Anna L. Hotton

Soluble Urokinase Receptor and Chronic Kidney Disease

BACKGROUND Relatively high plasma levels of soluble urokinase-type plasminogen activator receptor (suPAR) have been associated with focal segmental glomerulosclerosis and poor clinical outcomes in patients with various conditions. It is unknown whether elevated suPAR levels in patients with normal kidney function are associated with future decline in the estimated glomerular filtration rate (eGFR) and with incident chronic kidney disease. METHODS We measured plasma suPAR levels in 3683 persons enrolled in the Emory Cardiovascular Biobank (mean age, 63 years; 65% men; median suPAR level, 3040 pg per milliliter) and determined renal function at enrollment and at subsequent visits in 2292 persons. The relationship between suPAR levels and the eGFR at baseline, the change in the eGFR over time, and the development of chronic kidney disease (eGFR <60 ml per minute per 1.73 m(2) of body-surface area) were analyzed with the use of linear mixed models and Cox regression after adjustment for demographic and clinical variables. RESULTS A higher suPAR level at baseline was associated with a greater decline in the eGFR during follow-up; the annual change in the eGFR was -0.9 ml per minute per 1.73 m(2) among participants in the lowest quartile of suPAR levels as compared with -4.2 ml per minute per 1.73 m(2) among participants in the highest quartile (P<0.001). The 921 participants with a normal eGFR (≥ 90 ml per minute per 1.73 m(2)) at baseline had the largest suPAR-related decline in the eGFR. In 1335 participants with a baseline eGFR of at least 60 ml per minute per 1.73 m(2), the risk of progression to chronic kidney disease in the highest quartile of suPAR levels was 3.13 times as high (95% confidence interval, 2.11 to 4.65) as that in the lowest quartile. CONCLUSIONS An elevated level of suPAR was independently associated with incident chronic kidney disease and an accelerated decline in the eGFR in the groups studied. (Funded by the Abraham J. and Phyllis Katz Foundation and others.).

Substance use as a mediator of the relationship between life stress and sexual risk among young transgender women.

This study examined whether life stress was associated with elevated sexual risk among young transgender women and whether this relationship was mediated by alcohol and substance use. The analysis was based on data collected from 116 transgender women aged 16 to 25 as part of a baseline assessment for an HIV prevention intervention. The median age was 20; the majority identified as African American (48%) or Hispanic (32%). Controlling for age, high life stress was associated with an increased odds of sexual risk (OR = 2.39; 95% CI 1.12-5.12). This association was attenuated when substance and alcohol use were added to the model (OR = 1.82; 0.80-4.13). A formal test of the mediation hypothesis indicated a statistically significant indirect effect (β = 0.08; 95% CI 0.02-0.20). Interventions aimed at reducing sexual risk behavior should address problems with substance use as well as more distal factors that impact risk, such homelessness, joblessness, and lack of access to medical care.

Free Glycogen in Vaginal Fluids Is Associated with Lactobacillus Colonization and Low Vaginal pH

Objective Lactobacillus dominates the lower genital tract microbiota of many women, producing a low vaginal pH, and is important for healthy pregnancy outcomes and protection against several sexually transmitted pathogens. Yet, factors that promote Lactobacillus remain poorly understood. We hypothesized that the amount of free glycogen in the lumen of the lower genital tract is an important determinant of Lactobacillus colonization and a low vaginal pH. Methods Free glycogen in lavage samples was quantified. Pyrosequencing of the 16S rRNA gene was used to identify microbiota from 21 African American women collected over 8–11 years. Results Free glycogen levels varied greatly between women and even in the same woman. Samples with the highest free glycogen had a corresponding median genital pH that was significantly lower (pH 4.4) than those with low glycogen (pH 5.8; p<0.001). The fraction of the microbiota consisting of Lactobacillus was highest in samples with high glycogen versus those with low glycogen (median = 0.97 vs. 0.05, p<0.001). In multivariable analysis, having 1 vs. 0 male sexual partner in the past 6 months was negatively associated, while BMI ≥30 was positively associated with glycogen. High concentrations of glycogen corresponded to higher levels of L. crispatus and L. jensenii, but not L. iners. Conclusion These findings show that free glycogen in genital fluid is associated with a genital microbiota dominated by Lactobacillus, suggesting glycogen is important for maintaining genital health. Treatments aimed at increasing genital free glycogen might impact Lactobacillus colonization.

Incidence of HIV infection and sexually transmitted infections and related risk factors among very young men who have sex with men

Introduction:The HIV epidemic continues to disproportionately affect men who have sex with men (MSM) in the United States, with over a third of new infections in MSM occurring in younger men. Very few studies have reported on HIV and sexually transmitted infection (STI) incidence and related risks among younger MSM, particularly among minors under 18 years of age. Methods:Data analyzed herein are from a longitudinal study of HIV risk among 450 very young MSM in Chicago aged 16 to 20, recruited via respondent-driven sampling and followed-up for 2 years, with annual HIV and STI testing. We report estimated cumulative HIV and STI incidence over the 24-month follow-up using Kaplan–Meier methods and evaluated associations with incident infections using Cox proportional hazards regression. Results:The final analytic sample was primarily non-white (83%); median age was 19; 25% of the sample was under age 18. Twenty-six new HIV infections were detected over 632 person-years of follow-up. HIV incidence was 4.11/100 person-years [95% confidence interval (CI): 2.80 to 6.04] and STI incidence was 6.22/100 person-years (95% CI: 4.54 to 8.51). Cumulative HIV incidence over 24 months of follow-up was 7.32% (95% CI: 5.05 to 10.57), with higher incidence among racial/ethnic minorities. In multivariate analyses, non-white race and recent sexual partner concurrency were associated with both HIV and STI infection; HIV testing history and sex with an HIV-positive partner were associated with increased risk of HIV infection. Discussion:High rates of incident HIV infection and STIs among very young MSM and the relationship between incidence and race/ethnicity, concurrency and partner characteristics indicate potential focal points of future intervention and the need for continued vigilance.

Adding silver to the rainbow: the development of the nurses' health education about LGBT elders (HEALE) cultural competency curriculum.

AIM In 2009, the Howard Brown Health Center received funding from the US Department of Health and Human Services, and Health Resources and Services Administration to develop and disseminate a peer-reviewed, six-module curriculum entitled, Health Education about LGBT (lesbian, gay, bisexual and transgender) Elders (HEALE). BACKGROUND The HEALE curriculum targets nurses and health-care staff and is focused on the treatment of LGBT elders, a population that is largely misunderstood and discriminated against in health-care settings. The HEALE curriculum was presented in hospital academic centres, community-based clinics and nursing homes over a three-year period, and training staff provided education to over 500 nurses and health-care providers. METHOD A pre-test and post-test was administered to participants, and all data were collected and archived to measure knowledge gained. Participants also completed an evaluation at the conclusion of the training to report change in personal attitude and individual response to the curriculum. RESULTS AND CONCLUSIONS From March 2011 to June 2012, 848 individuals attended HEALE curriculum sessions at 23 locations in Chicago and surrounding areas. Participants were 40% white, 25% black, 9% Hispanic/Latino and 25% Asian race/ethnicity. The majority of participants were female and approximately 25% were under the age of 30 years. There were statistically significant gains in knowledge in each of the six modules both in nursing home/home health-care settings and in hospital/educational settings, although participants in nursing home/home health care settings had lower pre-test scores and smaller knowledge gains in each of the six modules than those in hospital/educational settings. Mean increases ranged from 6.4 points (an 8.7% increase) in module 1-14.6 points (a 26.2% increase) in Module 6 (P < 0.01). IMPLICATIONS FOR NURSING MANAGEMENT The HEALE curriculum sets a standard for best practices in nursing management and for LGBT cultural competency in geriatric education. As such, implementation of this cultural competency training will go a long way to establish fundamental concepts regarding LGBT elder care and provide long-term strategies for providing culturally sensitive patient care.

Demographic, psychosocial, and contextual correlates of tobacco use in sexual minority women

Demographic, psychosocial, and contextual correlates of tobacco use among sexual minority women (SMW) were assessed using data from a larger lesbian, gay, bisexual, and transgender (LGBT) study. Of the 171 participants, 42% (n = 71) were smokers. However, 61% of smokers reported a recent quit attempt, and 39% were taking action toward or planning to quit. In multivariable logistic regression, lack of insurance, frequent attendance at LGBT bars, greater awareness of anti-smoking messages, and fewer perceived deterrents to smoking were associated with greater odds of smoking. Our findings provide additional support for elevated smoking rates among SMW and help to identify factors associated with smoking in this population. Awareness of prevention campaigns, recent quit attempts, and intention to quit were high, suggesting opportunities for smoking cessation.

Glycogen Levels in Undiluted Genital Fluid and Their Relationship to Vaginal pH, Estrogen, and Progesterone

Background Colonization of the female lower genital tract with Lactobacillus provides protection against STIs and adverse pregnancy outcomes. Growth of genital Lactobacillus is postulated to depend on epithelial cell-produced glycogen. However, the amount of cell-free glycogen in genital fluid available for utilization by Lactobacillus is not known. Methods Eighty-five genital fluid samples from 7 pre-menopausal women taken over 4–6 weeks were obtained using the Instead SoftCup® (EvoFem, Inc., San Diego, CA, USA) by consented donors. Cell-free glycogen and glucose in genital fluids and estrogen and progesterone in blood were quantified. Findings Glycogen ranged from 0.1–32 μg/μl. There were significant differences between women in glycogen over the observation period. There was a strong negative correlation between glycogen and vaginal pH (r = -0.542, p<0.0001). In multivariable analysis, free glycogen levels were significantly negatively associated with both vaginal pH and progesterone (p < 0.001 and p = 0.004, respectively). Estrogen, glucose, age, sexual intercourse 24 hours prior to visit, and days after the initial visit were not significantly associated with free glycogen levels. Conclusion Cell-free glycogen concentrations can be very high, up to 3% of genital fluid, and are strongly associated with acidic vaginal pH. However, the fluctuations in glycogen levels in individuals and differences between individuals do not appear to be associated with estrogen.

Transmission clustering among newly diagnosed HIV patients in Chicago, 2008 to 2011: using phylogenetics to expand knowledge of regional HIV transmission patterns.

Introduction:HIV transmission cluster analyses can inform HIV prevention efforts. We describe the first such assessment for transmission clustering among HIV patients in Chicago. Methods:We performed transmission cluster analyses using HIV pol sequences from newly diagnosed patients presenting to Chicagos largest HIV clinic between 2008 and 2011. We compared sequences through progressive pairwise alignment, using neighbor joining to construct an unrooted phylogenetic tree. We defined clusters as >2 sequences among which each sequence had at least 1 partner within a genetic distance of ⩽1.5%. We used multivariable regression to examine factors associated with clustering and used geospatial analysis to assess geographic proximity of phylogenetically clustered patients. Results:We compared sequences from 920 patients, median age of 35 years, 75% male, 67% black, 23% Hispanic, and 8% had a rapid plasma reagin titer ≥1:16 concurrent with their HIV diagnosis. We had HIV transmission risk data for 54%; 43% identified as men who have sex with men (MSM). Phylogenetic analysis demonstrated 123 patients (13%) grouped into 26 clusters, the largest having 20 members. In multivariable regression, age <25, black race, MSM status, male gender, higher HIV viral load, and rapid plasma reagin ≥1:16 associated with clustering. We did not observe geographic grouping of genetically clustered patients. Discussion:Our results demonstrate high rates of HIV transmission clustering, without local geographic foci, among young black MSM in Chicago. Applied prospectively, phylogenetic analyses could guide prevention efforts and help break the cycle of transmission.

Awareness of Media-Based Antitobacco Messages Among a Community Sample of LGBT Individuals

Purpose. Study objectives were to measure awareness of general antitobacco messages in LGBT-focused and general media outlets among LGBT (lesbian, gay, bisexual, and transgender) individuals and to examine associations between sociodemographic characteristics and awareness levels. Method. Data were based on cross-sectional survey data from a racially diverse sample of participants (N = 726). Participants were primarily male (69.3%), with smaller percentages of female (21.8%) and transgender (8.9%). The median age was 31 years. Results. A higher proportion of participants reported awareness of antitobacco messages in general media outlets compared to LGBT-specific media outlets. Awareness of antitobacco messages in general media was positively associated with current smoking and negatively associated with female gender and Latino ethnicity. Awareness of antitobacco messages in LGBT media was positively associated with younger age, current smoking, frequent reading of LGBT newspapers or magazines, and frequent attendance at LGBT bars and negatively associated with Latino ethnicity. Conclusions. Despite frequent readership, awareness of antitobacco messages in LGBT newspapers/magazines was quite low. We speculate that low awareness is related to the absence of antitobacco messages in LGBT-related media. LGBT-specific media outlets provide an important opportunity for future antitobacco campaigns.

Use of Pre-exposure Prophylaxis (PrEP) in Young Men Who Have Sex with Men is Associated with Race, Sexual Risk Behavior and Peer Network Size

Pre-exposure prophylaxis (PrEP) is efficacious to prevent HIV infection, however, uptake among young men who have sex with men (YMSM) is relatively low. The purpose of this study was to describe PrEP use and related factors in a representative sample of YMSM in two cities, Chicago and Houston. YMSM, ages 16–29, were recruited via respondent-driven sampling (RDS) from 2014 to 2016. Correlates of PrEP uptake were assessed in weighted multivariable logistic regression models. A total of 12.2% of participants (of 394) reported ever taking PrEP; Black YMSM had the lowest rates of uptake (4.7%) and Whites the highest (29.5%). In a multivariable regression model, having an HIV positive sex partner, reporting recent group sex, peer network size, and city (Chicago) were significantly and positively associated with use of PrEP, while Black race was negatively associated with it. Given evidence of racial/ethnic disparities in PrEP uptake in this study, further research is needed to identify potential mechanisms of action and points of intervention.ResumenProfilaxis prexposición (PrEP) es eficaz para prevenir la infección por el VIH, sin embargo, la captación entre los hombres jóvenes que tienen relaciones sexuales con hombres (YMSM) es relativamente baja. El propósito de este estudio fue describir el uso de PrEP y factores relacionados en una muestra representativa de YMSM en dos ciudades, Chicago y Houston. YMSM, edades 16–29, fueron reclutados a través de respondent-driven sampling (RDS) desde 2014–2016. Los correlatos de la captación de PrEP se evaluaron en modelos de regresión logística multivariable. Un total de 12.2% de los participantes (de 394) haber tomado PrEP; Black YMSM tuvo las tasas más bajas (4.7%) y los blancos el más alto (29.5%). En un modelo de regresión multivariable, tener una pareja sexual positiva para el VIH, reportar sexo en grupo reciente, tamaño de la red de pares y ciudad (Chicago) se asociaron significativa y positivamente con el uso de PrEP, mientras que la raza negra se asoció negativamente con ella. Dada la evidencia de las disparidades raciales/étnicas en la captación de PrEP en este estudio, se necesitan más investigaciones para identificar posibles mecanismos de acción y puntos de intervención.