HIV Research Year in Review in Haiti

Introduction For this issue of the Epidemiologic Surveillance Bulletin, we summarize the prior year’s research on populations living with HIV (PLWH) in Haiti for World AIDS Day 2020. Methods We retrieved 50 articles from PubMed (pubmed.gov) for articles written in English using the search term [Haiti* AND (HIV OR human immunodeficiency virus OR AIDS)] from December 2019 to November 19, 2020 (approximately 1 year). We included studies that of cohorts of people living with HIV in Haiti, patients enrolled from Haiti in multi-country clinical studies and studies involving populations at substantial risk of HIV in Haiti. We excluded studies of Haitian populations in other countries, study protocols, perspectives, and opinion articles. The final review contains summaries of 28 studies. We grouped into relevant themes when possible and summarized each paper

Obstetrician-Gynecologist Perceptions and Utilization of Prescription Drug Monitoring Programs: A Survey Study

Query of Prescription Drug Monitoring Programs (PDMPs) is recommended before prescribing opioids by the US Centers for Disease Control and Prevention, to inform clinical practice and aid diversion prevention. Many states mandate prescriber PDMP use; however, little is known about PDMP perception of utility and use among Obstetricians-Gynecologists (OB/GYN), who are the primary provider for most women during pregnancy. This study examined OB/GYN perceptions and utilization of their state PDMP. Survey items were developed by expert consensus. A voluntary anonymous survey was emailed to a random sample of 5000 OB/GYNs (adjusted participants n = 1470, minus unread/refusals). Responses were stratified by state policy environment, where response frequency distributions were compared for OB/GYNs practicing in states with mandatory vs voluntary PDMP query. Adjusted response rate was 27% (n = 397). Most OB/GYNs (78%) were registered with their PDMP. The majority agreed that “…mandating physician use of the PDMP was a good idea” (51.4% mandatory state vs 58.3% voluntary state). Respondents in mandatory states reported that the primary purpose of the PDMP was “to allow the physician to verify medications that the patient is being prescribed” less frequently than those in voluntary states (38.3% vs 52.8%). Several report speaking with patients about controlled substance prescriptions after viewing PDMP reports (27.8% in mandatory vs 26.3% in voluntary states). In qualitative responses, reported frustration with PDMPs was evident. OB/GYNs are diverse in their perceptions regarding the utility and purpose of PDMPs. Tailored education is needed regarding clinical utility of PDMPs for OB/GYN practice

Medicare-Paid Naloxone: Trends in Non-Metropolitan and Metropolitan Areas

Overview of Key Findings Medicare pays for the largest share (\u3e 30%) of naloxone dispensed from retail pharmacies in non-metropolitan areas. Medicare-paid dispensing has grown since 2013, but from 2017-2018 dispensing growth in non-metropolitan areas slowed considerably compared to metropolitan areas (42% v 121%, respectively). As of 2018, the rate of naloxone dispensing to Medicare enrollees in metropolitan areas was approximately double that in non-metropolitan areas (4.9 v 2.9 per 1,000 enrollees, respectively)

Wastewater-based Estimation of Substances Discharged at the Rest Areas along the State Highways in Kentucky

The availability of licit and illicit stimulants and its adverse consequences on public health has emerged as a major drug threat to communities in the United States. Despite several drug-involved traffic incidents along the interstate highways, this report represents the first comprehensive and quantitative report of drugs discharged at the rest areas along the interstate highways. In this National Institute of Justice-funded study, the amount of several discharged drugs focusing on stimulants but also including opioids and prescription antipsychotics are being measured in raw wastewater collected from five rest areas and a truck servicing facility using a state-of-the-art mass spectrometry technique. Three stimulants (cocaine, methamphetamine, and amphetamine), two opioids (hydrocodone and tramadol), THC metabolite, and four antidepressants (venlafaxine, citalopram, fluoxetine, and sertraline) were detected in all of the collected wastewater samples in the early phases of the project. Methamphetamine was the most prevalent stimulant (40.0-1240 mg/d) followed by the cocaine metabolite (9.18-385 mg/d) and amphetamine (14.9-97.9 mg/d). The rest area users normalized methamphetamine discharge in Christian County rest area (I-24E) was 1.8 folds higher than in Whitehaven rest area (I-24W) and 7.8 folds higher than in the Laurel County truck service facility (I-75). The significantly higher ratio of cocaine and its metabolite (\u3e1.0) found in the Whitehaven rest area suggested the possibility of a direct discharge of cocaine in two select days in October. Overall, we established a unique collaboration among the Appalachian High Intensity Drug Trafficking Area (HIDTA), the Kentucky Transportation Cabinet, Cabinet for Health and Family Services, Murray State University and the University of Kentucky

Predictors of Chronic Opioid Therapy in Medicaid Beneficiaries with HIV Who Initiated Antiretroviral Therapy

The factors associated with chronic opioid therapy (COT) in patients with HIV is understudied. Using Medicaid data (2002-2009), this retrospective cohort study examines COT in beneficiaries with HIV who initiated standard combination anti-retroviral therapy (cART). We used generalized estimating equations on logistic regression models with backward selection to identify significant predictors of COT initiation. COT was initiated among 1014 out of 9615 beneficiaries with HIV (male: 10.4%; female: 10.7%). Those with older age, any malignancy, Hepatitis C infection, back pain, arthritis, neuropathy pain, substance use disorder, polypharmacy, (use of) benzodiazepines, gabapentinoids, antidepressants, and prior opioid therapies were positively associated with COT. In sex-stratified analyses, multiple predictors were shared between male and female beneficiaries; however, chronic obstructive pulmonary disease, liver disease, any malignancy, and antipsychotic therapy were unique to female beneficiaries. Comorbidities and polypharmacy were important predictors of COT in Medicaid beneficiaries with HIV who initiated cART

Risk Factors for Delayed Viral Suppression on First-Line Antiretroviral Therapy among Persons Living with HIV in Haiti, 2013-2017

Studies of viral suppression on first-line antiretroviral therapy (ART) in persons living with human immunodeficiency virus (PLHIV) in Haiti are limited, particularly among PLHIV outside of the Ouest department, where the capital Port-au-Prince is located. This study described the prevalence and risk factors for delayed viral suppression among PLHIV in all geographic departments of Haiti between 2013 and 2017. Individuals who received viral load testing 3 to 12 months after ART initiation were included. Data on demographics and clinical care were obtained from the Haitian Active Longitudinal Tracking of HIV database. Multivariable logistic regression was performed to predict delayed viral suppression, defined as a viral load ≥1000 HIV-1 RNA copies/mL after at least 3 months on ART. Viral load test results were available for 3,368 PLHIV newly-initiated on ART. Prevalence of delayed viral suppression was 40%, which is slightly higher than previous estimates in Haiti. In the multivariable analysis, delayed viral suppression was significantly associated with younger age, receiving of care in the Ouest department, treatment with lamivudine (3TC), zidovudine (AZT), and nevirapine (NVP) combined ART regimen, and CD4 counts below 200 cells/mm3. In conclusion, this study was the first to describe and compare differences in delayed viral suppression among PLHIV by geographic department in Haiti. We identified populations to whom public health interventions, such as more frequent viral load testing, drug resistance testing, and ART adherence counseling should be targeted

Frequency and Types of Healthcare Encounters in the Week Preceding a Sepsis Hospitalization: A Systematic Review

OBJECTIVES: Early recognition and treatment are critical to improving sepsis outcomes. We sought to identify the frequency and types of encounters that patients have with the healthcare system in the week prior to a sepsis hospitalization. DATA SOURCES: PubMed, Cumulative Index to Nursing and Allied Health Literature, Scopus, and the Cochrane Library. STUDY SELECTION: Observational cohort studies of patients hospitalized with sepsis or septic shock that were assessed for an outpatient or emergency department encounter with the healthcare system in the week prior to hospital admission. DATA EXTRACTION: The primary outcome was the proportion of patients with a healthcare encounter in the time period assessed (up to 1 week) prior to a hospitalization with sepsis. DATA SYNTHESIS: Six retrospective observational studies encompassing 6,785,728 sepsis admissions were included for evaluation, ranging from a 263-patient single-center cohort to a large database evaluating 6,731,827 sepsis admissions. The average (unweighted) proportion of patients having an encounter with the healthcare system in the week prior to a sepsis hospitalization was 32.7% and ranged from 10.3% to 52.9%. These encounters commonly involved presentation or potential symptoms of infectious diseases, antibiotic prescriptions, and appeared to increase in frequency closer to a sepsis hospitalization admission. No consistent factors were identified that distinguished a healthcare encounter as more or less likely to precede a sepsis hospitalization in the subsequent week. CONCLUSIONS: Patients that present to the hospital with sepsis are frequently evaluated in the healthcare system in the week prior to admission. Further research is necessary to understand if these encounters offer earlier opportunities for intervention to prevent the transition from infection to sepsis, whether they merely reflect the comorbidities of sepsis patients with a high baseline rate of healthcare encounters, or the declining trajectory of a patient\u27s overall health in response to infection

Inches, Centimeters, and Yards: Overlooked Definition Choices Inhibit Interpretation of Morphine Equivalence

Objective: Morphine-standardized doses are used in clinical practice and research to account for molecular potency. Ninety milligrams of morphine equivalents (MME) per day are considered a "high dose" risk threshold in guidelines, laws, and by payers. Although ubiquitously cited, the "CDC definition" of daily MME lacks a clearly defined denominator. Our objective was to assess denominator-dependency on "high dose" classification across competing definitions. Methods: To identify definitional variants, we reviewed literature and electronic prescribing tools, yielding 4 unique definitions. Using Prescription Drug Monitoring Programs data (July to September 2018), we conducted a population-based cohort study of 3,916,461 patients receiving outpatient opioid analgesics in California (CA) and Florida (FL). The binary outcome was whether patients were deemed "high dose" (>90 MME/d) compared across 4 definitions. We calculated I2 for heterogeneity attributable to the definition. Results: Among 9,436,640 prescriptions, 42% overlapped, which led denominator definitions to impact daily MME values. Across definitions, average daily MME varied 3-fold (range: 17 to 52 [CA] and 23 to 65 mg [FL]). Across definitions, prevalence of "high dose" individuals ranged 5.9% to 14.2% (FL) and 3.5% to 10.3% (CA). Definitional variation alone would impact a hypothetical surveillance study trying to establish how much more "high dose" prescribing was present in FL than CA: from 39% to 84% more. Meta-analyses revealed strong heterogeneity (I2 range: 86% to 99%). In sensitivity analysis, including unit interval 90.0 to 90.9 increased "high dose" population fraction by 15%. Discussion: While 90 MME may have cautionary mnemonic benefits, without harmonization of calculation, its utility is limited. Comparison between studies using daily MME requires explicit attention to definitional variation