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Papers by ingrid bassett

The Journal of Clinical Endocrinology & Metabolism

Open Forum Infectious Diseases, 2021

Background Obesity has been linked to severe clinical outcomes among people who are hospitalized ... more Background Obesity has been linked to severe clinical outcomes among people who are hospitalized with coronavirus disease 2019 (COVID-19). We tested the hypothesis that visceral adipose tissue (VAT) is associated with severe outcomes in patients hospitalized with COVID-19, independent of body mass index (BMI). Methods We analyzed data from the Massachusetts General Hospital COVID-19 Data Registry, which included patients admitted with polymerase chain reaction–confirmed severe acute respiratory syndrome coronavirus 2 infection from March 11 to May 4, 2020. We used a validated, fully automated artificial intelligence (AI) algorithm to quantify VAT from computed tomography (CT) scans during or before the hospital admission. VAT quantification took an average of 2 ± 0.5 seconds per patient. We dichotomized VAT as high and low at a threshold of ≥100 cm2 and used Kaplan-Meier curves and Cox proportional hazards regression to assess the relationship between VAT and death or intubation ove...

AIDS Care, 2021

Nearly 80 million people have been forcibly displaced by persecution, violence, and disaster. Dis... more Nearly 80 million people have been forcibly displaced by persecution, violence, and disaster. Displaced populations, including refugees, face health challenges such as resource shortages, food and housing insecurity, violence, and disrupted social support. People living with HIV in refugee settings have decreased engagement with HIV services compared to non-refugee populations, and interventions are needed to enhance linkage to care. However, designing health interventions in humanitarian settings is challenging. We used Intervention Mapping (IM), a six-step method for developing theory-and evidence-based health interventions, to design a program to increase linkage to HIV care for refugees and Ugandan nationals in Nakivale Refugee Settlement in Uganda. We engaged a diverse group of stakeholders (N = 14) in Nakivale, including community members and humanitarian actors, in an interactive workshop focusing on IM steps 1-4. We developed a chronic care program that would integrate HIV care with services for hypertension and diabetes at accessible community sites, thereby decreasing stigma around HIV treatment and improving access to care. IM provided an inclusive, efficient method for integrating community members and program implementers in the intervention planning process, and can be used as a method-driven approach to intervention design in humanitarian settings.

Statistical analysis and supplementary results tables. Variable selection procedure for random fo... more Statistical analysis and supplementary results tables. Variable selection procedure for random forests. Propensity score adjustment procedure. Imputation of CD4 values. Calculated effect of HIV. Table S1A and 1B â HIV-infected (1A) and HIV-uninfected (1B) comparing those with and without valid SA ID numbers. Table S2A and 2B show the standardized difference between the overall group (HIV-infected or HIV-uninfected) and the group with valid SA ID numbers. (DOCX 74 kb)

Journal of the International AIDS Society, 2022

Introduction: South Africa's government-led Central Chronic Medication Dispensing and Distributio... more Introduction: South Africa's government-led Central Chronic Medication Dispensing and Distribution (CCMDD) program offers people living with HIV the option to collect antiretroviral therapy at their choice of community-or clinic-based pickup points intended to increase convenience and decongest clinics. To understand CCMDD pickup point use among people living with HIV, we evaluated factors associated with uptake of a community-versus clinic-based pickup point at CCMDD enrolment. Methods: We collected baseline data from October 2018 to March 2020 on adults (≥18 years) who met CCMDD clinical eligibility criteria (non-pregnant, on antiretroviral therapy for ≥1 year and virologically suppressed) as part of an observational cohort in seven public clinics in KwaZulu-Natal. We identified factors associated with community-based pickup point uptake and fit a multivariable logistic regression model, including age, gender, employment status, self-perceived barriers to care, selfefficacy, HIV-related discrimination, and perceived benefits and challenges of CCMDD. Results and Discussion: Among 1521 participants, 67% were females, with median age 36 years (IQR 30-44). Uptake of a community-based pickup point was associated with younger age (aOR 1.18 per 10-year decrease, 95% CI 1.05-1.33), being employed ≥40 hours per week (aOR 1.42, 95% CI 1.10-1.83) versus being unemployed, no self-perceived barriers to care (aOR 1.42, 95% CI 1.09-1.86) and scoring between 36 and 39 (aOR 1.44, 95% CI 1.03-2.01) or 40 (aOR 1.91, 95% CI 1.39-2.63) versus 10-35 on the self-efficacy scale, where higher scores indicate greater self-efficacy. Additional factors included more convenient pickup point location (aOR 2.32, 95% CI 1.77-3.04) or hours (aOR 5.09, 95% CI 3.71-6.98) as perceived benefits of CCMDD, and lack of in-clinic follow-up after a missed collection date as a perceived challenge of CCMDD (aOR 4.37, 95% CI 2.30-8.31). Conclusions: Uptake of community-based pickup was associated with younger age, full-time employment, and systemic and structural factors of living with HIV (no self-perceived barriers to care and high self-efficacy), as well as perceptions of CCMDD (convenient pickup point location and hours, lack of in-clinic follow-up). Strategies to facilitate community-based pickup point uptake should be tailored to patients' age, employment, self-perceived barriers to care and self-efficacy to maximize the impact of CCMDD in decongesting clinics.

BMJ Open Respiratory Research, 2021

IntroductionObstructive lung diseases (asthma and chronic obstructive pulmonary disease (COPD)) a... more IntroductionObstructive lung diseases (asthma and chronic obstructive pulmonary disease (COPD)) and smoking are associated with greater risk of respiratory infections and hospitalisations, but conflicting data exist regarding their association with severity of COVID-19, and few studies have evaluated whether these associations differ by age.ObjectivesTo examine the associations between asthma, COPD and smoking on the severity of COVID-19 among a cohort of hospitalised patients, and to test for effect modification by age.MethodsWe performed a retrospective analysis of electronic health record data of patients admitted to Massachusetts General Hospital, assigning the maximal WHO Clinical Progression Scale score for each patient during the first 28 days following hospital admission. Using ordered logistic regression, we measured the association between maximal severity score and asthma, COPD and smoking and their interaction with age.Measurements and main resultsAmong 1391 patients hos...

The Journal of Clinical Endocrinology & Metabolism, 2021

Background Obesity is an established risk factor for severe COVID-19 outcomes. The mechanistic un... more Background Obesity is an established risk factor for severe COVID-19 outcomes. The mechanistic underpinnings of this association are not well-understood. Objective To evaluate the mediating role of systemic inflammation in obesity-associated COVID-19 outcomes. Methods This hospital-based, observational study included 3828 SARS-CoV-2-infected patients who were hospitalized February to May 2020 at Massachusetts General Hospital (MGH) or Columbia University Irving Medical Center/New York Presbyterian Hospital (CUIMC/NYP). We use mediation analysis to evaluate whether peak inflammatory biomarkers (C-reactive protein [CRP], erythrocyte sedimentation rate [ESR], D-dimer, ferritin, white blood cell count and interleukin-6) are in the causal pathway between obesity (BMI ≥ 30) and mechanical ventilation or death within 28 days of presentation to care. Results In the MGH cohort (n = 1202), obesity was associated with greater likelihood of ventilation or death (OR = 1.73; 95% CI = [1.25, 2.41]...

Reproductive Health, 2021

Background South Africa faces a high burden of unmet contraceptive need, particularly among adole... more Background South Africa faces a high burden of unmet contraceptive need, particularly among adolescent girls and young women. Providing contraception in community-based venues may overcome barriers to contraceptive access. Our objective was to explore the potential impact of the social environment and stylist–client interactions on perceived accessibility of contraceptives within hair salons. Methods We conducted 42 semi-structured, in-depth interviews with salon clients (100% identified as female, 100% identified as Black, median age 27.1 years) and 6 focus groups with 43 stylists (95% identified as female, 98% identified as Black, median age 29.6 years) in and around Umlazi Township, Durban, KwaZulu-Natal to explore perspectives on offering contraceptive services in hair salons. We used an inductive and deductive approach to generate the codebook, identified themes in the data, and then organized findings according to Rogers’ Individual Adoption Model as applied to community-based...

PLOS ONE, 2020

Background Predicting long-term care trajectories at the time of HIV diagnosis may allow targeted... more Background Predicting long-term care trajectories at the time of HIV diagnosis may allow targeted interventions. Our objective was to uncover distinct CD4-based trajectories and determine baseline demographic, clinical, and contextual factors associated with trajectory membership. Methods We used data from the Sizanani trial (NCT01188941), in which adults were enrolled prior to HIV testing in Durban, South Africa from August 2010-January 2013. We ascertained CD4 counts from the National Health Laboratory Service over 5y follow-up. We used groupbased statistical modeling to identify groups with similar CD4 count trajectories and Bayesian information criteria to determine distinct CD4 trajectories. We evaluated baseline factors that predict membership in specific trajectories using multinomial logistic regression. We examined calendar year of participant enrollment, age, gender, cohabitation, TB positivity, self-identified barriers to care, and ART initiation within 3 months of diagnosis. Results 688 participants had longitudinal data available. Group-based trajectory modeling identified four distinct trajectories: one with consistently low CD4 counts (21%), one with low CD4 counts that increased over time (22%), one with moderate CD4 counts that remained stable (41%), and one with high CD4 counts that increased over time (16%). Those with higher CD4 counts at diagnosis were younger, less likely to have TB, and less likely to identify

AIDS and Behavior, 2021

Assisted partner notification (APN) is recommended by the World Health Organization to notify sex... more Assisted partner notification (APN) is recommended by the World Health Organization to notify sexual partners of HIV exposure. Since 2018, APN has been offered in Uganda to Ugandan nationals and refugees. Distinct challenges faced by individuals in refugee settlements may influence APN utilization and effectiveness. To explore APN barriers and facilitators, we extracted index client and sexual partner data from APN registers at 11 health centers providing care to refugees and Ugandan nationals in West Nile Uganda and conducted qualitative interviews with health workers (N = 32). Since APN started, 882 index clients participated in APN identifying 1126 sexual partners. Following notification, 95% (1025/1126) of partners tested for HIV; 22% (230/1025) were diagnosed with HIV with 14% (139/1025) of tested partners newly diagnosed. Fear of stigma and disclosure-related violence limit APN utilization and effectiveness. Prospective research involving index clients and sexual partners is n...

Open Forum Infectious Diseases, 2020

Background In the United States, diabetes mellitus (DM) is among the most common chronic diseases... more Background In the United States, diabetes mellitus (DM) is among the most common chronic diseases, with approximately 34.2 million people affected. DM has also emerged as a commonly reported risk factor among people hospitalized with coronavirus disease 2019 (COVID-19). In this study, we sought to evaluate whether people with DM who are hospitalized with COVID-19 were more likely to experience poor early outcomes and whether this association remained after adjustment for obesity status. Methods We analyzed data from the Massachusetts General Hospital (MGH) COVID-19 Data Registry. The sample included 450 people with PCR-confirmed SARS-CoV-2 infection who were hospitalized at MGH between March 11, 2020 and April 30, 2020. The primary outcomes were (1) admission to the intensive care unit (ICU) and (2) need for mechanical ventilation or death, both within 14 days of presentation to care. Data were obtained by manual chart review and via an EMR-associated database. Logistic regression w...

AIDS Care, 2020

Changes in an individual's contextual factors following HIV diagnosis may influence long-term out... more Changes in an individual's contextual factors following HIV diagnosis may influence long-term outcomes. We evaluated how changes to contextual factors between HIV diagnosis and 9-month follow-up predict 5-year mortality among HIV-infected individuals in Durban, South Africa enrolled in the Sizanani Trial (NCT01188941). We used random survival forests to identify 9-month variables and changes from baseline predictive of time to mortality. We incorporated these into a Cox proportional hazards model including age, sex, and starting ART by 9 months a priori, 9-month social support and competing needs, and changes in mental health between

Objective: To evaluate differences by race/ethnicity in clinical characteristics and outcomes amo... more Objective: To evaluate differences by race/ethnicity in clinical characteristics and outcomes among hospitalized patients with Covid-19 at Massachusetts General Hospital (MGH). Methods: The MGH Covid-19 Registry includes confirmed SARS-CoV-2-infected patients hospitalized at MGH and is based on manual chart reviews and data extraction from electronic health records (EHRs). We evaluated differences between White/Non-Hispanic and Hispanic patients in demographics, complications and 14-day outcomes among the N=866 patients hospitalized with Covid-19 from March 11, 2020 - May 4, 2020. Results: Overall, 43% of patients hospitalized with Covid-19 were women, median age was 60.4 [IQR = (48.2, 75)], 11.3% were Black/non-Hispanic and 35.2% were Hispanic. Hispanic patients, representing 35.2% of patients, were younger than White/non-Hispanic patients [median age 51y; IQR = (40.6, 61.6) versus 72y; (58.0, 81.7) (p<0.001)]. Hispanic patients were symptomatic longer before presenting to care ...

BMC Cancer, 2020

Background Kaposi’s sarcoma (KS) is one of the most common HIV-associated malignancies in sub-Sah... more Background Kaposi’s sarcoma (KS) is one of the most common HIV-associated malignancies in sub-Saharan Africa. Worldwide, the availability of antiretroviral therapy (ART) has improved KS survival. In resource-rich settings, survival has also benefited from chemotherapy, which is widely available. Little is known, however, about the epidemiology of chemotherapy use for HIV-associated KS in resource-limited regions such as sub-Saharan Africa. Methods We identified all patients newly diagnosed with HIV-related KS from 2009 to 2012 in the 26-clinic AMPATH network, a large community-based care network in Kenya. We ascertained disease severity at diagnosis, frequency of initiation of chemotherapy, and distribution of chemotherapeutic regimens used. Indications for chemotherapy included AIDS Clinical Trial Group T1 stage and/or “severe” disease defined by WHO KS treatment guidelines. Results Of 674 patients diagnosed with KS, charts were available for 588; 61% were men, median age was 35 ye...

BackgroundIn the treat-all era of HIV, Kaposi’s sarcoma (KS) remains one of the most incident can... more BackgroundIn the treat-all era of HIV, Kaposi’s sarcoma (KS) remains one of the most incident cancers in sub-Saharan Africa. The majority of patients with KS are diagnosed at advanced disease stage in this setting. Staging systems for KS, specifically the AIDS Clinical Trials Group (ACTG) system, were developed in the pre-ART era, were not meant to guide treatment, and may not fully capture the clinical heterogeneity of advanced disease. There is no international consensus on which KS patients need chemotherapy in addition to antiretroviral therapy (ART). Understanding KS severity of disease in the current era would help to inform prognosis and clarify treatment guidelines.MethodsWe performed rapid case ascertainment (RCA) on people living with HIV ≥18 years old newly diagnosed with biopsy-proven KS from 2016 to 2019 at three clinic sites in Kenya and Uganda. As close as possible to time of diagnosis, we performed a structured interview, physical examination, and collection of labor...

BMC Infectious Diseases, 2019

Background: Little is known about contextual factors that predict long-term mortality following H... more Background: Little is known about contextual factors that predict long-term mortality following HIV testing in resource-limited settings. We evaluated the impact of contextual factors on 5-year mortality among HIV-infected and HIV-uninfected individuals in Durban, South Africa. Methods: We used data from the Sizanani trial (NCT01188941) in which adults (≥18y) were enrolled prior to HIV testing at 4 outpatient sites. We ascertained vital status via the South African National Population Register. We used random survival forests to identify the most influential predictors of time to death and incorporated these into a Cox model that included age, gender, HIV status, CD4 count, healthcare usage, health facility type, mental health, and self-identified barriers to care (i.e., service delivery, financial, logistical, structural and perceived health). Results: Among 4816 participants, 39% were HIV-infected. Median age was 31y and 49% were female. 380 of 2508 with survival information (15%) died during median follow-up of 5.8y. For both HIV-infected and HIV-uninfected participants, each additional barrier domain increased the HR of dying by 11% (HR 1.11, 95% CI 1.05-1.18). Every 10point increase in mental health score decreased the HR by 7% (HR 0.93, 95% CI 0.89-0.97). The hazard ratio (HR) for death of HIV-infected versus HIV-uninfected varied by age: HR of 6.59 (95% CI: 4.79-9.06) at age 20 dropping to a HR of 1.13 (95% CI: 0.86-1.48) at age 60. Conclusions: Independent of serostatus, more self-identified barrier domains and poorer mental health increased mortality risk. Additionally, the impact of HIV on mortality was most pronounced in younger persons. These factors may be used to identify high-risk individuals requiring intensive follow up, regardless of serostatus.

Journal of Community Health, 2019

Women experience challenges engaging with the healthcare system, but frequently utilize hair salo... more Women experience challenges engaging with the healthcare system, but frequently utilize hair salons; these are promising venues for family planning and HIV prevention services. Our objective was to assess the acceptability of nurse-offered contraceptive and PrEP services at hair salons in Durban, South Africa. We interviewed salon owners (N = 10) and clients (N = 42) and conducted focus groups with hair stylists (N = 43 stylists; 6 focus groups across five hair salons) to explore barriers and facilitators to providing contraception and PrEP in salons. After developing a codebook, we performed content analysis to identify themes within each conceptual area; 10% of transcripts were coded by two coders to ensure reliability. Content was analyzed according to the following categories: (1) facilitators of and (2) barriers to utilizing these services, and (3) factors to consider for program implementation. Participants identified convenience and female-oriented, supportive atmosphere as facilitators to offering HIV and contraceptive services in salons. Owners and stylists noted that establishing legitimacy was important for program success, including providing promotional pamphlets and employing nurses. Clients cited privacy concerns surrounding HIV testing in a public space as a significant barrier to using these services. Overall, participants were enthusiastic about the program. Convenience and a conducive environment were noted as facilitators to receiving health services in the hair salon; attention will have to be directed to establishing privacy and program legitimacy. Hair salons represent an innovative venue for reaching young women at high-risk for unintended pregnancy and HIV infection.

PLOS ONE, 2019

Background Guidelines recommend integrating hypertension screening for HIV-infected adults, but b... more Background Guidelines recommend integrating hypertension screening for HIV-infected adults, but blood pressure measurements may be dynamic around the time of HIV testing. Methods We measured a seated resting blood pressure in adults (�18 years) prior to HIV testing, and again after receiving HIV test results, in an ambulatory HIV clinic in KwaZulu-Natal, South Africa. We assessed sociodemographics, smoking, body mass index, diabetes, substance abuse, and anxiety/depression. We used blood pressure categories defined by the Seventh Joint National Committee (JNC 7) classifications, which includes normal, pre-hypertension, stage 1 hypertension, and stage 2 hypertension. Results Among 5,428 adults, mean age was 31 years, 51% were male, and 35% tested HIV-positive. Before HIV testing, 47% (2,634) had a normal blood pressure, 40% (2,225) had prehypertension, and 10% (569) had stage 1 or 2 hypertension. HIV-infected adults had significantly lower blood pressure measurements and less hypertension, as compared to HIVnegative adults before HIV testing; while also having significantly elevated blood pressures after HIV testing. In a multivariable model, HIV-infected adults had a 30% lower odds of hypertension, compared to HIV-uninfected adults (aOR = 0.70, 95% CI: 0.57-0.85). In a separate multivariable model, HIV-infected adults with CD4 �200 cells/mm 3 had a 44% lower odds of hypertension (aOR = 0.56, 95% CI: 0.38-0.83), as compared to adults with CD4 >200 cells/mm 3. The mean arterial blood pressure was 6.5 mmHg higher among HIVinfected adults after HIV testing (p <0.001).

BMC Infectious Diseases, 2019

Background: Community-based GeneXpert MTB/RIF testing may increase detection of prevalent TB in t... more Background: Community-based GeneXpert MTB/RIF testing may increase detection of prevalent TB in the community and improve rates of TB treatment completion. Methods: We conducted a pilot randomized trial to evaluate the impact of GeneXpert screening on a mobile HIV testing unit. Adults (≥18y) underwent rapid HIV testing and TB symptom screening and were randomized to usual mobile unit care (providing sputum on the mobile unit sent out for GeneXpert testing) or the "Test & Treat TB" intervention with immediate GeneXpert testing. Symptomatic participants in usual care produced sputum that was sent for hospital-based GeneXpert testing; participants were contacted~7 days later with results. In the "Test & Treat TB" intervention, HIV-infected or HIV-uninfected/TB symptomatic participants underwent GeneXpert testing on the mobile unit. GeneXpert+ participants received expedited TB treatment initiation, monthly SMS reminders and non-cash incentives. We assessed 6-month TB treatment outcomes. Results: 4815 were eligible and enrolled; median age was 27 years (IQR 22 to 35). TB symptoms included cough (5%), weight loss (4%), night sweats (4%), and fever (3%). 42% of eligible participants produced sputum (intervention: 56%; usual care: 26%). Seven participants tested GeneXpert+, six in the intervention (3%, 95% CI 1%, 5%) and one in usual care (1%, 95% CI 0%, 6%). 5 of 6 intervention participants completed TB treatment; the GeneXpert+ participant in usual care did not. Conclusion: GeneXpert MTB/RIF screening on a mobile HIV testing unit is feasible. Yield for GeneXpert+ TB was low, however, the "Test & Treat TB" strategy led to high rates of TB treatment completion. Trial registration: This study was registered on November 21, 2014 at ClinicalTrials.gov (NCT02298309).

The Journal of Clinical Endocrinology & Metabolism

Open Forum Infectious Diseases, 2021

Background Obesity has been linked to severe clinical outcomes among people who are hospitalized ... more Background Obesity has been linked to severe clinical outcomes among people who are hospitalized with coronavirus disease 2019 (COVID-19). We tested the hypothesis that visceral adipose tissue (VAT) is associated with severe outcomes in patients hospitalized with COVID-19, independent of body mass index (BMI). Methods We analyzed data from the Massachusetts General Hospital COVID-19 Data Registry, which included patients admitted with polymerase chain reaction–confirmed severe acute respiratory syndrome coronavirus 2 infection from March 11 to May 4, 2020. We used a validated, fully automated artificial intelligence (AI) algorithm to quantify VAT from computed tomography (CT) scans during or before the hospital admission. VAT quantification took an average of 2 ± 0.5 seconds per patient. We dichotomized VAT as high and low at a threshold of ≥100 cm2 and used Kaplan-Meier curves and Cox proportional hazards regression to assess the relationship between VAT and death or intubation ove...

AIDS Care, 2021

Nearly 80 million people have been forcibly displaced by persecution, violence, and disaster. Dis... more Nearly 80 million people have been forcibly displaced by persecution, violence, and disaster. Displaced populations, including refugees, face health challenges such as resource shortages, food and housing insecurity, violence, and disrupted social support. People living with HIV in refugee settings have decreased engagement with HIV services compared to non-refugee populations, and interventions are needed to enhance linkage to care. However, designing health interventions in humanitarian settings is challenging. We used Intervention Mapping (IM), a six-step method for developing theory-and evidence-based health interventions, to design a program to increase linkage to HIV care for refugees and Ugandan nationals in Nakivale Refugee Settlement in Uganda. We engaged a diverse group of stakeholders (N = 14) in Nakivale, including community members and humanitarian actors, in an interactive workshop focusing on IM steps 1-4. We developed a chronic care program that would integrate HIV care with services for hypertension and diabetes at accessible community sites, thereby decreasing stigma around HIV treatment and improving access to care. IM provided an inclusive, efficient method for integrating community members and program implementers in the intervention planning process, and can be used as a method-driven approach to intervention design in humanitarian settings.

Statistical analysis and supplementary results tables. Variable selection procedure for random fo... more Statistical analysis and supplementary results tables. Variable selection procedure for random forests. Propensity score adjustment procedure. Imputation of CD4 values. Calculated effect of HIV. Table S1A and 1B â HIV-infected (1A) and HIV-uninfected (1B) comparing those with and without valid SA ID numbers. Table S2A and 2B show the standardized difference between the overall group (HIV-infected or HIV-uninfected) and the group with valid SA ID numbers. (DOCX 74 kb)

Journal of the International AIDS Society, 2022

Introduction: South Africa's government-led Central Chronic Medication Dispensing and Distributio... more Introduction: South Africa's government-led Central Chronic Medication Dispensing and Distribution (CCMDD) program offers people living with HIV the option to collect antiretroviral therapy at their choice of community-or clinic-based pickup points intended to increase convenience and decongest clinics. To understand CCMDD pickup point use among people living with HIV, we evaluated factors associated with uptake of a community-versus clinic-based pickup point at CCMDD enrolment. Methods: We collected baseline data from October 2018 to March 2020 on adults (≥18 years) who met CCMDD clinical eligibility criteria (non-pregnant, on antiretroviral therapy for ≥1 year and virologically suppressed) as part of an observational cohort in seven public clinics in KwaZulu-Natal. We identified factors associated with community-based pickup point uptake and fit a multivariable logistic regression model, including age, gender, employment status, self-perceived barriers to care, selfefficacy, HIV-related discrimination, and perceived benefits and challenges of CCMDD. Results and Discussion: Among 1521 participants, 67% were females, with median age 36 years (IQR 30-44). Uptake of a community-based pickup point was associated with younger age (aOR 1.18 per 10-year decrease, 95% CI 1.05-1.33), being employed ≥40 hours per week (aOR 1.42, 95% CI 1.10-1.83) versus being unemployed, no self-perceived barriers to care (aOR 1.42, 95% CI 1.09-1.86) and scoring between 36 and 39 (aOR 1.44, 95% CI 1.03-2.01) or 40 (aOR 1.91, 95% CI 1.39-2.63) versus 10-35 on the self-efficacy scale, where higher scores indicate greater self-efficacy. Additional factors included more convenient pickup point location (aOR 2.32, 95% CI 1.77-3.04) or hours (aOR 5.09, 95% CI 3.71-6.98) as perceived benefits of CCMDD, and lack of in-clinic follow-up after a missed collection date as a perceived challenge of CCMDD (aOR 4.37, 95% CI 2.30-8.31). Conclusions: Uptake of community-based pickup was associated with younger age, full-time employment, and systemic and structural factors of living with HIV (no self-perceived barriers to care and high self-efficacy), as well as perceptions of CCMDD (convenient pickup point location and hours, lack of in-clinic follow-up). Strategies to facilitate community-based pickup point uptake should be tailored to patients' age, employment, self-perceived barriers to care and self-efficacy to maximize the impact of CCMDD in decongesting clinics.

BMJ Open Respiratory Research, 2021

IntroductionObstructive lung diseases (asthma and chronic obstructive pulmonary disease (COPD)) a... more IntroductionObstructive lung diseases (asthma and chronic obstructive pulmonary disease (COPD)) and smoking are associated with greater risk of respiratory infections and hospitalisations, but conflicting data exist regarding their association with severity of COVID-19, and few studies have evaluated whether these associations differ by age.ObjectivesTo examine the associations between asthma, COPD and smoking on the severity of COVID-19 among a cohort of hospitalised patients, and to test for effect modification by age.MethodsWe performed a retrospective analysis of electronic health record data of patients admitted to Massachusetts General Hospital, assigning the maximal WHO Clinical Progression Scale score for each patient during the first 28 days following hospital admission. Using ordered logistic regression, we measured the association between maximal severity score and asthma, COPD and smoking and their interaction with age.Measurements and main resultsAmong 1391 patients hos...

The Journal of Clinical Endocrinology & Metabolism, 2021

Background Obesity is an established risk factor for severe COVID-19 outcomes. The mechanistic un... more Background Obesity is an established risk factor for severe COVID-19 outcomes. The mechanistic underpinnings of this association are not well-understood. Objective To evaluate the mediating role of systemic inflammation in obesity-associated COVID-19 outcomes. Methods This hospital-based, observational study included 3828 SARS-CoV-2-infected patients who were hospitalized February to May 2020 at Massachusetts General Hospital (MGH) or Columbia University Irving Medical Center/New York Presbyterian Hospital (CUIMC/NYP). We use mediation analysis to evaluate whether peak inflammatory biomarkers (C-reactive protein [CRP], erythrocyte sedimentation rate [ESR], D-dimer, ferritin, white blood cell count and interleukin-6) are in the causal pathway between obesity (BMI ≥ 30) and mechanical ventilation or death within 28 days of presentation to care. Results In the MGH cohort (n = 1202), obesity was associated with greater likelihood of ventilation or death (OR = 1.73; 95% CI = [1.25, 2.41]...

Reproductive Health, 2021

Background South Africa faces a high burden of unmet contraceptive need, particularly among adole... more Background South Africa faces a high burden of unmet contraceptive need, particularly among adolescent girls and young women. Providing contraception in community-based venues may overcome barriers to contraceptive access. Our objective was to explore the potential impact of the social environment and stylist–client interactions on perceived accessibility of contraceptives within hair salons. Methods We conducted 42 semi-structured, in-depth interviews with salon clients (100% identified as female, 100% identified as Black, median age 27.1 years) and 6 focus groups with 43 stylists (95% identified as female, 98% identified as Black, median age 29.6 years) in and around Umlazi Township, Durban, KwaZulu-Natal to explore perspectives on offering contraceptive services in hair salons. We used an inductive and deductive approach to generate the codebook, identified themes in the data, and then organized findings according to Rogers’ Individual Adoption Model as applied to community-based...

PLOS ONE, 2020

Background Predicting long-term care trajectories at the time of HIV diagnosis may allow targeted... more Background Predicting long-term care trajectories at the time of HIV diagnosis may allow targeted interventions. Our objective was to uncover distinct CD4-based trajectories and determine baseline demographic, clinical, and contextual factors associated with trajectory membership. Methods We used data from the Sizanani trial (NCT01188941), in which adults were enrolled prior to HIV testing in Durban, South Africa from August 2010-January 2013. We ascertained CD4 counts from the National Health Laboratory Service over 5y follow-up. We used groupbased statistical modeling to identify groups with similar CD4 count trajectories and Bayesian information criteria to determine distinct CD4 trajectories. We evaluated baseline factors that predict membership in specific trajectories using multinomial logistic regression. We examined calendar year of participant enrollment, age, gender, cohabitation, TB positivity, self-identified barriers to care, and ART initiation within 3 months of diagnosis. Results 688 participants had longitudinal data available. Group-based trajectory modeling identified four distinct trajectories: one with consistently low CD4 counts (21%), one with low CD4 counts that increased over time (22%), one with moderate CD4 counts that remained stable (41%), and one with high CD4 counts that increased over time (16%). Those with higher CD4 counts at diagnosis were younger, less likely to have TB, and less likely to identify

AIDS and Behavior, 2021

Assisted partner notification (APN) is recommended by the World Health Organization to notify sex... more Assisted partner notification (APN) is recommended by the World Health Organization to notify sexual partners of HIV exposure. Since 2018, APN has been offered in Uganda to Ugandan nationals and refugees. Distinct challenges faced by individuals in refugee settlements may influence APN utilization and effectiveness. To explore APN barriers and facilitators, we extracted index client and sexual partner data from APN registers at 11 health centers providing care to refugees and Ugandan nationals in West Nile Uganda and conducted qualitative interviews with health workers (N = 32). Since APN started, 882 index clients participated in APN identifying 1126 sexual partners. Following notification, 95% (1025/1126) of partners tested for HIV; 22% (230/1025) were diagnosed with HIV with 14% (139/1025) of tested partners newly diagnosed. Fear of stigma and disclosure-related violence limit APN utilization and effectiveness. Prospective research involving index clients and sexual partners is n...

Open Forum Infectious Diseases, 2020

Background In the United States, diabetes mellitus (DM) is among the most common chronic diseases... more Background In the United States, diabetes mellitus (DM) is among the most common chronic diseases, with approximately 34.2 million people affected. DM has also emerged as a commonly reported risk factor among people hospitalized with coronavirus disease 2019 (COVID-19). In this study, we sought to evaluate whether people with DM who are hospitalized with COVID-19 were more likely to experience poor early outcomes and whether this association remained after adjustment for obesity status. Methods We analyzed data from the Massachusetts General Hospital (MGH) COVID-19 Data Registry. The sample included 450 people with PCR-confirmed SARS-CoV-2 infection who were hospitalized at MGH between March 11, 2020 and April 30, 2020. The primary outcomes were (1) admission to the intensive care unit (ICU) and (2) need for mechanical ventilation or death, both within 14 days of presentation to care. Data were obtained by manual chart review and via an EMR-associated database. Logistic regression w...

AIDS Care, 2020

Changes in an individual's contextual factors following HIV diagnosis may influence long-term out... more Changes in an individual's contextual factors following HIV diagnosis may influence long-term outcomes. We evaluated how changes to contextual factors between HIV diagnosis and 9-month follow-up predict 5-year mortality among HIV-infected individuals in Durban, South Africa enrolled in the Sizanani Trial (NCT01188941). We used random survival forests to identify 9-month variables and changes from baseline predictive of time to mortality. We incorporated these into a Cox proportional hazards model including age, sex, and starting ART by 9 months a priori, 9-month social support and competing needs, and changes in mental health between

Objective: To evaluate differences by race/ethnicity in clinical characteristics and outcomes amo... more Objective: To evaluate differences by race/ethnicity in clinical characteristics and outcomes among hospitalized patients with Covid-19 at Massachusetts General Hospital (MGH). Methods: The MGH Covid-19 Registry includes confirmed SARS-CoV-2-infected patients hospitalized at MGH and is based on manual chart reviews and data extraction from electronic health records (EHRs). We evaluated differences between White/Non-Hispanic and Hispanic patients in demographics, complications and 14-day outcomes among the N=866 patients hospitalized with Covid-19 from March 11, 2020 - May 4, 2020. Results: Overall, 43% of patients hospitalized with Covid-19 were women, median age was 60.4 [IQR = (48.2, 75)], 11.3% were Black/non-Hispanic and 35.2% were Hispanic. Hispanic patients, representing 35.2% of patients, were younger than White/non-Hispanic patients [median age 51y; IQR = (40.6, 61.6) versus 72y; (58.0, 81.7) (p<0.001)]. Hispanic patients were symptomatic longer before presenting to care ...

BMC Cancer, 2020

Background Kaposi’s sarcoma (KS) is one of the most common HIV-associated malignancies in sub-Sah... more Background Kaposi’s sarcoma (KS) is one of the most common HIV-associated malignancies in sub-Saharan Africa. Worldwide, the availability of antiretroviral therapy (ART) has improved KS survival. In resource-rich settings, survival has also benefited from chemotherapy, which is widely available. Little is known, however, about the epidemiology of chemotherapy use for HIV-associated KS in resource-limited regions such as sub-Saharan Africa. Methods We identified all patients newly diagnosed with HIV-related KS from 2009 to 2012 in the 26-clinic AMPATH network, a large community-based care network in Kenya. We ascertained disease severity at diagnosis, frequency of initiation of chemotherapy, and distribution of chemotherapeutic regimens used. Indications for chemotherapy included AIDS Clinical Trial Group T1 stage and/or “severe” disease defined by WHO KS treatment guidelines. Results Of 674 patients diagnosed with KS, charts were available for 588; 61% were men, median age was 35 ye...

BackgroundIn the treat-all era of HIV, Kaposi’s sarcoma (KS) remains one of the most incident can... more BackgroundIn the treat-all era of HIV, Kaposi’s sarcoma (KS) remains one of the most incident cancers in sub-Saharan Africa. The majority of patients with KS are diagnosed at advanced disease stage in this setting. Staging systems for KS, specifically the AIDS Clinical Trials Group (ACTG) system, were developed in the pre-ART era, were not meant to guide treatment, and may not fully capture the clinical heterogeneity of advanced disease. There is no international consensus on which KS patients need chemotherapy in addition to antiretroviral therapy (ART). Understanding KS severity of disease in the current era would help to inform prognosis and clarify treatment guidelines.MethodsWe performed rapid case ascertainment (RCA) on people living with HIV ≥18 years old newly diagnosed with biopsy-proven KS from 2016 to 2019 at three clinic sites in Kenya and Uganda. As close as possible to time of diagnosis, we performed a structured interview, physical examination, and collection of labor...

BMC Infectious Diseases, 2019

Background: Little is known about contextual factors that predict long-term mortality following H... more Background: Little is known about contextual factors that predict long-term mortality following HIV testing in resource-limited settings. We evaluated the impact of contextual factors on 5-year mortality among HIV-infected and HIV-uninfected individuals in Durban, South Africa. Methods: We used data from the Sizanani trial (NCT01188941) in which adults (≥18y) were enrolled prior to HIV testing at 4 outpatient sites. We ascertained vital status via the South African National Population Register. We used random survival forests to identify the most influential predictors of time to death and incorporated these into a Cox model that included age, gender, HIV status, CD4 count, healthcare usage, health facility type, mental health, and self-identified barriers to care (i.e., service delivery, financial, logistical, structural and perceived health). Results: Among 4816 participants, 39% were HIV-infected. Median age was 31y and 49% were female. 380 of 2508 with survival information (15%) died during median follow-up of 5.8y. For both HIV-infected and HIV-uninfected participants, each additional barrier domain increased the HR of dying by 11% (HR 1.11, 95% CI 1.05-1.18). Every 10point increase in mental health score decreased the HR by 7% (HR 0.93, 95% CI 0.89-0.97). The hazard ratio (HR) for death of HIV-infected versus HIV-uninfected varied by age: HR of 6.59 (95% CI: 4.79-9.06) at age 20 dropping to a HR of 1.13 (95% CI: 0.86-1.48) at age 60. Conclusions: Independent of serostatus, more self-identified barrier domains and poorer mental health increased mortality risk. Additionally, the impact of HIV on mortality was most pronounced in younger persons. These factors may be used to identify high-risk individuals requiring intensive follow up, regardless of serostatus.

Journal of Community Health, 2019

Women experience challenges engaging with the healthcare system, but frequently utilize hair salo... more Women experience challenges engaging with the healthcare system, but frequently utilize hair salons; these are promising venues for family planning and HIV prevention services. Our objective was to assess the acceptability of nurse-offered contraceptive and PrEP services at hair salons in Durban, South Africa. We interviewed salon owners (N = 10) and clients (N = 42) and conducted focus groups with hair stylists (N = 43 stylists; 6 focus groups across five hair salons) to explore barriers and facilitators to providing contraception and PrEP in salons. After developing a codebook, we performed content analysis to identify themes within each conceptual area; 10% of transcripts were coded by two coders to ensure reliability. Content was analyzed according to the following categories: (1) facilitators of and (2) barriers to utilizing these services, and (3) factors to consider for program implementation. Participants identified convenience and female-oriented, supportive atmosphere as facilitators to offering HIV and contraceptive services in salons. Owners and stylists noted that establishing legitimacy was important for program success, including providing promotional pamphlets and employing nurses. Clients cited privacy concerns surrounding HIV testing in a public space as a significant barrier to using these services. Overall, participants were enthusiastic about the program. Convenience and a conducive environment were noted as facilitators to receiving health services in the hair salon; attention will have to be directed to establishing privacy and program legitimacy. Hair salons represent an innovative venue for reaching young women at high-risk for unintended pregnancy and HIV infection.

PLOS ONE, 2019

Background Guidelines recommend integrating hypertension screening for HIV-infected adults, but b... more Background Guidelines recommend integrating hypertension screening for HIV-infected adults, but blood pressure measurements may be dynamic around the time of HIV testing. Methods We measured a seated resting blood pressure in adults (�18 years) prior to HIV testing, and again after receiving HIV test results, in an ambulatory HIV clinic in KwaZulu-Natal, South Africa. We assessed sociodemographics, smoking, body mass index, diabetes, substance abuse, and anxiety/depression. We used blood pressure categories defined by the Seventh Joint National Committee (JNC 7) classifications, which includes normal, pre-hypertension, stage 1 hypertension, and stage 2 hypertension. Results Among 5,428 adults, mean age was 31 years, 51% were male, and 35% tested HIV-positive. Before HIV testing, 47% (2,634) had a normal blood pressure, 40% (2,225) had prehypertension, and 10% (569) had stage 1 or 2 hypertension. HIV-infected adults had significantly lower blood pressure measurements and less hypertension, as compared to HIVnegative adults before HIV testing; while also having significantly elevated blood pressures after HIV testing. In a multivariable model, HIV-infected adults had a 30% lower odds of hypertension, compared to HIV-uninfected adults (aOR = 0.70, 95% CI: 0.57-0.85). In a separate multivariable model, HIV-infected adults with CD4 �200 cells/mm 3 had a 44% lower odds of hypertension (aOR = 0.56, 95% CI: 0.38-0.83), as compared to adults with CD4 >200 cells/mm 3. The mean arterial blood pressure was 6.5 mmHg higher among HIVinfected adults after HIV testing (p <0.001).

BMC Infectious Diseases, 2019

Background: Community-based GeneXpert MTB/RIF testing may increase detection of prevalent TB in t... more Background: Community-based GeneXpert MTB/RIF testing may increase detection of prevalent TB in the community and improve rates of TB treatment completion. Methods: We conducted a pilot randomized trial to evaluate the impact of GeneXpert screening on a mobile HIV testing unit. Adults (≥18y) underwent rapid HIV testing and TB symptom screening and were randomized to usual mobile unit care (providing sputum on the mobile unit sent out for GeneXpert testing) or the "Test & Treat TB" intervention with immediate GeneXpert testing. Symptomatic participants in usual care produced sputum that was sent for hospital-based GeneXpert testing; participants were contacted~7 days later with results. In the "Test & Treat TB" intervention, HIV-infected or HIV-uninfected/TB symptomatic participants underwent GeneXpert testing on the mobile unit. GeneXpert+ participants received expedited TB treatment initiation, monthly SMS reminders and non-cash incentives. We assessed 6-month TB treatment outcomes. Results: 4815 were eligible and enrolled; median age was 27 years (IQR 22 to 35). TB symptoms included cough (5%), weight loss (4%), night sweats (4%), and fever (3%). 42% of eligible participants produced sputum (intervention: 56%; usual care: 26%). Seven participants tested GeneXpert+, six in the intervention (3%, 95% CI 1%, 5%) and one in usual care (1%, 95% CI 0%, 6%). 5 of 6 intervention participants completed TB treatment; the GeneXpert+ participant in usual care did not. Conclusion: GeneXpert MTB/RIF screening on a mobile HIV testing unit is feasible. Yield for GeneXpert+ TB was low, however, the "Test & Treat TB" strategy led to high rates of TB treatment completion. Trial registration: This study was registered on November 21, 2014 at ClinicalTrials.gov (NCT02298309).