Showing papers by "John T. Brooks published in 2018"

Changes in Prevalence of Health Care–Associated Infections in U.S. Hospitals

Abstract: Background A point-prevalence survey that was conducted in the United States in 2011 showed that 4% of hospitalized patients had a health care–associated infection. We repeated the survey ...

Zika Virus Shedding in Semen of Symptomatic Infected Men

Abstract: Background Zika virus (ZIKV) is an emerging mosquito-borne flavivirus that has been linked to adverse birth outcomes. Previous reports have shown that person-to-person transmission can occur by means of sexual contact. Methods We conducted a prospective study involving men with symptomatic ZIKV infection to determine the frequency and duration of ZIKV shedding in semen and urine and to identify risk factors for prolonged shedding in these fluids. Specimens were obtained twice per month for 6 months after illness onset and were tested by real-time reverse-transcriptase–polymerase-chain-reaction (RT-PCR) assay for ZIKV RNA and by Vero cell culture and plaque assay for infectious ZIKV. Results A total of 1327 semen samples from 184 men and 1038 urine samples from 183 men were obtained 14 to 304 days after illness onset. ZIKV RNA was detected in the urine of 7 men (4%) and in the semen of 60 (33%), including in semen samples from 22 of 36 men (61%) who were tested within 30 days after illness onset. ...

Invasive Methicillin-Resistant Staphylococcus aureus Infections Among Persons Who Inject Drugs - Six Sites, 2005-2016.

Abstract: In the United States, age-adjusted opioid overdose death rates increased by >200% during 1999-2015, and heroin overdose death rates increased nearly 300% during 2011-2015 (1). During 2011-2013, the rate of heroin use within the past year among U.S. residents aged ≥12 years increased 62.5% overall and 114.3% among non-Hispanic whites, compared with 2002-2004 (2). Increases in human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections related to increases in injection drug use have been recently highlighted (3,4); likewise, invasive bacterial infections, including endocarditis, osteomyelitis, and skin and soft tissue infections, have increased in areas where the opioid epidemic is expanding (5-7). To assess the effects of the opioid epidemic on invasive methicillin-resistant Staphylococcus aureus (MRSA) infections during 2005-2016, surveillance data from CDC's Emerging Infections Program (EIP) were analyzed (8). Persons who inject drugs were estimated to be 16.3 times more likely to develop invasive MRSA infections than others. The proportion of invasive MRSA cases that occurred among persons who inject drugs increased from 4.1% in 2011 to 9.2% in 2016. Infection types were frequently those associated with nonsterile injection drug use. Continued increases in nonsterile injection drug use are likely to result in increases in invasive MRSA infections, underscoring the importance of public health measures to curb the opioid epidemic.

Zika virus as a sexually transmitted pathogen

Abstract: Purpose of reviewZika virus has recently emerged from an obscure mosquito-borne pathogen to an international public health concern. It is the first viral agent newly demonstrated to cause birth defects in several decades, and it is the only arbovirus now known to be transmitted sexually. The purpose

Prevalence, Incidence, and Clearance of Anal High-Risk Human Papillomavirus Infection Among HIV-Infected Men in the SUN Study

Abstract: Author(s): Patel, Pragna; Bush, Tim; Kojic, Erna Milunka; Conley, Lois; Unger, Elizabeth R; Darragh, Teresa M; Henry, Keith; Hammer, John; Escota, Gerome; Palefsky, Joel M; Brooks, John T | Abstract: Background:The natural history of anal human papilloma virus (HPV) infection among human immunodeficiency virus (HIV)-infected men is unknown. Methods:Annually, from 2004 to 2012, we examined baseline prevalence, incidence, and clearance of anal HPV infection at 48 months, and associated factors among HIV-infected men. Results:We examined 403 men who have sex with men (MSM) and 96 men who have sex with women (MSW) (median age 42 years for both, 78% versus 81% prescribed cART, median CD4+ T-lymphocyte cell count 454 versus 379 cells/mm3, and 74% versus 75% had undetectable viral load, respectively). Type 16 prevalence among MSM and MSW was 38% versus 14% (P l .001), and incidence 24% versus 7% (P = .001). Type 18 prevalence was 24% versus 8% (P l .001), and incidence 13% versus 4% (P = .027). Among MSM and MSW, clearance of prevalent HPV 16 and HPV 18 was 31% and 60% (P = .392), and 47% and 25% (P = .297), respectively. Among MSM, receptive anal sex (with or without a condom) was associated with persistent HPV 16 (OR 2.24, P l .001). Conclusions:MSM had higher prevalence and incidence of HPV than MSW, but similar clearance. Receptive anal sex may predict cancer risk among HIV-infected MSM.

HIV and viral hepatitis coinfection analysis using surveillance data from 15 US states and two cities.

Abstract: Coinfection with human immunodeficiency virus (HIV) and viral hepatitis is associated with high morbidity and mortality in the absence of clinical management, making identification of these cases crucial. We examined characteristics of HIV and viral hepatitis coinfections by using surveillance data from 15 US states and two cities. Each jurisdiction used an automated deterministic matching method to link surveillance data for persons with reported acute and chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infections, to persons reported with HIV infection. Of the 504 398 persons living with diagnosed HIV infection at the end of 2014, 2.0% were coinfected with HBV and 6.7% were coinfected with HCV. Of the 269 884 persons ever reported with HBV, 5.2% were reported with HIV. Of the 1 093 050 persons ever reported with HCV, 4.3% were reported with HIV. A greater proportion of persons coinfected with HIV and HBV were males and blacks/African Americans, compared with those with HIV monoinfection. Persons who inject drugs represented a greater proportion of those coinfected with HIV and HCV, compared with those with HIV monoinfection. Matching HIV and viral hepatitis surveillance data highlights epidemiological characteristics of persons coinfected and can be used to routinely monitor health status and guide state and national public health interventions.

Interval Since Last HIV Test for Men and Women with Recent Risk for HIV Infection — United States, 2006–2016

Abstract: Since 2006, CDC has recommended routine screening of all persons aged 13-64 years for human immunodeficiency virus (HIV) and at least annual rescreening of persons at higher risk (1). However, national surveillance data indicate that many persons at higher risk for HIV infection are not screened annually, and delays in diagnosis persist (2). CDC analyzed 2006-2016 data from the General Social Survey (GSS)* and estimated that only 39.6% of noninstitutionalized U.S. adults had ever tested for HIV. Among persons ever tested, the estimated median interval since last test was 1,080 days or almost 3 years. Only 62.2% of persons who reported HIV-related risk behaviors in the past 12 months were ever tested for HIV, and the median interval since last test in this group was 512 days (1.4 years). The percentage of persons ever tested and the interval since last test remained largely unchanged during 2006-2016. More frequent screening of persons with ongoing HIV risk is needed to achieve full implementation of CDC's screening recommendations and to prevent new infections. Integration of routine screening as standard clinical practice through existing strategies, such as electronic medical record prompts (3), or through new, innovative strategies might be needed to increase repeat screening of persons with ongoing risk.

A Strategy for PrEP Clinicians to Manage Ambiguous HIV Test Results During Follow-up Visits.

Abstract: Prompt determination of HIV infection status is critical during follow-up visits for patients taking pre-exposure prophylaxis (PrEP) medication Those who are uninfected can then continue safely taking PrEP, and those few who have acquired HIV infection can initiate an effective treatment regimen However, a few recent cases have been reported of ambiguous HIV test results using common testing algorithms in PrEP patients We review published reports of such cases and testing options that can be used to clarify true HIV status in these situations In addition, we review the benefits and risks of 3 antiretroviral management options in these patients: (1) continue PrEP while conducting additional HIV tests, (2) initiate antiretroviral therapy for presumptive HIV infection while conducting confirmatory tests, or (3) discontinue PrEP to reassess HIV status after a brief antiretroviral-free interval A clinical consultation resource is also provided

Prevalence and Incidence of Anal and Cervical High-Risk Human Papillomavirus (HPV) Types Covered by Current HPV Vaccines Among HIV-Infected Women in the SUN Study.

Abstract: Author(s): Kojic, Erna Milunka; Conley, Lois; Bush, Tim; Cu-Uvin, Susan; Unger, Elizabeth R; Henry, Keith; Hammer, John; Escota, Gerome; Darragh, Teresa M; Palefsky, Joel M; Brooks, John T; Patel, Pragna | Abstract: Background:Nonavalent (9v) human papilloma virus vaccine targets high-risk human papillomavirus (HR-HPV) types 16, 18, 31, 33, 45, 52, 58, and low-risk 6, 11. We examined prevalence, incidence, and clearance of anal and cervical HR-HPV in HIV-infected women. Methods:The SUN Study enrolled 167 US women in 2004-2006. Anal and cervical specimens were collected annually for cytology and identification of 37 HPV types: 14 HR included: 9v 16, 18, 31, 33, 45, 52, 58; non-9v 35, 39, 51, 56, 59, 66, 68. Results:Baseline characteristics of 126 women included: median age 38 years; 57% non-Hispanic black; 67% HIV RNA l 400 copies/mL; 90% CD4 counts ≥200 cells/mm3. HPV prevalence at anus and cervix was 90% and 83%; for 9v HR-HPV types, 67% and 51%; non-9v HR-HPV, 54% and 29%, respectively. The 9v and non-9v HR-HPV incidence rates/100 person-years were similar (10.4 vs 9.5; 8.5 vs 8.3, respectively); 9v clearance rates were 42% and 61%; non-9v 46% and 59%, in anus and cervix, respectively. Conclusions:Anal HR-HPV prevalence was higher than cervical, with lower clearance; incidence was similar. Although prevalence of non-9v HR-HPV was substantial, 9v HR-HPV types were generally more prevalent. These findings support use of nonavalent vaccine in HIV-infected women.

Disparities in HIV Viral Load Suppression by Race/Ethnicity Among Men Who Have Sex with Men in the HIV Outpatient Study.

Abstract: Maximizing the rates of virologic suppression (VS) among gay, bisexual, and other men who have sex with men (MSM) is essential to limiting HIV morbidity and sexual transmission of HIV in t...

Developing a Motion Comic for HIV/STD Prevention for Young People Ages 15-24, Part 2: Evaluation of a Pilot Intervention

Abstract: In the United States, young people (ages 15–24 years) are disproportionately affected by human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs), due at least in part to inadequate or incorrect HIV/STD-related knowledge, attitudes, beliefs, and behavioral intentions (KABI). Comic book narratives are a proven method of HIV/STD prevention communication to strengthen KABI for HIV/STD prevention. Motion comics, a new type of comic media, are an engaging and low-cost means of narrative storytelling. The objective of this study was to quantitatively evaluate the effectiveness of a pilot six-episode HIV/STD-focused motion comic series to improve HIV/STD-related KABI among young people. We assessed change in HIV/STD knowledge, HIV stigma, condom attitudes, HIV/STD testing attitudes, and behavioral intentions among 138 participants in 15 focus groups immediately before and after viewing the motion comic series. We used paired t-tests and indicators of overall improvement to assess...

Hepatitis A virus immunity and vaccination among at-risk persons receiving HIV medical care

Abstract: United States guidelines recommend hepatitis A virus (HAV) vaccination for persons living with HIV (PLWH) who are at increased risk for HAV infection, including men who have sex with men (MSM) and persons who inject drugs (PWID). However, nationally representative estimates of vaccine coverage and immunity for this population are lacking. We used medical record and interview data from the 2009–2012 cycles of the Medical Monitoring Project, a nationally representative surveillance system of PLWH receiving HIV medical care in the United States, to estimate the prevalence of HAV immunity, defined as receipt of at least one dose of vaccine or laboratory documentation of anti-HAV antibodies, among 8695 MSM and PWID. Among HAV-nonimmune PLWH, we then examined factors associated with HAV vaccination during the 12-month retrospective observation period using Rao-Scott chi-square tests. Among MSM and PWID receiving HIV medical care, 64% had evidence of HAV immunity. Among those who were nonimmune, 10% were vaccinated during the 12-month retrospective observation period. Factors associated with vaccination during follow-up included younger age (i.e., 18–29 years), self-reported black non-Hispanic race/ethnicity, having detectable HIV RNA, and having been diagnosed with HIV within the past 5 years. Over one third of MSM and PWID receiving HIV medical care during 2009–2012 cycles were not immune to HAV. This analysis suggests that a sizeable proportion of at risk MSM and PWID receiving HIV medical care do not receive HAV vaccination, which is currently recommended.

Brief Report: Cutaneous Melanoma Risk Among People With HIV in the United States and Canada.

Abstract: BACKGROUND Cutaneous melanoma incidence may be modestly elevated in people with HIV (PWH) vs. people without HIV. However, little is known about the relationship of immunosuppression, HIV replication, and antiretroviral therapy (ART) with melanoma risk. METHODS PWH of white race in the North American AIDS Cohort Collaboration on Research and Design were included. A standardized incidence ratio was calculated comparing risk with the white general population, standardizing by age, sex, and calendar period. Associations between melanoma incidence and current, lagged, and cumulative measures of CD4 count, HIV RNA level, and ART use were estimated with Cox regression, adjusting for established risk factors such as age and annual residential ultraviolet B (UVB) exposure. RESULTS Eighty melanomas were diagnosed among 33,934 white PWH (incidence = 40.75 per 100,000 person-years). Incidence was not elevated compared with the general population [standardized incidence ratio = 1.15, 95% confidence interval (95% CI) = 0.91 to 1.43]. Higher melanoma incidence was associated with older age [adjusted hazard ratio (aHR) per decade increase = 1.50, 95% CI = 1.20 to 1.89] and higher UVB exposure (aHR for exposure ≥35 vs. <35 mW/m = 1.62, 95% CI = 0.99 to 2.65). Current, lagged, and cumulative CD4 and HIV RNA were not associated with melanoma incidence. Melanoma incidence was higher among people ART-treated for a larger proportion of time in the previous 720 days (aHR per 10% increase = 1.16, 95% CI = 1.03 to 1.30). CONCLUSIONS These results suggest that HIV-induced immune dysfunction does not influence melanoma development. The association between ART and melanoma risk may be due to increased skin surveillance among PWH engaged in clinical care. Associations with age and UVB confirmed those established in the general population.

Developing a Motion Comic for HIV/STD Prevention for Young People Ages 15–24, Part 1: Listening to Your Target Audience

Abstract: Young people (15-24 years) in the United States are disproportionately affected by infection with human immunodeficiency virus (HIV) and sexually transmitted diseases (STD). Shortfalls in HIV/STD-related knowledge, attitudes, beliefs, and behavioral intentions (KABI) likely contribute to this discrepancy. In this report we describe our experience developing a novel means of health communication combining entertainment-education theory and recent technological advances to create a HIV/STD-focused "motion comic." We also report the audience satisfaction and acceptance of the intervention. We used the Health Belief Model (HBM), entertainment-education (EE) principles, and the Sabido Method (SM) and conducted three rounds of focus groups to develop a 38-minute HIV/STD focused motion comic for young people between the ages 15 and 24 years. Participants indicated that motion comics were an acceptable method of delivering HIV/STD prevention messages. They also expressed satisfaction with motion comics plot, story settings, the tone of humor, and drama. Our results suggest that motion comics are a viable new method of delivering health communication messages about HIV/STD and other public health issues, and warrant further development and broader evaluation.

Antiretroviral nonadherence and condomless sex in the HIV Outpatient Study, USA, 2007–2014:

Abstract: Effective antiretroviral therapy (ART) reduces plasma HIV RNA viral load (VL) to undetectable levels and its effectiveness depends on consistent adherence. Consistent adherence and use of safe sex practices may substantially decrease the risk of HIV transmission. We sought to explore the potential association between self-reported nonadherence to ART and engaging in unsafe sexual practices capable of transmitting HIV. Using clinical and audio computer-assisted self-interview data from the prospective HIV Outpatient Study from 2007 to 2014, we assessed the frequency of self-reported ART nonadherence during the three days prior to the survey among HIV-infected persons in care and factors associated with self-reported ART nonadherence. Of 1729 patients included in this analysis (median age = 48 years, 74.3% men who have sex with men), 17% were nonadherent, 15% had a detectable VL, and 42% reported condomless anal or vaginal sex in the past six months. In multivariable analysis, self-reported nonadherence was independently associated with younger age (adjusted odds ratio [aOR] 0.8 per additional ten years, [95% CI] 0.7-1.0), non-Hispanic black race/ethnicity (aOR 1.9; 95% CI 1.4-2.6 versus white), public health insurance (aOR 1.6, 95% CI 1.2-2.3 compared with private), survey date in 2011-2014 versus 2007-2010 (aOR 0.7, 95% CI 0.5-0.9), CD4 cell count ≥ 500 versus < 200 cells/mm3 (aOR 0.3, 95% CI 0.2-0.5), greater number of ART regimen doses (aOR 1.6, 95% CI 1.3-2.2), and binge drinking (aOR 1.4, 95% CI, 1.1-1.9). In this analysis, self-reported nonadherence was not associated with engaging in condomless sex.

Improving Estimation of HIV Viral Suppression in the United States: A Method to Adjust HIV Surveillance Estimates From the Medical Monitoring Project Using Cohort Data.

Abstract: The US Centers for Disease Control and Prevention has estimated human immunodeficiency virus (HIV) viral suppression (VS) using 2 data sources. The National HIV Surveillance System estimate (50% of HIV-diagnosed persons in 2012) is derived from viral load reporting from a subset of jurisdictions that vary yearly. The Medical Monitoring Project (MMP) estimate (42% of HIV-diagnosed persons in 2012) is based on a sample of persons receiving HIV care during the first 4 months of each year. We developed the cohort-adjustment method to reconstruct VS estimates, accounting for persons receiving care later in the year. Using the HIV Outpatient Study cohort, we assessed timing of care receipt, demographics, and VS at last test (<200 vs. ≥200 copies/mL), standardizing MMP to HIV Outpatient Study data using multivariable regression models and yielding adjusted VS estimates. We estimated that 52% (95% CI: 48, 56) of HIV-diagnosed persons achieved VS in 2012. Differences from previously published estimates were due to: 1) 23% underestimation of persons receiving HIV care, and 2) lower VS rates among persons receiving care outside versus inside the 4-month MMP sampling period (79% vs. 88%). This methodology yielded VS estimates closer to the National HIV Surveillance System estimate than previously published. Use of more, geographically diverse cohort data may enable assessment of temporal trends.

Integrating data from disparate data systems for improved HIV reporting: Lessons learned

Abstract: Objective: To assess the integration process of HIV data from disparate sources for reporting HIV prevention metrics in Scott County, Indiana Introduction: In 2015, the Indiana State Department of Health (ISDH) responded to a large HIV outbreak among persons who inject drugs (PWID) in Scott County 1 . Information to manage the public health response to this event and its aftermath included data from multiple sources such as surveillance, HIV testing, contact tracing, medical care, and HIV prevention activities. Each dataset was managed separately and had been tailored to the relevant HIV program area’s needs, which is a typical practice for health departments. Currently, integrating these disparate data sources is managed manually, which makes this dataset susceptible to inconsistent and redundant data. During the outbreak investigation, access to data to monitor and report progress was difficult to obtain in a timely and accurate manner for local and state health department staff. ISDH initiated efforts to integrate these disparate HIV data sources to better track HIV prevention metrics statewide, to support decision making and policies, and to facilitate a more rapid response to future HIV-related investigations. The Centers for Disease Control and Prevention (CDC) through its Info-Aid mechanism is providing technical assistance to support assessment of the ISDH data integration process. The project is expected to lead to the development of a dashboard prototype that will aggregate and improve critical data reporting to monitor the status of HIV prevention in Scott County. Methods: We assessed six different HIV-related datasets in addition to the state-level integrated HIV dataset developed to report HIV monitoring and prevention metrics. We conducted site visits to the ISDH and Scott County to assess the integration process. We also conducted key informant interviews and focus group discussions with data managers, analysts, program managers, and epidemiologists using HIV data systems at ISDH, Scott County and CDC. We also conducted a documentation review of summary reports of the HIV outbreak, workflow, a business process analysis, and information gathered during the site visit on operations, processes and attributes of HIV data sources. We, then, summarized the information flow, including the data collection process, reporting, and analysis at federal, state and county levels. Results: We have developed a list of lessons learned that can be translated for use in any state-level jurisdiction engaged in HIV prevention monitoring and reporting: Standardization of data formats: The disparate data sources storing HIV-related information were developed independently on different platforms using different architectures; they were not necessarily designed to link and exchange data. Hence, these systems could not seamlessly interact with each other, posing challenges when rapid data linkage was needed. To better manage unstructured data coming from disparate data sources and improve data integration efforts, we recommend standardization of data formats, unique identifiers for registered individuals, and coding across data systems. Use of standard operating procedures can streamline data flow and facilitate automated creation of integrated datasets. This approach may be helpful for future integration efforts in other healthcare domains. Data integration process: Manually integrating data is time intensive, increases workload, and poses significant risk of human error in data compilation. Hence, it may compromise data quality and the accuracy of HIV prevention metrics used by decision-makers. We propose an automated integration process using an extract, transform and load (ETL) method to extract HIV-related data from disparate data sources, transforming it to fit the prevention metrics reporting needs and loading it into a state-level integrated HIV dataset or database. This approach can drastically decrease dependency on manual methods and help avoid data compilation errors. Dashboard development: Major challenges in the process of integrating HIV-related data included disparate data sources, compromised data quality, and the lack of standard metrics for some of the HIV-related metrics of interest. Despite these challenges to data integration, creation of a dashboard to track HIV prevention metrics is feasible. Integrating data is a critical part of developing an HIV dashboard that can generate real-time metrics without creating additional burden for the health department staff, if manual integration is no longer needed. Stakeholder participation: Due to the immediate need for outbreak response, involvement of stakeholders at all levels was limited. Active stakeholder engagement in this process is essential. The stakeholders’ interest and participation can be improved by helping them understand the value of each other’s data, and providing regular feedback about their data and its best use in public health interventions. Conclusions: This assessment highlighted the importance of standardizing data formats, coding across systems for HIV data, and the use of unique identifiers to store individuals’ information across data systems. Promoting stakeholder understanding of the value and best use of their data is also essential in improving data integration efforts. The results of this assessment offer an opportunity to learn and apply these lessons to improve future public health informatics initiatives, including HIV (but not limited to HIV), at any state-level jurisdiction