Montina Befus

Use of the community viral load as a population- based biomarker of HIV burden

Objectives:Recent data suggest that community viral load (CVL) can be used as a population-level biomarker for HIV transmission and its reduction may be associated with a decrease in HIV incidence. Given the magnitude of the HIV epidemic in Washington, District of Columbia, we sought to measure the District of Columbias CVL. Design:An ecological analysis was conducted. Methods:Mean and total CVL were calculated using the most recent viral load for prevalent HIV/AIDS cases reported to District of Columbia HIV/AIDS surveillance through 2008. Univariate and multivariable analyses were conducted to assess differences in CVL availability, mean CVL, proportion of undetectable viral loads, and 5-year trends in mean CVL and new HIV/AIDS diagnoses. Geospatial analysis was used to map mean CVL and selected indicators of socioeconomic status by geopolitical designation. Results:Among 15 467 HIV/AIDS cases alive from 2004 to 2008, 48.2% had at least one viral load reported. Viral load data completeness increased significantly over the 5 years (P < 0.001). Mean CVL significantly decreased over time (P < 0.0001). At the end of 2008, the mean CVL was 33 847 copies/ml; 57.4% of cases had undetectable viral loads. Overlaps in the geographic distribution of CVL by census tract were observed with the highest means observed in areas with high poverty rates and low high school diploma rates. Conclusion:Mean and total CVL provide markers of access to care and treatment, are indicators of the populations viral burden, and are useful in assessing trends in local HIV/AIDS epidemics. Measurement of CVL is a novel tool for assessing the potential impact of population-level HIV prevention and treatment interventions.

Temporal association between expanded HIV testing and improvements in population-based HIV/AIDS clinical outcomes, District of Columbia

In 2006, the District of Columbia Department of Health (DC DOH) launched initiatives promoting routine HIV testing and improved linkage to care in support of revised the Centers for Disease Control and Prevention (CDC) HIV-testing guidelines. An ecological analysis was conducted using population-based surveillance data to determine whether these efforts were temporally associated with increased and earlier identification of HIV/AIDS cases and improved linkages to care. Publically funded HIV-testing data and HIV/AIDS surveillance data from 2005 to 2009 were used to measure the number of persons tested, new diagnoses, timing of entry into care, CD4 at diagnosis and rates of progression to AIDS. Tests for trend were used to determine whether statistically significant changes in these indicators were observed over the five-year period. Results indicated that from 2005 to 2009, publically funded testing increased 4.5-fold; the number of newly diagnosed HIV/AIDS cases remained relatively constant. Statistically significant increases in the proportion of cases entering care within three months of diagnosis were observed (p < 0.0001). Median CD4 counts at diagnosis increased over the five-year time period from 346 to 379 cells/µL. The proportion of cases progressing from HIV to AIDS and diagnosed with AIDS initially, decreased significantly (both p < 0.0001). Routine HIV testing and linkage to care efforts in the District of Columbia were temporally associated with earlier diagnoses of cases, more timely entry into HIV-specialized care, and a slowing of HIV disease progression. The continued use of surveillance data to measure the community-level impact of other programmatic initiatives including test and treat strategies will be critical in monitoring the response to the Districts HIV epidemic.

Prevalence and correlates of hepatitis C virus infection among inmates at two New York State correctional facilities.

Previous studies have reported decreasing hepatitis C virus (HCV) infection rates in the general population. However, differential susceptibility in institutionalized populations suggest that HCV infection is even more prevalent in prison populations than previously reported yet, routine screening for HCV infection among prisoners is not generally available. We estimated the HCV prevalence and identified associated exposures at two maximum-security prisons using data obtained from 2788 inmates from the Risk Factors for Spread of Staphylococcus aureus in Prisons Study in New York, which recruited participants from January 2009 and January 2013. HCV prevalence was 10.1% (n=295); injection drug use, injection drug use sex partners, and HIV diagnosis exhibited the strongest associations with HCV infection in multivariable models, adjusting for covariates. Taken together, the findings of the present study provide an updated estimate of HCV prevalence and suggest that incarcerated populations represent a declining yet significant portion of the hepatitis epidemic.

Obesity as a Determinant of Staphylococcus aureus Colonization Among Inmates in Maximum-Security Prisons in New York State

Obesity increases a persons susceptibility to a variety of infections, including Staphylococcus aureus infections, which is an important cause of morbidity in correctional settings. Using a cross-sectional design, we assessed the association between obesity and S. aureus colonization, a risk factor for subsequent infection, in New York State maximum-security prisons (2011-2013). Anterior nares and oropharyngeal cultures were collected. Structured interviews and medical records were used to collect demographic, behavioral, and medical data. Body mass index (BMI; weight (kg)/height (m(2))) was categorized as 18.5-24.9, 25-29.9, 30-34.9, or ≥35. The association between BMI and S. aureus colonization was assessed using log-binomial regression. Thirty-eight percent of 638 female inmates and 26% of 794 male inmates had a BMI of 30 or higher. More than 40% of inmates were colonized. Female inmates with a BMI of 25-29.9 (prevalence ratio (PR) = 1.37, 95% confidence interval (CI): 1.06, 1.76), 30-34.9 (PR = 1.52, 95% CI: 1.17, 1.98), or ≥35 (PR = 1.49, 95% CI: 1.13, 1.96) had a higher likelihood of colonization than did those with a BMI of 18.5-24.9 after we controlled for age, educational level, smoking status, diabetes status, and presence of human immunodeficiency virus. Colonization was higher among male inmates with a BMI of 30-34.9 (PR = 1.27, 95% CI: 1.01, 1.61). Our findings demonstrate an association between BMI and S. aureus colonization among female prisoners. Potential contributory biologic and behavioral factors should be explored.

Epidemiological and Biological Determinants of Staphylococcus aureus Clinical Infection in New York State Maximum Security Prisons

BACKGROUND Large outbreaks of Staphylococcus aureus (SA) infections have occurred in correctional facilities across the country. We aimed to define the epidemiological and microbiological determinants of SA infection in prisons to facilitate development of prevention strategies for this underserved population. METHODS We conducted a case-control study of SA infection at 2 New York State maximum security prisons. SA-infected inmates were matched with 3 uninfected controls. Subjects had cultures taken from sites of infection and colonization (nose and throat) and were interviewed via structured questionnaire. SA isolates were characterized by spa typing. Bivariate and multivariable analyses were conducted using conditional logistic regression. RESULTS Between March 2011 and January 2013, 82 cases were enrolled and matched with 246 controls. On bivariate analysis, the use of oral and topical antibiotics over the preceding 6 months was strongly associated with clinical infection (OR, 2.52; P < .001 and 4.38, P < .001, respectively). Inmates with clinical infection had 3.16 times the odds of being diabetic compared with inmates who did not have clinical infection (P < .001). Concurrent nasal and/or oropharyngeal colonization was also associated with an increased odds of infection (OR, 1.46; P = .002). Among colonized inmates, cases were significantly more likely to carry the SA clone spa t008 (usually representing the epidemic strain USA300) compared to controls (OR, 2.52; P = .01). CONCLUSIONS Several inmate characteristics were strongly associated with SA infection in the prison setting. Although many of these factors were likely present prior to incarceration, they may help medical staff identify prisoners for targeted prevention strategies.

Is Environmental Contamination Associated with Staphylococcus aureus Clinical Infection in Maximum Security Prisons

Over the past decade, large outbreaks of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infections have occurred in correctional facilities across the country.1,2 Although many have been managed with aggressive interventions, response to standard infection control procedures has been variable, highlighting our incomplete understanding of staphylococcal transmission in this setting.2 Environmental contamination has recently emerged as a possible target for novel prevention and control strategies.3,4 This study sought to characterize the relationship between environmental contamination and clinical infection in this vulnerable population. We conducted a case-control study of S. aureus environmental contamination at 2 New York State (NYS) maximum security prisons: Sing Sing (men) and Bedford Hills (women). Prisoners with documented S. aureus skin infections were identified by medical personnel at each prison. For every case, 2 uninfected controls—1 nasally and/or oropharyngeally colonized with S. aureus and 1 noncolonized—were selected from the same prison in a contemporaneous fashion. These were identified through our research group’s ongoing study of S. aureus colonization in NYS prisons.5 Consenting study participants had a standardized set of environmental surfaces cultured within 1 week of infection diagnosis (cases) or selection (controls). These included bed sheets, sink handles, toilet flushes, toilet seats, cell bars, light switches, soap dishes, window handles, locker handles, and radios but varied on the basis of the prisoner’s cell contents. Cultures were also obtained from shared gymnasiums in each prison at study initiation. All samples were collected using premoistened rayon-tipped swabs and qualitatively cultured as described else-where.5 S. aureus isolates were typed by polymerase chain reaction sequencing of the spa (staphylococcal protein A) gene.6 SAS (ver. 9.2; SAS Institute) was utilized for data analysis. The study was approved by the Columbia University and NYS Department of Corrections Institutional Review Boards. Ten cases were enrolled in this study. Twenty controls were selected, but 2 did not meet inclusion criteria. There were no significant associations between case status and the demographic and exposure variables assessed (sex, age, race/ ethnicity, self-perceived health, shower frequency, and gym use). The proportion of subjects with S. aureus contamination on 1 or more surfaces did not vary appreciably on the basis of infection status (3/10 cases [30%] vs 6/18 controls overall [33.3%]; Table 1). Despite this, environmental contamination of controls varied depending on their colonization status. Surface contamination, when present, was more frequent among cases than among controls (13/18 surfaces from 3 cases [72.2%] vs 20/43 surfaces from 6 controls [46.5%]; P = .07). Six clonal types were identified on surfaces of the 9 contaminated cells; only 1 cell had more than 1 clone present. None of the infectious, colonization, or personal environmental isolates were methicillin resistant. TABLE 1 Environmental Contamination of Cases and Controls Of the 20 items sampled in the Sing Sing gymnasium, 8 (40%) were positive for S. aureus. These included the gym door handle, boxing gloves, basketballs, abdominal crunch machine, seated and upright leg presses, and hand sanitizer dispenser. Among these surfaces, 6 clonal types were found (spa t002, t008, t334, t701, t1510, and t2334), and all were methicillin susceptible. The Bedford Hills gymnasium was not heavily contaminated; 2 (7.7%) of 26 surfaces were positive, 1 with methicillin-resistant spa t008. Few studies have assessed the prevalence and significance of bacterial surface contamination in jails or prisons. In 2009, Felkner et al7 cultured 132 surfaces from a Texas jail in a nonoutbreak setting. S. aureus was recovered from 10 surfaces (7.6%), with the majority of isolates (8/10) resistant to methicillin. A subset of isolates (6/10) underwent pulsed-field gel electrophoresis, and two-thirds were found to be identical to the USA300 epidemic strain (spa t008). Inmates at Sing Sing and Bedford Hills are known to have high rates of asymptomatic colonization with MRSA (11.2% and 11.1%, respectively) and USA300 (10% and 12.4%, respectively).5 Although this study documented a high prevalence of staphylococcal contamination, only 1 (0.4%) of the 283 environmental cultures was positive for MRSA. The etiology of this discrepancy is unclear. As previous studies have shown effective survival of USA300 and MRSA in the environment,6, 8 the comparatively low prevalence of surface contamination with these clones may be related to infection control strategies within the prison. Since USA300 is a common cause of skin abscesses, systemic antibiotics administered to those with active infection may reduce asymptomatic carriage and subsequent environmental contamination with this clone. Similarly, aggressive environmental hygiene may be differentially applied to locations highly contaminated with this strain if they are associated with purulent skin infections. Prisoners are responsible for disinfecting their own environments using quaternary ammonium products on a weekly basis. Despite this, the true frequency and intensity of cleaning may vary on the basis of prisoner preferences. Our finding of increased environmental contamination among colonized controls compared with that among noncolonized controls suggests that asymptomatic nasal and/or oropharyngeal carriage correlates with environmental reservoirs. Although every effort was made to culture cases’ cells immediately after an infection was identified, antimicrobials and disinfection administered immediately after ascertainment may have limited our ability to capture environmental contamination. Our study is further impaired by its small sample size, limited largely by a low incidence of infections over our study period. It is possible that investigations of environmental contamination during prison-based outbreaks could yield different results. Prospective studies with larger enrollments may be more effective in demonstrating small but significant trends in environmental colonization. While mounting evidence suggests a linkage between S. aureus surface contamination and clinical infection, data remain conflicting.3,4,6 Further research into prison-based infectious reservoirs will be essential to effectively protect this important population and the communities in which they reside.

Evaluating the utility of provider-recorded clinical status in the medical records of HIV-positive adults in a limited-resource setting.

Provider-reported summaries of clinical status may assist with clinical management of HIV in resource poor settings if they reflect underlying biological processes associated with HIV disease progression. However, their ability to do so is rarely evaluated. Therefore, we aimed to assess the relationship between a provider-recorded summary of clinical status and indicators of HIV progression. Data were abstracted from 201 randomly selected medical records at a large HIV clinic in the Dominican Republic. Multivariable logistic regressions were used to examine the relationship between provider-assigned clinical status and demographic (gender, age, nationality, education) and clinical factors (reported medication adherence, CD4 cell count, viral load). The mean age of patients was 41.2 (SD = ±10.9) years and most were female (n = 115, 57%). None of the examined characteristics were significantly associated with provider-recorded clinical status. Higher CD4 cell counts were more likely for females (OR = 2.2 CI: 1.12–4.31) and less likely for those with higher viral loads (OR = 0.33 CI: 0.15–0.72). Poorer adherence and lower CD4 cell counts were significantly associated with higher viral loads (OR = 4.46 CI: 1.11–20.29 and 6.84 CI: 1.47–37.23, respectively). Clinics using provider-reported summaries of clinical status should evaluate the performance of these assessments to ensure they are associated with biologic indicators of disease progression.

Factors Associated with Health Information Seeking, Processing, and Use Among HIV Positive Adults in the Dominican Republic

Effective treatment and management of human immunodeficiency virus (HIV) depend on patients’ ability to locate, comprehend, and apply health information. This study’s purpose was to identify characteristics associated with these skills among HIV positive adults in the Dominican Republic. An information behavior survey was administered to 107 participants then three logistic regressions were conducted to identify characteristics associated with information seeking, processing, and use. Never having cared for someone who was sick was significantly associated with less information seeking, processing, and use. Males were more likely to be active information seekers and those who had attended the clinic for six or fewer years were less likely to actively seek information. Younger individuals had increased odds of higher information processing and those without comorbidities had increased odds of more information use. Results may inform researchers, organizations, and providers about how patients interact with health information in limited resource settingsResumenEl tratamiento y manejo eficaz del virus de inmunodeficiencia humana (VIH) depende en la habilidad de un paciente de encontrar, comprender y aplicar la información acerca de la salud. El objetivo de este estudio fue identificar las características asociadas con estas capacidades necesarias entre adultos VIH positivos en La República Dominicana. Se realizó una entrevista con 107 participantes sobre el comportamiento de la información de la salud para luego ser analizada mediante regresión logística para identificar las características asociadas con la búsqueda, el procesamiento y el uso de la información de la salud. Los resultados mostraron que no haber cuidado de alguien en estado grave de salud estuvo asociado significativamente con menos búsqueda, procesamiento y uso de la información de la salud. Hombres tuvieron más probabilidad de buscar información de forma activa y aquellos con seis o menos años recibiendo atención en la clínica tuvieron menos probabilidad de buscar información de forma activa. Los participantes con menos de 42 años tuvieron más probabilidad de procesar la información en una manera alta y los participantes sin comorbilidades tuvieron más probabilidad de usar la información. Estos resultados pueden informar investigadores, organizaciones y proveedores de salud sobre como pacientes puedan interactuar y beneficiarse con la información de la salud en lugares con bajo recursos.

Predictors of Illicit Drug Use Among Prisoners.

ABSTRACT Background: The United States of America currently has the highest incarceration rate in the world, and approximately 80% of incarcerated individuals have a history of illicit drug use. Despite institutional prohibitions, drug use continues in prison, and is associated with a range of negative outcomes. Objectives: To assess the relationship between prison drug use, duration of incarceration, and a range of covariates. Results: Most participants self-reported a history of illicit drug use (77.5%). Seven percent reportedly used drugs during the previous six months of incarceration (n = 100). Participants who had been incarcerated for more than a year were less likely than those incarcerated for longer than a year to report using drugs (OR = 0.50; 95% CI = 0.26–0.98). Participants aged 37–89 were less likely than younger prisoners to use drugs (OR = 0.39; 95% CI = 0.19–0.80). Heroin users were twice as likely as nonheroin users to use drugs (OR = 2.28; 95% CI = 1.04–5.03); crack cocaine users were also twice as likely as participants with no history of crack cocaine usage to report drug use (OR = 2.53; 95% CI = 1.13–5.69). Conclusions: Correctional institutions should be used as a resource to offer evidence-based services to curb drug usage. Drug treatment programs for younger prisoners, heroin and crack cocaine users, and at the beginning of a prisoners sentence should be considered for this population.

Drug Use Is Associated With Purulent Skin and Soft Tissue Infections in a Large Urban Jail: 2011–2015

Abstract Background Skin and soft tissue infections (SSTIs) are a common problem in jails in the United States. This study aimed to identify factors associated with purulent SSTIs in the New York City jail system. Methods We conducted a case-control study of purulent SSTIs at the New York City jail. Cases were matched to controls by visit date to the jail’s urgent care clinic. Bivariate and multivariable analyses were conducted using conditional logistic regression. Results From April 2011 to April 2015, 1010 cases of SSTIs were identified and matched to 1010 controls. In multivariable analyses, report upon entry to jail of current injection drug use (odds ratio [OR], 2.76; 95% confidence interval [CI], 1.77–4.31), current snorting of drugs (OR, 1.50; 95% CI, 1.12–2.00), current heroin use (OR, 1.53; 95% CI, 1.08–2.17), current cocaine use (OR, 1.76; 95% CI, 1.18–2.65), and antibiotic use within the previous 6 months (OR, 4.05; 95% CI, 2.98–5.49) were significantly associated with SSTI diagnosis. Conclusions Skin and soft tissue infections were strongly associated with a history of drug use at jail entry. Targeting intravenous drug use may be a preventive strategy for SSTIs in this population. Strategies such as harm reduction programs may be investigated.