School start time delays and high school educational outcomes: Evidence from the START/LEARN study

INTRODUCTION

Delaying high school start times extends adolescents' nightly sleep, but it is less clear how it affects educational outcomes. We expect links between school start time delays and academic performance because getting enough sleep is a key input to the cognitive, health, and behavioral factors necessary for educational success. Thus, we evaluated how educational outcomes changed in the 2 years following a school start time delay.

METHODS

We analyzed 2153 adolescents (51% male, 49% female; mean age 15 at baseline) from START/LEARN, a cohort study of high school students in the Minneapolis-St. Paul, MN, USA metropolitan area. Adolescents experienced either a school start time delay ("policy change schools") or consistently early school start times ("comparison schools"). We compared patterns of late arrivals, absences, behavior referrals, and grade point average (GPA) 1 year before (baseline, 2015-2016) and 2 years after (follow-up 1, 2016-2017 and follow-up 2, 2017-2018) the policy change using a difference-in-differences analysis.

RESULTS

A school start time delay of 50-65 min led to three fewer late arrivals, one fewer absence, a 14% lower probability of behavior referral, and 0.07-0.17 higher GPA in policy change schools versus comparison schools. Effects were larger in the 2nd year of follow-up than in the 1st year of follow-up, and differences in absences and GPA emerged in the second year of follow-up only.

CONCLUSIONS

Delaying high school start times is a promising policy intervention not only for improving sleep and health but for improving adolescents' performance in school.

Impact of delaying high school start times on weight and related behaviors - the START study

In the US, few adolescents get adequate school night sleep, largely due to early school start times. In the START study we aimed to test the following hypothesis: That following the implementation of later high school start times students have lesser longitudinal increases in body mass index (BMI) and shift to more healthful weight-related behaviors relative to students attending schools that retain early start times. The study enrolled a cohort of students (n = 2426) in five high schools in the Twin Cities, MN metro. Heights and weights were measured objectively, and surveys were administered annually from 9th through 11th grades (2016-2018). All study schools started early (either 7:30 am or 7:45 am) at baseline (2016). At follow-up 1 (2017) and continuing through follow-up 2 (2018), two schools delayed their start times by 50-65 min, while three comparison schools started at 7:30 am throughout the observation period. Using a difference-in-differences natural experiment design, we estimated differences in changes in BMI and weight-related behaviors over time between policy change and comparison schools. Students' BMIs increased in parallel in both policy change and comparison schools over time. However relative to changes in comparison schools after the start time shift, students in policy change schools had a modestly more healthful profile of weight-related behaviors - for instance they had a relatively greater probability of eating breakfast, having supper with their family, getting more activity, eating fast food less frequently, and eating vegetables daily. Later start times could be a durable, population-wide strategy that promotes healthful weight behaviors.

Validity of university students' self-reported vaccination status after a meningococcal B outbreak

After an outbreak of meningococcal B (MenB) disease at a university, we surveyed students regarding their vaccination status 2 months and 20 months after campus-led vaccination campaigns and compared students' self-report to vaccination records. Nearly all participants accurately reported the number of vaccine doses at both visits. Among those who received two doses of the vaccine, accurate recall of the timing of MenB vaccination was 85.7% (95% CI: 82.7-88.6) in the short term and 62.9% (95% CI: 56.0-69.8) in the long term. After the outbreak, only one-third reported feeling 'very confident' in their MenB disease and vaccine knowledge. Our findings suggest that the validity of self-reported vaccination status among university students in an outbreak setting is high, but that if the duration of protection is unknown and additional doses of vaccine may be needed, documented vaccination records may be preferred over self-report to assess timing of vaccine receipt.

HiSTEP: A Single-Arm Pilot Study of a Technology-Assisted HIV Self-testing Intervention in Kampala, Uganda

We developed and pilot tested a 3-month HIV self-testing intervention called HiSTEP ("HIV Self-testing Engagement Project") among 95 adult (18+ years) at-risk (condomless sex < 3 months) adults in Kampala, Uganda. HiSTEP leverages theoretically-grounded (in the Information-Motivation-Behavioral Skills model) text messages, a telehealth centre with live support, and "last-mile" HIV self-testing kit delivery to a location chosen by the participant. Nearly 94% of participants were retained at month 3. HIV self-testing was highly acceptable across age and gender groups (94% very satisfied), although older women had slightly lower acceptability ratings (92% very satisfied). Only 13% of participants used HIV self-testing prior to enrollment. Over the 3-month study period, 86% of participants ordered a total of 169 HIV self-testing kits (69% for participant use; 31% for use by others). Findings show that the intervention approach taken in HiSTEP may be particularly valuable for engaging at-risk Ugandan adults in HIV self-testing using a novel technology-assisted promotion and delivery method.

Characterizing substance use typologies and their association with HIV viral load outcomes: A latent class analysis among sexual minority men living with HIV

BACKGROUND

Racially diverse sexual minority men (SMM) are disproportionately impacted by the U.S. HIV epidemic. Substance use, particularly stimulant use, may impact viral suppression for SMM living with HIV. The current study sought to characterize patterns of substance use via latent class analysis (LCA) and test associations between those patterns and future viral load outcomes, among SMM living with HIV.

METHODS

Data were drawn from Thrive With Me (TWM), an RCT of an mHealth intervention targeting ART adherence among SMM living with HIV. LCA was performed with six dichotomous indicators of substance use, derived from validated measures and urinalysis results, to determine substance use classes at baseline. Bivariate and multivariable logistic regression models tested associations between baseline substance use classes and HIV viral load 5-months post-baseline.

RESULTS

Among 383 SMM living with HIV, we identified a three-class model of substance use fit best: low probability substance use (81.3 %), high probability hazardous alcohol, marijuana, and cocaine use (7.5 %), and high probability methamphetamine and amphetamine use (11.2 %). Additionally, the high probability amphetamine use class was less likely to be virally suppressed at 5-month follow-up compared to the low probability substance use class [Adjusted Odds Ratio = 3.34, 95 % Confidence Interval = 1.39-7.99, p = .0069].

CONCLUSION

We identified that some patterns of substance use (i.e., methamphetamine and amphetamine use), but possibly not others (e.g., alcohol, marijuana, and cocaine use), are potentially important intervention targets for improving HIV-related outcomes among racially diverse SMM living with HIV.

The Feasibility, Acceptability and Preliminary Impact of Mobile Application to Increase Repeat HIV Testing Among Sexual Minority Men

We pilot tested the Status Update Project (SUP) mobile app intervention to promote repeat HIV testing among HIV-negative US MSM. Participants (Mean age = 29 years; 51% racial/ethnic minority; 63% single) who were eligible and enrolled were randomized to either the SUP mobile app or a no-treatment condition, with assessments at baseline and month 4 and 8. Eighty-three percent of men were retained at the 8-month follow up. Among men randomized to the SUP arm, the app's ease and simplicity, health information, HIV testing locator, and HIV test reminders were most liked. At month 4, men randomized to the SUP arm were more likely to be repeat testers compared to those in the control arm (RR = 4.4; 95% CI 0.9, 19.9), although differences diminished by month 8 (RR = 1.2; 95% CI 0.8, 2.0). These findings add to our understanding of how mHealth interventions may play an important role in encouraging repeat HIV testing among MSM.

Defining Sexual Risk in the Era of Biomedical HIV Prevention: Implications for HIV Research and Practice

Advancing HIV behavioral science and its integration with recent biomedical prevention strategies-treatment as prevention and pre-exposure prophylaxis (PrEP)-is complicated because traditional definitions of sexual risk (condomless anal sex [CAS] or CAS with a serodiscordant partner) may not suffice given the success of biomedical prevention in the absence of condoms. To better understand how to define and understand risk in the era of biomedical HIV prevention, we assessed correlates of four different definitions of high-risk sexual behavior among a sample of 401 adult HIV-positive MSM (57% African American) residing in the New York City area: (1) a traditional model of risk defined as CAS with an HIV-negative or unknown serostatus partner; (2) a definition that considered participant viral load (VL); (3) a definition that considered partner PrEP use; and (4) a definition that considered participant HIV VL and partner PrEP use. Among participants reporting anal sex (n = 281) with a man in the past 3 months, 42% were considered high risk under Definition 1, 6% under Definition 2, 25% under Definition 3, and 2% under Definition 4. Correlates of risk varied across definitions. For example, while education was the strongest predictor of high-risk sexual behavior in Definitions 1 and 2, alcohol use and enacted stigma were the strongest predictors in the model that only accounted for partner PrEP use (Definition 3). These findings have implications for whom to reach for intervention efforts, the difficulty in meeting recruitment goals, and the types of interventions that should be used.

A Pilot Study of a Mobile App to Support HIV Antiretroviral Therapy Adherence Among Men Who Have Sex with Men Who Use Stimulants

APP+ is a theoretically-grounded mobile app intervention to improve antiretroviral (ART) adherence among men who have sex with men (MSM) who use stimulants. We assessed the feasibility and acceptability of APP+ in a six-month randomized controlled trial among a national sample of 90 MSM recruited online; secondarily, we examined changes in self-reported ART adherence by study arm. Retention at the final assessment was 82%, and acceptability ratings were comparable to other technology-based interventions. MSM in the APP+ group reported higher self-reported percentage ART adherence in the past 30 days at the four-month timepoint compared to a no-treatment control group (89.0% vs. 77.2%). However, once access to the app was removed after month four, group differences in ART adherence diminished by month six. APP+ may be a potentially promising intervention approach for MSM living with HIV who use stimulants but would require enhancements to optimize acceptability and demonstrate more sustained effects.

Optimizing enrollment methods: Lessons learned from an mHealth, pilot HIV prevention randomized controlled trial with sexual minority men

Using data from eligible participants, we evaluated procedures of a multi-step enrollment process for an mHealth, pilot randomized controlled trial aimed to promote regular HIV testing among at-risk, diverse sexual minority men. Completion rates of eligible participants were calculated and characterized for these enrollment procedures. Among 3058 men who screened, 183 were eligible and 113 enrolled. Two groups emerged: "As planned" (n = 98) followed enrollment directions as designed; "Laggers" (n = 15) did not follow these directions and required additional efforts resulting in mixed results for improving enrollment. Findings suggest the need for pre-determined enrollment decision rules based on available resources.

Higher retention and viral suppression with adolescent-focused HIV clinic in South Africa

Objective

To determine retention in care and virologic suppression among HIV-infected adolescents and young adults attending an adolescent-friendly clinic compared to those attending the standard pediatric clinic at the same site.

Design

Retrospective cohort analysis.

Setting

Government supported, hospital-based antiretroviral clinic in KwaZulu-Natal, South Africa.

Participants

Two hundred forty-one perinatally HIV-infected adolescents and young adults aged 13 to 24 years attending an adolescent-friendly clinic or the standard pediatric clinic from April 2007 to November 2015.

Intervention

Attendance in an adolescent-friendly clinic compared to a standard pediatric clinic.

Outcomes measures

Retention in care defined as one clinic visit or pharmacy refill in the prior 6 months; HIV-1 viral suppression defined as < 400 copies/ml.

Results

Overall, among 241 adolescents and young adults, retention was 89% (214/241) and viral suppression was 81% (196/241). Retention was higher among those attending adolescent clinic (95%) versus standard pediatric clinic (85%; OR 3.7; 95% confidence interval (CI) 1.2–11.1; p = 0.018). Multivariable logistic regression adjusted for age at ART initiation, gender, pre-ART CD4 count, months on ART, and tuberculosis history indicated higher odds of retention in adolescents and young adults attending adolescent compared to standard clinic (AOR = 8.5; 95% CI 2.3–32.4; p = 0.002). Viral suppression was higher among adolescents and young adults attending adolescent (91%) versus standard pediatric clinic (80%; OR 2.5; 95% CI 1.1–5.8; p = 0.028). A similar multivariable logistic regression model indicated higher odds of viral suppression in adolescents and young adults attending adolescent versus standard pediatric clinic (AOR = 3.8; 95% CI 1.5–9.7; p = 0.005).

Conclusion

Adolescents and young adults attending an adolescent-friendly clinic had higher retention in care and viral suppression compared to adolescents attending the standard pediatric clinic. Further studies are needed to prospectively assess the impact of adolescent-friendly services on these outcomes.

Characteristics associated with virologic failure in high-risk HIV-positive participants with prior failure: a post hoc analysis of ACTG 5251

Patients with prior virologic failure (VF) are at an increased risk of subsequent failure, emergence of resistance, and death. This analysis identifies outcomes and correlates of VF in a high-risk population.

METHODS

A5251 was designed to evaluate an enhanced adherence counseling intervention delivered by nurses from a central call site on virologic suppression. Due to slow enrollment, the study was closed prematurely and revised study endpoints were evaluated (week 24 VF (HIV-1 RNA ≥200 copies/ml) and non-perfect adherence (<100% self-reported using both the ACTG adherence questionnaire and visual analog scale (VAS)).

RESULTS

Fifty-nine participants were enrolled, 43 (73%) black non-Hispanic and 23 (39%) women. Median prior antiretroviral regimen changes were three and the co-morbidity in this population was higher than typical for HIV clinical trials. At week 24 (n = 41), 24 (59%) failed to reach virologic suppression (HIV-1 RNA <200 copies/ml) and 25 (63%) reported non-perfect adherence. Higher depression (CES-D10) and adverse illness perceptions (IPQ-B) were associated with week 24 non-adherence. Early clinical assessments (week 12 HIV-RNA ≥200 copies/mL and non-perfect adherence) as well as higher depression and adverse illness perceptions were associated with week 24 VF.

DISCUSSION

In this high-risk population, the proportion of participants with suboptimal adherence and VF was unacceptably high. Interventions to address this treatment gap are clearly needed. Depression and a higher illness perception score, failure to achieve virologic suppression by week 12, and less than perfect adherence could be used to target individuals for early interventions in treatment-experienced, high-risk individuals at high risk for VF.

Characteristics of US Travelers to Zika Virus-Affected Countries in the Americas, March 2015-October 2016

Zika virus has recently been introduced to the Americas and is spreading rapidly. We evaluated the characteristics of US travelers to Zika virus–affected countries who were seen at Global TravEpiNet sites during March 2015–October 2016. Nearly three quarters of travelers were men or women of reproductive age.

Site nurse-initiated adherence and symptom support telephone calls for HIV-positive individuals starting antiretroviral therapy, ACTG 5031: substudy of ACTG 384

BACKGROUND

Effective and easy to implement interventions to improve adherence to antiretroviral therapy are needed.

OBJECTIVE

To compare site nurse-initiated adherence and symptom support telephone calls for HIV-positive individuals starting antiretroviral therapy to the study site's standard of care.

METHODS

A randomized controlled trial of site nurse-initiated adherence and symptom support telephone calls for HIV-positive individuals starting antiretroviral therapy. Subjects were randomized to receive site nurse-initiated telephone calls (intervention) or no additional calls to the site's standard of care (control). Subjects received calls 1 to 3 days after initiating antiretrovirals, on weeks 1, 2, 3, 6, 10, 14, 18, 22, and 26, and every 8 weeks thereafter. Self-reported adherence was captured during study visits.

RESULTS

A total of 333 subjects starting antiretrovirals as part of ACTG 384 were co-enrolled into ACTG 5031. Subjects were followed for up to 160 weeks and were contacted for 74% of scheduled calls. There was no significant difference in proportion of patients with ≯95% mean total adherence (87.9% and 91.2%; P = .34) and mean self-reported total adherence (97.9% and 98.4%) in the intervention and control groups, respectively, or in symptom distress and clinical endpoints.

CONCLUSIONS

In the context of a clinical trial where self-reported adherence was exceptionally high, the site nurse-initiated telephone calls did not further improve self-reported adherence, symptom distress, or clinical outcomes.

Cardiac arrhythmias in presidents and other athletes

We presented examples of both supraventricular and ventricular rhythm disorders which can occur in athletic individuals, even presidents. The vast majority of rhythm problems we deal with in athletes are fortunately benign, entities such as frequent atrial ectopic beats or VPBs. In each patient encountered, we ask ourselves the five questions noted in the discussion pertaining to symptomatology, anatomic source of the arrhythmia, presence or absence of underlying cardiac disease, and precipitating factors. The most common more sustained SVTs we see are AVNRT and atrial fibrillation. Atrial flutter is less common. These are more of a nuisance to patients rather than a threat to their lives, although rarely cerebral embolic events can occur. Therapy includes avoidance of precipitating factors and, when necessary, a sequential trial of available drugs, carefully documenting the response and watching closely for any pro-arrhythmic events. We infrequently see NSVT in athletes, even triplets of VPBs on exercise testing, and rarely see instances of sustained VT. The latter merits a careful search for underlying cardiac disease and usually electrophysiology-guided drug therapy. New techniques such as radiofrequency ablation of the dysrhythmic focus may obviate the need for chronic drug therapy in selected cases.