Faculty Bibliography

BACKGROUND:With declining HIV/AIDS funding globally, countries need to identify the optimally efficient mix of HIV interventions to avert new HIV infections. We evaluated optimal HIV/AIDS intervention portfolios to enable Eswatini to meet the 2030 Ending the HIV Epidemic (EHE) goal of a 90% reduction in HIV incidence compared to 2010. METHODS:Using Eswatini national demographic data and expenditure data on clinical, behavioral, and public health HIV interventions, we employed a validated HIV transmission model to simulate the effects of HIV interventions on diagnosis, treatment, and viral load suppression (costs, infections averted, life years gained, and quality-adjusted life years (QALYs) gained) for the Eswatini adult population from 2022 through 2030.We evaluated eleven alternative combinations of scaling-up interventions to goal coverage levels, with and without reallocating resources away from other interventions. RESULTS:With the current resource allocation, Eswatini will be delayed in meeting the EHE goal. However, with additional programmatic funding of US$8 million to additionally scaling up HST and LA-PrEP for the highest risk population and additional funding for defaulter tracing and risk communication, Eswatini will meet its EHE goal by 2030 by averting an additional 3,500 infections. CONCLUSION/CONCLUSIONS:Eswatini could meet its EHE goal with additional funding or resource reallocation from less efficient toward highly efficient interventions. These findings can inform allocation decisions that are more practical and realistic in this resource-limited setting with high HIV disease burden.

OBJECTIVE:We aimed to better understand patients' treatment preferences and quantify the level of cancer risk at which treatment preferences change (risk threshold) to inform better counseling of patients with intraductal papillary mucinous neoplasms (IPMNs). SUMMARY BACKGROUND DATA/BACKGROUND:The complexity of IPMN management provides an opportunity to align treatment with individual preference. METHODS:We surveyed a sample of healthy volunteers simulating a common scenario: undergoing an imaging study that incidentally identifies an IPMN. In the scenario, the estimated risk of cancer in the IPMN was 5%. Patients were asked their treatment preference (surgery or surveillance), to quantify the level of cancer risk in the IPMN at which their treatment preference would change (i.e. risk threshold), and their level of cancer anxiety as measured on a 5-point Likert scale. We examined associations between participant characteristics, treatment preferences, and risk threshold using multivariable linear regression. RESULTS:The median risk threshold among the 520 participants was 25% (IQR 2.3-50%). The risk threshold had a bimodal distribution: 40% of participants had a risk threshold between 0-10% and 47% had a risk threshold above 30%. When informed that the risk of cancer was 5%, 62% of participants (n=323) preferred surveillance, and the remaining 38% (n=197) preferred surgery. After adjusting for potential confounders, participants who expressed "worry" or "extreme worry" about the malignancy risk of IPMN had significantly lower risk thresholds than participants who were "not at all worried" (Coefficient -12, 95%CI -21 to -2, P=0.015 and Coefficient -18, 95%CI -29 to -8, P<0.001, respectively). CONCLUSIONS:Participants varied in treatment preference and risk threshold of incidentally identified IPMNs. Given the uncertainty in estimating the true malignant potential of IPMNs, a better understanding of a patient's risk threshold, as influenced by patient concern about malignancy, will help inform the shared decision-making process.

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.

The degree to which alcohol use is associated with the risk of all-cause mortality and hepatic decompensation after hepatitis C (HCV) diagnosis, treatment, and cure remains unknown. We sought to address this question among patients achieving sustained virologic response (SVR) after direct-acting antiviral treatment in the largest HCV health system in the United States. We extracted data on alcohol use, HCV treatment, SVR, HIV co-infection, demographics, risk behaviours, hepatic decompensation, and mortality from all patients in the 1945 to 1965 VA Birth Cohort. Alcohol use categories were generated using responses to the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questionnaire and diagnostic codes for alcohol use disorder (AUD): abstinent without a history of AUD, abstinent with a history of AUD, current lower-risk consumption, current moderate-risk consumption, and current high-risk consumption with or without AUD. Cox proportional hazard models were used to examine associations between alcohol category and the risk of hepatic decompensation and all-cause mortality. Among 50,581 patients in the analytic cohort, compared to current drinkers exhibiting lower risk alcohol consumption (referent), current high-risk consumption with or without AUD was associated with increased risk of all-cause mortality (aHR: 1.40, 95% CI: 1.21-1.63) and hepatic decompensation (HR: 2.15, 95% CI: 1.60-2.89) as was abstinence with a history of AUD diagnosis (mortality aHR: 1.63, 95% CI: 1.41-1.89; hepatic decompensation aHR: 1.85, 95% CI: 1.36-2.51). AUD and high-risk alcohol consumption are associated with the risk of hepatic decompensation and all-cause mortality among Veterans who have achieved SVR, including those categorised as being currently abstinent. Interventions for alcohol consumption and use disorder among individuals treated for HCV infection may reduce morbidity and mortality in this population.

BACKGROUND:People with opioid use disorder (POUD) who are incarcerated are disproportionately impacted by the overdose crisis. We sought to identify overdose policies that allocate resources with maximal efficiency to reduce mortality among POUD in the New Jersey (NJ) Department of Corrections. MAIN OUTCOMES/MEASURES/METHODS:We created a probabilistic state-transition model of a simulated cohort of POUD incarcerated in NJ to simulate maximizing medication for opioid use disorder (MOUD) during incarceration and/or post-release in the community and naloxone in the community. We estimated how maximizing each intervention individually and in combinations compared to current provision would impact five-year overdose deaths (ODDs), life-years (LYs), and quality-adjusted life-years (QALYs) among the simulated cohort, who moved between different modeled settings and opioid use statuses. Inputs were derived from literature reviews and expert opinion. Costs were in 2021 USD, employing a health sector perspective in base-case analyses and a limited societal perspective in sensitivity analyses, a 3% discount rate, cost-effectiveness criterion of ≤ $100,000/QALY, and life-year and lifetime horizons. RESULTS:At status quo, 141 five-year ODDs will occur in the cohort (n = 2,592), and the cohort will live an average of 17.0 discounted LYs, experiencing 13.3 discounted QALYs. Evaluating interventions individually compared to status quo, maximizing MOUD in incarceration prevents 14 five-year ODDs, adds 0.2 LYs, 0.3 QALYs per-person at a favorable incremental cost-effectiveness ratio (ICER; $34,000/QALY). Maximizing MOUD in the community prevents 40 five-year ODDs, adds 0.9 LYs, 1.1 QALYs at a favorable ICER ($25,000/QALY). Maximizing naloxone prevents 24 five-year ODDs, adds 0.3 LYs, 0.2 QALYs at a favorable ICER ($17,000/QALY). Comparing all combinations of interventions to status quo and each other, the most beneficial combination meeting cost-effectiveness criterion was jointly maximizing community MOUD and naloxone (ICER $25,000/QALY), preventing 56 five-year ODDs, adding 1.2 LYs, 1.3 QALYs. In sensitivity analyses using a limited societal perspective, all interventions were cost-saving. Maximizing all interventions was both most beneficial (42% reduction in death) and cost-saving ($300,000 per capita) over the cohort lifetime. CONCLUSION/CONCLUSIONS:Maximizing MOUD and community naloxone in New Jersey can reduce five-year ODDs by 40%. Considering societal cost-savings, maximizing all three also saves money.

BACKGROUND:Inappropriate imaging to stage low-risk prostate cancer is considered low-value care. Determining the effectiveness of a theory-based intervention, Prostate Cancer Imaging Stewardship (PCIS), to promote guideline-concordant imaging. METHODS:A stepped-wedge, cluster-randomized trial, PCIS, was conducted between March 2018 and March 2021 at ten Veterans Health Administration medical centers (VAMC) initially selected for prostate cancer volume, geographic diversity, and willingness to participate. Intervention initiation at sites were randomized in 3-month intervals. We enrolled 61 urology providers who treat prostate cancer at participating sites. Outcomes were assessed among 2,302 patients with incident prostate cancer aged 18-85 years. PCIS combines three evidence-based provider-focused behavior change strategies: 1) Clinical Reminder Order Check triggered when a provider attempted to order imaging for a patient with PSA < 20ng/mL; 2) VAMC-level academic detailing at initiation and every three months thereafter; 3) Audit and Feedback for providers to improve their imaging performance. The main outcome was guideline-discordant nuclear medicine bone scan (NMBS) imaging for low-risk prostate cancer patients. RESULTS:NMBS imaging would be consistent with National Comprehensive Cancer Network guidelines in 878 patients (38%) and inconsistent in 1424 patients (62%). Among patients not requiring NMBS, 141/690 (20.4%) received guideline-discordant imaging (ie, NMBS ordered) during Control compared to 109/734 (14.9%) during Intervention (OR = 0.54, p = .04). Among patients requiring a NMBS, 29/425 (6.8%) did not receive one (ie, guideline-discordant imaging) during Control compared to 25/453 (5.5%) during the Intervention (OR = 1.36, p = .36). CONCLUSION/CONCLUSIONS:PCIS significantly reduced low-value, guideline-discordant NMBS imaging among low-risk prostate cancer patients without negatively affecting necessary imaging for high-risk patients. CLINICAL TRIALS REGISTRATION/BACKGROUND:NCT03445559.

BACKGROUND:Communities hardest-hit by early SARS-CoV-2 outbreaks accrued more immunity, but prioritizing these communities for vaccination could reduce health disparities. Optimal vaccine allocation depends on inequality aversion, i.e., willingness to trade off aggregate health benefits to increase distributional equity. We evaluated the impact of vaccine prioritization strategies on COVID-19 infections and mortality in New York City (NYC). METHODS:We used a susceptible-exposed-infected-recovered COVID-19 transmission model calibrated to NYC neighborhood-level data to compare three vaccine distribution strategies: 1) uniform across neighborhoods (no prioritization); 2) prioritizing hardest-hit neighborhoods (exposure-based prioritization); and 3) prioritizing hardest-hit neighborhoods while maintaining mitigation measures in other neighborhoods (exposure-based prioritization plus mitigation). The model accounted for vaccine efficacy, rollout pace, pre-vaccine immunity, and heterogeneous neighborhood exposure risk. We categorized 42 NYC neighborhoods into quintiles of cumulative COVID-19 mortality rates from March 1, 2020, until first vaccine availability (December 14, 2020). We modeled total deaths and equally-distributed-equivalent (EDE) deaths (i.e., the equally preferred number of deaths, considering equity and efficiency) across a range of inequality aversion (Atkinson's index, ε=0-20). RESULTS:Exposure-based prioritization plus mitigation was estimated to avert the most citywide COVID-19 deaths (32.5 %) relative to no vaccination, regardless of adjustment for inequality aversion. Relative to no prioritization, exposure-based prioritization was estimated to avert 45 % fewer citywide deaths but generated 2.5 % more EDE-adjusted deaths at an Atkinson index of 10. Exposure-based prioritization outperformed no prioritization at an Atkinson index of ≥ 6. CONCLUSIONS:Prioritizing vaccination within the hardest-hit communities, paired with sustained mitigation efforts in communities with the greatest advantage, resulted in the greatest overall reduction in mortality and inequities. Emergency response teams should consider a community's ability to continue non-pharmaceutical mitigation efforts when allocating limited pharmaceutical supplies.

OBJECTIVES/OBJECTIVE:To evaluate patient preferences for decision-making role in the management of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas and to identify individual characteristics associated with those preferences. BACKGROUND:Management of IPMNs is rooted in uncertainty with current guidelines failing to incorporate patients' preferences and values. METHODS:A representative sample of participants aged 40-70 were recruited to evaluate a clinical vignette where they were given the option to undergo surveillance or surgical resection of their IPMN. Their preferred role in the decision-making process for the vignette was evaluated using the Control Preference Scale. The relationship between control preference and variables including cancer anxiety, health literacy, and education level was analyzed. RESULTS:Of the 520 participants in the study, most preferred an active role (65%), followed by shared (29%), and passive roles (6%) in the decision-making process. Lower health literacy was significantly associated with a more passive control preference (p = 0.003). Non-active preference was significantly associated with Latino race compared to White race (odds ratio = 0.52, p = 0.009) in multivariate analysis. We found no significant association between control preference and education level or cancer anxiety. CONCLUSIONS:Most patients preferred an active role in IPMN treatment decisions. Lower health literacy and Latino race were associated with a preference for non-active decision roles. Clinicians should strive to align patient involvement in IPMN treatment decisions with their patient's preferred role.

BACKGROUND:HIV transmission and disease progression may be driven by associations HIV risk behaviors have with a constellation of alcohol, other substance, and mood-related conditions (CASM). However, observational study-based measures of these associations are often prone to unmeasured confounding. While meta-analysis offers a systematic approach to summarize effect sizes across studies, the validity of these estimates can be compromised if similar biases exist across studies. Our analysis assesses the likelihood that unmeasured confounding explains meta-analysis-derived measures of association between CASM and HIV risk behaviors, and provides bias-adjusted estimates. METHODS:We first conducted systematic reviews and meta-analyses to assess associations between CASM conditions and four HIV risk behaviors (medication non-adherence, unprotected sex, transactional sex, and multiple sexual partners). We then adjusted for potential unmeasured confounders using two methods designed for meta-analyses - Point Estimate and Proportion of Meaningfully Strong Effects methods. We selected "risk propensity" as an illustrative and potentially important unmeasured confounder based on the extant literature and mechanistic plausibility. RESULTS:In analyses unadjusted for unmeasured confounding, 89% (24/27) of odds ratios (ORs) show strong evidence of a positive association, with alcohol use and stimulant use emerging as dominant risk factors for HIV risk behaviors. After adjusting for unmeasured confounding by risk propensity, 81% (22/27) of ORs still showed strong evidence of a positive association. Associations between mood-related conditions and HIV risk behaviors were more robust to unmeasured confounding than associations between alcohol use and other substance use and HIV risk behaviors. CONCLUSION/CONCLUSIONS:Despite residual confounding present in constituent studies, there remains strong evidence of associations between CASM and HIV risk behaviors as well as the clustered nature of CASM conditions. Our analysis provides an example of how to assess unmeasured confounding in meta-analysis-derived measures of association.