 Among approximately 4.6 million members of Kaiser Permanente Northern California, we examined associations of severe COVID-19 with demographic factors and comorbidities. As of July 23, 2021, 16 182 had been hospitalized, 2416 admitted to an ICU, and 1525 died due to COVID-19. Age was strongly associated with hospitalization, ICU admission, and death. Black persons and Hispanic ethnicity had higher risk of death compared with Whites. Among the comorbidities examined, Alzheimer's disease was associated with the highest risk for hospitalization (aHR 3.19, CI: 2.88-3.52) and death (aHR 4.04, CI: 3.32-4.91). Parkinson's disease had the second highest risk of death (aHR = 2.07, CI: 1.50-2.87). |
Methods to include persons living with HIV not receiving HIV care in the Medical Monitoring Project
Wei SC , Messina L , Hood J , Hughes A , Jaenicke T , Johnson K , Mena L , Scheer S , Udeagu CC , Wohl A , Robertson M , Prejean J , Chen M , Tang T , Bertolli J , Johnson CH , Skarbinski J . PLoS One 2019 14 (8) e0219996 The Medical Monitoring Project (MMP) is an HIV surveillance system that provides national estimates of HIV-related behaviors and clinical outcomes. When first implemented, MMP excluded persons living with HIV not receiving HIV care. This analysis will describe new case-surveillance-based methods to identify and recruit persons living with HIV who are out of care and at elevated risk for mortality and ongoing HIV transmission. Stratified random samples of all persons living with HIV were selected from the National HIV Surveillance System in five public health jurisdictions from 2012-2014. Sampled persons were located and contacted through seven different data sources and five methods of contact to collect interviews and medical record abstractions. Data were weighted for non-response and case reporting delay. The modified sampling methodology yielded 1159 interviews (adjusted response rate, 44.5%) and matching medical record abstractions for 1087 (93.8%). Of persons with both interview and medical record data, 264 (24.3%) would not have been included using prior MMP methods. Significant predictors were identified for successful contact (e.g., retention in care, adjusted Odds Ratio [aOR] 5.02; 95% Confidence Interval [CI] 1.98-12.73), interview (e.g. moving out of jurisdiction, aOR 0.24; 95% CI: 0.12-0.46) and case reporting delay (e.g. rural residence, aOR 3.18; 95% CI: 2.09-4.85). Case-surveillance-based sampling resulted in a comparable response rate to existing MMP methods while providing information on an important new population. These methods have since been adopted by the nationally representative MMP surveillance system, offering a model for public health program, research and surveillance endeavors seeking inclusion of all persons living with HIV. |
Behavioral and clinical characteristics of self-identified bisexual men living with HIV receiving medical care in the United States - Medical Monitoring Project, 2009-2013
Freedman MS , Beer L , Mattson CL , Sullivan PS , Skarbinski J . J Homosex 2019 68 (8) 1-19 Nationally representative data comparing demographic, risk, and clinical information among bisexual men with other MSM or heterosexuals are lacking. We described differences in demographic characteristics, behaviors, and clinical outcomes among self-identified HIV-positive bisexual, gay, and heterosexual men receiving HIV medical care in the United States. We analyzed data from the 2009-2013 cycles of the Medical Monitoring Project (MMP), a surveillance system that provides nationally representative estimates of behavioral and clinical characteristics of adults with diagnosed HIV in medical care. Altogether, 10% (95% confidence interval [CI] 9-11) of men self-identified as bisexual, 56% (CI 51-61) as gay, and 32% (CI 28-37) as heterosexual. We observed significant differences in demographic factors, clinical outcomes, drug use, and sexual behavior among bisexual men compared with gay and heterosexual men. Providers should consider sexual identities as well as sexual behaviors when developing and implementing prevention programs. |
Comparison of msp genotyping and a 24 SNP molecular assay for differentiating Plasmodium falciparum recrudescence from reinfection.
Fulakeza J , McNitt S , Vareta J , Saidi A , Mvula G , Taylor T , Mathanga DP , Small DS , Skarbinski J , Gutman JR , Seydel K . Malar J 2019 18 (1) 84 BACKGROUND: Current World Health Organization guidelines for conducting anti-malarial drug efficacy clinical trials recommend genotyping Plasmodium falciparum genes msp1 and msp2 to distinguish recrudescence from reinfection. A more recently developed potential alternative to this method is a molecular genotyping assay based on a panel of 24 single nucleotide polymorphism (SNP) markers. METHODS: Performance parameters of these two genotyping methods were compared using data from two recently completed drug efficacy trials. Blood samples from two anti-malarial therapeutic trials were analysed by both msp genotyping and the 24 SNP assay. Additionally, to conserve time and resources, the statistical program R was used to select the most informative SNPs for a set of unrelated Malawian samples to develop a truncated SNP-based assay for the region surrounding Blantyre, Malawi. The ability of this truncated assay to distinguish reinfection from recrudescence when compared to the full 24 SNP assay was then analysed using data from the therapeutic trials. RESULTS: A total of 360 samples were analysed; 66 for concordance of msp and SNP barcoding methodologies, and 294 for assessing the most informative of the 24 SNP markers. SNP genotyping performed comparably to msp genotyping, with only one case of disagreement among the 50 interpretable results, where the SNP assay identified the sample as reinfection and the msp typing as recrudescence. Furthermore, SNP typing was more robust; only 6% of samples were uninterpretable by SNP typing, compared to 19.7% when msp genotyping was used. For discriminating reinfection from recrudescence, a truncated 6 SNP assay was found to perform at 95.1% the accuracy of the full 24 SNP bar code. CONCLUSIONS: The use of SNP analysis has similar sensitivity to the standard msp genotyping in determining recrudescence from reinfection. Although more expensive, SNP typing is faster and less work intensive. Limiting the assay to those SNPs most informative in the geographical region of interest may further decrease the workload and the cost, making this technique a feasible and affordable alternative in drug efficacy trials. |
Prevalence and patterns of antiretroviral therapy prescription in the United States
Tie Y , Skarbinski J , Qin G , Frazier EL . Open AIDS J 2018 12 (1) 181-194 Background: The use of Antiretroviral Therapy (ART) in HIV-infected persons has proven to be effective in the reduction of risk of disease progression and prevention of HIV transmission. Objective: U.S. Antiretroviral Therapy (ART) guidelines specify recommended initial, alternative initial, and not-recommended regimens, but data on ART prescribing practices and real-world effectiveness are sparse. Methods: Nationally representative annual cross sectional survey of HIV-infected adults receiving medical care in the United States, 2009-2012 data cycles. Using data from 18,095 participants, we assessed percentages prescribed ART regimens based on medical record documentation and the associations between ART regimens and viral suppression (most recent viral load test <200 copies/ml in past year) and ART-related side effects. Results: Among HIV-infected adults receiving medical care in the United States, 91.8% were prescribed ART; median time since ART initiation to interview date was 9.8 years. The percentage prescribed ART was significantly higher in 2012 compared to 2009 (92.7% vs 88.7%; p < 0.001). Of those prescribed ART, 51.6% were prescribed recommended initial regimens, 6.1% alternative initial regimens, 29.0% not-recommended as initial regimens, and 13.4% other regimens. Overall, 79.5% achieved viral suppression and 15.7% reported side effects. Of those prescribed ART and initiated ART in the past year, 80.5% were prescribed recommended initial regimens. Conclusion: Among persons prescribed ART, the majority were prescribed recommended initial regimens. Monitoring of ART use should be continued to provide ongoing assessments of ART effectiveness and tolerability in the United States. |
Latent tuberculous infection testing among HIV-infected persons in clinical care, United States, 2010-2012
Reaves EJ , Shah NS , France AM , Morris SB , Kammerer S , Skarbinski J , Bradley H . Int J Tuberc Lung Dis 2017 21 (10) 1118-1126 SETTING: Current guidelines recommend latent tuberculous infection (LTBI) testing at the time of human immunodeficiency virus (HIV) diagnosis and annually thereafter for persons at high risk of LTBI. OBJECTIVES: To estimate LTBI testing prevalence and describe the characteristics of HIV-infected persons who would benefit from annual LTBI testing. DESIGN: We estimated the proportions of LTBI testing among a nationally representative sample of HIV-infected adults in care between 2010 and 2012, and compared the patient characteristics of those with a positive LTBI test result to those with a negative result using chi2 tests. RESULTS: Among 2772 patients, 68.8% had been tested for LTBI at least once since HIV diagnosis, and 39.4% had been tested during the previous 12 months. Among patients tested at least once, 6.9% tested positive, 80.7% tested negative, and 12.4% had an indeterminate or undocumented result. Patients with a positive test were significantly more likely to be foreign-born, have lower educational attainment, and a household income at or below the federal poverty level. CONCLUSIONS: More than 30% of HIV-infected patients had never been tested for LTBI. Providers should test all patients for LTBI at the time of HIV diagnosis. The patient characteristics associated with a positive LTBI test result may guide provider decisions about annual testing. |
Delivery of HIV antiretroviral therapy adherence support services by HIV care providers in the United States, 2013 to 2014
Weiser J , Beer L , Brooks JT , Irwin K , West BT , Duke CC , Gremel GW , Skarbinski J . J Int Assoc Provid AIDS Care 2017 16 (6) 2325957417729754 BACKGROUND: Little is known about clinicians' adoption of recommendations of the International Association of Providers of AIDS Care and others for supporting adherence to antiretroviral therapy (ART). METHODS: We surveyed a probability sample of US HIV care providers to estimate the percentage offering 3 ART adherence support services to most or all patients and assessed the characteristics of providers offering all 3 services (comprehensive support) to most or all patients. RESULTS: Almost all providers (95.5%) discussed ART adherence at every visit, 60.1% offered advice about tools to increase adherence, 53.5% referred nonadherent patients for supportive services, and 42.8% provided comprehensive support. Nurse practitioners were more likely to offer comprehensive support as were providers who practiced at Ryan White HIV/AIDS Program-funded facilities, provided primary care, or started caring for HIV-infected patients within 10 years. CONCLUSION: Less than half of HIV care providers offered comprehensive ART adherence support. Certain subgroups may benefit from interventions to increase delivery of adherence support. |
Antiretroviral prescription and viral suppression in a representative sample of HIV-infected persons in care in four large metropolitan areas of the United States, Medical Monitoring Project, 2011 - 2013
Wohl AR , Benbow N , Tejero J , Johnson C , Scheer S , Brady K , Gagner A , Hughes A , Eberhart M , Mattson C , Skarbinski J . J Acquir Immune Defic Syndr 2017 76 (2) 158-170 BACKGROUND: Comparisons of ART prescription and viral suppression among people in HIV care across U.S. metropolitan areas are limited. 2011-2013 Medical Monitoring Project data were used to describe and compare associations between socio-demographics and ART prescription and viral suppression for persons receiving HIV care. SETTING: Chicago, Los Angeles County (LAC), Philadelphia, and San Francisco in the United States. METHODS: Bivariate and multivariable methods were used. RESULTS: The proportion of patients prescribed ART (91-93%) and virally suppressed (79-88%) was consistent although more persons were virally suppressed in San Francisco compared to the other areas, and a smaller proportion was virally suppressed in Philadelphia compared to Chicago. In the combined cohort, persons ages 30-49 (aPR=0.97, CI:0.94-0.99) were less likely than persons 50+, persons reporting non-injection drug use (aPR=0.94, CI:0.90-0.98) were less likely than non-users, and Hispanics were more likely than whites (aPR=1.04, CI:1.01-1.08) to be prescribed ART. Blacks (aPR=0.93; CI:0.87-0.99) and homeless persons (aPR=0.87; CI:0.80-0.95) were less likely to be virally suppressed in the combined cohort. In LAC, persons 30-49 were less likely than those 50+ to be prescribed ART (aPR=0.94, CI:0.90-0.98). Younger persons (18-29) (aPR=0.77; CI:0.60-0.99) and persons with less than a high school education (aPR=0.80; CI:0.67-0.95) in Philadelphia, blacks (aPR=0.90; CI:0.83-0.99) and MSW (aPR=0.89; CI:0.80-0.99) in Chicago, and homeless individuals in LAC (aPR=0.80; CI:0.67-0.94) were less likely to be virally suppressed. CONCLUSION: Data highlight the need to increase ART prescription to achieve viral suppression among younger persons, non-injection drug users, blacks, and homeless persons in U.S. metropolitan areas and underscores the importance of region-specific strategies for affected sub-groups. |
Prescribing of human immunodeficiency virus (HIV) pre-exposure prophylaxis by HIV medical providers in the United States, 2013-2014
Weiser J , Garg S , Beer L , Skarbinski J . Open Forum Infect Dis 2017 4 (1) ofx003 Background. Clinical trials have demonstrated the effectiveness of human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) for reducing HIV acquisition. Understanding how HIV care providers are prescribing PrEP is necessary to ensure success of this prevention strategy. Methods. During 2013-2014, we surveyed US HIV care providers who also provided care to HIV-negative patients. We estimated percentages who had prescribed PrEP and assessed associations between provider characteristics and PrEP prescribing. Results. An estimated 26% (95% confidence interval [CI], 20-31) had ever prescribed PrEP. Of these, 74% (95% CI, 61-87) prescribed for men who have sex with men (MSM), 30% (95% CI, 21-39) for women who have sex with men, 23% (95% CI, 9-37) for men who have sex with women, 23% (95% CI, 15-30) for uninfected partners in HIV-discordant couples trying to conceive, and 1% (95% CI, 0-2) for persons who inject drugs. The following provider characteristics were significantly associated with having prescribed PrEP: male vs female (32% vs 16%; adjusted prevalence ratio [aPR], 1.5; 95% CI, 1.0-2.2), lesbian/gay/bisexual vs heterosexual orientation (50% vs 21%; aPR, 2.0; 95% CI, 1.3-2.9), and HIV caseload (> 200, 51-200, and <50 patients, 39%, 29%, and 14%, respectively; > 200 vs <50 patients, aPR 2.4, 95% CI 1.1-5.2, and 51-200 vs <50 patients, aPR 2.2, 95% CI 1.2-4.0). Conclusions. In 2013-2014, one quarter of HIV care providers reported having prescribed PrEP, most commonly for MSM and rarely for persons who inject drugs. Lesbian/gay/bisexual providers and male providers were more likely than others to have prescribed PrEP. Additional efforts may enable more providers to prescribe PrEP to underserved clients needing the service. |
Prevalence of internalized HIV-related stigma among HIV-infected adults in care, United States, 2011-2013
Baugher AR , Beer L , Fagan JL , Mattson CL , Freedman M , Skarbinski J , Shouse RL . AIDS Behav 2017 21 (9) 2600-2608 HIV-infected U.S. adults have reported internalized HIV-related stigma; however, the national prevalence of stigma is unknown. We sought to determine HIV-related stigma prevalence among adults in care, describe which socio-demographic groups bear the greatest stigma burden, and assess the association between stigma and sustained HIV viral suppression. The Medical Monitoring Project measures characteristics of U.S. HIV-infected adults receiving care using a national probability sample. We used weighted data collected from June 2011 to May 2014 and assessed self-reported internalized stigma based on agreement with six statements. Overall, 79.1% endorsed ≥1 HIV-related stigma statements (n = 13,841). The average stigma score was 2.4 (out of a possible high score of six). White males had the lowest stigma scores while Hispanic/Latina females and transgender persons who were multiracial or other race had the highest. Although stigma was associated with viral suppression, it was no longer associated after adjusting for age. Stigma was common among HIV-infected adults in care. Results suggest individual and community stigma interventions may be needed, particularly among those who are <50 years old or Hispanic/Latino. Stigma was not independently associated with viral suppression; however, this sample was limited to adults in care. Examining HIV-infected persons not in care may elucidate stigma's association with viral suppression. |
Is diabetes prevalence higher among HIV-infected individuals compared with the general population? Evidence from MMP and NHANES 2009-2010
Hernandez-Romieu AC , Garg S , Rosenberg ES , Thompson-Paul AM , Skarbinski J . BMJ Open Diabetes Res Care 2017 5 (1) e000304 BACKGROUND: Nationally representative estimates of diabetes mellitus (DM) prevalence among HIV-infected adults in the USA are lacking, and whether HIV-infected adults are at increased risk of DM compared with the general adult population remains controversial. METHODS: We used nationally representative survey (2009-2010) data from the Medical Monitoring Project (n=8610 HIV-infected adults) and the National Health and Nutrition Examination Survey (n=5604 general population adults) and fit logistic regression models to determine and compare weighted prevalences of DM between the two populations, and examine factors associated with DM among HIV-infected adults. RESULTS: DM prevalence among HIV-infected adults was 10.3% (95% CI 9.2% to 11.5%). DM prevalence was 3.8% (CI 1.8% to 5.8%) higher in HIV-infected adults compared with general population adults. HIV-infected subgroups, including women (prevalence difference 5.0%, CI 2.3% to 7.7%), individuals aged 20-44 (4.1%, CI 2.7% to 5.5%), and non-obese individuals (3.5%, CI 1.4% to 5.6%), had increased DM prevalence compared with general population adults. Factors associated with DM among HIV-infected adults included age, duration of HIV infection, geometric mean CD4 cell count, and obesity. CONCLUSIONS: 1 in 10 HIV-infected adults receiving medical care had DM. Although obesity contributes to DM risk among HIV-infected adults, comparisons to the general adult population suggest that DM among HIV-infected persons may develop at earlier ages and in the absence of obesity. |
Challenges in the evaluation of interventions to improve engagement along the HIV care continuum in the United States: A systematic review
Risher KA , Kapoor S , Daramola AM , Paz-Bailey G , Skarbinski J , Doyle K , Shearer K , Dowdy D , Rosenberg E , Sullivan P , Shah M . AIDS Behav 2017 21 (7) 2101-2123 In the United States (US), there are high levels of disengagement along the HIV care continuum. We sought to characterize the heterogeneity in research studies and interventions to improve care engagement among people living with diagnosed HIV infection. We performed a systematic literature search for interventions to improve HIV linkage to care, retention in care, reengagement in care and adherence to antiretroviral therapy (ART) in the US published from 2007-mid 2015. Study designs and outcomes were allowed to vary in included studies. We grouped interventions into categories, target populations, and whether results were significantly improved. We identified 152 studies, 7 (5%) linkage studies, 33 (22%) retention studies, 4 (3%) reengagement studies, and 117 (77%) adherence studies. 'Linkage' studies utilized 11 different outcome definitions, while 'retention' studies utilized 39, with very little consistency in effect measurements. The majority (59%) of studies reported significantly improved outcomes, but this proportion and corresponding effect sizes varied substantially across study categories. This review highlights a paucity of assessments of linkage and reengagement interventions; limited generalizability of results; and substantial heterogeneity in intervention types, outcome definitions, and effect measures. In order to make strides against the HIV epidemic in the US, care continuum research must be improved and benchmarked against an integrated, comprehensive framework. |
Barriers to universal prescribing of antiretroviral therapy by HIV care providers in the United States, 2013-2014
Weiser J , Brooks JT , Skarbinski J , West BT , Duke CC , Gremel GW , Beer L . J Acquir Immune Defic Syndr 2016 74 (5) 479-487 INTRODUCTION: HIV treatment guidelines recommend initiating ART regardless of CD4 cell (CD4) count, barring contraindications or barriers to treatment. An estimated 6% of persons receiving HIV care in 2013 were not prescribed antiretroviral therapy (ART). We examined reasons for this gap in the care continuum. METHODS: During 2013-2014, we surveyed a probability sample of HIV care providers, of whom 1,234 returned surveys (64.0% adjusted response rate). We estimated percentages of providers who followed guidelines and their characteristics, and who deferred ART prescribing for any reason. RESULTS: Barring contraindications, 71.2% of providers initiated ART regardless of CD4 count. Providers less likely to initiate had caseloads ≤ 20 vs. >200 patients (adjusted prevalence ratios [aPR] 0.69, 95% confidence interval [CI] 0.47-1.02, P=.03), practiced at non-Ryan White HIV/AIDS Program (RWHAP)-funded facilities (aPR 0.85, 95% CI 0.74-0.98, P=.02), or reported pharmaceutical assistance programs provided insufficient medication to meet patients' needs (aPR 0.79, 95% CI 0.65-0.98, P=.02). In all, 17.0% never deferred prescribing ART, 69.6% deferred for 1-10% of patients, and 13.3% deferred for >10%. Among providers who had deferred ART, 59.4% cited patient refusal as a reason in >50% of cases; 31.1% reported adherence concerns due to mental health disorders or substance abuse and 21.4% reported adherence concerns due to social problems, e.g., homelessness, as factors in >50% of cases when deferring ART. CONCLUSIONS: An estimated 29% of HIV care providers had not adopted recommendations to initiate ART regardless of CD4 count, barring contraindications or barriers to treatment. Low-volume providers and those at non-RWHAP-funded facilities were less likely to follow this guideline. Among all providers, leading reasons for deferring ART included patient refusal and adherence concerns. |
Erectile dysfunction medication prescription and condomless intercourse in HIV-infected men who have sex with men in the United States
Lin X , Mattson CL , Freedman M , Skarbinski J . AIDS Behav 2016 21 (4) 1129-1137 Using nationally representative data, we assessed the prevalence of erectile dysfunction medication (EDM) prescription, and its association with insertive condomless anal intercourse (CAI) with an HIV-serodiscordant partner among sexually-active HIV-infected men who have sex with men (MSM) receiving medical care in the United States. Overall, 14 % (95 % CI 12-16) were prescribed EDM and 21 % (95 % CI 19-23) engaged in serodiscordant CAI. MSM who were prescribed EDM were more likely to engage in insertive CAI with a serodiscordant casual partner than those not prescribed EDM after adjusting for illicit drug use before or during sex (adjusted prevalence ratio = 1.38; 95 % CI 1.01-1.88). We found no association with main partners. Only 40 % (95 % CI 36-44) of MSM prescribed EDM received risk-reduction counseling from healthcare professionals. Risk-reduction counseling should be provided at least annually to all HIV-infected persons as recommended, especially at the time of EDM prescription. |
Design and weighting methods for a nationally representative sample of HIV-infected adults receiving medical care in the United States - Medical Monitoring Project
Iachan R , Johnson C H , Harding R L , Kyle T , Saavedra P , Frazier E L , Beer L , Mattson C L , Skarbinski J . Open AIDS J 2016 10 164-81 BACKGROUND: Health surveys of the general US population are inadequate for monitoring human immunodeficiency virus (HIV) infection because the relatively low prevalence of the disease (<0.5%) leads to small subpopulation sample sizes. OBJECTIVE: To collect a nationally and locally representative probability sample of HIV-infected adults receiving medical care to monitor clinical and behavioral outcomes, supplementing the data in the National HIV Surveillance System. This paper describes the sample design and weighting methods for the Medical Monitoring Project (MMP) and provides estimates of the size and characteristics of this population. METHODS: To develop a method for obtaining valid, representative estimates of the in-care population, we implemented a cross-sectional, three-stage design that sampled 23 jurisdictions, then 691 facilities, then 9,344 HIV patients receiving medical care, using probability-proportional-to-size methods. The data weighting process followed standard methods, accounting for the probabilities of selection at each stage and adjusting for nonresponse and multiplicity. Nonresponse adjustments accounted for differing response at both facility and patient levels. Multiplicity adjustments accounted for visits to more than one HIV care facility. RESULTS: MMP used a multistage stratified probability sampling design that was approximately self-weighting in each of the 23 project areas and nationally. The probability sample represents the estimated 421,186 HIV-infected adults receiving medical care during January through April 2009. Methods were efficient (i.e., induced small, unequal weighting effects and small standard errors for a range of weighted estimates). CONCLUSION: The information collected through MMP allows monitoring trends in clinical and behavioral outcomes and informs resource allocation for treatment and prevention activities. |
Prescription of pneumocystis jiroveci pneumonia prophylaxis in HIV-infected patients
Lin X , Garg S , Mattson CL , Luo Q , Skarbinski J . J Int Assoc Provid AIDS Care 2016 15 (6) 455-458 The US treatment guidelines recommend Pneumocystis jiroveci pneumonia (PCP) prophylaxis for all HIV-infected persons with a CD4 count <200 cells/mm3 (ie, eligible for PCP prophylaxis). However, some studies suggest PCP prophylaxis may be unnecessary in virally suppressed patients. Using national data of HIV-infected adults receiving medical care in the United States during 2009 to 2012, the authors assessed the weighted percentage of eligible patients who were prescribed PCP prophylaxis and the independent association between PCP prophylaxis prescription and viral suppression. Overall, 81% of eligible patients were prescribed PCP prophylaxis. Virally suppressed eligible patients were less likely to be prescribed PCP prophylaxis (prevalence ratio: 0.84; 95% confidence interval: 0.80-0.89). Although guidelines recommend PCP prophylaxis for all eligible patients, some HIV care providers might not prescribe PCP prophylaxis to virally suppressed patients. Additional data on the risk for PCP among virally suppressed patients are needed to clarify this controversy. |
Cardiovascular disease risk prediction in the HIV outpatient study
Thompson-Paul AM , Lichtenstein KA , Armon C , Palella FJ Jr , Skarbinski J , Chmiel JS , Hart R , Wei SC , Loustalot F , Brooks JT , Buchacz K . Clin Infect Dis 2016 63 (11) 1508-1516 BACKGROUND: Cardiovascular disease (CVD) risk prediction tools are often applied to populations beyond those in which they were designed when validated tools for specific subpopulations are unavailable. METHODS: Using data from 2,283 HIV-infected adults aged ≥18 years, who were active in the HIV Outpatient Study (HOPS), we assessed performance of three commonly used CVD prediction models developed for general populations: Framingham general cardiovascular Risk Score (FRS), American College of Cardiology/American Heart Association Pooled Cohort equations (PCE), and Systematic COronary Risk Evaluation (SCORE) high-risk equation, and one model developed in HIV-infected persons: the Data Collection on Adverse Effects of Anti-HIV Drugs (D:A:D) study equation. C-statistics assessed model discrimination and the ratio of expected to observed events (E/O) and Hosmer-Lemeshow chi2 P-value assessed calibration. RESULTS: From January 2002 through September 2013, 195 (8.5%) HOPS participants experienced an incident CVD event in 15,056 person-years. The FRS demonstrated moderate discrimination and was well calibrated (C-statistic: 0.66, E/O: 1.01, P=0.89). The PCE and D:A:D risk equations demonstrated good discrimination but were less well calibrated (C-statistics: 0.71, 0.72 and E/O: 0.88, 0.80, respectively; P<0.001 for both), while SCORE performed poorly (C-statistic: 0.59, E/O: 1.72, P =0.48). CONCLUSION: Only the FRS accurately estimated risk of CVD events, while PCE and D:A:D underestimated risk. Although these models could potentially be used to rank U.S. HIV-infected individuals at higher or lower risk for CVD, the models may fail to identify substantial numbers of HIV-infected persons with elevated CVD risk who could potentially benefit from additional medical treatment. |
The association of recent incarceration and health outcomes among HIV-infected adults receiving care in the United States
Nasrullah M , Frazier E , Fagan J , Hardnett F , Skarbinski J . Int J Prison Health 2016 12 (3) 135-44 Purpose The purpose of this paper is to describe factors associated with incarceration as well as the association between recent incarceration and HIV-related sexual risk behaviors, access to insurance, healthcare utilization (emergency department (ED) and hospital use), antiretroviral therapy (ART) prescription, and viral suppression. Design/methodology/approach Using 2009-2010 data from a cross-sectional, nationally representative three-stage sample of HIV-infected adults receiving care in the USA, the authors assessed the demographic characteristics, healthcare utilization, and clinical outcomes of HIV-infected persons who had been recently incarcerated (detention for>24 hours in the past year) using bivariate analyses. The authors used multivariable logistic regression to examine associations of recent incarceration with insurance status as well as clinical and behavioral outcomes. Findings An estimated 22,949 (95 percent confidence interval (CI) 19,062-26,836) or 5.4 percent (CI: 4.7-6.1) of all HIV-infected persons receiving care were recently incarcerated. Factors associated with recent incarceration were age <50 years, being a smoker, having high school diploma or less, being homeless, income at or below the poverty guidelines, having a geometric mean of CD4 count <500 cells/ muL, and using drugs in the past 12 months. Results from multivariable modeling indicated that incarcerated persons were more likely to use ED services, and to have been hospitalized, and less likely to have achieved viral suppression. Originality/value Recent incarceration independently predicted worse health outcomes and greater use of emergency services among HIV-infected adults currently in HIV care. Options to improve the HIV continuum of care, including pre-enrollment for healthcare coverage and discharge planning, may lead to better health outcomes for HIV-infected inmates post-release. |
Qualifications, demographics, satisfaction, and future capacity of the HIV care provider workforce in the United States, 2013-2014
Weiser J , Beer L , West BT , Duke CC , Gremel GW , Skarbinski J . Clin Infect Dis 2016 63 (7) 966-975 BACKGROUND: The U.S. HIV-infected population is increasing by about 30,000 annually (new infections minus deaths). With improvements in diagnosis and engagement in care, additional qualified HIV care providers may be needed. METHODS: We surveyed a probability sample of 2,023 U.S. HIV care providers in 2013-2014, including those at Ryan White HIV/AIDS Program (RWHAP)-funded facilities and in private practices. We estimated future patient care capacity by comparing counts of providers entering and planning to leave practice within five years, and the number of patients under their care. RESULTS: Of surveyed providers, 1,234 responded (adjusted response rate, 64%): 63% were white, 11% black, 11% Hispanic, and 16% other race/ethnicity; 37% were satisfied/very satisfied with salary/reimbursement, 33% were satisfied/very satisfied with administrative time. Compared to providers in private practice, more providers at RWHAP-funded facilities were HIV specialists (71% vs. 43%, p<.0001) and planned to leave HIV practice within five years (11% vs 4%, p=.0004). An estimated 190 more full-time equivalent (FTE) providers (defined as 40 HIV clinical care hours per week) entered practice in the past five years than expected to leave in the next five years. If these rates continue, by 2019 patient care capacity will increase by 65,000, compared to an increased requirement of at least 100,000. CONCLUSIONS: Projected workforce growth by 2019 will not accommodate the increased number of HIV-infected persons requiring care. RWHAP-funded facilities may face attrition of highly-qualified providers. Dissatisfaction with salary/reimbursement and administrative burden is substantial and black and Hispanic providers are underrepresented relative to HIV patients. |
Understanding cross-sectional racial, ethnic, and gender disparities in antiretroviral use and viral suppression among HIV patients in the United States
Beer L , Mattson CL , Bradley H , Skarbinski J . Medicine (Baltimore) 2016 95 (13) e3171 To examine racial/ethnic and gender disparities in antiretroviral (ART) use and viral suppression among HIV-infected persons in care and identify factors that might account for observed disparities.The Medical Monitoring Project (MMP) is a complex sample survey of HIV-infected adults receiving medical care in the United States.We used weighted interview and medical record data collected 06/2009 to 05/2012 to estimate the prevalence of ART use and viral suppression among gender-stratified racial/ethnic groups. We used chi tests to identify significant differences in outcomes between white men versus other groups, and logistic regression models to identify the most parsimonious set of factors that could account for each observed difference.We found no significant disparity in ART use between white and Hispanic men, and no disparities between white men and white and Hispanic women after adjustment for disease stage, age, and poverty. Disparities in ART use between white men and black persons persisted after adjusting for other factors, but the observed differences were relatively small. Differences in ART use and adherence, demographic characteristics, and social determinants of health such as poverty, education, and insurance accounted for the observed disparities in viral suppression between white men and all groups except black men. In our model, accounting for these factors reduced the prevalence difference in viral suppression between white and black men by almost half.We found that factors associated with disparities differed among men and women of the same race/ethnicity, lending support to the assertion that gender affects access to care and health status among HIV-infected patients. In addition to supporting efforts to increase ART use and adherence among persons living with HIV, our analysis provides evidence for the importance of social determinants of health in understanding racial/ethnic and gender differences in ART use and viral suppression. |
Antiretroviral therapy and viral suppression among foreign-born HIV-infected persons receiving medical care in the United States: a complex sample, cross-sectional survey
Myers TR , Lin X , Skarbinski J . Medicine (Baltimore) 2016 95 (11) e3051 Immigrants to the United States are more likely to be diagnosed with human immunodeficiency virus (HIV) infection compared with native-born persons. Navigating access to healthcare in the United States can be challenging for foreign-born persons, and HIV treatment outcomes may be suboptimal for these persons. We compared characteristics of and assessed disparities in clinical outcomes of foreign-born persons in care for HIV in the United States.The Medical Monitoring Project is a complex sample, cross-sectional survey designed to be nationally representative of HIV-infected adults receiving medical care in the United States.Using data from 2009, 2010, and 2011, we conducted descriptive analyses and multivariable logistic regression to assess associations between foreign-born status and antiretroviral therapy (ART) prescription, and between foreign-born status and viral suppression.In all, 13.4% of HIV-infected persons were self-identified as foreign-born; the most common regions of birth were Central America and Mexico (45.4%) and the Caribbean (16.0%). Nearly 90% of foreign-born persons were diagnosed with HIV after entry into the United States. Compared with US-born persons, foreign-born persons were more likely to be younger, Hispanic, less educated, and uninsured. The prevalence of ART prescription (prevalence ratio 1.00; 95% confidence interval 0.98-1.02) was not significantly different between foreign-born and US-born persons. A higher percentage of foreign-born persons achieved viral suppression compared with US-born persons (prevalence ratio 1.05; 95% confidence interval 1.00-1.09).No major disparities in ART prescription and viral suppression were found between foreign-born and US-born HIV-infected persons receiving medical care, despite higher percentages being uninsured. |
Screening for cervical cancer and sexually transmitted diseases among HIV-infected women
Frazier EL , Sutton MY , Tie Y , McNaghten AD , Blair JM , Skarbinski J . J Womens Health (Larchmt) 2016 25 (2) 124-32 BACKGROUND: Women living with HIV infection are at higher risk for cervical cancer, an AIDS-defining diagnosis. We examined the prevalence of cervical cancer and sexually transmitted disease (STD) screening among human immunodeficiency virus (HIV)-infected women and factors associated with the receipt of Papanicolaou (Pap) tests. METHODS: We did a cross-sectional analysis of weighted data from a sample of HIV-infected adults receiving outpatient medical care. We used matched interview (report of Pap test) and medical record data (STD screenings) from HIV-infected women. We performed logistic regression to compute adjusted prevalence ratios and 95% confidence intervals for the association between demographic, behavioral, and clinical factors and receipt of Pap tests among HIV-infected women. RESULTS: Data were available for 2,270 women, who represent 112,894 HIV-infected women; 62% were African American, 17% were Hispanic/Latina, and 18% were white. Most (78%) reported having a Pap test in the past year. Among sexually active women (n = 1234), 20% reported sex without condoms, 27% were screened for gonorrhea, and 29% were screened for chlamydia. Being screened for STDs was less likely among women who did not have a Pap test in the past year (adjusted prevalence ratios 0.82, 95% confidence interval 0.77-0.87). Women who were ≥50 years of age and reported income above federal poverty level, no sexual activity, depression, no HIV care from an obstetrician/gynecologist, and no documented STD tests, were less likely to report a Pap test (p < 0.05). CONCLUSIONS: Screening for cervical cancer and STDs among HIV-infected women is suboptimal. Clinical visits for Pap tests are an important opportunity for HIV-infected sexually active women to also receive STD screenings and counseling regarding condoms. |
A matter of perspective: Comparison of the characteristics of persons with HIV infection in the United States from the HIV Outpatient Study, Medical Monitoring Project, and National HIV Surveillance System
Buchacz K , Frazier EL , Hall HI , Hart R , Huang P , Franklin D , Hu X , Palella FJ , Chmiel JS , Novak RM , Wood K , Yangco B , Armon C , Brooks JT , Skarbinski J . Open AIDS J 2015 9 123-133 Comparative analyses of the characteristics of persons living with HIV infection (PLWH) in the United States (US) captured in surveillance and other observational databases are few. To explore potential joint data use to guide HIV treatment and prevention in the US, we examined three CDC-funded data sources in 2012: the HIV Outpatient Study (HOPS), a multisite longitudinal cohort; the Medical Monitoring Project (MMP), a probability sample of PLWH receiving medical care; and the National HIV Surveillance System (NHSS), a surveillance system of all PLWH. Overall, data from 1,697 HOPS, 4,901 MMP, and 865,102 NHSS PLWH were analyzed. Compared with the MMP population, HOPS participants were more likely to be older, non-Hispanic/Latino white, not using injection drugs, insured, diagnosed with HIV before 2009, prescribed antiretroviral therapy, and to have most recent CD4+ T-lymphocyte cell count ≥ 500 cells/mm(3) and most recent viral load <200 copies/mL. The MMP population was demographically similar to all PLWH in NHSS, except it tended to be slightly older, HIV diagnosed more recently, and to have AIDS. Our comparative results provide an essential first step for combined epidemiologic data analyses to inform HIV care and prevention for PLWH in the US. |
Delayed entry into HIV medical care in a nationally representative sample of HIV-infected adults receiving medical care in the USA
Robertson M , Wei SC , Beer L , Adedinsewo D , Stockwell S , Dombrowski JC , Johnson C , Skarbinski J . AIDS Care 2015 28 (3) 1-9 Before widespread antiretroviral therapy (ART), an estimated 17% of people delayed HIV care. We report national estimates of the prevalence and factors associated with delayed care entry in the contemporary ART era. We used Medical Monitoring Project data collected from June 2009 through May 2011 for 1425 persons diagnosed with HIV from May 2004 to April 2009 who initiated care within 12 months. We defined delayed care as entry >three months from diagnosis. Adjusted prevalence ratios (aPRs) were calculated to identify risk factors associated with delayed care. In this nationally representative sample of HIV-infected adults receiving medical care, 7.0% (95% confidence interval [CI]: 5.3-8.8) delayed care after diagnosis. Black race was associated with a lower likelihood of delay than white race (aPR 0.38). Men who have sex with women versus women who have sex with men (aPR 1.86) and persons required to take an HIV test versus recommended by a provider (aPR 2.52) were more likely to delay. Among those who delayed 48% reported a personal factor as the primary reason. Among persons initially diagnosed with HIV (non-AIDS), those who delayed care were twice as likely (aPR 2.08) to develop AIDS as of May 2011. Compared to the pre-ART era, there was a nearly 60% reduction in delayed care entry. Although relatively few HIV patients delayed care entry, certain groups may have an increased risk. Focus on linkage to care among persons who are required to take an HIV test may further reduce delayed care entry. |
Delivery of HIV transmission risk-reduction services by HIV care providers in the United States-2013
Beer L , Weiser J , West BT , Duke C , Gremel G , Skarbinski J . J Int Assoc Provid AIDS Care 2015 15 (6) 494-504 OBJECTIVES: Evidence-based guidelines have long recommended that HIV care providers deliver HIV transmission risk-reduction (RR) services, but recent data are needed to assess their adoption. METHODS: The authors surveyed a probability sample of 1234 US HIV care providers on delivery of 9 sexual behavior- and 7 substance use-related HIV transmission RR services and created an indicator of "adequate" delivery of services in each area, defined as performing approximately 70% or more of applicable services. RESULTS: Providers were most likely to encourage patients to disclose HIV status to all partners since HIV diagnosis (81%) and least likely to ask about disclosure to new sex and drug injection partners at follow-up visits (both 41%). Adequate delivery of sexual behavior- and substance use-related RR services was low (37% and 43%, respectively). CONCLUSION: The majority of US HIV care providers may need additional support to improve delivery of comprehensive HIV transmission RR services. |
Impact of sulfadoxine-pyrimethamine resistance on effectiveness of intermittent preventive therapy for malaria in pregnancy at clearing infections and preventing low birth weight
Desai M , Gutman J , Taylor SM , Wiegand RE , Khairallah C , Kayentao K , Ouma P , Coulibaly SO , Kalilani L , Mace KE , Arinaitwe E , Mathanga DP , Doumbo O , Otieno K , Edgar D , Chaluluka E , Kamuliwo M , Ades V , Skarbinski J , Shi YP , Magnussen P , Meshnick S , Ter Kuile FO . Clin Infect Dis 2015 62 (3) 323-333 BACKGROUND: Monitoring the effectiveness of intermittent preventive therapy in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is crucial owing to increasing SP resistance in sub-Saharan Africa. METHODS: Between 2009 and 2013, both the efficacy of IPTp-SP at clearing existing peripheral malaria infections and the effectiveness of IPTp-SP at reducing low birthweight (LBW) were assessed among HIV-negative participants in 8 sites in 6 countries. Sites were classified as high, medium or low resistance after measuring mutations conferring SP resistance. An individual-level prospective pooled analysis was conducted. RESULTS: Among 1,222 parasitaemic pregnant women, overall PCR-uncorrected and -corrected failure rates by day 42 were 21.3% and 10.0%, respectively (39.7% and 21.1% in high-resistance areas; 4.9% and 1.1% in low-resistance areas). Median time to recurrence decreased with increasing prevalence of Pfdhps-K540E. Among 6,099 women at delivery, each incremental dose of IPTp-SP was associated with a 22% reduction in the risk of LBW (prevalence ratio [PR]=0.78 [95% CI 0.69-0.88], p<0.001). This association was not modified by insecticide-treated net use or gravidity, and remained significant in areas with SP resistance (PR=0.81 [0.67-0.97], p=0.02). CONCLUSIONS: The efficacy of SP to clear peripheral parasites and prevent new infections during pregnancy is compromised in areas with >90% prevalence of Pfdhps-K540E. Nevertheless, in these high resistance areas, IPTp-SP use remains associated with increases in birthweight and maternal haemoglobin. The effectiveness of IPTp in eastern and southern Africa is threatened by further increases in SP-resistance and reinforces the need to evaluate alternative drugs and strategies for the control of malaria in pregnancy. |
Characteristics of transgender women living with HIV receiving medical care in the United States
Mizuno Y , Frazier EL , Huang P , Skarbinski J . LGBT Health 2015 2 (3) 228-234 PURPOSE: Little has been reported from population-based surveys on the characteristics of transgender persons living with HIV. Using Medical Monitoring Project (MMP) data, we describe the characteristics of HIV-infected transgender women and examine their care and treatment needs. METHODS: We used combined data from the 2009 to 2011 cycles of MMP, an HIV surveillance system designed to produce nationally representative estimates of the characteristics of HIV-infected adults receiving medical care in the United States, to compare demographic, behavioral, and clinical characteristics, and met and unmet needs for supportive services of transgender women with those of non-transgender persons using Rao-Scott chi-square tests. RESULTS: An estimated 1.3% of HIV-infected persons receiving care in the United States self-identified as transgender women. Transgender women were socioeconomically more marginalized than non-transgender men and women. We found no differences between transgender women and non-transgender men and women in the percentages prescribed antiretroviral therapy (ART). However, a significantly lower percentage of transgender women compared to non-transgender men had 100% ART dose adherence (78.4% vs. 87.4%) and durable viral suppression (50.8% vs. 61.4%). Higher percentages of transgender women needed supportive services. No differences were observed in receipt of most of supportive services, but transgender women had higher unmet needs than non-transgender men for basic services such as food and housing. CONCLUSION: We found little difference between transgender women and non-transgender persons in regards to receipt of care, treatment, and most of supportive services. However, the noted disparities in durable viral suppression and unmet needs for basic services should be explored further. |
Nearly half of US adults living with HIV received federal disability benefits in 2009
Huang YL , Frazier EL , Sansom SL , Farnham PG , Shrestha RK , Hutchinson AB , Fagan JL , Viall AH , Skarbinski J . Health Aff (Millwood) 2015 34 (10) 1657-65 The effects of HIV infection on national labor-force participation have not been rigorously evaluated. Using data from the Medical Monitoring Project and the National Health Interview Survey, we present nationally representative estimates of the receipt of disability benefits by adults living with HIV receiving care compared with the general US adult population. We found that in 2009, adults living with HIV were nine times more likely than adults in the general population to receive disability benefits. The risk of being on disability is also greater for younger and more educated adults living with HIV compared to the general population, which suggests that productivity losses can result from HIV infection. To prevent disability, early diagnosis and treatment of HIV are essential. This study offers a baseline against which to measure the impacts of recently proposed or enacted changes to Medicaid and private insurance markets, including the Affordable Care Act and proposed revisions to the Social Security Administration's HIV Infection Listings. |
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