Chris Grasso

Effect of Same-Sex Marriage Laws on Health Care Use and Expenditures in Sexual Minority Men: A Quasi-Natural Experiment

OBJECTIVES We sought to determine whether health care use and expenditures among gay and bisexual men were reduced following the enactment of same-sex marriage laws in Massachusetts in 2003. METHODS We used quasi-experimental, prospective data from 1211 sexual minority male patients in a community-based health center in Massachusetts. RESULTS In the 12 months after the legalization of same-sex marriage, sexual minority men had a statistically significant decrease in medical care visits (mean = 5.00 vs mean = 4.67; P = .05; Cohens d = 0.17), mental health care visits (mean = 24.72 vs mean = 22.20; P = .03; Cohens d = 0.35), and mental health care costs (mean =

Nonadherence to medical appointments is associated with increased plasma HIV RNA and decreased CD4 cell counts in a community-based HIV primary care clinic

2442.28 vs mean =

Substance use among HIV-infected patients engaged in primary care in the United States: findings from the Centers for AIDS Research Network of Integrated Clinical Systems cohort.

2137.38; P = .01; Cohens d = 0.41), compared with the 12 months before the law change. These effects were not modified by partnership status, indicating that the health effect of same-sex marriage laws was similar for partnered and nonpartnered men. CONCLUSIONS Policies that confer protections to same-sex couples may be effective in reducing health care use and costs among sexual minority men.

Raltegravir, tenofovir DF, and emtricitabine for postexposure prophylaxis to prevent the sexual transmission of HIV: safety, tolerability, and adherence.

Abstract This study examined the association of appointment nonadherence to markers of disease severity using one year of demographic and health information on 995 individuals with HIV in primary care at an urban community health centre. At the latest visit, 106 of 946 valid cases (11.2%) had a CD4 less than or equal to 200, and 454 of 936 valid cases (48.5%) had detectable plasma HIV RNA (greater than 50 copies/ml). Using logistic regression, appointment nonadherence (number of missed appointments) was a significant predictor (p<.03) of having an AIDS-defining CD4 count over and above the effects of number of kept appointments (p<.0001), and whether or not the patient was taking HAART (p<.002). Appointment nonadherence was also a significant predictor (p<.05) of having a detectable viral load over and above the effects of number of kept appointments (p<.003), HAART (p<.0001) and age (p<.004). Looking only at individuals with a detectable viral load at the earliest visit, the only significant unique predictor of improvement to an undetectable viral load at the latest visit was being on HAART (p<.05). Looking at those only with an undetectable viral load at the earliest visit, the only predictor of declining to a detectable viral load was number of kept appointments (p < 003), and being on HAART (p<.05).

Tenofovir DF plus lamivudine or emtricitabine for nonoccupational postexposure prophylaxis (NPEP) in a Boston Community Health Center.

OBJECTIVES The purpose of this study was to better understand substance use behaviors and deleterious health consequences among individuals with HIV. METHODS We examined a multicenter cohort of HIV-infected patients (n = 3,413) receiving care in 4 US cities (Seattle, Birmingham, San Diego, Boston) between December 2005 and April 2010 in the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS). We used generalized estimating equations to model specific substance use outcomes. RESULTS Overall, 24% of patients reported recent use of marijuana; 9% reported amphetamine use, 9% reported crack-cocaine use, 2% reported opiate use, 3.8% reported injection drug use, and 10.3% reported polydrug use. In adjusted multivariable models, those who reported unprotected anal sex had higher odds of marijuana, amphetamine, injection drug, and polydrug use. An increased number of distinct vaginal sexual partners was associated with polydrug and crack-cocaine use. Nonadherence to antiretroviral therapy was associated with the use of all substances other than marijuana. CONCLUSIONS The co-occurrence of substance use, unprotected intercourse, and medication nonadherence could attenuate the public health benefits of test, treat, and link to care strategies. Prevention programs are needed that address these coprevalent conditions.

End-Stage Renal Disease Among HIV-Infected Adults in North America

Abstract:Antiretroviral drugs have been recommended for postexposure prophylaxis (PEP) after high-risk sexual exposures for more than a decade. Three drug regimens could offer the highest levels of protection, particularly if the infectious source is taking medication, but drug intolerance has often led to suboptimal adherence. The current study evaluated a novel 3-drug PEP regimen, consisting of raltegravir, tenofovir DF, and emtricitabine. Of 100 participants enrolled in this study at a Boston community health center that has had a comprehensive PEP program for more than a decade, 85 were evaluable at 3 months and none became HIV infected. Fifty seven percent of those enrolled completed the regimen as prescribed, and 27% took their medicine daily, but sometimes missed the second daily dose of Raltegravir. The most common side effects reported included nausea or vomiting (27%), diarrhea (21%), headache (15%), fatigue (14%), abdominal symptoms (including pain, gas, or bloating) (16%), and myalgias or arthralgias (8%), all of which were mild and tended to be self-limited, not resulting in drug discontinuation. The side effects were significantly less common than those reported by historical controls, who used a 3-drug PEP regimen including zidovudine, lamivudine, and a ritonavir-boosted protease inhibitor. Raltegravir, tenofovir DF, and emtricitabine may be useful as a 3-drug regimen for PEP.

Disparities in the Quality of HIV Care When Using US Department of Health and Human Services Indicators

Background:Nonoccupational postexposure prophylaxis (NPEP) has been used to decrease HIV transmission after high-risk exposures. However, suboptimal adherence in completing the recommended 28-day course has resulted in prophylaxis failures. Fenway Community Health, the largest center caring for HIV-infected and high-risk men who have sex with men (MSM) in New England, began an NPEP program in 1997, initially using zidovudine-based regimens. Methods:Two phase 4 studies, using tenofovir DF regimens combined with either lamivudine or emtricitabine, were conducted. This paper evaluates the experience of those who used tenofovir-based NPEP regimens, comparing the subjects to historical controls who used zidovudine-containing regimens. Results:Between May 2004 and March 2005, 44 individuals who presented after high-risk sexual exposure were prescribed tenofovir DF/lamivudine for NPEP. Between March 2005 and March 2006, 68 individuals with 72 high-risk experiences received tenofovir DF/emtricitabine, and were compared to122 historical controls who were prescribed 126 courses of zidovudine plus lamivudine between January 2000 and May 2004. Seventy-two percent of those who took tenofovir DF and emtricitabine, and 87.5% of the participants who took tenofovir DF and lamivudine, for NPEP completed their regimens as prescribed, whereas only 42.1% of those who took zidovudine plus lamivudine did so (P < 0.0001). Participants who took tenofovir DF-containing regimens were more likely to report diarrhea or abdominal discomfort; patients who took zidovudine-containing regimens were more likely to report nausea and vomiting, which was often severe enough to lead to product discontinuation. Conclusions:Tenofovir DF-containing regimens for NPEP are generally well tolerated with high completion rates. Tolerability and adherence compared favorably to zidovudine-containing regimens used previously. Tenofovir DF-containing regimens should be considered for PEP to enhance adherence and regimen completion.

Gonococcal, chlamydia, and syphilis infection positivity among MSM attending a large primary care clinic, Boston, 2003 to 2004.

BACKGROUND Human immunodeficiency virus (HIV)-infected adults, particularly those of black race, are at high-risk for end-stage renal disease (ESRD), but contributing factors are evolving. We hypothesized that improvements in HIV treatment have led to declines in risk of ESRD, particularly among HIV-infected blacks. METHODS Using data from the North American AIDS Cohort Collaboration for Research and Design from January 2000 to December 2009, we validated 286 incident ESRD cases using abstracted medical evidence of dialysis (lasting >6 months) or renal transplant. A total of 38 354 HIV-infected adults aged 18-80 years contributed 159 825 person-years (PYs). Age- and sex-standardized incidence ratios (SIRs) were estimated by race. Poisson regression was used to identify predictors of ESRD. RESULTS HIV-infected ESRD cases were more likely to be of black race, have diabetes mellitus or hypertension, inject drugs, and/or have a prior AIDS-defining illness. The overall SIR was 3.2 (95% confidence interval [CI], 2.8-3.6) but was significantly higher among black patients (4.5 [95% CI, 3.9-5.2]). ESRD incidence declined from 532 to 303 per 100 000 PYs and 138 to 34 per 100 000 PYs over the time period for blacks and nonblacks, respectively, coincident with notable increases in both the prevalence of viral suppression and the prevalence of ESRD risk factors including diabetes mellitus, hypertension, and hepatitis C virus coinfection. CONCLUSIONS The risk of ESRD remains high among HIV-infected individuals in care but is declining with improvements in virologic suppression. HIV-infected black persons continue to comprise the majority of cases, as a result of higher viral loads, comorbidities, and genetic susceptibility.

Prevalent and Incident Hepatitis C Virus Infection Among HIV-Infected Men Who Have Sex With Men Engaged in Primary Care in a Boston Community Health Center

We estimated US Department of Health and Human Services (DHHS)-approved human immunodeficiency virus (HIV) indicators. Among patients, 71% were retained in care, 82% were prescribed treatment, and 78% had HIV RNA ≤200 copies/mL; younger adults, women, blacks, and injection drug users had poorer outcomes. Interventions are needed to reduce retention- and treatment-related disparities.

Hepatitis C Viremia and the Risk of Chronic Kidney Disease in HIV-Infected Individuals

Background: In the past decade, increases in syphilis and rectal gonorrhea have been reported among men who have sex with men (MSM) in the United States; however, limited sexually transmitted disease (STD) positivity data are available on MSM who receive their healthcare from primary care or general medical clinics. The current study sought to elucidate STD positivity in asymptomatic MSM seen at the largest primary care clinic for MSM in New England and to describe STD test positivity by reason for STD testing. Methods: As part of the Centers for Disease Control and Prevention’s MSM Prevalence Monitoring Project, all medical visits between 2003 and 2004 (n = 21,927) among MSM attending Fenway Community Health (Boston) were reviewed. The prevalence of positive STD tests (chlamydia, gonorrhea, and syphilis reactivity) was determined and analyzed by demographic characteristics, HIV status, symptoms, and reason for testing. Results: Overall, 23.4% of MSM visits included STD testing during the observation period. Their mean age was 39 years (range: 18–65 years); 84% were white, 5% were black, and 5% were Hispanic. Sixty-five percent of MSM tested were asymptomatic with 7% of asymptomatic MSM testing positive for at least one STD. STD prevalence varied by reason for STD testing: 4.4% of MSM routinely screened had at least one STD, compared to 6.9% of MSM who reported having high risk sex in the preceding 3 months, and 17% of MSM reporting an exposure to an STD. Among all asymptomatic MSM tested, 1.0% had urethral gonorrhea; 1.7% had pharyngeal gonorrhea; 5.6% had rectal gonorrhea; 2.2% had urethral chlamydia; and 4.3% were seroreactive for syphilis. Conclusions: Rectal gonorrhea and syphilis seropositivity were frequently diagnosed in asymptomatic MSM; STD prevalence was highest in MSM tested due to an STD exposure or reporting high-risk sex, underscoring the need to promote routine screening in high risk MSM populations.