Faculty Bibliography

Cisgender women are underserved by current HIV prevention efforts, and substantial gender disparities persist in pre-exposure prophylaxis (PrEP) use. Recent diagnoses with a bacterial sexually transmitted infection (STI) are objective, readily available indicators of PrEP-eligibility that could be used to improve PrEP prescribing for cisgender women. To better understand missed opportunities for prescribing, we examined the prevalence and correlates of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) diagnoses among cisgender women seeking care at a New York City obstetrics and gynecology (Ob/Gyn) clinic, along with the number of PrEP prescriptions provided post-STI diagnosis. A cross-sectional, retrospective review of electronic health record data was conducted for all HIV-negative cisgender women tested for CT and/or NG at the clinic between September 1, 2021 and September 19, 2022. Counts and prevalence for CT and NG infection were calculated, and multivariable log-binomial regression was used to examine associated factors. Among 7593 cisgender women receiving CT/NG testing during the study period, 186 had ≥ 1 CT infection (prevalence: 2.45%) and 18 had ≥ 1 NG infection (prevalence: 0.24%). In a multivariable model, CT/NG infection was significantly associated with age, having Spanish as a primary language, and a marital status of divorced, widowed, or separated. No cisgender women who received CT or NG diagnoses were prescribed PrEP during the study period. These findings highlight how opportunities to prescribe PrEP to cisgender women continue to be missed, even with readily available indicators for PrEP eligibility. More effective strategies are needed to promote PrEP prescribing among diverse populations of cisgender women, particularly in Ob/Gyn settings.

We developed and implemented a PrEP navigation program ("SNAPS") in a NYC safety-net hospital with the objectives to co-locate navigation, clinical PrEP services, and payment assistance. Adherence and retention to PrEP-related care were assessed by mean medication possession ratios (MPRs) and number of appointments over 12 months. Compared to the pre-SNAPS cohort, the post-SNAPS cohort was less likely to be cisgender male (64.8% vs. 84.2%), White (6.5% vs. 23%) and to speak English (33.3% vs. 80.6%) (all p < 0.001). Mean MPR was lower for post-SNAPS (0.68, SD = 0.33) compared to pre-SNAPS (0.89, SD = 0.22) (p = 0.001). Among post-SNAPS patients, cisgender men and MSM were more likely to be retained in PrEP care compared to cisgender women (p < 0.05). Although SNAPS linked diverse patients to PrEP-care, mean MPR was lower post-SNAPS compared to the pre-SNAPS. Continued investments to strengthen later stages of the PrEP cascade model for all populations vulnerable to HIV are needed.

BACKGROUND:New HIV infections are increasing among heterosexual Black and Latino populations in the United States, yet little is known about the shared characteristics of HIV risk behaviors and oral PrEP use among these populations. This study sought to understand factors influencing HIV risk behaviors and oral PrEP use among low income, limited English proficient (LEP), Black and Latino men with heterosexual contact in New York City (NYC). METHODS:Sixteen Black and Latino cisgender men with heterosexual contact and indication for PrEP were recruited from an urban safety net hospital in NYC between 2021 and 2022. In-depth interviews were conducted with participants in English and Spanish. Thematic content analysis was conducted. RESULTS:Participants described multi-faceted experiences around PrEP use informed by HIV stigma, limited understanding of PrEP, and PrEP attitudes from participants and their social networks. Participants' HIV risk behaviors were informed by sexual decision making rooted in hegemonic masculinity, trust, and perceived HIV and STI susceptibility. Participants disclosed the mixed and diverse nature of their sexual networks (i.e., cisgender women, gay men, transgender women, and sex workers). Among LEP Spanish-speaking participants, HIV risk behaviors were contextually embedded in histories of sexual or physical abuse, child labor, and/or substance use problems. CONCLUSIONS:Our results call for interventions that improve sexual health knowledge, reduce stigma, and foster open discussions around sexual networks. Combined, these interventions may contribute to more accurate understanding of HIV risk behaviors and reduction of HIV transmission, especially among communities impacted by sociopolitical disenfranchisement such as LEP Spanish-speakers.

Cisgender women and transgender men are less likely to be assessed for PrEP eligibility, prescribed PrEP, or retained in PrEP care. Thus, this pilot PrEP educational intervention was tailored for healthcare providers (HCPs) in obstetrics/gynecology who provide care to cisgender women and transgender men in an academically-affiliated, public hospital women's health clinic. The three-lecture educational curriculum designed for HCPs focused on PrEP eligibility and counseling, formulations and adherence, and prescription and payment assistance programs. Pre- and post-intervention surveys assessed HCP knowledge and barriers to PrEP counseling and prescription. Among n = 49 participants (mean age = 32.8 years; 85.7% cisgender women, mean years practicing = 4.2 years) pre-intervention, 8.7% had prior PrEP training and 61.2% felt very/somewhat uncomfortable prescribing PrEP. Post-intervention, knowledge of PrEP contraindications, eligibility, follow-up care, and assistance programs all increased. HCPs identified key barriers to PrEP care including lack of a dedicated PrEP navigator, culturally and linguistically appropriate patient materials on PrEP resources/costs, and PrEP-related content integrated into EHRs. Ongoing PrEP educational sessions can provide opportunities to practice PrEP counseling, including information on financial assistance. At the institutional level, incorporating PrEP screening in routine clinical practice via EMR prompts, facilitating PrEP medication monitoring, and enhancing telehealth for follow-up care could enhance PrEP prescription.

HIV infections disproportionately impact Latinx populations in the United States, yet oral pre-exposure prophylaxis (PrEP) uptake is low. This study was a secondary gendered analysis of interviews with Latina cisgender women (n = 20) recruited from an urban safety net hospital inNew York City between August 2019 and October 2022. All women were indicated for PrEP by the provider. In-depth interviews were conducted with participants in English and Spanish and asked about social determinants of health, sexual partnerships and behaviors, and PrEP-specific enablers and barriers. Secondary thematic content analysis was conducted to identify gender-related factors influencing PrEP uptake. The following themes emerged from the data:structural factors (e.g., employment), partner-related factors, low sexual health knowledge, and resilience and empowerment. Partner-related factors were the most salient; partner infidelity served as reasons for initiating PrEP. Despite being constrained by low power in relationships, women made empowered choices to initiate PrEP and protect themselves. Findings indicated that the impact of gender inequity was an important factor in Latina women's PrEP decision making, pointing to a need to address partner-driven HIV risk, imbalance of power in relationships, and gender norms.

We assessed factors associated with increased risk to loss of follow-up with infectious diseases staff in OPAT patients. Discharge to subacute healthcare facilities is strongly associated with loss to follow-up. We did not identify sociodemographic disparities. Poor communication between OPAT providers and subacute healthcare facilities remains a serious issue.

The 2022 mpox outbreak in New York City posed challenges to rapidly scaling up treatment capacity. We describe a telehealth treatment model launched during this outbreak that facilitated healthcare provider treatment capacity, and was able to adhere to a Centers for Disease Control and Prevention (CDC)-sponsored expanded access investigational new drug (EA-IND) protocol for tecovirimat. Sixty-nine patients were evaluated and prescribed tecovirimat for mpox through telehealth visits at NYC Health + Hospitals/Bellevue and NYU Langone Health from June to August 2022. Thirty-two (46.4%) were previously diagnosed with HIV. Forty-four (63.8%) reported full recovery, with the remainder lost to follow-up. Most patients (n = 60, 87.0%) attended at least one follow-up visit (either in person or through telehealth) after starting treatment. We observed favorable treatment outcomes, with no serious adverse events, hospitalizations, or deaths related to mpox. While equitable access to telehealth remains a limitation that needs to be addressed, this telehealth model enabled a rapid scale-up of tecovirimat prescription during the mpox outbreak, and should be considered as an important tool used to respond to future infectious disease outbreaks.

In the spring of 2022, mpox spread to non-endemic countries, including the United States. In New York City (NYC), vaccine demand grew as quickly as case counts. With the leadership of the Regional Emerging Special Pathogens Treatment Center (RESPTC) at NYC Health and Hospitals/Bellevue (NYC H+H)-part of the largest public hospital system in the United States-an innovative vaccination model was established that overcame challenges involving health inequities, inadequate access, and lack of vaccine uptake, to successfully administer JYNNEOS vaccines to over 12,000 patients. Transmission has slowed since its peak in August 2022, which has been attributed to successful vaccination campaigns, infection-induced immunity, and behavioral changes among those at highest risk; however, a Centers for Disease Control and Prevention (CDC) assessment released on 4 April 2023 suggests jurisdictions with low vaccination levels (<35%) remain at risk for an mpox resurgence. Here, we summarize the critical aspects of our mpox vaccination model in NYC, which include integration into routine clinical care, prioritization of health equity, and reutilization of COVID-19 vaccination systems, to provide valuable insights for healthcare institutions as we move into the next stage of this ongoing outbreak.