BACKGROUND:Stagnating decreases in Kaposi sarcoma (KS) among men with HIV (MWH) following Treat-All policies necessitate evaluating changes in clinical drivers of KS. We examined clinical factors and their associations with KS rates among MWH in North America. METHODS:Among MWH in the North American AIDS Cohort Collaboration on Research and Design, we estimated annual KS rates (per 100 000 person-years [PY]) by viral suppression (<200 copies/mL), CD4 count (<500 vs ≥500 cells/mm3), and time since ART initiation (<1 year/naive vs ≥1 year) from 2009-2019. We quantified associations between clinical factors and KS rates using negative binomial regression, estimating incidence rate ratios (IRRs) with 95% CIs. Among MWH with KS, we estimated average annual percentage changes (AAPCs) in clinical factor distribution using joinpoint regression. RESULTS:There were 61 155 MWH (370 624 PY) contributing 262 KS diagnoses. KS decreased from 132 to 43 cases per 100 000 PY between 2009 and 2019. Viral suppression (IRR2009: .09 [95% CI: .04-.20]; IRR2019: .69 [.31-1.54]), recent/no ART initiation (IRR2009: .14 [.07-.30]; IRR2019: 1.16 [.53, 2.56]), and CD4 count ≥500 cells/mm3 (IRR2009: .13 [.05-.31]; IRR2019: .44 [.18-1.10]) were associated with reduced KS rates, attenuating over time. Unsuppressed viral load at KS diagnosis decreased by 10.6% (-15.8%, -4.8%) as did those on ART ≤1 year/naive (70%-40%; AAPC: -6.3% [-13.8%, 2.1%]). CONCLUSIONS:Our findings underscore the importance of early HIV diagnosis/treatment in reducing KS burden. Attenuating associations with HIV factors indicate that those successfully managing HIV increasingly represent KS patients. KS drivers are evolving, requiring patient/population-level monitoring.

Background People of Asian ethnicity represent one of the fastest-growing populations in the United States and may experience unique social and cultural challenges to accessing sexual healthcare. This analysis explores disparities in annual sexually transmitted infection screening and diagnosis rates per person-year between Asian and non-Asian people with human immunodeficiency virus in Washington, District of Columbia (DC). Methods Using District Columbia cohort data, a longitudinal study of people living with human immunodeficiency virus receiving care in Washington, DC, we analyzed people with human immunodeficiency virus aged 18 or older with at least 1 year of follow-up between 2018 and 2023. Logistic regression was used to examine differences in sexually transmitted infection screening and diagnoses between Asian and non-Asian participants, while linear trend analyses were used to assess changes in the number of screenings and diagnoses between Asian and non-Asian participants. Results Among 8679 eligible participants, 0.88% (n = 76) were Asian. No significant differences in total sexually transmitted infection screenings or diagnoses were observed. However, Asian participants had higher screening rates per person-year for pharyngeal and urogenital gonorrhea, pharyngeal chlamydia, and syphilis. Chlamydia incidence was higher among Asian than non-Asian participants. Over 30% of both groups met the annual screening recommendation during the study period. Conclusions Asians had comparable screening rates to non-Asians, but the small sample size limited the generalizability of our findings. Nonetheless, this study helps address an existing gap in the literature on Asian sexual health. Larger studies with detailed ethnic and social data are needed to deepen our understanding of sexual health service use within Asian communities.

Plasma HIV-1 RNA viral loads (VLs) are measured via laboratory assays with changing lower limits of quantification over time. We described an approach to produce an analytic-ready dataset of VLs over time and across longitudinal cohorts of adults. A 3-step approach was used: (1) initial data cleaning, (2) data checking with visualization, and (3) final data cleaning. Assumptions, data-driven decisions, and information from cohort-specific data managers produce an analytic-ready dataset of VLs with minimal missing data for date of blood draw, HIV-1 RNA result (copies/mL), below the lower limit of quantification (BLLQ) indicator, and the lower limit of quantification (LLQ). Among 3 663 786 VLs from 186 990 participants (median number of VLs per participant = 12, interquartile range 4-27) measured from 1988 to 2021, 61% of VL records were harmonized via the 3-step approach. The proportion of VLs below the lower limit of quantification increased from 39% to 60% after application of this approach. Changes to LLQ, VL result, and BLLQ indicator variables were made to 45%, 36%, and 22% of VLs, respectively. Stated assumptions, visualized data distributions, and a documented approach to preparing an analytic-ready dataset of pooled individual-level longitudinal data revealed data idiosyncrasies, informed assumptions, and improved the data for research inference.

Background People with HIV (PWH) are at increased risk of hepatitis C virus (HCV) coinfection and experiencing negative clinical outcomes. We evaluated direct-acting antiviral (DAA) initiation among PWH with HCV to identify factors associated with initiation. Methods U.S. and Canadian PWH ≥ 18 years with a detectable HCV RNA in NA-ACCORD were followed from the latest of first detectable HCV viremia, ART initiation, enrollment date, or 1/1/2014; until the first of DAA prescription, clearance of HCV viremia, loss-to-follow-up, death or 12/31/2021. We estimated the cumulative incidence of DAA initiation accounting for the competing risks of death and HCV viral clearance. Cox proportional hazard models estimated crude and adjusted hazard ratios (aHR) and 95% confidence intervals to identify factors associated with DAA initiation. Results Among 6,300 PWH with a detectable HCV RNA, 3,672 (58%) initiated DAA. Accounting for the competing risks of death and HCV clearance, by 8 years after study entry 6% of eligible PWH had not initiated DAA. A lower rate of DAA initiation was identified among non-Hispanic Black and Hispanic PWH compared with non-Hispanic white PWH. DAA initiation was lower among PWH reporting injection drug use as their HIV acquisition risk, at-risk alcohol use, smoking, detectable HIV viremia, and a history of AIDS. A higher FIB-4 score was associated with increased DAA initiation. Conclusions The DAA initiation gap among PWH engaged in care and eligible for treatment has greatly narrowed over time. Targeted approaches to increase equity in DAA initiation are needed to eliminate HCV among PWH.

Background:People with human immunodeficiency virus (HIV; PWH) are at increased risk of hepatitis C virus (HCV) coinfection and experiencing negative clinical outcomes. We evaluated direct-acting antiviral (DAA) initiation among PWH with HCV to identify factors associated with initiation. Methods:US and Canadian PWH ≥18 years with a detectable HCV RNA in the North American AIDS Cohort Collaboration on Research and Design were followed up from the latest of first detectable HCV viremia, antiretroviral therapy initiation, enrollment date, or 1 January 2014 until the first of DAA prescription, clearance of HCV viremia, loss to follow-up, death, or 31 December 2021. We estimated the cumulative incidence of DAA initiation accounting for the competing risks of death and HCV viral clearance. Cox proportional hazard models estimated crude and adjusted hazard ratios and 95% confidence intervals to identify factors associated with DAA initiation. Results:Among 6300 PWH with a detectable HCV RNA, 3672 (58%) initiated DAA. Accounting for the competing risks of death and HCV clearance, by 8 years after study entry 6% of eligible PWH had not initiated DAA. A lower rate of DAA initiation was identified among non-Hispanic black and Hispanic PWH compared with non-Hispanic white PWH. DAA initiation was lower among PWH reporting injection drug use as their HIV acquisition risk, at-risk alcohol use, smoking, detectable HIV viremia, or a history of AIDS. A higher Fibrosis-4 score was associated with increased DAA initiation. Conclusions:The DAA initiation gap among PWH engaged in care and eligible for treatment has greatly narrowed over time. Targeted approaches to increase equity in DAA initiation are needed to eliminate HCV among PWH.

During this unprecedented time of uncertainty and disruption, the 2025 Annual Conference of the Health Care Systems Research Network (HCSRN) took place on April 8 to 10, 2025, in St. Louis, Missouri, at the Marriott St. Louis Grand. Nearly 265 participants from 19 HCSRN member institutions came together to network, collaborate, and connect at the conference, which featured the theme, “Optimizing Collaborations to Advance Health in a Dynamic Research Landscape.”

BACKGROUND:Dermatologic disease (DD) remains a significant morbidity among people with human immunodeficiency virus (HIV) (PWH), yet epidemiologic data in the modern antiretroviral therapy (ART) era are limited. OBJECTIVE:To characterize the prevalence, incidence, and risk factors of DD among PWH. METHODS:This longitudinal cohort study included 11,738 adults enrolled in the DC Cohort between 2011 and 2023. DDs were identified using ICD-9/10 codes and categorized as infectious dermatoses, inflammatory dermatoses, or cutaneous malignancies (CM). Prevalence, incidence trends, and multivariable logistic regression were used to identify risk factors. RESULTS:Among participants, 49.4% had ≥1 dermatologic diagnosis, with infectious conditions most common (41.4%). Incidence declined from 2011 to 2024 across all categories: infectious (463 to 41), inflammatory (306 to 62), and malignant (31 to 6) cases per 1000 (all P < .0001). Cisgender females had over sixfold greater odds of CM. Lower nadir CD4 count, older age, public insurance, and prior opportunistic infections were associated with higher DD risk. LIMITATIONS:Use of ICD codes may have introduced misclassification; dermatology specialty access likely varied by site. CONCLUSION:DD incidence has declined over time, reflecting advances in HIV care and treatment. Despite modern ART, DD remains prevalent. Demographic, immune, structural, and behavioral factors drive risk among PWH, underscoring the need for targeted care.

Importance:Doxycycline postexposure prophylaxis (doxyPEP) has been shown to decrease the incidence of bacterial sexually transmitted infections (STIs) among people assigned male sex at birth in clinical trials, but data from clinical practice are limited. Objective:To describe early uptake of doxyPEP and evaluate changes in STI incidence following doxyPEP initiation. Design, Setting, and Participants:This retrospective cohort study of adults (aged ≥18 years) dispensed HIV preexposure prophylaxis (PrEP) at Kaiser Permanente Northern California during November 1, 2022, to December 31, 2023, examined electronic health record data to compare HIV PrEP users dispensed and not dispensed doxyPEP and rates of bacterial STIs before and after starting doxyPEP. Individuals were followed up from their first recorded STI test on or after November 1, 2020, until December 31, 2023, or discontinuation of health plan membership. Exposure:Pharmacy dispensing data were used to define doxyPEP recipients. Main Outcomes and Measures:Demographic and clinical characteristics were compared between individuals dispensed and not dispensed doxyPEP. Primary outcomes were incident chlamydia, gonorrhea, or infectious syphilis measured as quarterly STI positivity (proportion of individuals testing positive at least once per quarter). Among doxyPEP recipients, rate ratios (RRs) compared mean quarterly STI positivity from 24 months before to 12 months after starting doxyPEP. In an exploratory analysis, STI trends were evaluated for the full cohort, stratified by receipt of doxyPEP. Results:Among 11 551 HIV PrEP users (mean [SD] age, 39.9 [12.1] years; 95.1% male), 2253 (19.5%) were dispensed doxyPEP, of whom 2228 (98.9%) were male and 1096 (48.6%) had an STI in the year before starting doxyPEP. Compared with individuals not dispensed doxyPEP, doxyPEP recipients were older (mean [SD] age, 40.4 [10.8] vs 39.8 [12.4] years; P = .04) and had used HIV PrEP longer (mean [SD], 4.2 [2.8] vs 3.4 [2.6] years; P < .001), and a higher proportion were commercially insured (2091 [92.8%] vs 8270 [88.9%]; P < .001). Among doxyPEP recipients, quarterly chlamydia positivity decreased from 9.6% (95% CI, 9.0%-10.3%) before starting doxyPEP to 2.0% (95% CI, 1.5%-2.6%) after starting doxyPEP (RR, 0.21; 95% CI, 0.16-0.27; P < .001), with significant declines for each anatomic site of infection. Quarterly gonorrhea positivity decreased from 10.2% (95% CI, 9.6%-10.9%) before starting doxyPEP to 9.0% (95% CI, 8.0%-10.1%) after starting doxyPEP (RR, 0.88; 95% CI, 0.77-1.00; P = .048); site-specific declines were significant for rectal (RR, 0.81; 95% CI, 0.67-0.97; P = .02) and urethral (RR, 0.56; 95% CI, 0.40-0.79; P = .001) gonorrhea, but not pharyngeal gonorrhea. Quarterly syphilis positivity decreased from 1.7% (95% CI, 1.4%-1.9%) before starting doxyPEP to 0.3% (95% CI, 0.2%-0.6%) after starting doxyPEP (RR, 0.20; 95% CI, 0.11-0.37; P < .001). Positivity for STIs remained stable in individuals not dispensed doxyPEP. Conclusions and Relevance:This study found that receipt of doxyPEP was associated with substantial declines in chlamydia and syphilis incidence and modest declines in urethral and rectal gonorrhea incidence among individuals using HIV PrEP. These findings suggest that doxyPEP may offer substantial benefits for reducing population-level STI transmission with broader implementation.

BACKGROUND:Hospitalization causes among persons with HIV (PWH) have shifted to non-AIDS conditions, but the complete disease profile of hospitalized PWH has not been well described. To inform hospitalization and readmission prevention efforts, we examined non-AIDS disease prevalence among PWH hospitalized in 4 US cohorts and 1 Canadian cohort. METHODS:Among PWH with ≥1 hospitalization from 2008 to 2018, we used log-binomial regression with generalized estimating equations to estimate trends in the annual prevalence of hepatitis B virus (HBV), hepatitis C virus (HCV), hypertension, hyperlipidemia, diabetes mellitus, chronic kidney disease (CKD) stage ≥3, and multimorbidity (≥2 and ≥3 conditions), defined using longitudinal diagnosis, medication, and laboratory data. RESULTS:We examined 6781 hospitalized PWH who were 75% cisgender men, 40% White, and 38% Black. From 2008 to 2018, the proportion of PWH in care who had ≥1 hospitalization decreased from 9.6% to 6.3%. Age- and cohort-adjusted prevalence increased for hyperlipidemia (relative change per year: 3.6% [95% CI: 2.5%-4.7%]), diabetes mellitus (2.8% [1.3%-4.4%]), CKD (3.3% [1.7%-4.9%]), ≥2 conditions (1.3% [0.6%-2.0%]), and ≥3 conditions (3.0% [1.7%-4.3%]), decreased for HCV infection (-2.0% [-3.0%, -0.9%]), and remained stable for HBV infection (1.6% [-1.1%, 4.3%]) and hypertension (0.4% [-0.2%, 1.1%]). CONCLUSIONS:Hospitalized PWH had an increasing burden of several non-AIDS conditions and multimorbidity not accounted for by aging alone. Further work is needed to understand these conditions' role in hospitalization risk among PWH. Our findings reinforce that hospital discharge planning in PWH should include efforts to ensure chronic conditions are adequately managed.

Background Diabetes-related lower extremity complications, such as foot ulceration and amputation, are on the rise, currently affecting nearly 131 million people worldwide. Methods for early detection of individuals at high risk remain elusive. While data-driven diabetic polyneuropathy algorithms exist, high-performing, clinically useful tools to assess risk are needed to improve clinical care. Objective This study aimed to develop an electronic medical record–based machine learning algorithm that would predict lower extremity complications. Methods We conducted a retrospective longitudinal cohort study to predict the risk of lower extremity complications within 24 months of an initial diagnosis of diabetic polyneuropathy. From an initial cohort of 468,162 individuals with at least 1 diagnosis of diabetic polyneuropathy at one of 2 multispecialty health care systems (based in northern California and Colorado) between April 2012 and December 2016, we created an analytic cohort of 48,209 adults with continuous enrollment, who were newly diagnosed with no evidence of end-of-life care. The outcome was any lower extremity complication, including foot ulceration, osteomyelitis, gangrene, or lower extremity amputation. We randomly split the data into training (38,569/48209; 80%) and testing (9,640/48209; 20%) datasets. In the training dataset, we used super Learner (SL), an ensemble learning method that employs cross-validation and combines multiple candidate risk predictors, into a single risk predictor. We evaluated the performance of the SL risk predictor in the testing dataset using the receiver operating characteristic curve and a calibration plot. Results Of the 48,209 individuals in the cohort, 2327 developed a lower extremity complication during follow-up. The SL risk estimator exhibited good discrimination (AUC=0.845, 95% CI 0.826-0.863) and calibration. A modified version of our SL algorithm, simplified to facilitate real-world adoption, had only slightly reduced discrimination (AUC=0.817, 95%CI 0.797-0.837). The modified version slightly outperformed the naïve logistic regression model (AUC=0.804, 95% CI 0.783-0.825) in terms of precision gained relative to the frequency of alerts and number of patients that needed to be evaluated. Conclusions We have built a machine learning–based risk estimator with the potential to improve clinical detection of diabetic patients at high risk for lower extremity complications at the time of an initial diabetic polyneuropathy diagnosis. The algorithm exhibited good discriminant validity and calibration using only data from the electronic medical record. Additional research will be needed to identify optimal contexts and strategies for maximizing algorithmic fairness in both interpretation and deployment.

BACKGROUND:Two respiratory syncytial virus (RSV) vaccines, Pfizer's Abrysvo and GSK's Arexvy, were licensed in 2023 in the U.S. However, population-based assessments of their safety in adults ≥60 years have not been widely published. We provide results from two complementary investigations of vaccinated adults in the Vaccine Safety Datalink (VSD). METHODS:The rapid cycle analysis (RCA) used a sequential cohort design and biweekly analyses of near real-time data to compare the incidence of 12 pre-specified outcomes in two post-vaccination risk intervals (1-21, 1-42 days) with the incidence in comparison intervals. The surveillance period was August 1, 2023, through September 28, 2024; nine of 13 VSD sites participated. Statistically significant signals were investigated by medical record review with re-analysis of confirmed outcomes. The self-controlled tree-based data mining analysis was designed to identify temporal clustering of ICD-10 diagnosis codes in the inpatient or emergency department settings 1-56 days post-vaccination, without pre-specifying outcomes or risk intervals. The study period was July 1, 2023, through December 31, 2023; 10 sites participated. RESULTS:The RCA analysis included 436,823 persons who received an RSV vaccine. No statistical signal was identified for 11 of 12 adverse events. A signal was detected for immune thrombocytopenic purpura following Arexvy, but re-analysis following medical record review did not confirm an association. The tree-based data mining analysis included 248,056 vaccinees, identified 53,734 counts of 3429 diagnosis codes, and identified no statistically significant clusters for either vaccine. CONCLUSIONS:These post-licensure safety assessments provide evidence supporting the safety of RSV vaccines in older adults. As more data accrue, additional monitoring is warranted for rare adverse events.

Background: The association of anemia as a predictive and prognostic indicator of non-AIDS defining cancer (NADC) among people with HIV (PWH) remains unknown. We evaluated the presence of anemia and its severity as a predictor of NADC and 5-year all-cause survival following an NADC diagnosis among PWH who had initiated antiretroviral therapy. Setting: North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) Methods: We included PWH (≥18 years) on ART between 01/01/2007-12/31/2016 with no prior cancer diagnosis. Annual median hemoglobin was categorized into mild (11.0-12.9g/dL men, 11.0-11.9g/dL women) and moderate/severe (<10.9g/dL regardless of sex) anemia. Discrete time-to-event models using a complementary log-log link estimated crude and adjusted hazards ratios (aHR) and 95% confidence intervals for NADC by anemia severity. Five-year mortality following NADC diagnosis by anemia was evaluated. Results: Among 67,228 PWH contributing 301,421 annual median hemoglobin observations, 244,658 (81%) were not anemic, 40,134 (13%) had mild and 16,629 (6%) had moderate/severe anemia. The risk of NADC was higher among PWH with anemia (aHR 2.40[2.19-2.63]) (vs. no anemia) and greater among males (aHR 2.42[2.20-2.66]) than females (aHR 2.02[1.42-2.89]). NADC risk increased with worsening anemia (mild: aHR 2.01[1.81-2.23], moderate/severe: aHR 3.59[3.13-4.11]). The five-year all-cause mortality following NADC diagnosis was higher (aHR 1.37[1.21-1.55]) among PWH with anemia. Conclusions: Among PWH who initiated ART, anemia may serve as a predictive indicator of NADC risk. Identification of anemia should warrant investigations into the underlying etiology, including evaluation for NADC. Anemia is also a prognostic indicator among PWH diagnosed with NADC.

Objective:Hypertension is a major risk factor for dementia, but sustained blood pressure control is difficult to achieve. We evaluated whether inadequately controlled hypertension may contribute to excess dementia risk among people with HIV. Design:A retrospective cohort study. Methods:We studied demographically matched people with and without HIV between July 1, 2013, and December 31, 2021, who were at least 50 years old and had a hypertension diagnosis but no dementia diagnosis. Hypertension control was calculated using a disease management index (DMI), which captured degree and duration above the hypertension treatment goals of SBP less than 140 mmHg and DBP less than 90 mmHg. DMI values ranged from 0 to 100% (perfect control); hypertension was considered 'inadequately controlled' if DMI was less than 80% (i.e., in control for <80% of the time). Annual, time-updated DMI was calculated for SBP and DBP. Associations of SPB and DPB control with incident dementia were evaluated using extended Cox regression models. Results:The study included 3099 hypertensive people with HIV (mean age: 58.3 years, 90.2% men) and 66 016 people without HIV. Each year of inadequate SBP control was associated with greater dementia risk in both people with HIV (adjusted hazard ratio [aHR] = 1.26, 0.92-1.64) and people without HIV (aHR = 1.27 (1.21-1.33); P-interaction = 0.85). Similarly, inadequate DBP control was associated with greater dementia risk in both people with HIV (aHR = 1.43, 0.90-1.95) and people without HIV (aHR = 1.71, 1.50-1.93; P-interaction = 0.57). Conclusion:Findings suggest the association of inadequate hypertension control with greater dementia risk is similar by HIV status. Stronger associations of DBP control with dementia merit further investigation.

Aim:Patient reported outcomes (PROs) can help to evaluate gaps and areas for improvement along the HIV care continuum. We sought to describe the methodology and processes of a PROs study within the DC Cohort study population, describe the PROs results to date, report on lessons learned, and describe future directions of the research. Subject and Methods:Each study site recruited participants from the DC Cohort, a longitudinal study on people with HIV, to complete the electronic PROs baseline and annual follow-up surveys, which consisted of previously validated measures of social determinants of health, mental health, substance use, medication adherence, and other related measures. The recruitment, enrollment, and data linkage process strengths and limitations were described. Participants' PROs survey responses were linked to their DC Cohort data to better understand participant's health overall. Results:There have been 1,739 baseline, 610 first annual, and 142 second annual completed surveys between May 2021 and May 2024. Among PROs participants, the most common reported unmet need was food insecurity (33.5%) and the most common mental health condition was generalized anxiety disorder (39.5%). A majority (59.7%) of participants reported being sexually active, but at least half did not use barrier protection. Conclusion:PROs surveys complement electronic health record data collected in the DC Cohort study, allowing for examination of health outcomes and factors collected in a longitudinal manner. PROs results could be integrated into near-real time dashboards for use by clinicians and incorporated into routine clinical care to provide a more holistic understanding of the patient.

BACKGROUND:Women with HIV are at an elevated risk for HPV. Antiretroviral therapy (ART) effectively treats HIV; however, there is no noninvasive pharmacologic treatment for HPV. Previous studies have shown varied effects of ART class on HPV clearance, with some demonstrating an association. Our objective was to evaluate the association between ART class and HPV clearance among women with HIV/HPV coinfections. METHODS:We analyzed electronic health records from participants with HPV in the DC Cohort Longitudinal HIV Study from time at HPV detection to January 1, 2024. We investigated time to HPV clearance based on time-updated ART status using Cox proportional hazards and Kaplan-Meier models, focusing on protease inhibitors (PIs) and integrase strand transfer inhibitors. RESULTS:Among 362 women with HIV/HPV coinfections, 94.8% were non-Hispanic Black, 81.2% had public insurance, and 45.6% were smokers. Overall, 74.0% cleared their HPV infection. A higher proportion of participants who cleared HPV were on PIs at baseline compared with those who did not ( P = 0.03). Those who did not achieve clearance had lower nadir CD4 counts ( P = 0.04) and did not achieve viral suppression ( P = 0.0005). In the survival analysis, women on PI-based regimens had shorter time to HPV clearance than those on integrase strand transfer inhibitors (HR = 2.12, 95% CI: 1.39 to 3.24). CONCLUSIONS:This study suggests that PIs may be associated with a higher likelihood of HPV clearance among women with HIV. Our results provide evidence on the influence of clinical and sociodemographic factors, including ART, that may affect HPV clearance among women with HIV.Key words: HIV/HPV co-infection, antiretrovial therapy, HPV clearance.

The Health Care Systems Research Network (HCSRN) kicked off the 2024 Annual Conference on April 9, 2024, in Milwaukee at the Hyatt Regency with nearly 275 participants from 19 HCSRN member institutions. This year, HCSRN attendees joined their colleagues to reconnect and network during the three-day conference featuring the theme, “Advancing High-Quality, Equitable Research in the Age of New Health Care Technologies.”

BackgroundEstimating the medical complexity of people aging with HIV can inform clinical programs and policy to meet future healthcare needs. The objective of our study was to forecast the prevalence of comorbidities and multimorbidity among people with HIV (PWH) using antiretroviral therapy (ART) in the United States (US) through 2030.Methods and findingsUsing the PEARL model-an agent-based simulation of PWH who have initiated ART in the US-the prevalence of anxiety, depression, stage ≥3 chronic kidney disease (CKD), dyslipidemia, diabetes, hypertension, cancer, end-stage liver disease (ESLD), myocardial infarction (MI), and multimorbidity (≥2 mental or physical comorbidities, other than HIV) were forecasted through 2030. Simulations were informed by the US CDC HIV surveillance data of new HIV diagnosis and the longitudinal North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) data on risk of comorbidities from 2009 to 2017. The simulated population represented 15 subgroups of PWH including Hispanic, non-Hispanic White (White), and non-Hispanic Black/African American (Black/AA) men who have sex with men (MSM), men and women with history of injection drug use and heterosexual men and women. Simulations were replicated for 200 runs and forecasted outcomes are presented as median values (95% uncertainty ranges are presented in the Supporting information). In 2020, PEARL forecasted a median population of 670,000 individuals receiving ART in the US, of whom 9% men and 4% women with history of injection drug use, 60% MSM, 8% heterosexual men, and 19% heterosexual women. Additionally, 44% were Black/AA, 32% White, and 23% Hispanic. Along with a gradual rise in population size of PWH receiving ART-reaching 908,000 individuals by 2030-PEARL forecasted a surge in prevalence of most comorbidities to 2030. Depression and/or anxiety was high and increased from 60% in 2020 to 64% in 2030. Hypertension decreased while dyslipidemia, diabetes, CKD, and MI increased. There was little change in prevalence of cancer and ESLD. The forecasted multimorbidity among PWH receiving ART increased from 63% in 2020 to 70% in 2030. There was heterogeneity in trends across subgroups. Among Black women with history of injection drug use in 2030 (oldest demographic subgroup with median age of 66 year), dyslipidemia, CKD, hypertension, diabetes, anxiety, and depression were most prevalent, with 92% experiencing multimorbidity. Among Black MSM in 2030 (youngest demographic subgroup with median age of 42 year), depression and CKD were highly prevalent, with 57% experiencing multimorbidity. These results are limited by the assumption that trends in new HIV diagnoses, mortality, and comorbidity risk observed in 2009 to 2017 will persist through 2030; influences occurring outside this period are not accounted for in the forecasts.ConclusionsThe PEARL forecasts suggest a continued rise in comorbidity and multimorbidity prevalence to 2030, marked by heterogeneities across race/ethnicity, gender, and HIV acquisition risk subgroups. HIV clinicians must stay current on the ever-changing comorbidities-specific guidelines to provide guideline-recommended care. HIV clinical directors should ensure linkages to subspecialty care within the clinic or by referral. HIV policy decision-makers must allocate resources and support extended clinical capacity to meet the healthcare needs of people aging with HIV.

HIV care continuum outcome disparities by health insurance status have been noted among people with HIV (PWH). We therefore examined associations between state Medicaid expansion and HIV outcomes in the United States. Adults (≥18 years) with ≥1 visit in NA-ACCORD clinical cohorts from 2012-2017 contributed person-time annually between first and final visit or death; in each calendar year, clinical retention was ≥2 completed visits > 90 days apart, antiretroviral therapy (ART) receipt was receipt of ≥3 antiretroviral agents, and viral suppression was last measured HIV-1 RNA < 200 copies/mL. CD4 at enrollment was obtained within 6 months of enrollment in cohort. Difference-in-difference (DID) models quantified associations between Medicaid expansion changes (by state of residence) and HIV outcomes. Across 50 states, 87 290 PWH contributed 325 113 person-years of follow-up. Medicaid expansion had a substantial positive effect on CD4 at enrollment (DID = 93.5, 95% CI: 52.9, 134 cells/mm3), a small negative effect on proportions clinically retained (DID = -0.19, 95% CI: -0.037, -0.01), and no effects on ART receipt (DID = 0.001, 95% CI: -0.003, 0.005) or viral suppression (DID = -0.14, 95% CI: -0.34, 0.07). Medicaid expansion had a positive effect on CD4 at entry, suggesting more timely HIV testing and care linkage, but generally null effects on downstream HIV care continuum measures.

Background: The effect of initial antiretroviral therapy (ART) class on cancer risk in people with HIV (PWH) remains unclear. Setting: Cohort study of 36,322 PWH enrolled (1996-2014) in the North American AIDS Cohort Collaboration on Research and Design. Methods: We followed individuals from ART initiation (protease inhibitor [PI]-, non-nucleoside reverse transcriptase inhibitor [NNRTI]-, or integrase strand transfer inhibitor [INSTI]-based) until incident cancer, death, loss-to-follow-up, 12/31/2014, 85 months (intention-to-treat analyses [ITT]), or 30 months (per-protocol [PP] analyses). Cancers were grouped (non-mutually exclusive) as: any cancer, AIDS-defining cancers (ADC), non-AIDS-defining cancers (NADC), any infection-related cancer, and common individual cancer types. We estimated adjusted hazard ratios (aHR) comparing cancer risk by ART class using marginal structural models emulating ITT and PP trials. Results: We observed 17,004 PWH (954 cancers) with PI-based (median 6 years follow-up), 17,536 (770 cancers) with NNRTI-based (median 5 years follow-up) and 1,782 (29 cancers) with INSTI-based ART (median 2 years follow-up). Analyses with 85 months follow-up indicated no cancer risk differences. In truncated analyses, risk of ADCs (aHR 1.33; 95% CI 1.00, 1.77 [PP-analysis]) and NADCs (aHR 1.23; 95% CI 1.00, 1.51[ITT-analysis]) were higher comparing PIs vs. NNRTIs. Conclusions: Results with longer-term follow-up suggest being on a PI- versus NNRTI-based ART regimen does not affect cancer risk. We observed shorter-term associations that should be interpreted cautiously and warrant further study. Further research with longer duration of follow-up that can evaluate INSTIs, the current first-line recommended therapy, is needed to comprehensively characterize the association between ART class and cancer risk.