Christy M. Anderson

Are We Prepped for Preexposure Prophylaxis (PrEP)? Provider Opinions on the Real-World Use of PrEP in the United States and Canada

BACKGROUND  Preexposure prophylaxis (PrEP) with tenofovir disoproxil fumarate and emtricitabine (Truvada) has demonstrated efficacy in placebo-controlled clinical trials involving men who have sex with men, high-risk heterosexuals, serodiscordant couples, and intravenous drug users. To assist in the real-world provision of PrEP, the Centers for Disease Control and Prevention (CDC) has released guidance documents for PrEP use. METHODS  Adult infectious disease physicians were surveyed about their opinions and current practices of PrEP through the Emerging Infections Network (EIN). Geographic information systems analysis was used to map out provider responses across the United States. RESULTS  Of 1175 EIN members across the country, 573 (48.8%) responded to the survey. A majority of clinicians supported PrEP but only 9% had actually provided it. Despite CDC guidance, PrEP practices were variable and clinicians reported many barriers to its real-world provision. CONCLUSIONS  The majority of adult infectious disease physicians across the United States and Canada support PrEP but have vast differences of opinion and practice, despite the existence of CDC guidance documents. The success of real-world PrEP will likely require multifaceted programs addressing barriers to its provision and will be assisted with the development of comprehensive guidelines for real-world PrEP.

Disparities in smoke-free workplace policies among food service workers.

Information is lacking on which groups of workers are protected from job-related environmental tobacco smoke. Data from the Census Bureau’s Current Population Survey are analyzed for trends in smoke-free workplace policies among 38 major occupations. Data are also analyzed to determine the degree of compliance with such policies. Although over three fourths of white collar workers are covered by smoke-free policies, including 90% of teachers, just 43% of the country’s 6.6 million food preparation and service occupations workers benefit from this level of protection. Compliance with workplace restrictions is not a significant human resources issue because only 3.8% of workers reported that someone violated a smoke-free policy in 1999, down from 4.9% in 1996. Protection for workers is increasing, but those in food preparation and service occupations are significantly less protected than others.

Using HIV Networks to Inform Real Time Prevention Interventions

Objective To reconstruct the local HIV-1 transmission network from 1996 to 2011 and use network data to evaluate and guide efforts to interrupt transmission. Design HIV-1 pol sequence data were analyzed to infer the local transmission network. Methods We analyzed HIV-1 pol sequence data to infer a partial local transmission network among 478 recently HIV-1 infected persons and 170 of their sexual and social contacts in San Diego, California. A transmission network score (TNS) was developed to estimate the risk of HIV transmission from a newly diagnosed individual to a new partner and target prevention interventions. Results HIV-1 pol sequences from 339 individuals (52.3%) were highly similar to sequences from at least one other participant (i.e., clustered). A high TNS (top 25%) was significantly correlated with baseline risk behaviors (number of unique sexual partners and insertive unprotected anal intercourse (p = 0.014 and p = 0.0455, respectively) and predicted risk of transmission (p<0.0001). Retrospective analysis of antiretroviral therapy (ART) use, and simulations of ART targeted to individuals with the highest TNS, showed significantly reduced network level HIV transmission (p<0.05). Conclusions Sequence data from an HIV-1 screening program focused on recently infected persons and their social and sexual contacts enabled the characterization of a highly connected transmission network. The network-based risk score (TNS) was highly correlated with transmission risk behaviors and outcomes, and can be used identify and target effective prevention interventions, like ART, to those at a greater risk for HIV-1 transmission.

Patterns of adolescent smoking initiation rates by ethnicity and sex

OBJECTIVE To define US national sex specific rates of smoking initiation among Hispanic, non-Hispanic white, and African American adolescents aged 12–17 years for each calendar year from 1940 through 1992. METHODS Adult survey data from the tobacco use supplement of the Current Population Survey in 1992-93 and 1995-96 were used to reconstruct the age at which individuals began to smoke and the calendar year in which they were that age. From these data, the number of individuals who began a calendar year as never smokers and who were aged 12–17 years during that year could be estimated and formed the denominator of the initiation rate. The number of these individuals who reported taking up smoking during that year formed the numerator of the initiation rate. RESULTS Initiation rates among male adolescents in each of the three racial/ethnic groups have declined since 1945. However, since 1983, initiation rates among male adolescents overall have increased. Non-Hispanic white male adolescents generally initiated cigarette smoking at higher rates than Hispanic or African American male adolescents. Initiation rates among Hispanic male adolescents have not been statistically different from initiation rates among African American male adolescents. From 1978 to 1982, initiation rates among Hispanic and African American male adolescents experienced a sharp decline, and the rate of decline was steeper than that experienced by non-Hispanic white male adolescents. Initiation rates among female adolescents have increased since 1940, catching up to male adolescent initiation rates by the mid 1970s. Initiation rates among female adolescents appeared to level off or increased slightly again from the mid 1980s to 1990. Non-Hispanic white female adolescents generally initiate cigarette smoking at higher rates than Hispanic or African American female adolescents. Initiation rates among non-Hispanic white and African American female adolescents equalled the initiation rates of their male counterparts by the mid 1970s, but initiation rates among Hispanic female adolescents did not overlap with initiation rates of Hispanic male adolescents until 1990. From 1975 to 1980, initiation rates among African American female adolescents decreased sharply, but, unlike initiation rates among the two other ethnic groups, rates continued to decline from 1984 to 1990. CONCLUSIONS Different patterns of increasing and decreasing smoking initiation among sex and ethnic adolescent groups suggest the effect of varying social and cultural influences. These findings support the importance of including ethnic factors in studies of smoking behaviour.

Smoking Cessation and Relapse during a Lung Cancer Screening Program

Background: The potential for negative screening to reduce smoking cessation and long-term abstinence is a concern in lung cancer screening. We examine whether consistently negative results during long-term participation in a lung cancer screening program reduce cessation or increase relapse. Methods: Participants (N = 2,078) in the Early Lung Cancer Action Program received annual screenings and periodic smoking behavior surveys over a follow-up period as long as 12 years. Point abstinence and prolonged abstinence were examined among 730 baseline smokers. Relapse was examined among 1,227 former smokers who quit for 1 year or more at enrollment, 121 recent quitters at enrollment, and 155 baseline smokers who quit during follow-up. Abstinence and relapse for participants with consistently negative computerized tomography scan results were compared with those with non-cancer–positive results using stratified Cox models. Results: Baseline smokers with negative computerized tomography scans had a 28% lower likelihood of achieving point abstinence at one or more follow-up assessments compared with those with positive scans (hazard ratio, 0.72; P < 0.0004), but consistently negative scans were not associated with a lower likelihood of prolonged abstinence. A consistently negative scan was not associated with a higher likelihood of relapse back to smoking for long-term former smokers, recent quitters, or those who quit during follow-up. Conclusions: We did not detect a lower long-term smoking abstinence or increased relapse over a 6-year period of follow-up among individuals participating in a lung cancer screening program who have a consistently negative screening compared with those with a positive, but noncancer, screening result. (Cancer Epidemiol Biomarkers Prev 2009;18(12):3476–83)

Do changes in cigarette design influence the rise in adenocarcinoma of the lung

BackgroundIncidence rates for adenocarcinoma of the lung are increasing and are higher in the United States than in many other developed countries. We examine whether these trends may be associated with changes in cigarette design.MethodsLung cancer risk equations based on observations during 1960–1972 from the American Cancer Society Cancer Prevention Study I are applied to 5-year birth cohort–specific estimates of changes in smoking behaviors to predict birth cohort–specific rates of squamous cell carcinoma and adenocarcinoma of the lung among US White men for the period 1973–2000. These expected rates are compared to observed rates for the same birth cohorts of White men in the US Surveillance, Epidemiology and End Results (SEER) data.ResultsChanges in smoking behaviors over the past several decades adequately explain the changes in squamous cell carcinoma rates observed in the SEER data. However, predicted rates for adenocarcinoma do not match the observed SEER data without inclusion of a term increasing the risk for adenocarcinoma with the duration of smoking after 1965.ConclusionThe risk of developing squamous cell carcinoma from smoking appears to have remained stable in the United States over the past several decades; however, the risk of adenocarcinoma has increased substantially in a pattern temporally associated with changes in cigarette design.

Cytomegalovirus DNA in Semen and Blood Is Associated With Higher Levels of Proviral HIV DNA

Over three-fourths of human immunodeficiency virus (HIV)-infected men who have sex with men (MSM) have at least one herpesvirus detected in their semen, and cytomegalovirus (CMV) is the most prevalent. The presence of CMV is associated with higher T-cell immune activation and with HIV disease progression in treated and untreated individuals. In this study of 113 antiretroviral (ART)-naive HIV-infected MSM, we found that CMV replication in blood and semen was associated with higher levels of HIV DNA in peripheral blood mononuclear cells. These observations suggest that interventions aimed to reduce CMV replication and, thus, systemic immune activation could decrease the size of the latent HIV reservoir.

Association between home smoking restrictions and changes in smoking behaviour among employed women

Study objective: Examine trends in home smoking restrictions among employed women not living alone and assess the associations of such restrictions with smoking behaviour. Design: Multivariate logistic regression analysis of major demographic variables and household composition characteristics. Study participants: 128 024 employed female respondents to the Census Bureau’s current population survey over the 10 year period 1992 to 2002. Main results: The prevalence of smoke free homes has increased significantly over the past decade. This increase was evident across all demographic and household characteristics examined with the greatest rate of increase seen among smoking households. Nearly 90% of households consisting of all never smoking adult members reported having a smoke free home in 2001–02 compared with 22% of households consisting of all smokers. The extent of smoking restrictions in the home was the most powerful determinant of cessation of all the factors examined in the regression model. Odds of becoming a former smoker (any length) and quit for three months or more were seven to eight times greater among those women reporting their homes were smoke free compared with those whose homes permitted smoking anywhere in the home. Conclusions: Smoke free homes were associated with a highly significant increase in quitting (p<0.0001). However, at this time it is not clear what proportion of the observed effect can be attributed to living in a smoke free home. None the less, the significantly increased probability of quitting correlated with having a smoke free home found in this analysis, are substantially higher than the odds reported in most workplace studies published to date; additional studies are needed to elucidate this relation.

Factors associated with drug-related harms related to policing in Tijuana, Mexico

ObjectiveTo assess factors associated with drug-related harms related to policing among injection drug users (IDUs) in Tijuana, Mexico.MethodsIDUs who were over 18 years old and had injected drugs within the last six months were recruited via respondent-driven sampling and underwent questionnaires and testing for HIV (human immunodeficiency virus), syphilis and TB (tuberculosis). Random effects logistic regression was used to simultaneously model factors associated with five drug-related harms related to policing practices in the prior six months (i.e., police led them to rush injections; affected where they bought drugs; affected locations where they used drugs; feared that police will interfere with their drug use; receptive syringe sharing).ResultsOf 727 IDUs, 85% were male; median age was 38 years. Within the last 6 months, 231 (32%) of IDUs reported that police had led them to rush injections, affected where they bought or used drugs or were very afraid police would interfere with their drug use, or shared syringes. Factors independently associated with drug-related harms related to policing within the last six months included: recent arrest, homelessness, higher frequencies of drug injection, use of methamphetamine, using the local needle exchange program and perceiving a decrease in the purity of at least one drug.ConclusionsIDUs who experienced drug-related harms related to policing were those who were most affected by other micro and macro influences in the physical risk environment. Police education programs are needed to ensure that policing practices do not exacerbate risky behaviors or discourage protective behaviors such as needle exchange program use, which undermines the right to health for people who inject drugs.

Development and Validation of the San Diego Early Test Score to Predict Acute and Early HIV Infection Risk in Men Who Have Sex With Men

BACKGROUND Although men who have sex with men (MSM) represent a dominant risk group for human immunodeficiency virus (HIV), the risk of HIV infection within this population is not uniform. The objective of this study was to develop and validate a score to estimate incident HIV infection risk. METHODS Adult MSM who were tested for acute and early HIV (AEH) between 2008 and 2014 were retrospectively randomized 2:1 to a derivation and validation dataset, respectively. Using the derivation dataset, each predictor associated with an AEH outcome in the multivariate prediction model was assigned a point value that corresponded to its odds ratio. The score was validated on the validation dataset using C-statistics. RESULTS Data collected at a single HIV testing encounter from 8326 unique MSM were analyzed, including 200 with AEH (2.4%). Four risk behavior variables were significantly associated with an AEH diagnosis (ie, incident infection) in multivariable analysis and were used to derive the San Diego Early Test (SDET) score: condomless receptive anal intercourse (CRAI) with an HIV-positive MSM (3 points), the combination of CRAI plus ≥5 male partners (3 points), ≥10 male partners (2 points), and diagnosis of bacterial sexually transmitted infection (2 points)-all as reported for the prior 12 months. The C-statistic for this risk score was >0.7 in both data sets. CONCLUSIONS The SDET risk score may help to prioritize resources and target interventions, such as preexposure prophylaxis, to MSM at greatest risk of acquiring HIV infection. The SDET risk score is deployed as a freely available tool at http://sdet.ucsd.edu.