Jean Anderson’s research while affiliated with Johns Hopkins Medicine and other places

Background Loss to follow-up to HIV care following delivery puts birthing parents with HIV at higher risk of loss of viral suppression, disease progression, and HIV partner transmission. This study assessed factors associated with retention in postpartum HIV care. Methods This is a retrospective cohort study at a single academic medical center and included patients followed from January 2014 to December 2022. The primary outcome was retention in postpartum HIV care (any healthcare encounter discussing HIV medication adherence or viral load within 12 months postpartum). Data was analyzed using Chi-square and student T-test for discrete and continuous variables. Univariate and multivariable log regressions were used to measure independent associations on care retention and healthcare utilization outcomes. Results Of the 111 patients with planned follow up at our facility, 93 (83.8%) of participants had ≥ 1 HIV care encounter within 12 months of delivery. Participants had a mean age of 31.2 (± 5.84), were predominantly Black (79.3%), non-Hispanic (91%), non-U.S. born (57.5%) with substantial exposure of prior IPV (29.6%). Participants retained in care were more likely to use ART during pregnancy (92/99% vs 16/94.2%, P=0.01) and have viral suppression at delivery (n= 83/90% vs 12/67%, P=.02). Retention in care was negatively associated with substance use during pregnancy (aOR 0.29, 95% CI 0.09-0.95) following adjustment for social health covariates. Conclusion While almost 84% of participants were retained in HIV care within 12 months of delivery, substance use in pregnancy was a significant risk factor for HIV care attrition postpartum.

In the United States, women account for one-fourth of people living with HIV. Most women living with HIV are Black or Hispanic and acquired HIV from heterosexual contact. Many face significant barriers to appropriate medical care, with lower retention in care and viral suppression than men who acquire HIV from male-to-male sexual contact. Many factors contribute to these disparities, including high rates of alcohol abuse, substance use, intimate partner violence, depression, and socioeconomic marginalisation. HIV, substance use, and violence each contribute independently to the collective health burden on women. The co-occurrence of these factors, termed the SAVA (substance abuse, violence, and HIV/AIDS) syndemic, is particularly hard to address, as the conditions act synergistically to negatively influence health outcomes. In addition, mental health conditions frequently coexist and further contribute to adverse outcomes. Unfortunately, clinician knowledge of this syndemic is low, and patients living with HIV and other elements of SAVA, including depression, are not recognised and referred for appropriate services. In this paper we describe our pilot educational and quality improvement program and the subsequent educational program we developed to increase knowledge of SAVA with the goal of improving health outcomes for women living with HIV.

Background Finding the Invisible Patient (FIP): Substance abuse (SA), interpersonal violence (IPV), depression and HIV are part of overlapping epidemics adversely affect HIV and the burden of each (SAVA). The Johns Hopkins HIV Women's Clinic (JHWC) initiated screening for SAVA to better identify these problems, link to needed services and evaluate the impact. Challenges included time and impact on clinic flow; need for clinic wide training and sensitization and a systems approach. SAVA Project ECHO- FIP took the learnings from FIP and expanded it to ten small groups across the US in order to enhance the reach and share the learnings Methods FIP: Education and a series of clinic-wide changes were implemented at JHWC. Patients were now routinely screened for SAVA. and if positive sent for care. Resources were developed for patients including linkage to local assistance programs, temporary housing, posters on bathroom doors and emergency contacts. SAVA Project ECHO- FIP featured expert specialists to provide ongoing telementoring to clinicians through regularly scheduled educational sessions over five weeks. There were ten separate workshops, each covering a 5-part curriculum. Results FIP: Of 116 women 60% were + for SAVA. Six months post-intervention, 56% were engaged in care; 39% were given a referral for psych/SUD/IPA therapy; 50% entered psychologic therapy; 28% entered substance abuse treatment; 39% for mental health issues. SAVA Project ECHO- FIP trained 208 clinicians to become experts in screening, identifying and treating SAVA. There was a 105% increase in confidence on identifying and treating SAVA and a 177% improvement in competence. Clinicians shared insights around building relationships with their patients and utilizing local community-based programs to help patients overcome SAVA. Conclusion SAVA is common among many women in HIV care and is likely underestimated. There was a significant correlation with + screens and higher no show rates, reflecting increased resources needed to optimize VLS screening for components of SAVA. Screening for SAVA should be routine in HIV care settings. Resources for appropriate referral are critical. SAVA Project ECHO- FIP demonstrated knowledge transfer and practice improvement through its curriculum and small-group engagement. Disclosures Jean Anderson, MD, Merck & Co: Stocks/Bonds

Shared decision making for infant feeding in the context of HIV in high-resourced settings is necessary to acknowledge patient autonomy, meet increasing patient requests and address the changing reality of perinatal HIV care. In low-to middle-income countries (LMIC), where the majority of individuals living with HIV reside, persons with HIV are recommended to breastfeed their infants. In the setting of maternal anti-retroviral therapy (ART) use throughout pregnancy, viral suppression and appropriate neonatal post-exposure prophylaxis (PEP) use, updated information indicates that the risk of HIV transmission through breastmilk may be between 0.3 and 1%. While not endorsing or recommending breastfeeding, the United States’ DHHS perinatal guidelines are similarly pivoting, stating that individuals should “receive patient-centred, evidence-based counselling on infant feeding options.” Similar statements appear in the British, Canadian, Swiss, European, and Australasian perinatal guidelines. We assembled a multi-disciplinary group at our institution to develop a structured shared decision-making process and protocol for successful implementation of breastfeeding. We recommend early and frequent counselling about infant feeding options, which should include well known benefits of breastfeeding even in the context of HIV and the individual’s medical and psychosocial circumstances, with respect and support for patient’s autonomy in choosing their infant feeding option.

Objectives: Despite the high burden of HPV-related disease in women living with HIV (WLHIV), the incidence of HPV vaccination in this population has not been described. Large population databases centered on WLHIV have not captured HPV vaccination, and those capturing vaccine rates fail to collect HIV status. The National Health and Nutrition Examination Survey (NHANES) database is the only nationally representative database to our knowledge that captures both variables. This study aimed to describe the frequency of HPV vaccination in WLHIV compared to HIV-negative women. Methods: This is a retrospective cohort study utilizing the NHANES database of women aged 18-59 years, from 2007 to 2018. The NHANES survey, administered annually, includes demographic, socioeconomic, and health-related questions. HIV status is determined by laboratory testing. HPV vaccination status, defined as receipt of at least one vaccine dose, is obtained via patient interview. Bivariate analyses were performed using Chi-square and students’ t-test. Logistic regression was used for multivariate analysis. All analyses adjusted for NHANES sample weights and design effects. Results: We identified 11,039 women from 2007 to 2018 with HIV testing, representing 79.6 million women. Most women were White (61%), US-born (80%), married/living with a partner (63%), and privately insured (60%). Twenty-five (0.2%) were WLHIV, representing 114,292 women nationally. WLHIV were older (mean age: 43 vs 38 years old), more likely to be non-Hispanic Black (76% vs 12%), publicly insured (55% vs 20%), and had HPV infection (90% vs 40%) compared to women without HIV. Overall, 1,333 (12%) women reported HPV vaccination. In WLHIV, the frequency was 35% compared to 12% in women without HIV (p=0.002). In a multivariate analysis controlling for age, race, poverty index, insurance status, heart disease, and HPV infection, WLHIV were four times more likely to be vaccinated than women without HIV (aOR: 4.0, 95% CI: 2.0-8.2). In an exploratory analysis, we restricted the population to HPV-vaccine eligible women (9-26 years) between the years 2007 and 2018. In this restricted cohort, there were only four (< 0.1%) WLHIV, representing 17,365 women. HPV vaccination levels in WLHIV were 87% compared to 27% in women without HIV. No further analyses were performed due to sample size limitations. Conclusions: In this population-based analysis of the only nationally-representative dataset with both HIV status and HPV vaccination status, WLHIV were noted to have a higher frequency of HPV vaccination compared to women without HIV. However, the small number of WLHIV in this database highlights the importance of future studies to monitor HPV vaccine uptake in this vulnerable population.

BACKGROUND: Few data are available on COVID-19 outcomes among pregnant women in sub-Saharan Africa (SSA), where high-risk comorbidities are prevalent. We investigated the impact of pregnancy on SARS-CoV-2 infection and of SARS-CoV-2 infection on pregnancy to generate evidence for health policy and clinical practice. METHODS: We conducted a 6-country retrospective cohort study among hospitalized women of childbearing age between 1 March 2020 and 31 March 2021. Exposures were (1) pregnancy and (2) a positive SARS-CoV-2 RT-PCR test. The primary outcome for both analyses was intensive care unit (ICU) admission. Secondary outcomes included supplemental oxygen requirement, mechanical ventilation, adverse birth outcomes, and in-hospital mortality. We used log-binomial regression to estimate the effect between pregnancy and SARS-CoV-2 infection. Factors associated with mortality were evaluated using competing-risk proportional subdistribution hazards models. RESULTS: Our analyses included 1315 hospitalized women: 510 pregnant women with SARS-CoV-2, 403 nonpregnant women with SARS-CoV-2, and 402 pregnant women without SARS-CoV-2 infection. Among women with SARS-CoV-2 infection, pregnancy was associated with increased risk for ICU admission (adjusted risk ratio [aRR]: 2.38; 95% CI: 1.42–4.01), oxygen supplementation (aRR: 1.86; 95% CI: 1.44–2.42), and hazard of in-hospital death (adjusted sub-hazard ratio [aSHR]: 2.00; 95% CI: 1.08–3.70). Among pregnant women, SARS-CoV-2 infection increased the risk of ICU admission (aRR: 2.0; 95% CI: 1.20–3.35), oxygen supplementation (aRR: 1.57; 95% CI: 1.17–2.11), and hazard of in-hospital death (aSHR: 5.03; 95% CI: 1.79–14.13). CONCLUSIONS: Among hospitalized women in SSA, both SARS-CoV-2 infection and pregnancy independently increased risks of ICU admission, oxygen supplementation, and death. These data support international recommendations to prioritize COVID-19 vaccination among pregnant women.

Background. Few data are available on COVID-19 outcomes among pregnant women in sub-Saharan Africa (SSA), where high-risk comorbidities are prevalent. We investigated the impact of pregnancy on SARS-CoV-2 infection and of SARS-CoV-2 infection on pregnancy to generate evidence for health policy and clinical practice. Methods. We conducted a 6-country retrospective cohort study among hospitalized women of childbearing age between 1 March 2020 and 31 March 2021. Exposures were (1) pregnancy and (2) a positive SARS-CoV-2 RT-PCR test. The primary outcome for both analyses was intensive care unit (ICU) admission. Secondary outcomes included supplemental oxygen requirement, mechanical ventilation, adverse birth outcomes, and in-hospital mortality. We used log-binomial regression to estimate the effect between pregnancy and SARS-CoV-2 infection. Factors associated with mortality were evaluated using competing-risk proportional subdistribution hazards models. Results. Our analyses included 1315 hospitalized women: 510 pregnant women with SARS-CoV-2, 403 nonpregnant women with SARS-CoV-2, and 402 pregnant women without SARS-CoV-2 infection. Among women with SARS-CoV-2 infection, pregnancy was associated with increased risk for ICU admission (adjusted risk ratio [aRR]: 2.38; 95% CI: 1.42-4.01), oxygen supplementation (aRR: 1.86; 95% CI: 1.44-2.42), and hazard of in-hospital death (adjusted sub-hazard ratio [aSHR]: 2.00; 95% CI: 1.08-3.70). Among pregnant women, SARS-CoV-2 infection increased the risk of ICU admission (aRR: 2.0; 95% CI: 1.20-3.35), oxygen supplementation (aRR: 1.57; 95% CI: 1.17-2.11), and hazard of in-hospital death (aSHR: 5.03; 95% CI: 1.79-14.13). Conclusions. Among hospitalized women in SSA, both SARS-CoV-2 infection and pregnancy independently increased risks of ICU admission, oxygen supplementation, and death. These data support international recommendations to prioritize COVID-19 vaccination among pregnant women.

Background: Few data are available on COVID-19 outcomes among pregnant women in sub-Saharan Africa (SSA), where high-risk comorbidities are prevalent. We investigated the impact of pregnancy on SARS-CoV-2 infection and of SARS-CoV-2 infection on pregnancy to generate evidence for health policy and clinical practice. Methods: We conducted a 6-country retrospective cohort study among hospitalized women of childbearing age between 1 March 2020 and 31 March 2021. Exposures were (1) pregnancy and (2) a positive SARS-CoV-2 RT-PCR test. The primary outcome for both analyses was intensive care unit (ICU) admission. Secondary outcomes included supplemental oxygen requirement, mechanical ventilation, adverse birth outcomes, and in-hospital mortality. We used log-binomial regression to estimate the effect between pregnancy and SARS-CoV-2 infection. Factors associated with mortality were evaluated using competing-risk proportional subdistribution hazards models. Results: Our analyses included 1315 hospitalized women: 510 pregnant women with SARS-CoV-2, 403 nonpregnant women with SARS-CoV-2, and 402 pregnant women without SARS-CoV-2 infection. Among women with SARS-CoV-2 infection, pregnancy was associated with increased risk for ICU admission (adjusted risk ratio [aRR]: 2.38; 95% CI: 1.42-4.01), oxygen supplementation (aRR: 1.86; 95% CI: 1.44-2.42), and hazard of in-hospital death (adjusted sub-hazard ratio [aSHR]: 2.00; 95% CI: 1.08-3.70). Among pregnant women, SARS-CoV-2 infection increased the risk of ICU admission (aRR: 2.0; 95% CI: 1.20-3.35), oxygen supplementation (aRR: 1.57; 95% CI: 1.17-2.11), and hazard of in-hospital death (aSHR: 5.03; 95% CI: 1.79-14.13). Conclusions: Among hospitalized women in SSA, both SARS-CoV-2 infection and pregnancy independently increased risks of ICU admission, oxygen supplementation, and death. These data support international recommendations to prioritize COVID-19 vaccination among pregnant women.

Objective: Fetal tissue research has driven significant medical advances but remains publicly contentious in the United States. The views of pregnant individuals in the United States regarding the donation of fetal tissue offer an important and previously unexplored perspective on this issue. Methods: We conducted a secondary analysis of data from two separate, broader qualitative studies. Pregnant and recently pregnant individuals (N=79) from clinical sites at the University of North Carolina at Chapel Hill, Johns Hopkins University, and Massachusetts General Hospital were interviewed individually using a semi-structured guide addressing a range of issues related to infectious disease research and pregnancy, including the acceptability of fetal tissue research. Interviews were transcribed, coded, and analyzed for emergent themes. Results: Among this sample of predominantly Black (61%), reproductive-aged pregnant and recently pregnant participants, the majority (72%) generally supported fetal tissue research. The following three themes were identified: choice, respect, and meaning. Respondents discussed the deeply personal nature of decisions surrounding fetal tissue research, emphasizing the importance of informed consent and respect for the person's emotional state when approaching for consent. The ways in which participants regarded how to respectfully handle fetal tissue also shaped views about the acceptability of donation, both for and against. For many participants, fetal tissue donation to research represented one way of ascribing meaning to pregnancy termination or loss. Conclusion: Among this diverse sample of pregnant and recently pregnant individuals, most were supportive of fetal tissue donation for research. A better understanding of pregnant individuals' views on this topic may lead to policies and practices that are congruent with the needs and values of people facing decisions regarding the disposition of fetal remains.