PURPOSE:The COVID-19 pandemic impacted testing and incidence of sexually transmitted infections (STIs), with some studies showing uneven effects across sociodemographic groups. We aim to determine whether rates of gonorrhea and chlamydia testing and infections were affected by the pandemic, overall and by subgroups, defined by sociodemographic factors and comorbidities. METHODS:We conducted a retrospective cohort study from January 1, 2016, through December 31, 2022, among adolescents and young adults ages 15-29 years within Kaiser Permanente Northern California (KPNC). We determined the rate of testing for gonorrhea/chlamydia, and the incident rates of infections before and during the COVID-19 pandemic by sociodemographic factors. We compared incidence rates of gonorrhea/chlamydia testing and infection before and during the pandemic using Poisson regression. RESULTS:Gonorrhea/chlamydia testing during the pandemic was 19% lower than prepandemic baseline. Testing among Black patients was 1.8-fold higher than White patients. Black patients had 5.5 and 3.6-fold higher rate of gonorrhea and chlamydia infections, respectively, compared with White patients. Patients living in more deprived neighborhoods also had higher rates of infection compared to those in the least deprived neighborhoods. In multivariable analyses stratified by the period before and during the COVID-19 pandemic, there were no significant differences in the incidence rate ratios of testing or infections for any specific sociodemographic factor. DISCUSSION:STI testing in adolescents and young adults dropped dramatically after the start of the pandemic and has not recovered to its prior levels. Preexisting disparities in STI testing and infections were not exacerbated by the pandemic.

Background:While cannabis use is prevalent among people with HIV (PWH), factors associated with higher-risk use require further study. We examined factors associated with indicators risk for cannabis use disorder (CUD) among PWH who used cannabis. Methods:Participants included adult (≥18 years old) PWH from 3 HIV primary care clinics in Kaiser Permanente Northern California who reported past three-month cannabis use through the computerized Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) screening. Primary outcome was TAPS cannabis score (range 1-3), categorized as any use (1) and higher risk for CUD (≥2). Measures included sociodemographics (age, sex, race, neighborhood deprivation index [NDI]), Charlson Comorbidity Index (CCI), HIV RNA, CD4 cell counts, higher risk tobacco use (TAPS tobacco score≥2), depression, and anxiety symptoms. Unadjusted and multivariable logistic regression examined factors associated with higher risk for CUD. Results:Of the complete sample (N=978; 94.1% Male; 58.3% White; Age Mode=51-60), 35.8% reported higher risk for CUD. Unadjusted models indicated younger age, Black race, higher CCI, depression, anxiety, and higher risk tobacco use were associated with higher risk, while only Black race (OR=1.84, 95% CI[1.29, 2.63]), anxiety (OR=1.91, 95% CI[1.22, 2.98]), and higher risk tobacco use (OR=2.27, 95% CI[1.47, 3.51]) remained significant in the multivariable model. Conclusions:Black race, anxiety and tobacco use, but not HIV clinical markers, were associated with higher risk for CUD among PWH. Clinical efforts to screen and provide interventions for preventing CUD alongside anxiety and tobacco use among PWH should be evaluated.

BACKGROUND:People with HIV (PWH) are at elevated risk for suicidal ideation (SI), yet few studies have examined how substance use, clinical and sociodemographic factors are associated with SI among PWH. METHOD:We used substance use (Tobacco, Alcohol, Prescription Medication, and Other Substance Use [TAPS]) and depression (PHQ-9) data from computerized screening of adult PWH in primary care clinics in Northern California, combined with health record data on psychiatric diagnoses, HIV diagnosis, treatment, and control (HIV RNA, CD4), insurance, and neighborhood deprivation index (NDI) to examine factors associated with SI (PHQ-9 item 9 score > 0). Adjusted odds ratios (aOR) for SI were obtained from logistic regression models. RESULTS:Among 2829 PWH screened (92 % male; 56 % white; mean (SD) age of 54 (13) years; 220 (8 %) reported SI. Compared with no problematic use, SI was higher among those reporting one (aOR = 1.65, 95 % CI = 1.17, 2.33), two (aOR = 2.23, 95 % CI = 1.42, 3.49), or ≥ 3 substances (aOR = 4.49, 95 % CI = 2.41, 8.39). SI risk was higher for those with stimulant use (aOR = 3.55, 95 % CI = 2.25, 5.59), depression (aOR = 4.18, 95 % CI = 3.04, 5.74), and anxiety diagnoses (aOR = 1.67, 95 % CI = 1.19, 2.34), or Medicaid (aOR = 2.11, 95%CI = 1.24, 3.60) compared with commercial/other insurance. SI was not associated with HIV-related measures or NDI. LIMITATIONS:SI was assessed with a single PHQ-9 item. Simultaneous SI and exposure data collection restricts the ability to establish substance use as a risk factor. CONCLUSIONS:HIV care providers should consider multiple substance use, stimulant use, depression or anxiety, and public insurance as risk factors for SI and provide interventions when needed.

Background Influenza vaccination is recommended for adults regardless of human immunodeficiency virus (HIV) status. There may be facilitators or barriers to vaccinating people with HIV (PWH) that differ from people without HIV (PWoH). We sought to describe the uptake of influenza vaccination by HIV status and identify factors associated with vaccination. Methods We abstracted data from the electronic health records of PWH and PWoH in Kaiser Permanente Northern California during 6 influenza seasons (2013-2018). We determined vaccination uptake and used Poisson regression models to evaluate factors associated with vaccination in PWH and PWoH. Results 9272 PWH and 194 393 PWoH matched by age, sex, and race/ethnicity were included (mean age: 48 vs 49 years; men: 91% vs 90%; White race: 53% for both groups). PWH were more likely to receive the influenza vaccine (65-69% across years for PWH and 37-41% for PWoH) with an adjusted risk ratio for all years of 1.48 (95% CI: 1.46-1.50). For PWH, lower vaccination uptake was associated with several factors that suggested more complex health needs, such as lower CD4 cell counts, higher HIV viral loads, prior depression diagnoses, having Medicare insurance, and having a higher number of comorbidities. Associations with vaccination uptake were attenuated in PWH, compared with PWoH, for smoking, alcohol, and demographic factors. Conclusions PWH had an almost 50% higher uptake of influenza vaccination than PWoH, possibly reflecting greater engagement with the healthcare system. We also found that PWH with more complex health needs had reduced vaccination uptake. Findings may inform outreach strategies to increase influenza vaccination in PWH. In a large cohort study of Kaiser Permanente Northern California members, people with HIV had a 50% higher influenza vaccine uptake than people without HIV. Factors associated with lower rates of vaccination were also identified.

We characterized polysubstance use burden and associations with mental health problems across demographic subgroups of PWH. In 2018–2020, as part of a primary care-based intervention study, PWH in care at three medical centers in Kaiser Permanente Northern California were screened for depression (PHQ-9≥10), anxiety (GAD-2≥3), and substance use (Tobacco, Alcohol, Prescription medication, and other Substance use [TAPS]≥1 per substance). We used Poisson regression to estimate prevalence ratios (PRs) comparing polysubstance use prevalence (TAPS≥1 for ≥2 substances) between PWH with positive screens for depression or anxiety vs. neither, among all PWH, and stratified by race/ethnicity and age (restricted to men), adjusting for sociodemographics, CD4, and HIV load. Screened PWH (N = 2865) included 92% men, 56% White, 19% Black, and 15% Hispanic PWH, with a median age of 55 years. Overall, polysubstance use prevalence was 26.4% (95% CI 24.9%-28.1%). PWH with depression or anxiety (n = 515) had an adjusted polysubstance use PR of 1.26 (1.09–1.46) vs. PWH with neither (n = 2350). Adjusted PRs were 1.47 (1.11–1.96), 1.07 (0.74–1.54), and 1.10 (0.85–1.41) among Black, Hispanic, and White men, respectively. Adjusted PRs did not differ by age group. Interventions should consider jointly addressing mental health and substance use problems and potential drivers, e.g. stigma or socioeconomic factors.

Abstract Background Mental health and substance use disorders disproportionately affect people with HIV (PWH), and may have been exacerbated during COVID-19. The Promoting Access to Care Engagement (PACE) trial was designed to assess the effectiveness of electronic screening for mental health and substance use in HIV primary care and enrolled PWH from October 2018 to July 2020. Our objective here was to compare screening rates and results for PWH before (October 2018 – February 2020) and early in the COVID-19 pandemic (March-July 2020). Methods Adult (≥ 18 years) PWH from 3 large HIV primary care clinics in a US-based integrated healthcare system were offered electronic screening online or via in-clinic tablet computer every 6 months. Screening completion and results (for depression, suicidal ideation, anxiety, and substance use) were analyzed using logistic regression with generalized estimating equations to estimate prevalence ratios (PR) before and after the start of the regional COVID-19 shelter-in-place orders on March 17, 2020. Models adjusted for demographics (age, sex, race/ethnicity), HIV risk factors (men who have sex with men, injection drug use, heterosexual, other), medical center, and modality of screening completion (online or tablet). We conducted qualitative interviews with providers participating in the intervention to evaluate how the pandemic impacted patient care. Results Of 8,954 eligible visits, 3,904 completed screenings (420 during COVID, 3,484 pre-COVID), with lower overall completion rates during COVID (38% vs. 44%). Patients completing screening during COVID were more likely to be White (63% vs. 55%), male (94% vs. 90%), and MSM (80% vs., 75%). Adjusted PRs comparing COVID and pre-COVID (reference) were 0.70 (95% CI), 0.92 (95% CI), and 0.54 (95% CI) for tobacco use, any substance use, and suicidal ideation, respectively. No significant differences were found by era for depression, anxiety, alcohol, or cannabis use. These results were in contrast to provider-reported impressions of increases in substance use and mental health symptoms. Conclusion Findings suggest PWH had modest declines in screening rates early in the COVID-19 pandemic which may have been affected by the shift to telemedicine. There was no evidence that mental health problems and substance use increased for PWH in primary care. Trial registration NCT03217058 (First registration date: 7/13/2017); https://clinicaltrials.gov/ct2/show/NCT03217058

Background. Rapid antiretroviral therapy (ART) is the recommended treatment strategy for patients newly diagnosed with HIV, but the literature supporting this strategy has focused on short-term outcomes. We examined both long-term outcomes and predictors of rapid ART among patients newly diagnosed with HIV within an integrated health care system in Northern California. Methods. This observational cohort study included adults newly diagnosed with HIV between January 2015 and December 2020 at Kaiser Permanente Northern California. Rapid ART was defined as ART initiation within 7 days of HIV diagnosis. We collected demographic and clinical data to determine short-term and long-term outcomes, including viral suppression, care retention, medication adherence, and cumulative viral burden. Logistic regression models were used to identify predictors of rapid ART initiation. Results. We enrolled 1409 adults; 34.1% initiated rapid ART. The rapid ART group achieved viral suppression faster (48 vs 77 days; P < .001) and experienced lower cumulative viral burden (log10 viremia copy-years, 3.63 vs 3.82; P < .01) but had slightly reduced medication adherence (74.8% vs 75.2%; P < .01). There was no improvement in long-term viral suppression and care retention in the rapid group during follow-up. Patients were more likely to initiate rapid ART after 2017 and were less likely if they required an interpreter. Conclusions. Patients who received rapid ART had an improved cumulative HIV burden but no long-term improvement in care retention and viral suppression. Our findings suggest that rapid ART should be offered but additional interventions may be needed for patients newly diagnosed with HIV.

Outcomes of PWH with unhealthy alcohol use, such as alcohol use reduction or progression to AUD, are not well-known and may differ by baseline patterns of unhealthy alcohol use. Among 1299 PWH screening positive for NIAAA-defined unhealthy alcohol use in Kaiser Permanente Northern California, 2013–2017, we compared 2-year probabilities of reduction to low-risk/no alcohol use and rates of new AUD diagnoses by baseline use patterns, categorized as exceeding: only daily limits (72

The coronavirus disease 2019 (COVID-19) pandemic disrupted health systems. For patients newly diagnosed with human immunodeficiency virus, starting immediate antiretroviral therapy (ART) is recommended. For periods before and during the COVID-19 pandemic, Kaiser Permanente Northern California found similar rates of rapid ART initiation and time to viral suppression, concurrent with an increase in telemedicine.

Background Despite increased efforts to promote HIV screening, a large proportion of the US population have never been tested for HIV. Objective To determine whether provider education and personalised HIV screening report cards can increase HIV screening rates within a large integrated healthcare system. Design This quality improvement study provided a cohort of primary care physicians (PCPs) a brief educational intervention and personalised HIV screening report cards with quarterly performance data. Participants Participants included a volunteer cohort of 20 PCPs in the department of adult and family medicine. Main measures Per cent of empaneled patients screened for HIV by cohort PCPs compared with PCPs at the Kaiser Permanente Oakland Medical Center (KPOAK) and the non-Oakland Medical Centers in Northern California region (Kaiser Permanente Northern California (KPNC)). Key results Of the 20 participating PCPs, 13 were female and 7 were male. Thirteen were internal medicine and seven family medicine physicians. The average age was 40 years and average practice experience was 9 years after residency. During the 12-month intervention, the estimated increase in HIV screening in the cohort PCP group was 2.6% as compared with 1.9% for KPOAK and 1.8% for KPNC. Conclusions These findings suggest that performance-related report cards are associated with modestly increased rates of HIV screening by PCPs.

Aim To determine whether home‐use icterometry improves parental recognition of neonatal jaundice, early care seeking and treatment to minimize risks of bilirubin encephalopathy. Methods Cluster‐randomised controlled trial of community‐level icterometry used at home by mothers in C hi L inh, V ietnam. Rural health‐care workers identified and enrolled term newborns. Post‐partum mothers received jaundice education and icterometry instructions and were cluster‐randomised by commune. Cases received icterometers (icterometer group ( IG )) and controls did not (control group ( CG )). Subjects received mobile telephone calls from post‐natal days 2–7 to determine maternal recognition by visual inspection and icterometer detection of jaundice (≥3.0 on five‐point scale). Mothers without telephones, premature newborns (<35 weeks) or newborns hospitalised >5 days were excluded. Results Three hundred fifty‐two subjects were enrolled (183 IG and 169 CG ), of whom 11 (3.4%) were lost to telephone follow‐up. Jaundice was recognised and/or detected in 94 (27%) of all newborns. Icterometry helped 11 mothers (6%) detect neonatal jaundice that was not visually recognised by IG mothers. Detection by IG mothers was not statistically greater than CG mothers ( P = 0.09). Follow‐up care seeking was 8% in both groups ( P = 0.2), and 11% of jaundiced newborns received treatment (9% IG vs. 16% CG , P = 0.3). Newborns who received care had bilirubin measurements that averaged 257 μmol/L IG vs. 322 μmol/L CG ( P = 0.3). There were no deaths. Conclusions In this pilot study, home‐use icterometry may help improve parental detection of jaundice in rural V ietnam. However, larger studies are necessary to determine the changes in recognition, care seeking and treatment.

Background: In Vietnam, only 2.5% of newborns receive routine care before two weeks, generally only for symptomatic illnesses. Late recognition of jaundice delays treatment, increasing risks of bilirubin encephalopathy. We determined whether community-level icterometry improves parental recognition of jaundice and early care-seeking. Methods: Randomized controlled trial of community-level icterometry by mothers in rural Vietnam. Postpartum mothers were educated about jaundice and cluster-randomized by commune. Cases received icterometers and instructions (education+icterometer, EIG), controls (education only, EOG) education only. We assessed bilirubin knowledge using a 38-item questionnaire postnatally and at home two weeks later. All subjects received mobile telephone calls from days 2-7 to determine maternal recognition and icterometer detection of jaundice ( >3.5 on five-point scale). Care-seeking data were obtained during home visits. We excluded mothers without telephones, or whose infants were premature (< 37 wks) or hospitalized >5 days. Results: We present data on 205 of 264 subjects enrolled to date. Enrollment was 98%; 14 cases were excluded (1 hospitalized, 11 no telephone, 2 refusals). Post-test scores were 14% higher than pre-test (p=0.000). We successfully contacted parents on 4.9 (mean) of 6 days. Icterometry increased maternal recognition of jaundice from 20% (both groups) to 66% (EIG). Follow-up care-seeking remained 7% in both groups (p=0.948). Only 2% received treatment for hyperbilirubinemia; 3.2% (EOG) vs 0.9% (EIG) (p=0.237). Conclusions: Home-use icterometry increases parental detection of jaundice, but not care-seeking, in rural Vietnam. Perinatal education with telephone follow-up could be a feasible, low-cost way to improve parental recognition of symptomatic newborn illnesses.