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Feelemyer J, Abrams J, Mazumdar M, Irvine NM, Scheidell JD, Turpin RE, Dyer TV, Brewer RA, Hucks-Ortiz C, Caniglia EC, Remch M, Scanlon F, Gaydos CA, Sandh S, Cleland CM, Mayer KH, Khan MR. Age Differences in the Associations Between Incarceration and Subsequent Substance Use, Sexual Risk-Taking, and Incident STI Among Black Sexual Minority Men and Black Transgender Women in the HIV Prevention Trials 061 Cohort. Am J Mens Health 2023; 17:15579883231204120. [PMID: 37942721 PMCID: PMC10637158 DOI: 10.1177/15579883231204120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 08/30/2023] [Accepted: 09/12/2023] [Indexed: 11/10/2023] Open
Abstract
Incarceration can lead to different risk behaviors often due to increased distress and disruption of social networks. It is not well known, however, how these associations may differ by age. In this study, we measure age differences in longitudinal associations between incarceration and substance use, sex risk, and sexually transmitted infection (STI) among Black sexual minority men and Black transgender women (BSMM/BTW). We recruited BSMM/BTW from 2009 to 2011 that were part of the HIV Prevention Trials Network 061 study. We compared those less than 30 years old (n = 375) to those 30 years old or greater (n = 794) examining substance use, sex risk, and STI infection stratified by age. Logistic regression with inverse probability weighting was used for the statistical analysis. Approximately 59% of the sample reported incarceration history. In adjusted analysis, incarceration was more strongly associated with alcohol use and stimulant use among older individuals as was sexual risk behaviors including buying and selling sex. Concurrent partnerships were associated with the younger age groups. STI incidence was associated with younger individuals while associations with HIV infection were similar for the two age groups. Understanding differences in substance use and STI risk among age cohorts is imperative to the design and implementation of re-entry programs. Younger BSMM/BTW participating in re-entry support programs may benefit in particular from HIV/STI prevention and care efforts, while post-release substance abuse treatment and harm reduction programs should target older individuals with continued substance abuse.
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Affiliation(s)
- Jonathan Feelemyer
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Jasmyn Abrams
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Medha Mazumdar
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Natalia M. Irvine
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Joy D. Scheidell
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Rodman E. Turpin
- Department of Epidemiology and Biostatistics, University of Maryland School of Public Health, College Park, MD, USA
| | - Typhanye V. Dyer
- Department of Epidemiology and Biostatistics, University of Maryland School of Public Health, College Park, MD, USA
| | | | | | - Ellen C. Caniglia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Molly Remch
- UNC Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Faith Scanlon
- Department of Psychological Sciences, Texas Tech University, Lubbock, TX, USA
| | | | - Simon Sandh
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Charles M. Cleland
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Kenneth H. Mayer
- The Fenway Institute, Fenway Health, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Maria R. Khan
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
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Feelemyer JP, Richard E, Khan MR, Scheidell JD, Caniglia EC, Manandhar-Sasaki P, Ban KF, Charles D, Braithwaite RS. Does the Association Between Stimulant use and High Risk Sexual Behavior Vary by Injection Drug Use, Sexual Minority Status, or HIV Infection Status? A Meta-analysis. AIDS Behav 2023; 27:2883-2890. [PMID: 36786937 PMCID: PMC10423740 DOI: 10.1007/s10461-023-04012-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2023] [Indexed: 02/15/2023]
Abstract
There is strong evidence linking stimulant use, namely methamphetamine use, to sexual risk behavior among sexual minority men (SMM); we do not, however, have a good understanding of this relationship among other at-risk populations. In this study, we systematically reviewed associations between stimulant use (i.e., methamphetamine, crack cocaine, cocaine) and sexual risk behaviors among populations facing elevated risk of HIV transmission and acquisition (i.e., SMM, people who inject drugs (PWID), and people living with HIV/AIDS (PLWH)). Random-effects meta-analyses and sensitivity analyses that included crude and adjusted estimates separately were conducted to evaluate the impact of potential confounding variables. The results showed strong relationships between stimulant use and condomless sex, transactional sex, and multiple sexual partners. Results were broadly consistent when analyses were stratified by type of stimulant (methamphetamine, crack cocaine, and other stimulants) and risk group. Sensitivity analyses with confounding variables did not greatly impact results. The results indicate that stimulant use is associated with numerous sexual risk behaviors regardless of risk group, suggesting prevention efforts focused on reducing methamphetamine-related HIV risk should target a range of at-risk populations.
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Affiliation(s)
- Jonathan P Feelemyer
- Department of Population Health, New York University School of Medicine, 180 Madison 5th Floor, 10016, New York, NY, USA.
| | | | - Maria R Khan
- Department of Population Health, New York University School of Medicine, 180 Madison 5th Floor, 10016, New York, NY, USA
| | - Joy D Scheidell
- Department of Population Health, New York University School of Medicine, 180 Madison 5th Floor, 10016, New York, NY, USA
| | - Ellen C Caniglia
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Prima Manandhar-Sasaki
- Department of Population Health, New York University School of Medicine, 180 Madison 5th Floor, 10016, New York, NY, USA
| | - Kaoon Francois Ban
- Department of Population Health, New York University School of Medicine, 180 Madison 5th Floor, 10016, New York, NY, USA
| | - Dyanna Charles
- Department of Population Health, New York University School of Medicine, 180 Madison 5th Floor, 10016, New York, NY, USA
| | - Ronald Scott Braithwaite
- Department of Population Health, New York University School of Medicine, 180 Madison 5th Floor, 10016, New York, NY, USA
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3
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Kinsey EW, Widen EM, Quinn JW, Huynh M, Van Wye G, Lovasi GS, Neckerman KM, Caniglia EC, Rundle AG. Neighborhood Food Environment and Birth Weight Outcomes in New York City. JAMA Netw Open 2023; 6:e2317952. [PMID: 37306998 DOI: 10.1001/jamanetworkopen.2023.17952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2023] Open
Abstract
Importance Infants born with unhealthy birth weight are at greater risk for long-term health complications, but little is known about how neighborhood characteristics (eg, walkability, food environment) may affect birth weight outcomes. Objective To assess whether neighborhood-level characteristics (poverty rate, food environment, and walkability) are associated with risk of unhealthy birth weight outcomes and to evaluate whether gestational weight gain mediated these associations. Design, Setting, and Participants The population-based cross-sectional study included births in the 2015 vital statistics records from the New York City Department of Health and Mental Hygiene. Only singleton births and observations with complete birth weight and covariate data were included. Analyses were performed from November 2021 to March 2022. Exposures Residential neighborhood-level characteristics, including poverty, food environment (healthy and unhealthy food retail establishments), and walkability (measured by both walkable destinations and a neighborhood walkability index combining walkability measures like street intersection and transit stop density). Neighborhood-level variables categorized into quartiles. Main Outcomes and Measures The main outcomes were birth certificate birth weight measures including small for gestational age (SGA), large for gestational age (LGA), and sex-specific birth weight for gestational age z-score. Generalized linear mixed-effects models and hierarchical linear models estimated risk ratios for associations between density of neighborhood-level characteristics within a 1-km buffer of residential census block centroid and birth weight outcomes. Results The study included 106 194 births in New York City. The mean (SD) age of pregnant individuals in the sample was 29.9 (6.1) years. Prevalence of SGA and LGA were 12.9% and 8.4%, respectively. Residence in the highest density quartile of healthy food retail establishments compared with the lowest quartile was associated with lower adjusted risk of SGA (with adjustment for individual covariates including gestational weight gain z-score: risk ratio [RR], 0.89; 95% CI 0.83-0.97). Higher neighborhood density of unhealthy food retail establishments was associated with higher adjusted risk of delivering an infant classified as SGA (fourth vs first quartile: RR, 1.12; 95% CI, 1.01-1.24). The RR for the association between density of unhealthy food retail establishments and risk of LGA was higher after adjustment for all covariates in each quartile compared with quartile 1 (second: RR, 1.12 [95% CI, 1.04-1.20]; third: RR, 1.18 [95% CI, 1.08-1.29]; fourth: RR, 1.16; [95% CI, 1.04-1.29]). There were no associations between neighborhood walkability and birth weight outcomes (SGA for fourth vs first quartile: RR, 1.01 [95% CI, 0.94-1.08]; LGA for fourth vs first quartile: RR, 1.06 [95% CI, 0.98-1.14]). Conclusions and Relevance In this population-based cross-sectional study, healthfulness of neighborhood food environments was associated with risk of SGA and LGA. The findings support use of urban design and planning guidelines to improve food environments to support healthy pregnancies and birth weight.
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Affiliation(s)
- Eliza W Kinsey
- Department of Family Medicine & Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Elizabeth M Widen
- Department of Nutritional Sciences and Population Research Center, University of Texas at Austin
| | - James W Quinn
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Mary Huynh
- Bureau of Vital Statistics, New York City Department of Health and Mental Hygiene, New York
| | - Gretchen Van Wye
- Bureau of Vital Statistics, New York City Department of Health and Mental Hygiene, New York
| | - Gina S Lovasi
- Epidemiology and Biostatistics, Urban Health Collaborative, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - Kathryn M Neckerman
- Columbia Population Research Center, Columbia University, New York, New York
| | - Ellen C Caniglia
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Andrew G Rundle
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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Caniglia EC, Zash R, Fennell C, Diseko M, Mayondi G, Heintz J, Mmalane M, Makhema J, Lockman S, Mumford SL, Murray EJ, Hernández-Díaz S, Shapiro R. Emulating Target Trials to Avoid Immortal Time Bias - An Application to Antibiotic Initiation and Preterm Delivery. Epidemiology 2023; 34:430-438. [PMID: 36805380 PMCID: PMC10263190 DOI: 10.1097/ede.0000000000001601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
BACKGROUND Randomized trials in pregnancy are extremely challenging, and observational studies are often the only option to evaluate medication safety during pregnancy. However, such studies are often susceptible to immortal time bias if treatment initiation occurs after time zero of follow-up. We describe how emulating a sequence of target trials avoids immortal time bias and apply the approach to estimate the safety of antibiotic initiation between 24 and 37 weeks gestation on preterm delivery. METHODS The Tsepamo Study captured birth outcomes at hospitals throughout Botswana from 2014 to 2021. We emulated 13 sequential target trials of antibiotic initiation versus no initiation among individuals presenting to care <24 weeks, one for each week from 24 to 37 weeks. For each trial, eligible individuals had not previously initiated antibiotics. We also conducted an analysis susceptible to immortal time bias by defining time zero as 24 weeks and exposure as antibiotic initiation between 24 and 37 weeks. We calculated adjusted risk ratios (RR) and 95% confidence intervals (CI) for preterm delivery. RESULTS Of 111,403 eligible individuals, 17,009 (15.3%) initiated antibiotics between 24 and 37 weeks. In the sequence of target trials, RRs (95% CIs) ranged from 1.04 (0.90, 1.19) to 1.24 (1.11, 1.39) (pooled RR: 1.11 [1.06, 1.15]). In the analysis susceptible to immortal time bias, the RR was 0.90 (0.86, 0.94). CONCLUSIONS Defining exposure as antibiotic initiation at any time during follow-up after time zero resulted in substantial immortal time bias, making antibiotics appear protective against preterm delivery. Conducting a sequence of target trials can avoid immortal time bias in pregnancy studies.
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Affiliation(s)
- Ellen C. Caniglia
- University of Pennsylvania Perelman School of Medicine
- Botswana-Harvard AIDS Institute Partnership
| | - Rebecca Zash
- Botswana-Harvard AIDS Institute Partnership
- Beth Israel Deaconess Medical Centerss
| | | | | | | | | | | | | | - Shahin Lockman
- Botswana-Harvard AIDS Institute Partnership
- Harvard T.H. Chan School of Public Health
- Brigham and Women’s Hospital
| | | | | | | | - Roger Shapiro
- Botswana-Harvard AIDS Institute Partnership
- Harvard T.H. Chan School of Public Health
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Scheidell JD, Townsend T, Ban KF, Caniglia EC, Charles D, Edelman EJ, Marshall BDL, Gordon AJ, Justice AC, Braithwaite RS, Khan MR. Cessation of self-reported opioid use and impacts on co-occurring health conditions. Drug Alcohol Depend 2023; 242:109712. [PMID: 36469994 PMCID: PMC10108375 DOI: 10.1016/j.drugalcdep.2022.109712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 10/31/2022] [Accepted: 11/18/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Among veterans in care reporting opioid use, we investigated the association between ceasing opioid use on subsequent reduction in report of other substance use and improvements in pain, anxiety, and depression. METHODS Using Veterans Aging Cohort Study survey data collected between 2003 and 2012, we emulated a hypothetical randomized trial (target trial) of ceasing self-reported use of prescription opioids and/or heroin, and outcomes including unhealthy alcohol use, smoking, cannabis use, cocaine use, pain, and anxiety and depressive symptoms. Among those with baseline opioid use, we compared participants who stopped reporting opioid use at the first follow-up (approximately 1 year after baseline) with those who did not. We fit logistic regression models to estimate associations with change in each outcome at the second follow-up (approximately 2 years after baseline) among participants with that condition at baseline. We examined two sets of adjusted models that varied temporality assumptions. RESULTS Among 2473 participants reporting opioid use, 872 did not report use, 606 reported use, and 995 were missing data on use at the first follow-up. Ceasing opioid use was associated with no longer reporting cannabis (adjusted odds ratio [AOR]=1.82, 95% confidence interval [CI] 1.10, 3.03) and cocaine use (AOR=1.93, 95% CI 1.16, 3.20), and improvements in pain (AOR=1.53, 95% CI 1.05, 2.24) and anxiety (AOR=1.56, 95% CI 1.01, 2.41) symptoms. CONCLUSION Cessation of opioid misuse may be associated with subsequent cessation of other substances and reduction in pain and anxiety symptoms, which supports efforts to screen and provide evidence-based intervention where appropriate.
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Affiliation(s)
- Joy D Scheidell
- NYU Grossman School of Medicine, Department of Population Health, 227 E 30th Street, Sixth Floor, New York, NY 10016, USA.
| | - Tarlise Townsend
- NYU Grossman School of Medicine, Department of Population Health, 227 E 30th Street, Sixth Floor, New York, NY 10016, USA
| | - Kaoon Francois Ban
- NYU Grossman School of Medicine, Department of Population Health, 227 E 30th Street, Sixth Floor, New York, NY 10016, USA
| | - Ellen C Caniglia
- University of Pennsylvania Perelman School of Medicine, Department of Biostatistics, Epidemiology, and Informatics, Philadelphia, PA, USA
| | - Dyanna Charles
- NYU Grossman School of Medicine, Department of Population Health, 227 E 30th Street, Sixth Floor, New York, NY 10016, USA
| | - E Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Adam J Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT, USA; Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), University of Utah School of Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Amy C Justice
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA
| | - R Scott Braithwaite
- NYU Grossman School of Medicine, Department of Population Health, 227 E 30th Street, Sixth Floor, New York, NY 10016, USA
| | - Maria R Khan
- NYU Grossman School of Medicine, Department of Population Health, 227 E 30th Street, Sixth Floor, New York, NY 10016, USA
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Jackson-Gibson M, Diseko M, Caniglia EC, Mayondi G, Mabuta J, Luckett R, Moyo S, Lawrence P, Matshaba M, Mosepele M, Mmalane M, Banga J, Lockman S, Makhema J, Zash R, Shapiro RL. Association of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection With Maternal Mortality and Neonatal Birth Outcomes in Botswana by Human Immunodeficiency Virus Status. Obstet Gynecol 2023; 141:135-143. [PMID: 36701614 PMCID: PMC10462386 DOI: 10.1097/aog.0000000000005020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 08/11/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To evaluate the combined association of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and human immunodeficiency virus (HIV) infection on adverse birth outcomes in an HIV-endemic region. METHODS The Tsepamo Study abstracts data from antenatal and obstetric records in government maternity wards across Botswana. We assessed maternal mortality and adverse birth outcomes for all singleton pregnancies from September 2020 to mid-November 2021 at 13 Tsepamo sites among individuals with documented SARS-CoV-2 screening tests and known HIV status. RESULTS Of 20,410 individuals who gave birth, 11,483 (56.3%) were screened for SARS-CoV-2 infection; 4.7% tested positive. People living with HIV were more likely to test positive (144/2,421, 5.9%) than those without HIV (392/9,030, 4.3%) (P=.001). Maternal deaths occurred in 3.7% of those who had a positive SARS-CoV-2 test result compared with 0.1% of those who tested negative (adjusted relative risk [aRR] 31.6, 95% CI 15.4-64.7). Maternal mortality did not differ by HIV status. The offspring of individuals with SARS-CoV-2 infection experienced more overall adverse birth outcomes (34.5% vs 26.6%; aRR 1.2, 95% CI 1.1-1.4), severe adverse birth outcomes (13.6% vs 9.8%; aRR 1.2, 95% CI 1.0-1.5), preterm delivery (21.4% vs 13.4%; aRR 1.4, 95% CI 1.2-1.7), and stillbirth (5.6% vs 2.7%; aRR 1.7 95% CI 1.2-2.5). Neonates exposed to SARS-CoV-2 and HIV infection had the highest prevalence of adverse birth outcomes (43.1% vs 22.6%; aRR 1.7, 95% CI 1.4-2.0). CONCLUSION Infection with SARS-CoV-2 at the time of delivery was associated with 3.7% maternal mortality and 5.6% stillbirth in Botswana. Most adverse birth outcomes were worse among neonates exposed to both SARS-CoV-2 and HIV infection.
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Affiliation(s)
| | - Modiegi Diseko
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | - Gloria Mayondi
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Judith Mabuta
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Rebecca Luckett
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Internal Medicine, University of Botswana, Gaborone, Botswana
| | - Sikhulile Moyo
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Internal Medicine, University of Botswana, Gaborone, Botswana
| | - Pamela Lawrence
- Department of Internal Medicine, University of Botswana, Gaborone, Botswana
| | - Mogomotsi Matshaba
- Ministry of Health and Wellness, Gaborone, Botswana
- Botswana-Baylor Children’s Clinical Centre of Excellence, Gaborone, Botswana
| | | | - Mompati Mmalane
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Jaspreet Banga
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Shahin Lockman
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Joseph Makhema
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Rebecca Zash
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Roger L. Shapiro
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Caniglia EC, Hinkle SN. Point: Benchmarking can supplement transportability to answer critical questions about the effectiveness of antenatal corticosteroid administration. Paediatr Perinat Epidemiol 2023; 37:9-11. [PMID: 35988915 DOI: 10.1111/ppe.12923] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/08/2022] [Indexed: 02/01/2023]
Affiliation(s)
- Ellen C Caniglia
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Stefanie N Hinkle
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Dryden-Peterson S, Kim A, Kim AY, Caniglia EC, Lennes IT, Patel R, Gainer L, Dutton L, Donahue E, Gandhi RT, Baden LR, Woolley AE. Nirmatrelvir Plus Ritonavir for Early COVID-19 in a Large U.S. Health System : A Population-Based Cohort Study. Ann Intern Med 2023; 176:77-84. [PMID: 36508742 PMCID: PMC9753458 DOI: 10.7326/m22-2141] [Citation(s) in RCA: 75] [Impact Index Per Article: 75.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND In the EPIC-HR (Evaluation of Protease Inhibition for Covid-19 in High-Risk Patients) trial, nirmatrelvir plus ritonavir led to an 89% reduction in hospitalization or death among unvaccinated outpatients with early COVID-19. The clinical impact of nirmatrelvir plus ritonavir among vaccinated populations is uncertain. OBJECTIVE To assess whether nirmatrelvir plus ritonavir reduces risk for hospitalization or death among outpatients with early COVID-19 in the setting of prevalent SARS-CoV-2 immunity and immune-evasive SARS-CoV-2 lineages. DESIGN Population-based cohort study analyzed to emulate a clinical trial using inverse probability-weighted models to account for anticipated bias in treatment. SETTING A large health care system providing care for 1.5 million patients in Massachusetts and New Hampshire during the Omicron wave (1 January to 17 July 2022). PATIENTS 44 551 nonhospitalized adults (90.3% with ≥3 vaccine doses) aged 50 years or older with COVID-19 and no contraindications for nirmatrelvir plus ritonavir. MEASUREMENTS The primary outcome was a composite of hospitalization within 14 days or death within 28 days of a COVID-19 diagnosis. RESULTS During the study period, 12 541 (28.1%) patients were prescribed nirmatrelvir plus ritonavir, and 32 010 (71.9%) were not. Patients prescribed nirmatrelvir plus ritonavir were more likely to be older, have more comorbidities, and be vaccinated. The composite outcome of hospitalization or death occurred in 69 (0.55%) patients who were prescribed nirmatrelvir plus ritonavir and 310 (0.97%) who were not (adjusted risk ratio, 0.56 [95% CI, 0.42 to 0.75]). Recipients of nirmatrelvir plus ritonavir had lower risk for hospitalization (adjusted risk ratio, 0.60 [CI, 0.44 to 0.81]) and death (adjusted risk ratio, 0.29 [CI, 0.12 to 0.71]). LIMITATION Potential residual confounding due to differential access to COVID-19 vaccines, diagnostic tests, and treatment. CONCLUSION The overall risk for hospitalization or death was already low (1%) after an outpatient diagnosis of COVID-19, but nirmatrelvir plus ritonavir reduced this risk further. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Scott Dryden-Peterson
- Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, Massachusetts, and Botswana Harvard AIDS Institute, Gaborone, Botswana (S.D.)
| | - Andy Kim
- Brigham and Women's Hospital, Boston, Massachusetts (A.K., L.D., E.D., L.R.B., A.E.W.)
| | - Arthur Y Kim
- Massachusetts General Hospital, Boston, Massachusetts (A.Y.K., I.T.L., R.T.G.)
| | - Ellen C Caniglia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (E.C.C.)
| | - Inga T Lennes
- Massachusetts General Hospital, Boston, Massachusetts (A.Y.K., I.T.L., R.T.G.)
| | - Rajesh Patel
- Beth Israel Lahey Health, Cambridge, Massachusetts (R.P.)
| | - Lindsay Gainer
- Mass General Brigham Integrated Care, Somerville, Massachusetts (L.G.)
| | - Lisa Dutton
- Brigham and Women's Hospital, Boston, Massachusetts (A.K., L.D., E.D., L.R.B., A.E.W.)
| | - Elizabeth Donahue
- Brigham and Women's Hospital, Boston, Massachusetts (A.K., L.D., E.D., L.R.B., A.E.W.)
| | - Rajesh T Gandhi
- Massachusetts General Hospital, Boston, Massachusetts (A.Y.K., I.T.L., R.T.G.)
| | - Lindsey R Baden
- Brigham and Women's Hospital, Boston, Massachusetts (A.K., L.D., E.D., L.R.B., A.E.W.)
| | - Ann E Woolley
- Brigham and Women's Hospital, Boston, Massachusetts (A.K., L.D., E.D., L.R.B., A.E.W.)
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9
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Hoff L, Scheidell JD, Mazumdar M, Feelemyer J, Dyer TV, Turpin RE, Cleland CM, Caniglia EC, Remch M, Brewer R, Hucks-Ortiz C, Irvine NM, Mayer KH, Khan MR. The associations of incarceration and depression with healthcare experiences and utilization among Black men who have sex with men in HPTN 061. AIDS Care 2022; 34:1169-1178. [PMID: 34384304 PMCID: PMC8837705 DOI: 10.1080/09540121.2021.1966695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 08/03/2021] [Indexed: 01/26/2023]
Abstract
Associations of incarceration with healthcare access and utilization among Black sexual minority men (BSMM) and differences in association among those with and without pre-incarceration symptoms of depression were measured. Secondary analysis using survey data from the longitudinal cohort HIV Prevention Trials Network 061 study was conducted among 1553 BSMM from six major U.S. cities from 2009 to 2011. We used modified log-binomial regression with robust standard errors to estimate associations of incarceration (reported at 6 month follow-up) on next six-month healthcare utilization and access (reported at the 12 month follow-up). We tested the significance of baseline depressive symptoms by incarceration interaction and reported differences in associations when observed. Participants with a history of incarceration were more likely to have depressive symptoms at baseline compared to those without. Recent incarceration was associated with almost twice the risk of mistrust in healthcare providers and emergency room utilization. Among men reporting depressive symptoms, a history of incarceration was associated with almost tripled risk of reporting providers do not communicate understandably. Among those with depression, one in five reported a missed visit regardless of incarceration status.
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Affiliation(s)
- Lee Hoff
- SUNY Downstate Medical Center School of Public Health, New York, NY
- New York University Grossman School of Medicine, Department of Population Health, New York, NY
| | - Joy D Scheidell
- New York University Grossman School of Medicine, Department of Population Health, New York, NY
| | - Medha Mazumdar
- New York University Grossman School of Medicine, Department of Population Health, New York, NY
| | - Jonathan Feelemyer
- New York University Grossman School of Medicine, Department of Population Health, New York, NY
| | - Typhanye V Dyer
- University of Maryland School of Public Health, Department of Epidemiology and Biostatistics, College Park, MD
| | - Rodman E Turpin
- University of Maryland School of Public Health, Department of Epidemiology and Biostatistics, College Park, MD
| | - Charles M Cleland
- New York University Grossman School of Medicine, Department of Population Health, New York, NY
| | - Ellen C Caniglia
- New York University Grossman School of Medicine, Department of Population Health, New York, NY
| | - Molly Remch
- University of North Carolina at Chapel Hill Gillings School of Global Public Health, Department of Epidemiology, Chapel Hill, NC
| | - Russell Brewer
- University of Chicago, Department of Medicine, Chicago, IL
| | | | - Natalia M Irvine
- New York University Grossman School of Medicine, Department of Population Health, New York, NY
| | | | - Maria R Khan
- New York University Grossman School of Medicine, Department of Population Health, New York, NY
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10
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Brummel SS, Stringer J, Mills E, Tierney C, Caniglia EC, Colbers A, Chi BH, Best BM, Gaaloul ME, Hillier S, Jourdain G, Khoo SH, Mofenson LM, Myer L, Nachman S, Stranix-Chibanda L, Clayden P, Sachikonye M, Lockman S. Clinical and population-based study design considerations to accelerate the investigation of new antiretrovirals during pregnancy. J Int AIDS Soc 2022; 25 Suppl 2:e25917. [PMID: 35851758 PMCID: PMC9294861 DOI: 10.1002/jia2.25917] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 04/28/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Pregnant women are routinely excluded from clinical trials, leading to the absence or delay in even the most basic pharmacokinetic (PK) information needed for dosing in pregnancy. When available, pregnancy PK studies use a small sample size, resulting in limited safety information. We discuss key study design elements that may enhance the timely availability of pregnancy data, including the role and timing of randomized controlled trials (RCTs) to evaluate pregnancy safety; efficacy and safety outcome measures; stand‐alone protocols, platform trials, single arm studies, sample size and the effect that follow‐up time during gestation has on analysis interpretations; and observational studies. Discussion Pregnancy PK should be studied during drug development, after dosing in non‐pregnant persons is established (unless non‐clinical or other data raise pregnancy concerns). RCTs should evaluate the safety during pregnancy of priority new HIV agents that are likely to be used by large numbers of females of childbearing age. Key endpoints for pregnancy safety studies include birth outcomes (prematurity, small for gestational age and stillbirth) and neonatal death, with traditional adverse events and infant growth also measured (congenital anomalies are best studied through surveillance). We recommend that viral efficacy be studied as a secondary endpoint of pregnancy RCTs, once PK studies confirm adequate drug exposure in pregnancy. RCTs typically use a stand‐alone protocol for new agents. In contrast, master protocols using a platform design can add agents over time, possibly speeding safety data ascertainment. To speed accrual, stand‐alone pregnancy trial protocols can include pre‐specified starting rules based upon adequate PK levels in pregnancy; and seamless master protocols or platform trials can include a pregnancy PK and safety component. When RCTs are unethical or cost‐prohibitive, observational studies should be conducted, preferably using target trial emulation to avoid bias. Conclusions Pregnancy PK needs to be obtained earlier in drug evaluation. Timely RCTs are needed to understand safety in pregnancy for high‐priority new HIV agents. RCTs that enrol pregnant women should focus on outcomes unique to pregnancy, and observational studies should focus on questions that RCTs are not equipped to answer.
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Affiliation(s)
- Sean S Brummel
- Department of Biostatistics, Center for Biostatistics in AIDS Research, Boston, Massachusetts, USA.,Harvard T.H. Chan School of Public Heath, Boston, Massachusetts, USA
| | - Jeff Stringer
- School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Ed Mills
- MTEK Sciences, Vancouver, British Columbia, Canada.,MTEK Sciences, Kigali, Rwanda
| | - Camlin Tierney
- Department of Biostatistics, Center for Biostatistics in AIDS Research, Boston, Massachusetts, USA.,Harvard T.H. Chan School of Public Heath, Boston, Massachusetts, USA
| | - Ellen C Caniglia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Angela Colbers
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Benjamin H Chi
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Brookie M Best
- Skaggs School of Pharmacy and Pharmaceutical Sciences, San Diego, California, USA.,Pediatrics Department - Rady Children's Hospital San Diego, University of California San Diego, La Jolla, California, USA
| | - Myriam El Gaaloul
- Product Development, Medicines for Malaria Venture, Geneva, Switzerland
| | - Sharon Hillier
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh and the Magee-Womens Research Institute, Pittsburgh, Pennsylvania, USA
| | | | - Saye H Khoo
- Department of Pharmacology, University of Liverpool, Liverpool, UK
| | - Lynne M Mofenson
- Research Department, Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Sharon Nachman
- Department of Pediatrics, The State University of New York (SUNY), Stony Brook, New York, USA
| | - Lynda Stranix-Chibanda
- Child and Adolescent Health Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | | | | | - Shahin Lockman
- Harvard T.H. Chan School of Public Heath, Boston, Massachusetts, USA.,Brigham and Women's Hospital, Boston, Massachusetts, USA
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11
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Dryden-Peterson S, Kim A, Kim AY, Caniglia EC, Lennes I, Patel R, Gainer L, Dutton L, Donahue E, Gandhi RT, Baden LR, Woolley AE. Nirmatrelvir plus ritonavir for early COVID-19 and hospitalization in a large US health system. medRxiv 2022:2022.06.14.22276393. [PMID: 35734084 PMCID: PMC9216724 DOI: 10.1101/2022.06.14.22276393] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Background In the EPIC-HR trial, nirmatrelvir plus ritonavir led to an 88% reduction in hospitalization or death among unvaccinated outpatients with early COVID-19. Clinical impact of nirmatrelvir plus ritonavir among vaccinated populations is uncertain. Objective To assess whether nirmatrelvir plus ritonavir reduces risk of hospitalization among outpatients with early COVID-19 in the setting of prevalent SARS-CoV-2 immunity and immune evasive SARS-CoV-2 lineages. Design Population-based cohort study analyzed to emulate a clinical trial utilizing two-stage, inverse-probability weighted models to account for anticipated bias in testing and treatment. Setting A large healthcare system providing care for 1.5 million patients in Massachusetts and New Hampshire during Omicron wave (January 1 to May 15, 2022) with staged access and capacity to prescribe nirmatrelvir plus ritonavir. Patients 30,322 non-hospitalized adults (87.2% vaccinated) aged 50 and older with COVID-19 and without contraindications to nirmatrelvir plus ritonavir. Measurement Primary outcome was hospitalization within 14 days of COVID-19 diagnosis. Results During the study period, 6036 (19.9%) patients were prescribed nirmatrelvir plus ritonavir and 24,286 (80.1%) patients were not. Patients prescribed nirmatrelvir were more likely to be older, have more comorbidities, and be unvaccinated. Hospitalization occurred in 40 (0.66%) and 232 (0.96%) patients prescribed and not prescribed nirmatrelvir plus ritonavir, respectively. The adjusted risk ratio was 0.55 (95% confidence interval 0.38 to 0.80, p = 0.002). Observed risk reduction was greater among unvaccinated patients and obese patients. Limitations Potential for residual confounding due to differential access and uptake of COVID-19 vaccines, diagnostics, and treatment. Conclusions The overall risk of hospitalization was already low (<1%) following an outpatient diagnosis of COVID-19, but this risk was 45% lower among patients prescribed nirmatrelvir plus ritonavir. Funding National Institutes of Health (P30 AI060354 and R01 CA236546).
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Affiliation(s)
- Scott Dryden-Peterson
- Brigham and Women's Hospital, Boston, Massachusetts
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health
- Botswana Harvard AIDS Institute
| | - Andy Kim
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Arthur Y Kim
- Massachusetts General Hospital, Boston, Massachusetts
| | - Ellen C Caniglia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Inga Lennes
- Massachusetts General Hospital, Boston, Massachusetts
| | - Rajesh Patel
- Beth Israel Lahey Health, Cambridge, Massachusetts
| | | | - Lisa Dutton
- Brigham and Women's Hospital, Boston, Massachusetts
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12
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Caniglia EC, Zash R, Swanson SA, Smith E, Sudfeld C, Finkelstein JL, Diseko M, Mayondi G, Mmalane M, Makhema J, Fawzi W, Lockman S, Shapiro RL. Iron, folic acid, and multiple micronutrient supplementation strategies during pregnancy and adverse birth outcomes in Botswana. Lancet Glob Health 2022; 10:e850-e861. [PMID: 35561720 PMCID: PMC9309424 DOI: 10.1016/s2214-109x(22)00126-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 02/10/2022] [Accepted: 03/16/2022] [Indexed: 12/18/2022]
Abstract
Background Methods Findings Interpretation Funding
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Affiliation(s)
- Ellen C Caniglia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Rebecca Zash
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana; Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Emily Smith
- School of Public Health, George Washington University, Washington DC, USA
| | - Christopher Sudfeld
- Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Julia L Finkelstein
- Division of Nutritional Sciences, Cornell College of Human Ecology, Cornell University, Ithaca, NY, USA
| | - Modiegi Diseko
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Gloria Mayondi
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Mompati Mmalane
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Joseph Makhema
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Wafaie Fawzi
- Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Shahin Lockman
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana; Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Roger L Shapiro
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana; Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
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13
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Jackson-Gibson M, Zash R, Mussa A, Caniglia EC, Diseko M, Mayondi G, Mabuta J, Morroni C, Mmalane M, Lockman S, Makhema J, Shapiro RL. High risk of adverse birth outcomes among adolescents living with HIV in Botswana compared to adult women living with HIV and adolescents without HIV. BMC Pregnancy Childbirth 2022; 22:372. [PMID: 35490225 PMCID: PMC9055710 DOI: 10.1186/s12884-022-04687-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 04/07/2022] [Indexed: 11/21/2022] Open
Abstract
Background Adolescent girls are three times more likely to be living with HIV than boys of the same age. Prior studies have found associations between adolescent pregnancies and increased maternal morbidity and infant mortality, but few studies have assessed the impact of HIV infection on maternal and infant outcomes in adolescents. Methods The Tsepamo Study abstracts maternal and infant data from obstetric records in government maternity wards in Botswana. We assessed maternal complications and adverse birth outcomes for all singleton pregnancies from August 2014 to August 2020 at eighteen Tsepamo sites among adolescents (defined as 10–19 years of age) and adults (defined as 20–35 years of age), by HIV status. Univariate and multivariate logistic regression using a complete case analysis method were used to evaluate differences in outcomes. Results This analysis included 142,258 singleton births, 21,133 (14.9%) to adolescents and 121,125 (85.1%) to adults. The proportion of adults living with HIV (N = 22,114, 22.5%) was higher than adolescents (N = 1593, 7.6%). The proportion of most adverse birth outcomes was higher in adolescents. Among adolescents, those with HIV had increased likelihoods of anemia (aOR = 1.89, 95%CI 1.66, 2.15) and cesarean sections (aOR = 1.49, 95%CI 1.3,1.72), and infants with preterm birth (aOR = 1.15, 95%CI 1.0, 1.32), very preterm birth (aOR = 1.35, 95%CI 1.0,1.8), small for gestational age (aOR = 1.37, 95%CI 1.20,1.58), and very small for gestational age (aOR = 1.46, 95%CI 1.20, 1.79). Conclusions Adolescent pregnancy and adolescent HIV infection remain high in Botswana. Adolescents have higher risk of adverse maternal and infant birth outcomes than adults, with the worst outcomes among adolescents living with HIV. Linking HIV prevention and family planning strategies for this age group may help minimize the number of infants with poor birth outcomes among this already vulnerable population.
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Affiliation(s)
- Maya Jackson-Gibson
- Feinberg School of Medicine Northwestern University, Chicago, Illinois, USA.
| | - Rebecca Zash
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Aamirah Mussa
- Botswana-Harvard Partnership AIDS Institute, Gaborone, Botswana
| | - Ellen C Caniglia
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Modiegi Diseko
- Botswana-Harvard Partnership AIDS Institute, Gaborone, Botswana
| | - Gloria Mayondi
- Botswana-Harvard Partnership AIDS Institute, Gaborone, Botswana
| | - Judith Mabuta
- Botswana-Harvard Partnership AIDS Institute, Gaborone, Botswana
| | - Chelsea Morroni
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, Scotland
| | - Mompati Mmalane
- Botswana-Harvard Partnership AIDS Institute, Gaborone, Botswana
| | - Shahin Lockman
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Joseph Makhema
- Botswana-Harvard Partnership AIDS Institute, Gaborone, Botswana
| | - Roger L Shapiro
- Harvard T. H Chan School of Public Health, Boston, Massachusetts, USA
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14
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Becker WC, Li Y, Caniglia EC, Vickers-Smith R, Feinberg T, Marshall BD, Edelman EJ. Cannabis use, pain interference, and prescription opioid receipt among persons with HIV: a target trial emulation study. AIDS Care 2022; 34:469-477. [PMID: 34180721 PMCID: PMC10450359 DOI: 10.1080/09540121.2021.1944597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 06/09/2021] [Indexed: 10/21/2022]
Abstract
Concomitant with expanded legalization, cannabis is increasingly used to treat chronic pain among persons with HIV (PWH), despite equivocal benefit in research limited by small sample sizes and short duration of follow-up. To address these limitations, among a sample of PWH with pain interference enrolled in the Veterans Aging Cohort Study, we performed a target trial emulation study to compare the impact of four cannabis use strategies on pain interference. Among those receiving long-term opioid therapy (LTOT), we also explored impact of these strategies on ≥ 25% LTOT dose reduction. Among the analytic sample (N = 1284), the majority were men with a mean age of 50. Approximately 31% used cannabis and 12% received LTOT at baseline. Adjusting for demographic and clinical factors, cannabis use in any of 4 longitudinal patterns was not associated with resolved pain interference over 12- to 24-month follow-up. Among 153 participants receiving LTOT at baseline, cannabis use at both baseline and follow-up was negatively associated with LTOT dose reduction compared to no use at both baseline and follow-up. These findings support other observational studies finding no association between cannabis use and improved chronic pain or LTOT reduction among PWH.
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Affiliation(s)
- William C. Becker
- VA Connecticut Healthcare System, 950 Campbell Avenue, Mail Stop 151B, West Haven, CT 06516, USA
- Yale School of Medicine, 367 Cedar Street, New Haven, CT 06510, USA
| | - Yu Li
- Brown University School of Public Health, Department of Epidemiology, 121 South Main Street, Providence, RI 02912, USA
| | | | - Rachel Vickers-Smith
- Department of Epidemiology, University of Kentucky College of Public Health, Lexington, KY 40536
- Center on Drug and Alcohol Research, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, KY 40508
| | - Termeh Feinberg
- VA Connecticut Healthcare System, 950 Campbell Avenue, Mail Stop 151B, West Haven, CT 06516, USA
- Yale School of Medicine, 367 Cedar Street, New Haven, CT 06510, USA
| | - Brandon D.L. Marshall
- Brown University School of Public Health, Department of Epidemiology, 121 South Main Street, Providence, RI 02912, USA
| | - E. Jennifer Edelman
- Yale School of Medicine, 367 Cedar Street, New Haven, CT 06510, USA
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT 06510, USA
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15
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Barnard-Mayers R, Kouser H, Cohen JA, Tassiopoulos K, Caniglia EC, Moscicki AB, Campos NG, Caunca MR, Seage GRS, Murray EJ. A case study and proposal for publishing directed acyclic graphs: The effectiveness of the quadrivalent human papillomavirus vaccine in perinatally HIV Infected girls. J Clin Epidemiol 2022; 144:127-135. [PMID: 34998951 PMCID: PMC8977269 DOI: 10.1016/j.jclinepi.2021.12.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 12/22/2021] [Accepted: 12/29/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Developing a causal graph is an important step in etiologic research planning and can be used to highlight data flaws and irreparable bias and confounding. As a case study, we consider recent findings that suggest human papillomavirus (HPV) vaccine is less effective against HPV-associated disease among girls living with HIV compared to girls without HIV. OBJECTIVES To understand the relationship between HIV status and HPV vaccine effectiveness, it is important to outline the key assumptions of the causal mechanisms before designing a study to investigate the effect of the HPV vaccine in girls living with HIV infection. METHODS We present a causal graph to describe our assumptions and proposed approach to explore this relationship. We hope to obtain feedback on our assumptions before data analysis and exemplify the process for designing causal graphs to inform an etiologic study. CONCLUSION The approach we lay out in this paper may be useful for other researchers who have an interest in using causal graphs to describe and assess assumptions in their own research before undergoing data collection and/or analysis.
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Affiliation(s)
| | - Hiba Kouser
- Department of Epidemiology, Boston University, Boston, MA, USA; Breast Oncology Center, Dana Farber Cancer Institute, Boston, MA, USA
| | - Jamie A Cohen
- Health Policy PhD Program, Harvard University, Cambridge, MA, USA
| | | | - Ellen C Caniglia
- Department of Population Health, NYU School of Medicine, New York, NY, USA
| | - Anna-Barbara Moscicki
- Department of Pediatrics, Division of Adolescent Medicine, University of California, Los Angeles, CA, USA
| | - Nicole G Campos
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Michelle R Caunca
- Medical Scientist Training Program, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - George R Seage Seage
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
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16
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Scheidell JD, Dyer TV, Knittel AK, Caniglia EC, Thorpe LE, Troxel AB, Lejuez CW, Khan MR. Incarceration and Subsequent Pregnancy Loss: Exploration of Sexually Transmitted Infections as Mediating Pathways. J Womens Health (Larchmt) 2022; 31:242-251. [PMID: 34061656 PMCID: PMC8864438 DOI: 10.1089/jwh.2020.8980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background: Incarceration is linked to risk of sexually transmitted infection (STI) postrelease among women. There has been little examination of incarceration's association with related sexual and reproductive outcomes such as pelvic inflammatory disease (PID) and pregnancy loss, or the role of STI in this relationship and whether these relationships differ between Black and White women. Methods: Using data from the National Longitudinal Study of Adolescent to Adult Health, we examined cross-sectional associations between incarceration (Wave IV; 2007-2008; ages 24-34) and history of STI and PID (n = 5,968), and longitudinal associations between incarceration and later pregnancy loss in mid-adulthood (Wave V; 2016-2018; ages 34-43) among women who had ever been pregnant (n = 2,353); we estimated racial differences. Using causal mediation, we explored whether STI mediated associations with pregnancy loss. Results: Incarceration was associated with a history of STI (White adjusted prevalence ratio [APR]: 1.54, 95% confidence interval [CI] 1.14-2.06; Black APR: 1.26, 95% CI 1.02-1.56); the association between incarceration and PID was null among White women (APR: 0.99, 95% CI 0.47-2.09) and elevated among Black women (APR: 2.82, 95% CI 1.36-5.83). Prior incarceration did not appear associated with pregnancy loss among White women (APR: 1.01, 95% CI 0.70-1.45), but was associated among Black women (APR: 1.38, 95% CI: 0.97-1.97), with STI appearing to partially mediate. Conclusions: Pregnancy loss may be elevated among Black women who have been incarcerated, and incarceration-related increases in STI may account for some of this association.
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Affiliation(s)
- Joy D. Scheidell
- Division of Comparative Effectiveness and Decision Science, Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA.,Division of Epidemiology, Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA.,Address correspondence to: Joy D. Scheidell, PhD, MPH, Division of Epidemiology, Department of Population Health, New York University Grossman School of Medicine, 227 East 30th Street, Office 624, New York, NY 6402, USA
| | - Typhanye V. Dyer
- Department of Epidemiology and Biostatistics, University of Maryland School of Public Health, College Park, Maryland, USA
| | - Andrea K. Knittel
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ellen C. Caniglia
- Division of Comparative Effectiveness and Decision Science, Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA.,Division of Epidemiology, Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Lorna E. Thorpe
- Division of Comparative Effectiveness and Decision Science, Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA.,Division of Epidemiology, Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Andrea B. Troxel
- Division of Comparative Effectiveness and Decision Science, Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA.,Division of Epidemiology, Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Carl W. Lejuez
- Department of Psychological Sciences, University of Connecticut, Storrs, Connecticut, USA
| | - Maria R. Khan
- Division of Comparative Effectiveness and Decision Science, Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA.,Division of Epidemiology, Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
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17
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Caniglia EC, Khan M, Ban K, Braithwaite RS. Integrating Screening and Treatment of Unhealthy Alcohol Use and Depression with Screening and Treatment of Anxiety, Pain, and Other Substance Use Among People with HIV and Other High-Risk Persons. AIDS Behav 2021; 25:339-346. [PMID: 33829369 PMCID: PMC8610949 DOI: 10.1007/s10461-021-03245-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 02/06/2023]
Abstract
We review and synthesize results from a series of analyses estimating the benefit of screening for unhealthy alcohol use, depression, and tobacco to detect individuals at heightened risk for co-occurring anxiety, pain, depression, unhealthy alcohol use, and other substance use among people with HIV and HIV-uninfected individuals in the Veterans Aging Cohort Study. We also examine the potential impact of reducing unhealthy alcohol use and depressive symptoms on the incidence of co-occurring conditions. We found that screening for alcohol and depression may help identify co-occurring symptoms of anxiety, depression, and pain interference, treating unhealthy alcohol use may improve co-occurring pain interference and substance use, and improving depressive symptoms may improve co-occurring anxiety, pain interference, and smoking. We propose that an integrated approach to screening and treatment for unhealthy alcohol use, depression, anxiety, pain, and other substance use may facilitate diagnostic assessment and treatment of these conditions, improving morbidity and mortality.
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Caniglia EC, Abrams J, Diseko M, Mayondi G, Mabuta J, Makhema J, Mmalane M, Lockman S, Bernstein A, Zash R, Shapiro R. Seasonality of adverse birth outcomes in women with and without HIV in a representative birth outcomes surveillance study in Botswana. BMJ Open 2021; 11:e045882. [PMID: 34479931 PMCID: PMC8420660 DOI: 10.1136/bmjopen-2020-045882] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Sub-Saharan Africa has the largest number of people with HIV, one of the most severe burdens of adverse birth outcomes globally and particular vulnerability to climate change. We examined associations between seasonality and adverse birth outcomes among women with and without HIV in a large geographically representative birth outcomes surveillance study in Botswana from 2015 to 2018. METHODS We evaluated stillbirth, preterm delivery, very preterm delivery, small for gestational age (SGA), very SGA, and combined endpoints of any adverse or severe birth outcome. We estimated the risk of each outcome by month and year of delivery, and adjusted risks ratios (ARRs) of outcomes during the early wet (1 November-15 January), late wet (16 January-31 March) and early dry (1 April-15 July) seasons, compared with the late dry (16 July-31 October) season. Analyses were conducted overall and separately by HIV status. RESULTS Among 73 178 women (24% with HIV), the risk of all adverse birth outcomes peaked in November-January and reached low points in September. Compared with the late dry season, the ARRs for any adverse birth outcome were 1.03 (95% CI 1.00 to 1.06) for the early dry season, 1.08 (95% CI 1.04 to 1.11) for the early wet season and 1.07 (95% CI 1.03 to 1.10) for the late wet season. Comparing the early wet season to the late dry season, we found that ARRs for stillbirth and very preterm delivery were higher in women with HIV (1.23, 95% CI 0.96 to 1.59, and 1.33, 95% CI 1.10 to 1.62, respectively) than in women without HIV (1.07, 95% CI 0.91 to 1.26, and 1.19, 95% CI 1.04 to 1.36, respectively). CONCLUSIONS We identified a modest association between seasonality and adverse birth outcomes in Botswana, which was greatest among women with HIV. Understanding seasonal patterns of adverse birth outcomes and the role of HIV status may allow for mitigation of their impact in the face of seasonal extremes related to climate change.
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Affiliation(s)
- Ellen C Caniglia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jasmyn Abrams
- Department of Population Health, NYU Langone Health, New York, New York, USA
| | - Modiegi Diseko
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Gloria Mayondi
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Judith Mabuta
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Joseph Makhema
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Mompati Mmalane
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Shahin Lockman
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Infectious Disease, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Aaron Bernstein
- Immunology and Infectious Diseases, Center for Climate, Health, and the Global Environment, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Rebecca Zash
- Department of Infectious Diseases, BIDMC, Boston, Massachusetts, USA
| | - Roger Shapiro
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Immunology and Infectious Diseases, Center for Climate, Health, and the Global Environment, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Khan MR, Ban K, Caniglia EC, Edelman JE, Gaither J, Crystal S, Chichetto NE, Young KE, Tate J, Justice AC, Braithwaite RS. Brief original report: Does smoking status provide information relevant to screening for other substance use among US adults? Prev Med Rep 2021; 23:101483. [PMID: 34345578 PMCID: PMC8319511 DOI: 10.1016/j.pmedr.2021.101483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 06/25/2021] [Accepted: 07/03/2021] [Indexed: 11/02/2022] Open
Abstract
We assessed whether tobacco screening provides clinically meaningful information about other substance use, including alcohol and other drug use, potentially facilitating targeting of screening for substance use. Using data from the Veterans Aging Cohort Study survey sample (VACS; N = 7510), we calculated test performance characteristics of tobacco use screening results for identification of other substance use including sensitivity, specificity, positive-likelihood-ratio (+LR = [sensitivity/(1-specificity)]: increase in odds of substance use informed by a positive tobacco screen), and negative-likelihood-ratio (-LR: [(1-sensitivity)/specificity]: reduction in odds of substance use informed by a negative tobacco screen). The sample was 95% male, 75% minority, and 43% were current and 33% were former smokers. Never smoking, versus any history, indicated an approximate four-fold decrease in the odds of injection drug use (-LR = 0.26), an approximate 2.5-fold decrease in crack/cocaine (-LR = 0.35) and unhealthy alcohol use (-LR = 0.40), an approximate two-fold decrease in marijuana (-LR = 0.51) and illicit opioid use (-LR = 0.48), and an approximate 30% decrease in non-crack/cocaine stimulant use (-LR = 0.75). Never smoking yielded more information than current non-smoking (never/former smoking). Positive results on tobacco screening were less informative than negative results; current smoking, versus former/never smoking, provided more information than lifetime smoking and was associated with a 40% increase in the odds of non-crack/cocaine stimulant use (+LR = 1.40) and opioid use (+LR = 1.44), 50% increase in marijuana use (+LR = 1.52) and injection drug use (+LR = 1.55), and an 80-90% increase in crack/cocaine use (+LR = 1.93) and unhealthy alcohol use (+LR = 1.75). When comprehensive screening for substance use is not possible, tobacco screening may inform decisions about targeting substance use screening.
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Affiliation(s)
- Maria R Khan
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States
| | - Kaoon Ban
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States
| | - Ellen C Caniglia
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States
| | - Jennifer E Edelman
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Julie Gaither
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, United States
| | - Stephen Crystal
- Center for Health Services Research on Pharmacotherapy, Chronic Disease Management, and Outcomes, Institute for Health, Health Care Policy and Aging Research, Rutgers University, The State University of New Jersey, New Brunswick, NJ, United States
| | - Natalie E Chichetto
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Kailyn E Young
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States
| | - Janet Tate
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Amy C Justice
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States.,VA Connecticut Healthcare System, West Haven, CT, United States
| | - R Scott Braithwaite
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States
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Barnard-Mayers R, Childs E, Corlin L, Caniglia EC, Fox MP, Donnelly JP, Murray EJ. Assessing knowledge, attitudes, and practices towards causal directed acyclic graphs: a qualitative research project. Eur J Epidemiol 2021; 36:659-667. [PMID: 34114186 PMCID: PMC8609501 DOI: 10.1007/s10654-021-00771-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 06/04/2021] [Indexed: 10/21/2022]
Abstract
Causal graphs provide a key tool for optimizing the validity of causal effect estimates. Although a large literature exists on the mathematical theory underlying the use of causal graphs, less literature exists to aid applied researchers in understanding how best to develop and use causal graphs in their research projects. We sought to understand why researchers do or do not regularly use DAGs by surveying practicing epidemiologists and medical researchers on their knowledge, level of interest, attitudes, and practices towards the use of causal graphs in applied epidemiology and health research. We used Twitter and the Society for Epidemiologic Research to disseminate the survey. Overall, a majority of participants reported being comfortable with using causal graphs and reported using them 'sometimes', 'often', or 'always' in their research. Having received training appeared to improve comprehension of the assumptions displayed in causal graphs. Many of the respondents who did not use causal graphs reported lack of knowledge as a barrier to using DAGs in their research. Causal graphs are of interest to epidemiologists and medical researchers, but there are several barriers to their uptake. Additional training and clearer guidance are needed. In addition, methodological developments regarding visualization of effect measure modification and interaction on causal graphs is needed.
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Affiliation(s)
- Ruby Barnard-Mayers
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, 02118, USA.
| | - Ellen Childs
- Division of Health and Environment, Abt Associates, Cambridge, MA, USA
| | - Laura Corlin
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Ellen C Caniglia
- Department of Population Health, School of Medicine, New York University, New York, NY, USA
| | - Matthew P Fox
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, 02118, USA
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - John P Donnelly
- Department of Learning Health Sciences, School of Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Eleanor J Murray
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, 02118, USA
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21
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Caniglia EC, Murray EJ, Hernán MA, Shahn Z. Estimating optimal dynamic treatment strategies under resource constraints using dynamic marginal structural models. Stat Med 2021; 40:4996-5005. [PMID: 34184763 DOI: 10.1002/sim.9107] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 03/23/2021] [Accepted: 06/06/2021] [Indexed: 11/07/2022]
Abstract
Methods for estimating optimal treatment strategies typically assume unlimited access to resources. However, when a health system has resource constraints, such as limited funds, access to medication, or monitoring capabilities, medical decisions must account for competition between individuals in resource usage. The problem of incorporating resource constraints into optimal treatment strategies has been solved for point exposures (1), that is, treatment strategies entailing a decision at just one time point. However, attempts to directly generalize the point exposure solution to dynamic time-varying treatment strategies run into complications. We sidestep these complications by targeting the optimal strategy within a clinically defined subclass. Our approach is to employ dynamic marginal structural models to estimate (counterfactual) resource usage under the class of candidate treatment strategies and solve a constrained optimization problem to choose the optimal strategy for which expected resource usage is within acceptable limits. We apply this method to determine the optimal dynamic monitoring strategy for people living with HIV when resource limits on monitoring exist using observational data from the HIV-CAUSAL Collaboration.
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Affiliation(s)
- Ellen C Caniglia
- Department of Population Health, New York University School of Medicine, New York, USA
| | - Eleanor J Murray
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Miguel A Hernán
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Zach Shahn
- IBM Research, Yorktown Heights, New York, USA.,MIT-IBM Watson AI Lab, Cambridge, Massachusetts, USA
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22
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Zash R, Caniglia EC, Diseko M, Mayondi G, Mabuta J, Luckett R, Hofmeyr GJ, Morroni C, Ramogola‐Masire D, Williams PL, Zera C, Wylie BJ, Makhema J, Lockman S, Shapiro RL. Maternal weight and birth outcomes among women on antiretroviral treatment from conception in a birth surveillance study in Botswana. J Int AIDS Soc 2021; 24:e25763. [PMID: 34176240 PMCID: PMC8236225 DOI: 10.1002/jia2.25763] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 05/13/2021] [Accepted: 05/25/2021] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Antiretrovirals such as dolutegravir (DTG) and tenofovir alafenamide (TAF) have been associated with excessive weight gain. The objective of this study was to understand the potential impact of ART-associated weight gain on pregnancy outcomes among women living with HIV. METHODS Using data from the Tsepamo birth outcomes surveillance study in Botswana, we evaluated the relationship between maternal weight (and weight gain) and severe birth outcomes (very preterm delivery <32 weeks, very small for gestational age (SGA) <3rd percentile, perinatal death), macrosomia (birthweight > 4000 g) and maternal hypertension. We estimated the relative risk of each outcome by baseline weight (first weight in pregnancy <24 weeks) and second trimester average weekly weight gain (kg/week from 12 ± 2 to 24 ± 2 weeks) using log binomial regression and evaluated effect modification by ART regimen (DTG vs. Efavirenz (EFV)). RESULTS Of 22,828 women on ART at conception with singleton deliveries between August 2014 and April 2020, 16,300 (71.4%) had a weight measured <24 weeks' gestation (baseline weight) and 4437 (19.2%) had weight measured both at 12 (±2) weeks and 24 (±2) weeks, allowing second trimester weight gain calculation. Compared to women with baseline weight 60 to 70 kg, low baseline weight (<50 kg) was associated with increased risk of very preterm delivery (aRR 1.30, 95% CI 1.03, 1.65) and very SGA (aRR1.96, 95% CI 1.69, 2.28). High baseline weight (>90 kg) was associated with increased risk of macrosomia (aRR 3.24, 95% CI 2.36, 4.44) and maternal hypertension (aRR 1.79, 95% CI 1.62, 1.97). Baseline weight was not associated with stillbirth or early neonatal death. For all outcomes, second trimester weight gain showed weaker associations than did baseline weight. Duration of pre-pregnancy ART (years) was associated with higher baseline weight for DTG but not for EFV, and the risk of maternal hypertension by baseline weight category was higher for DTG than EFV for all strata. CONCLUSIONS ART regimens associated with weight gain may reduce the number of women at risk for certain severe adverse pregnancy outcomes associated with low weight but increase the number at risk of macrosomia and maternal hypertension. Further research could determine whether weight-based ART treatment strategies improve maternal and child health.
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Affiliation(s)
- Rebecca Zash
- Beth Israel Deaconess Medical CenterBostonMAUSA
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
- Harvard T.H. Chan School of Public HealthBostonMAUSA
| | | | - Modiegi Diseko
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
| | - Gloria Mayondi
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
| | - Judith Mabuta
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
| | - Rebecca Luckett
- Beth Israel Deaconess Medical CenterBostonMAUSA
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
- University of BotswanaGaboroneBotswana
| | | | - Chelsea Morroni
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
- Liverpool School of Tropical MedicineLiverpoolUK
| | | | | | - Chloe Zera
- Beth Israel Deaconess Medical CenterBostonMAUSA
| | | | - Joseph Makhema
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
| | - Shahin Lockman
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
- Harvard T.H. Chan School of Public HealthBostonMAUSA
- Brigham and Women’s HospitalBostonMAUSA
| | - Roger L Shapiro
- Botswana‐Harvard AIDS Institute PartnershipGaboroneBotswana
- Liverpool School of Tropical MedicineLiverpoolUK
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23
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Braithwaite RS, Ban KF, Stevens ER, Caniglia EC. Rounding up the usual suspects: confirmation bias in epidemiological research. Int J Epidemiol 2021; 50:1053-1057. [PMID: 33928375 PMCID: PMC8407862 DOI: 10.1093/ije/dyab091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Kaoon Francois Ban
- Department of Population Health, NYU School of Medicine, New York, NY, USA
| | | | - Ellen C Caniglia
- Department of Population Health, NYU School of Medicine, New York, NY, USA
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Caniglia EC, Shapiro R, Diseko M, Wylie BJ, Zera C, Davey S, Isaacson A, Mayondi G, Mabuta J, Luckett R, Makhema J, Mmalane M, Lockman S, Zash R. Weight gain during pregnancy among women initiating dolutegravir in Botswana. EClinicalMedicine 2020; 29-30:100615. [PMID: 33437946 PMCID: PMC7788432 DOI: 10.1016/j.eclinm.2020.100615] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 10/02/2020] [Accepted: 10/13/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Recent data suggests clinically significant weight gain among non-pregnant HIV-positive adults after starting dolutegravir-based ART (DTG). Excess or insufficient weight gain in pregnancy could adversely impact pregnancy outcomes, but data for pregnant women receiving DTG are limited. METHODS The Tsepamo Study captured data at delivery sites in Botswana from 2014 to 2019. HIV testing, HIV treatment information, and weight measurements during antenatal care were abstracted from the maternity obstetric record at delivery. HIV-positive women initiating DTG or efavirenz-based ART (EFV) between conception and 17 weeks gestation and HIV-uninfected women first presenting for antenatal care before 17 weeks gestation were included. We evaluated weekly weight gain, total 18-week weight gain, excess weight gain (>0.59 kg/week), insufficient weight gain (<0.18 kg/week), and weight loss between 18±2 and 36±2 weeks gestation, adjusting for demographic and clinical variables. FINDINGS Baseline characteristics were similar by exposure group, including pre-pregnancy and early pregnancy weight. Compared with EFV, mean weekly weight gain between 18 and 36 weeks gestation was 0.05 (95% CI 0.03, 0.07) kg/week higher for women initiating DTG and 0.12 (0.10, 0.14) kg/week higher for HIV-uninfected women. Mean 18-week weight gain was 1.05 (95% CI 0.61, 1.49) kg higher for women initiating DTG and 2.31 (1.85, 2.77) kg higher for HIV-uninfected women, compared with EFV. Women initiating DTG were more likely to gain excess weight but less likely to gain insufficient weight or lose weight than women initiating EFV. INTERPRETATION Women initiating DTG compared with EFV during pregnancy gained more weight between 18 and 36 weeks gestation. Neither group gained as much weight as HIV-uninfected women. Initiating DTG compared with EFV during pregnancy could increase the risk of excess weight gain but decrease the risk of insufficient weight gain and weight loss, which could have positive and negative consequences in pregnancy. Our findings are consistent with prior studies in non-pregnant adults.
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Affiliation(s)
- Ellen C. Caniglia
- Department of Population Health, New York University School of Medicine, New York, United States
- Harvard T.H. Chan School of Public Health, Boston, United States
| | - Roger Shapiro
- Harvard T.H. Chan School of Public Health, Boston, United States
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Modiegi Diseko
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Blair J. Wylie
- Beth Israel Deaconess Medical Center, Boston, United States
| | - Chloe Zera
- Beth Israel Deaconess Medical Center, Boston, United States
| | - Sonya Davey
- University of Pennsylvania Perelman School of Medicine, Philadelphia, United States
| | | | - Gloria Mayondi
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Judith Mabuta
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | - Joseph Makhema
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Mompati Mmalane
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Shahin Lockman
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Brigham and Women's Hospital, Boston, United States
| | - Rebecca Zash
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Beth Israel Deaconess Medical Center, Boston, United States
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Caniglia EC, Stevens ER, Khan M, Young KE, Ban K, Marshall BDL, Chichetto NE, Gaither JR, Crystal S, Edelman EJ, Fiellin DA, Gordon AJ, Bryant KJ, Tate J, Justice AC, Braithwaite RS. Does Reducing Drinking in Patients with Unhealthy Alcohol Use Improve Pain Interference, Use of Other Substances, and Psychiatric Symptoms? Alcohol Clin Exp Res 2020; 44:2257-2265. [PMID: 33030753 DOI: 10.1111/acer.14455] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/27/2020] [Accepted: 09/01/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND We aimed to investigate the impact of reducing drinking in patients with unhealthy alcohol use on improvement of chronic pain interference, substance use, and psychiatric symptoms. METHODS We analyzed longitudinal data from 2003 to 2015 in the Veterans Aging Cohort Study, a prospective, multisite observational study of US veterans, by emulating a hypothetical randomized trial (a target trial). Alcohol use was assessed using the Alcohol Use Disorders Identification Test (AUDIT) questionnaire, and outcome conditions were assessed via validated survey items. Individuals were followed from the first time their AUDIT score was ≥ 8 (baseline), a threshold consistent with unhealthy alcohol use. We compared individuals who reduced drinking (AUDIT < 8) at the next follow-up visit with individuals who did not (AUDIT ≥ 8). We fit separate logistic regression models to estimate odds ratios for improvement of each condition 2 years postbaseline among individuals who had that condition at baseline: moderate or severe pain interference symptoms, tobacco smoking, cannabis use, cocaine use, depressive symptoms, and anxiety symptoms. Inverse probability weighting was used to account for potential selection bias and confounding. RESULTS Adjusted 2-year odds ratios (95% confidence intervals) for associations between reducing drinking and improvement or resolution of each condition were as follows: 1.49 (0.91, 2.42) for pain interference symptoms, 1.57 (0.93, 2.63) for tobacco smoking, 1.65 (0.92, 2.95) for cannabis use, 1.83 (1.03, 3.27) for cocaine use, 1.11 (0.64, 1.92) for depressive symptoms, and 1.33 (0.80, 2.22) for anxiety symptoms. CONCLUSIONS We found some evidence for improvement of pain interference symptoms and substance use after reducing drinking among US veterans with unhealthy alcohol use, but confidence intervals were wide.
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Affiliation(s)
- Ellen C Caniglia
- From the, Department of Population Health, (ECC, ERS, MK, KEY, KB, RSB), NYU School of Medicine, New York, New York, USA
| | - Elizabeth R Stevens
- From the, Department of Population Health, (ECC, ERS, MK, KEY, KB, RSB), NYU School of Medicine, New York, New York, USA
| | - Maria Khan
- From the, Department of Population Health, (ECC, ERS, MK, KEY, KB, RSB), NYU School of Medicine, New York, New York, USA
| | - Kailyn E Young
- From the, Department of Population Health, (ECC, ERS, MK, KEY, KB, RSB), NYU School of Medicine, New York, New York, USA
| | - Kaoon Ban
- From the, Department of Population Health, (ECC, ERS, MK, KEY, KB, RSB), NYU School of Medicine, New York, New York, USA
| | - Brandon D L Marshall
- Department of Epidemiology, (BDLM), Brown University School of Public Health, Providence, Rhode Island, USA
| | | | - Julie R Gaither
- Yale School of Medicine, (JRG, EJE,DAF,JT,ACJ), New Haven, Connecticut, USA
| | - Stephen Crystal
- Rutgers School of Social Work, (SC), New Brunswick, New Jersey, USA
| | | | - David A Fiellin
- Yale School of Medicine, (JRG, EJE,DAF,JT,ACJ), New Haven, Connecticut, USA
| | - Adam J Gordon
- School of Medicine, (AJG), University of Utah, Salt Lake City, Utah, USA
| | | | - Janet Tate
- Yale School of Medicine, (JRG, EJE,DAF,JT,ACJ), New Haven, Connecticut, USA
| | - Amy C Justice
- Yale School of Medicine, (JRG, EJE,DAF,JT,ACJ), New Haven, Connecticut, USA
| | - Ronald Scott Braithwaite
- From the, Department of Population Health, (ECC, ERS, MK, KEY, KB, RSB), NYU School of Medicine, New York, New York, USA
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Murray EJ, Farland LV, Caniglia EC, Dorans KS, DuPre NC, Hughes KC, Kim IY, Pernar CH, Tanz LJ, Zack RM. IS THIS A PORTRAIT OF JOHN GRAUNT? AN ART HISTORY MYSTERY. Am J Epidemiol 2020; 189:1204-1207. [PMID: 31576411 DOI: 10.1093/aje/kwz212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 04/05/2020] [Accepted: 04/06/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- Eleanor J Murray
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA
| | - Leslie V Farland
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ
| | - Ellen C Caniglia
- NYU School of Medicine Department of Population Health, New York, NY
| | - Kirsten S Dorans
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA
| | - Natalie C DuPre
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
- Channing Division of Network Medicine, Brigham & Women’s Hospital, Boston, MA
- Department of Epidemiology and Population Health, University of Louisville School of Public Health and Information Sciences, Louisville, KY
| | - Katherine C Hughes
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Iris Y Kim
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
- Nuffield Department of Population Health, Big Data Institute, University of Oxford, Oxford, United Kingdom
| | - Claire H Pernar
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Lauren J Tanz
- Division of Women’s Health, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Rachel M Zack
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
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Caniglia EC, Rojas-Saunero LP, Hilal S, Licher S, Logan R, Stricker B, Ikram MA, Swanson SA. Emulating a target trial of statin use and risk of dementia using cohort data. Neurology 2020; 95:e1322-e1332. [PMID: 32753444 DOI: 10.1212/wnl.0000000000010433] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 03/16/2020] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Observational data can be used to attempt to emulate a target trial of statin use and estimate analogues of intention-to-treat and per protocol effects on dementia risk. METHODS Using data from a prospective cohort study in the Netherlands, we conceptualized a sequence of "trials" in which eligible individuals ages 55-80 years were classified as statin initiators or noninitiators for every consecutive month between 1993 and 2007 and were followed until diagnosis of dementia, death, loss to follow-up, or the end of follow-up. We estimated 2 types of effects of statin use on dementia and a combined endpoint of dementia or death: the effect of initiation vs no initiation and the effect of sustained use vs no use. We estimated risk by statin treatment strategy over time via pooled logistic regression. We used inverse-probability weighting to account for treatment-confounder feedback in estimation of per-protocol effects. RESULTS Of 233,526 eligible person-trials (6,373 individuals), there were 622 initiators and 232,904 noninitiators. Comparing statin initiation with no initiation, the 10-year risk differences (95% confidence interval) were -0.1% (-2.3% to 1.8%) for dementia and 0.3% (-2.7% to 3.3%) for dementia or death. Comparing sustained statin use vs no use, the 10-year risk differences were -2.2% (-5.2% to 1.6%) for dementia and -5.1% (-10.5% to -1.1%) for dementia or death. CONCLUSIONS Individuals with sustained statin use, but not statin initiation alone, had reduced 10-year risks of dementia and dementia or death. Our results should be interpreted with caution due to the small number of initiators and events and potential for residual confounding.
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Affiliation(s)
- Ellen C Caniglia
- From the Department of Population Health (E.C.C.), New York University School of Medicine, New York; Departments of Epidemiology (L.P.R.-S., S.H., S.L., B.S., M.A.I., S.A.S.) and Radiology and Nuclear Medicine (S.H.), Erasmus MC-University Medical Center Rotterdam, the Netherlands; and Department of Epidemiology (E.C.C., R.L., S.A.S.), Harvard T.H. Chan School of Public Health, Boston, MA. S. Hilal is presently at Saw Swee Hock School of Public Health, National University of Singapore.
| | - L Paloma Rojas-Saunero
- From the Department of Population Health (E.C.C.), New York University School of Medicine, New York; Departments of Epidemiology (L.P.R.-S., S.H., S.L., B.S., M.A.I., S.A.S.) and Radiology and Nuclear Medicine (S.H.), Erasmus MC-University Medical Center Rotterdam, the Netherlands; and Department of Epidemiology (E.C.C., R.L., S.A.S.), Harvard T.H. Chan School of Public Health, Boston, MA. S. Hilal is presently at Saw Swee Hock School of Public Health, National University of Singapore
| | - Saima Hilal
- From the Department of Population Health (E.C.C.), New York University School of Medicine, New York; Departments of Epidemiology (L.P.R.-S., S.H., S.L., B.S., M.A.I., S.A.S.) and Radiology and Nuclear Medicine (S.H.), Erasmus MC-University Medical Center Rotterdam, the Netherlands; and Department of Epidemiology (E.C.C., R.L., S.A.S.), Harvard T.H. Chan School of Public Health, Boston, MA. S. Hilal is presently at Saw Swee Hock School of Public Health, National University of Singapore
| | - Silvan Licher
- From the Department of Population Health (E.C.C.), New York University School of Medicine, New York; Departments of Epidemiology (L.P.R.-S., S.H., S.L., B.S., M.A.I., S.A.S.) and Radiology and Nuclear Medicine (S.H.), Erasmus MC-University Medical Center Rotterdam, the Netherlands; and Department of Epidemiology (E.C.C., R.L., S.A.S.), Harvard T.H. Chan School of Public Health, Boston, MA. S. Hilal is presently at Saw Swee Hock School of Public Health, National University of Singapore
| | - Roger Logan
- From the Department of Population Health (E.C.C.), New York University School of Medicine, New York; Departments of Epidemiology (L.P.R.-S., S.H., S.L., B.S., M.A.I., S.A.S.) and Radiology and Nuclear Medicine (S.H.), Erasmus MC-University Medical Center Rotterdam, the Netherlands; and Department of Epidemiology (E.C.C., R.L., S.A.S.), Harvard T.H. Chan School of Public Health, Boston, MA. S. Hilal is presently at Saw Swee Hock School of Public Health, National University of Singapore
| | - Bruno Stricker
- From the Department of Population Health (E.C.C.), New York University School of Medicine, New York; Departments of Epidemiology (L.P.R.-S., S.H., S.L., B.S., M.A.I., S.A.S.) and Radiology and Nuclear Medicine (S.H.), Erasmus MC-University Medical Center Rotterdam, the Netherlands; and Department of Epidemiology (E.C.C., R.L., S.A.S.), Harvard T.H. Chan School of Public Health, Boston, MA. S. Hilal is presently at Saw Swee Hock School of Public Health, National University of Singapore
| | - M Arfan Ikram
- From the Department of Population Health (E.C.C.), New York University School of Medicine, New York; Departments of Epidemiology (L.P.R.-S., S.H., S.L., B.S., M.A.I., S.A.S.) and Radiology and Nuclear Medicine (S.H.), Erasmus MC-University Medical Center Rotterdam, the Netherlands; and Department of Epidemiology (E.C.C., R.L., S.A.S.), Harvard T.H. Chan School of Public Health, Boston, MA. S. Hilal is presently at Saw Swee Hock School of Public Health, National University of Singapore
| | - Sonja A Swanson
- From the Department of Population Health (E.C.C.), New York University School of Medicine, New York; Departments of Epidemiology (L.P.R.-S., S.H., S.L., B.S., M.A.I., S.A.S.) and Radiology and Nuclear Medicine (S.H.), Erasmus MC-University Medical Center Rotterdam, the Netherlands; and Department of Epidemiology (E.C.C., R.L., S.A.S.), Harvard T.H. Chan School of Public Health, Boston, MA. S. Hilal is presently at Saw Swee Hock School of Public Health, National University of Singapore
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Stevens ER, Mazumdar M, Caniglia EC, Khan MR, Young KE, Edelman EJ, Gordon AJ, Fiellin DA, Maisto SA, Chichetto NE, Crystal S, Gaither JR, Justice AC, Braithwaite RS. Insights Provided by Depression Screening Regarding Pain, Anxiety, and Substance use in a Veteran Population. J Prim Care Community Health 2020; 11:2150132720949123. [PMID: 32772883 PMCID: PMC7418233 DOI: 10.1177/2150132720949123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: We sought to quantify the extent to which a depression screening instrument commonly used in primary care settings provides additional information regarding pain interference symptoms, anxiety, and substance use. Methods: Veterans Aging Cohort Study (VACS) data collected from 2003 through 2015 was used to calculate odds ratios (OR) for associations between positive depression screening result cutoffs and clustering conditions. We assessed the test performance characteristics (likelihood ratio value, positive predictive value, and the percentage of individuals correctly classified) of a positive Patient Health Questionnaire (PHQ-9 & PHQ-2) depression screen for the identification of pain interference symptoms, anxiety, and substance use. Results: A total 7731 participants were included in the analyses. The median age was 50 years. The PHQ-9 threshold of ≥20 was strongly associated with pain interference symptoms (OR 21.6, 95% CI 17.5-26.7) and anxiety (OR 72.1, 95% CI 52.8-99.0) and yielded likelihood ratio values of 7.5 for pain interference symptoms and 21.8 for anxiety and positive predictive values (PPV) of 84% and 95%, respectively. A PHQ-9 score of ≥10 still showed significant associations with pain interference symptoms (OR 6.1, 95% CI 5.4-6.9) and symptoms of anxiety (OR 11.3, 95% CI 9.7-13.1) and yet yielded lower likelihood ratio values (4.36 & 8.24, respectively). The PHQ-9 was less strongly associated with various forms of substance use. Conclusion: Depression screening provides substantial additional information regarding the likelihood of pain interference symptoms and anxiety and should trigger diagnostic assessments for these other conditions.
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Feelemyer J, Dyer TV, Turpin RE, Brewer RA, Hucks-Oritz C, van Der Mei WF, Cleland CM, Mazumdar M, Caniglia EC, Geller A, Scheidell JD, Feldman JM, Mayer KH, Khan MR. Longitudinal associations between the disruption of incarceration and community re-entry on substance use risk escalation among Black men who have sex with men; A causal analysis. Drug Alcohol Depend 2020; 213:108123. [PMID: 32593152 PMCID: PMC8059073 DOI: 10.1016/j.drugalcdep.2020.108123] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/29/2020] [Accepted: 06/04/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND AIMS While substance use can lead to incarceration, the disruptive effects of incarceration may lead to, or increase psychosocial vulnerability and substance use. Using causal inference methods, we measured longitudinal associations between incarceration and post-release substance use among Black men who have sex with men (BMSM), populations facing disproportionate risk of incarceration and substance use. METHODS Using data from the HIV Prevention Trials Network (HPTN 061) study (N = 1553) we estimated associations between past 6-month incarceration and binge drinking, marijuana use, and stimulant use post release (at 12-month follow-up visit). Adjusted models used inverse probability weighting (IPW) to control for baseline (pre-incarceration) substance use and additional risk factors. RESULTS There were 1133 participants present at the twelve-month follow-up visit. Participants were predominately non-Hispanic Blacks and unemployed. At baseline, 60.1 % reported a lifetime history of incarceration, 22.9 % were HIV positive and 13.7 % had a history of an STI infection. A total of 43 % reported a history of depression. In adjusted analyses with IPW, recent incarceration was associated with crack-cocaine (adjusted odds ratio (AOR): 1.53, 95 % confidence interval (CI): 1.03, 2.23) and methamphetamine use (AOR: 1.52, 95 % CI: 0.94-2.45). Controlling for pre-incarceration binge drinking, incarceration was associated with post-release binge drinking (AOR: 1.47, 95 % CI: 1.05, 2.04); in fully adjusted models the AOR was 1.14 (95 % CI: 0.81, 1.62). Incarceration was not associated with marijuana use. CONCLUSION Findings underscore the need to provide substance use treatment in custody and post-release, and to consider alternatives to incarceration for substance using populations.
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Affiliation(s)
- Jonathan Feelemyer
- New York University Grossmna School of Medicine, Department of Population Health, New York, NY, United States.
| | - Typhanye V Dyer
- Department of Epidemiology and Biostatistics, University of Maryland School of Public Health, College Park, MD, United States
| | - Rodman E Turpin
- Department of Epidemiology and Biostatistics, University of Maryland School of Public Health, College Park, MD, United States
| | - Russell A Brewer
- Department of Medicine, University of Chicago, Chicago, IL, United States
| | | | - Willem F van Der Mei
- New York University Grossmna School of Medicine, Department of Population Health, New York, NY, United States
| | - Charles M Cleland
- New York University Grossmna School of Medicine, Department of Population Health, New York, NY, United States
| | - Medha Mazumdar
- New York University Grossmna School of Medicine, Department of Population Health, New York, NY, United States
| | - Ellen C Caniglia
- New York University Grossmna School of Medicine, Department of Population Health, New York, NY, United States
| | - Amanda Geller
- Department of Sociology, New York University, New York, NY, United States
| | - Joy D Scheidell
- New York University Grossmna School of Medicine, Department of Population Health, New York, NY, United States
| | - Justin M Feldman
- New York University Grossmna School of Medicine, Department of Population Health, New York, NY, United States
| | - Kenneth H Mayer
- Fenway Health and Harvard Medical School, Boston, MA, United States
| | - Maria R Khan
- New York University Grossmna School of Medicine, Department of Population Health, New York, NY, United States
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30
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Khan MR, Young KE, Caniglia EC, Fiellin DA, Maisto SA, Marshall BDL, Edelman EJ, Gaither JR, Chichetto NE, Tate J, Bryant KJ, Severe M, Stevens ER, Justice A, Braithwaite SR. Association of Alcohol Screening Scores With Adverse Mental Health Conditions and Substance Use Among US Adults. JAMA Netw Open 2020; 3:e200895. [PMID: 32163167 PMCID: PMC7068229 DOI: 10.1001/jamanetworkopen.2020.0895] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE Alcohol screening may be associated with health outcomes that cluster with alcohol use (ie, alcohol-clustering conditions), including depression, anxiety, and use of tobacco, marijuana, and illicit drugs. OBJECTIVE To quantify the extent to which alcohol screening provides additional information regarding alcohol-clustering conditions and to compare 2 alcohol use screening tools commonly used for this purpose. DESIGN, SETTING, AND PARTICIPANTS This longitudinal cohort study used data from the Veterans Aging Cohort Study. Data were collected at 8 Veterans Health Administration facilities from 2003 through 2012. A total of 7510 participants were enrolled, completed a baseline survey, and were followed up. Veterans with HIV were matched with controls without HIV by age, race, sex, and site of care. Data were analyzed from January 2019 to December 2019. EXPOSURES The Alcohol Use Disorders Identification Test (AUDIT) and Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) were used to assess alcohol use, with 4 risk groups delineated for each test: score 0 to 7 (reference), score 8 to 15, score 16 to 19, and score 20 to 40 (maximum score) for the full AUDIT and score 0 to 3 (reference), score 4 to 5, score 6 to 7, and score 8 to 12 (maximum score) for the AUDIT-C. MAIN OUTCOMES AND MEASURES Alcohol-clustering conditions, including self-reported symptoms of depression and anxiety and use of tobacco, marijuana, cocaine, other stimulants, opioids, and injection drugs. RESULTS A total of 6431 US patients (6104 [95%] men; median age during survey years 2003-2004, 50 years [range, 28-86 years; interquartile range, 44-55 years]) receiving care in the Veterans Health Administration completed 1 or more follow-up surveys when the AUDIT was administered and were included in the present analyses. Of the male participants, 4271 (66%) were African American, 1498 (24%) were white, and 590 (9%) were Hispanic. The AUDIT and AUDIT-C scores were associated with each alcohol-clustering condition. In particular, an AUDIT score of 20 or higher (vs <8, the reference) was associated with symptoms of depression (odds ratio [OR], 8.37; 95% CI, 6.20-11.29) and anxiety (OR, 8.98; 95% CI, 6.39-12.60) and with self-reported use of tobacco (OR, 14.64; 95% CI, 8.94-23.98), marijuana (OR, 12.41; 95% CI, 8.61-17.90), crack or cocaine (OR, 39.47; 95% CI, 27.38-56.90), other stimulants (OR, 21.31; 95% CI, 12.73-35.67), and injection drugs (OR, 8.67; 95% CI, 5.32-14.13). An AUDIT score of 20 or higher yielded likelihood ratio (sensitivity / 1 - specificity) values greater than 3.5 for depression, anxiety, crack or cocaine use, and other stimulant use. Associations between AUDIT-C scores and alcohol-clustering conditions were more modest. CONCLUSIONS AND RELEVANCE Alcohol screening can inform decisions about further screening and diagnostic assessment for alcohol-clustering conditions, particularly for depression, anxiety, crack or cocaine use, and other stimulant use. Future studies using clinical diagnoses rather than screening tools to assess alcohol-clustering conditions may be warranted.
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Affiliation(s)
- Maria R. Khan
- Department of Population Health, New York University School of Medicine, New York
| | - Kailyn E. Young
- Department of Population Health, New York University School of Medicine, New York
| | - Ellen C. Caniglia
- Department of Population Health, New York University School of Medicine, New York
| | - David A. Fiellin
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | | | - E. Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Julie R. Gaither
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Natalie E. Chichetto
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Janet Tate
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - MacRegga Severe
- Department of Population Health, New York University School of Medicine, New York
| | - Elizabeth R. Stevens
- Department of Population Health, New York University School of Medicine, New York
| | - Amy Justice
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Scott R. Braithwaite
- Department of Population Health, New York University School of Medicine, New York
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31
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Emilsson L, García-Albéniz X, Logan RW, Caniglia EC, Kalager M, Hernán MA. Examining Bias in Studies of Statin Treatment and Survival in Patients With Cancer. JAMA Oncol 2019; 4:63-70. [PMID: 28822996 DOI: 10.1001/jamaoncol.2017.2752] [Citation(s) in RCA: 117] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Patients with cancer who use statins appear to have a substantially better survival than nonusers in observational studies. However, this inverse association between statin use and mortality may be due to selection bias and immortal-time bias. Objective To emulate a randomized trial of statin therapy initiation that is free of selection bias and immortal-time bias. Design, Setting, and Participants We used observational data on 17 372 patients with cancer from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2007-2009) with complete follow-up until 2011. The SEER-Medicare database links 17 US cancer registries and claims files from Medicare and Medicaid in 12 US states. We included individuals with a new diagnosis of colorectal, breast, prostate, or bladder cancer who had not been prescribed statins for at least 6 months before the cancer diagnosis. Individuals were duplicated, and each replicate was assigned to either the strategy "statin therapy initiation within 6 months after diagnosis" or "no statin therapy initiation." Replicates were censored when they stopped following their assigned strategy, and the potential selection bias was adjusted for via inverse-probability weighting. Hazard ratios (HRs), cumulative incidences, and risk differences were calculated for all-cause mortality and cancer-specific mortality. We then compared our estimates with those obtained using the same analytic approaches used in previous observational studies. Exposures Statin therapy initiation within 6 months after cancer diagnosis. Main Outcomes and Measures Cancer-specific and all-cause mortality using SEER-Medicare data and data from previous studies. Results Of the 17 372 patients whose data were analyzed, 8440 (49%) were men, and 8932 (51%) were women (mean [SD] age, 76.4 [7.4] years; range, 66-115 years). The adjusted HR (95% CI) comparing statin therapy initiation vs no initiation was 1.00 (0.88-1.15) for cancer-specific mortality and 1.07 (0.93-1.21) for overall mortality. Cumulative incidence curves for both groups were almost overlapping (the risk difference never exceeded 0.8%). In contrast, the methods used by prior studies resulted in an inverse association between statin use and mortality (pooled hazard ratio 0.69). Conclusion and Relevance After using methods that are not susceptible to selection bias from prevalent users and to immortal time bias, we found that initiation of therapy with statins within 6 months after cancer diagnosis did not appear to improve 3-year cancer-specific or overall survival.
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Affiliation(s)
- Louise Emilsson
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Institute of Health and Society, University of Oslo, Oslo, Norway.,Primary Care Research Unit, Vårdcentralen Värmlands Nysäter, Värmland County, Sweden
| | - Xabier García-Albéniz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Roger W Logan
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Ellen C Caniglia
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Mette Kalager
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Miguel A Hernán
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Harvard-MIT Division of Health Science and Technology, Boston, Massachusetts
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32
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Caniglia EC, Zash R, Swanson SA, Wirth KE, Diseko M, Mayondi G, Lockman S, Mmalane M, Makhema J, Dryden-Peterson S, Kponee-Shovein KZ, John O, Murray EJ, Shapiro RL. Methodological Challenges When Studying Distance to Care as an Exposure in Health Research. Am J Epidemiol 2019; 188:1674-1681. [PMID: 31107529 PMCID: PMC6735874 DOI: 10.1093/aje/kwz121] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 03/08/2019] [Accepted: 03/12/2019] [Indexed: 01/27/2023] Open
Abstract
Distance to care is a common exposure and proposed instrumental variable in health research, but it is vulnerable to violations of fundamental identifiability conditions for causal inference. We used data collected from the Botswana Birth Outcomes Surveillance study between 2014 and 2016 to outline 4 challenges and potential biases when using distance to care as an exposure and as a proposed instrument: selection bias, unmeasured confounding, lack of sufficiently well-defined interventions, and measurement error. We describe how these issues can arise, and we propose sensitivity analyses for estimating the degree of bias.
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Affiliation(s)
- Ellen C Caniglia
- Department of Population Health, New York University School of Medicine, New York, New York
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Rebecca Zash
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Sonja A Swanson
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Kathleen E Wirth
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Modiegi Diseko
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Gloria Mayondi
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Shahin Lockman
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Mompati Mmalane
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Joseph Makhema
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Scott Dryden-Peterson
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | - Oaitse John
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Eleanor J Murray
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Roger L Shapiro
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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33
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Caniglia EC, Robins JM, Cain LE, Sabin C, Logan R, Abgrall S, Mugavero MJ, Hernández-Díaz S, Meyer L, Seng R, Drozd DR, Seage Iii GR, Bonnet F, Le Marec F, Moore RD, Reiss P, van Sighem A, Mathews WC, Jarrín I, Alejos B, Deeks SG, Muga R, Boswell SL, Ferrer E, Eron JJ, Gill J, Pacheco A, Grinsztejn B, Napravnik S, Jose S, Phillips A, Justice A, Tate J, Bucher HC, Egger M, Furrer H, Miro JM, Casabona J, Porter K, Touloumi G, Crane H, Costagliola D, Saag M, Hernán MA. Emulating a trial of joint dynamic strategies: An application to monitoring and treatment of HIV-positive individuals. Stat Med 2019; 38:2428-2446. [PMID: 30883859 DOI: 10.1002/sim.8120] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 01/18/2019] [Accepted: 01/19/2019] [Indexed: 12/13/2022]
Abstract
Decisions about when to start or switch a therapy often depend on the frequency with which individuals are monitored or tested. For example, the optimal time to switch antiretroviral therapy depends on the frequency with which HIV-positive individuals have HIV RNA measured. This paper describes an approach to use observational data for the comparison of joint monitoring and treatment strategies and applies the method to a clinically relevant question in HIV research: when can monitoring frequency be decreased and when should individuals switch from a first-line treatment regimen to a new regimen? We outline the target trial that would compare the dynamic strategies of interest and then describe how to emulate it using data from HIV-positive individuals included in the HIV-CAUSAL Collaboration and the Centers for AIDS Research Network of Integrated Clinical Systems. When, as in our example, few individuals follow the dynamic strategies of interest over long periods of follow-up, we describe how to leverage an additional assumption: no direct effect of monitoring on the outcome of interest. We compare our results with and without the "no direct effect" assumption. We found little differences on survival and AIDS-free survival between strategies where monitoring frequency was decreased at a CD4 threshold of 350 cells/μl compared with 500 cells/μl and where treatment was switched at an HIV-RNA threshold of 1000 copies/ml compared with 200 copies/ml. The "no direct effect" assumption resulted in efficiency improvements for the risk difference estimates ranging from an 7- to 53-fold increase in the effective sample size.
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Affiliation(s)
- Ellen C Caniglia
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Department of Population Health, School of Medicine, New York University, New York, New York
| | - James M Robins
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Lauren E Cain
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | - Roger Logan
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | - Michael J Mugavero
- School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sonia Hernández-Díaz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | | | | | - George R Seage Iii
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Fabrice Bonnet
- Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Fabien Le Marec
- Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Richard D Moore
- School of Medicine, The Johns Hopkins University, Baltimore, Maryland
| | - Peter Reiss
- Academisch Medisch Centrum Geneeskunde, Amsterdam, The Netherlands
| | - Ard van Sighem
- Academisch Medisch Centrum Geneeskunde, Amsterdam, The Netherlands
| | - William C Mathews
- Department of Medicine, University of California San Diego Health, San Diego, California
| | - Inma Jarrín
- National Center of Epidemiology, Instituto de Salud Carlos III, Madrid, Spain
| | - Belén Alejos
- National Center of Epidemiology, Instituto de Salud Carlos III, Madrid, Spain
| | - Steven G Deeks
- School of Medicine, University of California, San Francisco, San Francisco, California
| | | | | | - Elena Ferrer
- Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Joseph J Eron
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - John Gill
- Southern Alberta HIV Program, Calgary, Canada
| | | | | | - Sonia Napravnik
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | | | - Amy Justice
- School of Public Health, Yale University, New Haven, Connecticut
| | - Janet Tate
- School of Public Health, Yale University, New Haven, Connecticut
| | | | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Hansjakob Furrer
- Division of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | | | | | - Giota Touloumi
- Department of Hygiene, Epidemiology and Medical Statistics, Athens University Medical School, Athens, Greece
| | - Heidi Crane
- University of Washington, Seattle, Washington
| | | | - Michael Saag
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Miguel A Hernán
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Harvard-MIT Division of Health Sciences and Technology, Boston, Massachusetts
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Murray EJ, Caniglia EC, Swanson SA, Hernández-Díaz S, Hernán MA. Patients and investigators prefer measures of absolute risk in subgroups for pragmatic randomized trials. J Clin Epidemiol 2018; 103:10-21. [PMID: 29966732 DOI: 10.1016/j.jclinepi.2018.06.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 04/03/2018] [Accepted: 06/15/2018] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Pragmatic randomized trials are important tools for shared decision-making, but no guidance exists on patients' preferences for types of causal information. We aimed to assess preferences of patients and investigators toward causal effects in pragmatic randomized trials. STUDY DESIGN AND SETTING We (a) held three focus groups with patients (n = 23) in Boston, MA; (b) surveyed (n = 12) and interviewed (n = 5) investigators with experience conducting pragmatic trials; and (c) conducted a systematic literature review of pragmatic trials (n = 63). RESULTS Patients were distrustful of new-to-market medications unless substantially more effective than existing choices, preferred stratified absolute risks, and valued adherence-adjusted analyses when they expected to adhere. Investigators wanted both intention-to-treat and per-protocol effects but felt methods for estimating per-protocol effects were lacking. When estimating per-protocol effects, many pragmatic trials used inappropriate methods to adjust for adherence and loss to follow-up. CONCLUSION We made four recommendations for pragmatic trials to improve patient centeredness: (1) focus on superiority in effectiveness or safety, rather than noninferiority; (2) involve patients in specifying a priori subgroups; (3) report absolute measures of risk; and (4) complement intention-to-treat effect estimates with valid per-protocol effect estimates.
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Affiliation(s)
- Eleanor J Murray
- Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA.
| | - Ellen C Caniglia
- Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA
| | - Sonja A Swanson
- Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA; Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Sonia Hernández-Díaz
- Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA
| | - Miguel A Hernán
- Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA; Harvard-MIT Division of Health Sciences and Technology, Boston, MA 02139, USA
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Caniglia EC, Cain LE, Sabin CA, Robins JM, Logan R, Abgrall S, Mugavero MJ, Hernández-Díaz S, Meyer L, Seng R, Drozd DR, Seage GR, Bonnet F, Dabis F, Moore RD, Reiss P, van Sighem A, Mathews WC, Del Amo J, Moreno S, Deeks SG, Muga R, Boswell SL, Ferrer E, Eron JJ, Napravnik S, Jose S, Phillips A, Justice AC, Tate JP, Gill J, Pacheco A, Veloso VG, Bucher HC, Egger M, Furrer H, Porter K, Touloumi G, Crane H, Miro JM, Sterne JA, Costagliola D, Saag M, Hernán MA. Comparison of dynamic monitoring strategies based on CD4 cell counts in virally suppressed, HIV-positive individuals on combination antiretroviral therapy in high-income countries: a prospective, observational study. Lancet HIV 2017; 4:e251-e259. [PMID: 28411091 PMCID: PMC5492888 DOI: 10.1016/s2352-3018(17)30043-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 01/14/2017] [Accepted: 01/19/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND Clinical guidelines vary with respect to the optimal monitoring frequency of HIV-positive individuals. We compared dynamic monitoring strategies based on time-varying CD4 cell counts in virologically suppressed HIV-positive individuals. METHODS In this observational study, we used data from prospective studies of HIV-positive individuals in Europe (France, Greece, the Netherlands, Spain, Switzerland, and the UK) and North and South America (Brazil, Canada, and the USA) in The HIV-CAUSAL Collaboration and The Centers for AIDS Research Network of Integrated Clinical Systems. We compared three monitoring strategies that differ in the threshold used to measure CD4 cell count and HIV RNA viral load every 3-6 months (when below the threshold) or every 9-12 months (when above the threshold). The strategies were defined by the threshold CD4 counts of 200 cells per μL, 350 cells per μL, and 500 cells per μL. Using inverse probability weighting to adjust for baseline and time-varying confounders, we estimated hazard ratios (HRs) of death and of AIDS-defining illness or death, risk ratios of virological failure, and mean differences in CD4 cell count. FINDINGS 47 635 individuals initiated an antiretroviral therapy regimen between Jan 1, 2000, and Jan 9, 2015, and met the eligibility criteria for inclusion in our study. During follow-up, CD4 cell count was measured on average every 4·0 months and viral load every 3·8 months. 464 individuals died (107 in threshold 200 strategy, 157 in threshold 350, and 200 in threshold 500) and 1091 had AIDS-defining illnesses or died (267 in threshold 200 strategy, 365 in threshold 350, and 459 in threshold 500). Compared with threshold 500, the mortality HR was 1·05 (95% CI 0·86-1·29) for threshold 200 and 1·02 (0·91·1·14) for threshold 350. Corresponding estimates for death or AIDS-defining illness were 1·08 (0·95-1·22) for threshold 200 and 1·03 (0·96-1·12) for threshold 350. Compared with threshold 500, the 24 month risk ratios of virological failure (viral load more than 200 copies per mL) were 2·01 (1·17-3·43) for threshold 200 and 1·24 (0·89-1·73) for threshold 350, and 24 month mean CD4 cell count differences were 0·4 (-25·5 to 26·3) cells per μL for threshold 200 and -3·5 (-16·0 to 8·9) cells per μL for threshold 350. INTERPRETATION Decreasing monitoring to annually when CD4 count is higher than 200 cells per μL compared with higher than 500 cells per μL does not worsen the short-term clinical and immunological outcomes of virally suppressed HIV-positive individuals. However, more frequent virological monitoring might be necessary to reduce the risk of virological failure. Further follow-up studies are needed to establish the long-term safety of these strategies. FUNDING National Institutes of Health.
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Affiliation(s)
- Ellen C Caniglia
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA.
| | - Lauren E Cain
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | | | - James M Robins
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA; Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Roger Logan
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Sophie Abgrall
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France; Assistance Publique-Hopitaux de Paris (AP-HP), Hopital Antoine Béclère, Service de Médecine Interne, Clamart, France
| | - Michael J Mugavero
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; UAB Center for AIDS Research, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sonia Hernández-Díaz
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Laurence Meyer
- Université Paris Sud, INSERM CESP U1018, Paris, France; AP-HP, Hopital de Bicêtre, Service de Santé Publique, le Kremlin Bicêtre, France
| | - Remonie Seng
- Université Paris Sud, INSERM CESP U1018, Paris, France; AP-HP, Hopital de Bicêtre, Service de Santé Publique, le Kremlin Bicêtre, France
| | - Daniel R Drozd
- School of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - George R Seage
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Fabrice Bonnet
- Institut de Santé Publique, d'Epidémiologie et de Développement, Université de Bordeaux, Bordeaux, France; Department of Internal Medicine, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Francois Dabis
- INSERM U897, Centre INSERM Epidémiologie et Biostatistique, Université de Bordeaux, Bordeaux, France; Department of Internal Medicine, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Richard D Moore
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Peter Reiss
- Stichting HIV Monitoring, Amsterdam, Netherlands; Academic Medical Center, Department of Global Health and Division of Infectious Diseases, University of Amsterdam, Amsterdam, Netherlands; Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
| | | | | | - Julia Del Amo
- National Centre of Epidemiology, Instituto de Salud Carlos III, Madrid, Spain; Consorcio de Investigación Biomédica de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Santiago Moreno
- Ramón y Cajal Hospital, IRYCIS, Madrid, Spain; University of Alcalá de Henares, Madrid, Spain
| | - Steven G Deeks
- Positive Health Program, San Francisco General Hospital, San Francisco, CA, USA
| | - Roberto Muga
- Servei de Medicina Interna, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Elena Ferrer
- Hospital Universitari de Bellvitge-Bellvitge Institute for Biomedical Research, Hospitalet de Llobregat, Barcelona, Spain
| | - Joseph J Eron
- Division of Infectious Diseases, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sonia Napravnik
- Division of Infectious Diseases, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | - Amy C Justice
- Yale School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA
| | - Janet P Tate
- Yale School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA
| | - John Gill
- Southern Alberta HIV Clinic, University of Calgary, Calgary, AB, Canada
| | - Antonio Pacheco
- Programa de Computação Científica, FIOCRUZ, Rio de Janeiro, Brazil
| | | | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Matthias Egger
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; University of Bern, Institute for Social and Preventive Medicine, Bern, Switzerland
| | - Hansjakob Furrer
- Department of Infectious Diseases, Bern University Hospital and University of Bern, Bern, Switzerland
| | | | - Giota Touloumi
- Department of Hygiene, Epidemiology and Medical Statistics, Athens University Medical School, Athens, Greece
| | - Heidi Crane
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Jose M Miro
- Infectious Diseases, Hospital Clinic-IDIBAPS, Barcelona, Spain
| | - Jonathan A Sterne
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Dominique Costagliola
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France
| | - Michael Saag
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Miguel A Hernán
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA; Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA, USA; Harvard-MIT Division of Health Sciences and Technology, Boston, MA, USA
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Cain LE, Caniglia EC, Phillips A, Olson A, Muga R, Pérez-Hoyos S, Abgrall S, Costagliola D, Rubio R, Jarrín I, Bucher H, Fehr J, van Sighem A, Reiss P, Dabis F, Vandenhende MA, Logan R, Robins J, Sterne JAC, Justice A, Tate J, Touloumi G, Paparizos V, Esteve A, Casabona J, Seng R, Meyer L, Jose S, Sabin C, Hernán MA. Efavirenz versus boosted atazanavir-containing regimens and immunologic, virologic, and clinical outcomes: A prospective study of HIV-positive individuals. Medicine (Baltimore) 2016; 95:e5133. [PMID: 27741139 PMCID: PMC5072966 DOI: 10.1097/md.0000000000005133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 07/26/2016] [Accepted: 07/27/2016] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To compare regimens consisting of either ritonavir-boosted atazanavir or efavirenz and a nucleoside reverse transcriptase inhibitor (NRTI) backbone with respect to clinical, immunologic, and virologic outcomes. DESIGN Prospective studies of human immunodeficiency virus (HIV)-infected individuals in Europe and the United States included in the HIV-CAUSAL Collaboration. METHODS HIV-positive, antiretroviral therapy-naive, and acquired immune deficiency syndrome (AIDS)-free individuals were followed from the time they started an atazanavir or efavirenz regimen. We estimated an analog of the "intention-to-treat" effect for efavirenz versus atazanavir regimens on clinical, immunologic, and virologic outcomes with adjustment via inverse probability weighting for time-varying covariates. RESULTS A total of 4301 individuals started an atazanavir regimen (83 deaths, 157 AIDS-defining illnesses or deaths) and 18,786 individuals started an efavirenz regimen (389 deaths, 825 AIDS-defining illnesses or deaths). During a median follow-up of 31 months, the hazard ratios (95% confidence intervals) were 0.98 (0.77, 1.24) for death and 1.09 (0.91, 1.30) for AIDS-defining illness or death comparing efavirenz with atazanavir regimens. The 5-year survival difference was 0.1% (95% confidence interval: -0.7%, 0.8%) and the AIDS-free survival difference was -0.3% (-1.2%, 0.6%). After 12 months, the mean change in CD4 cell count was 20.8 (95% confidence interval: 13.9, 27.8) cells/mm lower and the risk of virologic failure was 20% (14%, 26%) lower in the efavirenz regimens. CONCLUSION Our estimates are consistent with a smaller 12-month increase in CD4 cell count, and a smaller risk of virologic failure at 12 months for efavirenz compared with atazanavir regimens. No overall differences could be detected with respect to 5-year survival or AIDS-free survival.
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Affiliation(s)
- Lauren E. Cain
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
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Caniglia EC, Sabin C, Robins JM, Logan R, Cain LE, Abgrall S, Mugavero MJ, Hernandez-Diaz S, Meyer L, Seng R, Drozd DR, Seage GR, Bonnet F, Dabis F, Moore RR, Reiss P, van Sighem A, Mathews WC, del Amo J, Moreno S, Deeks SG, Muga R, Boswell SL, Ferrer E, Eron JJ, Napravnik S, Jose S, Phillips A, Olson A, Justice AC, Tate JP, Bucher HC, Egger M, Touloumi G, Sterne JA, Costagliola D, Saag M, Hernán MA. When to Monitor CD4 Cell Count and HIV RNA to Reduce Mortality and AIDS-Defining Illness in Virologically Suppressed HIV-Positive Persons on Antiretroviral Therapy in High-Income Countries: A Prospective Observational Study. J Acquir Immune Defic Syndr 2016; 72:214-21. [PMID: 26895294 PMCID: PMC4866894 DOI: 10.1097/qai.0000000000000956] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 12/22/2015] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To illustrate an approach to compare CD4 cell count and HIV-RNA monitoring strategies in HIV-positive individuals on antiretroviral therapy (ART). DESIGN Prospective studies of HIV-positive individuals in Europe and the USA in the HIV-CAUSAL Collaboration and The Center for AIDS Research Network of Integrated Clinical Systems. METHODS Antiretroviral-naive individuals who initiated ART and became virologically suppressed within 12 months were followed from the date of suppression. We compared 3 CD4 cell count and HIV-RNA monitoring strategies: once every (1) 3 ± 1 months, (2) 6 ± 1 months, and (3) 9-12 ± 1 months. We used inverse-probability weighted models to compare these strategies with respect to clinical, immunologic, and virologic outcomes. RESULTS In 39,029 eligible individuals, there were 265 deaths and 690 AIDS-defining illnesses or deaths. Compared with the 3-month strategy, the mortality hazard ratios (95% CIs) were 0.86 (0.42 to 1.78) for the 6 months and 0.82 (0.46 to 1.47) for the 9-12 month strategy. The respective 18-month risk ratios (95% CIs) of virologic failure (RNA >200) were 0.74 (0.46 to 1.19) and 2.35 (1.56 to 3.54) and 18-month mean CD4 differences (95% CIs) were -5.3 (-18.6 to 7.9) and -31.7 (-52.0 to -11.3). The estimates for the 2-year risk of AIDS-defining illness or death were similar across strategies. CONCLUSIONS Our findings suggest that monitoring frequency of virologically suppressed individuals can be decreased from every 3 months to every 6, 9, or 12 months with respect to clinical outcomes. Because effects of different monitoring strategies could take years to materialize, longer follow-up is needed to fully evaluate this question.
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Affiliation(s)
- Ellen C. Caniglia
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | | | - James M. Robins
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Roger Logan
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Lauren E. Cain
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Sophie Abgrall
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France
- Assistance Publique-Hopitaux de Paris (AP-HP), Hopital Antoine Béclère, Service de Médecine Interne, Clamart, France
| | | | - Sonia Hernandez-Diaz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Laurence Meyer
- Université Paris Sud, INSERM CESP U1018, and AP-HP, Hopital de Bicêtre, Service de Santé Publique, le Kremlin Bicêtre, France
| | - Remonie Seng
- Université Paris Sud, INSERM CESP U1018, and AP-HP, Hopital de Bicêtre, Service de Santé Publique, le Kremlin Bicêtre, France
| | - Daniel R. Drozd
- Division of Allergy and Infectious Diseases, School of Medicine, University of Washington, Seattle, WA
| | - George R. Seage
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Fabrice Bonnet
- Bordeaux University, ISPED, INSERM U897 CHU de Bordeaux, Bordeaux, France
| | - Francois Dabis
- INSERM U897, Centre Inserm Epidémiologie et Biostatistique, Université de Bordeaux, and Department of Internal Medicine, Bordeaux University Hospital, Bordeaux, France
| | | | - Peter Reiss
- Stichting HIV Monitoring, Amsterdam, Netherlands; Academic Medical Center, Department of Global Health and Division of Infectious Diseases, University of Amsterdam, and Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
| | | | | | - Julia del Amo
- National Centre of Epidemiology, Instituto de Salud Carlos III, Madrid, Spain; Consorcio de Investigación Biomédica de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Santiago Moreno
- Ramón y Cajal Hospital, IRYCIS, Madrid, Spain, University of Alcalá de Henares, Madrid, Spain
| | - Steven G. Deeks
- Positive Health Program, San Francisco General Hospital, San Francisco, CA
| | - Roberto Muga
- Servei de Medicina Interna, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | | | - Elena Ferrer
- Hospital Universitari de Bellvitge-Bellvitge Institute for Biomedical Research, Hospitalet de Llobregat
| | - Joseph J. Eron
- Division of Infectious Diseases, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Sonia Napravnik
- Division of Infectious Diseases, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Sophie Jose
- University College London, London, United Kingdom
| | | | - Ashley Olson
- Medical Research Council Clinical Trials Unit, University College London, London, United Kingdom
| | - Amy C. Justice
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Janet P. Tate
- Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Heiner C. Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Matthias Egger
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- University of Bern, Institute for Social and Preventive Medicine, Bern, Switzerland
| | - Giota Touloumi
- Department of Hygiene, Epidemiology and Medical Statistics, Athens University Medical School, Athens, Greece
| | - Jonathan A. Sterne
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom; and
| | - Dominique Costagliola
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France
| | - Michael Saag
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Miguel A. Hernán
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
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Caniglia EC, Hernan MA. Author response. Neurology 2015; 84:632-633. [PMID: 25811065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
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Caniglia EC, Cain LE, Justice A, Tate J, Logan R, Sabin C, Winston A, van Sighem A, Miro JM, Podzamczer D, Olson A, Arribas JR, Moreno S, Meyer L, del Romero J, Dabis F, Bucher HC, Wandeler G, Vourli G, Skoutelis A, Lanoy E, Gasnault J, Costagliola D, Hernán MA. Antiretroviral penetration into the CNS and incidence of AIDS-defining neurologic conditions. Neurology 2014; 83:134-41. [PMID: 24907236 DOI: 10.1212/wnl.0000000000000564] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The link between CNS penetration of antiretrovirals and AIDS-defining neurologic disorders remains largely unknown. METHODS HIV-infected, antiretroviral therapy-naive individuals in the HIV-CAUSAL Collaboration who started an antiretroviral regimen were classified according to the CNS Penetration Effectiveness (CPE) score of their initial regimen into low (<8), medium (8-9), or high (>9) CPE score. We estimated "intention-to-treat" hazard ratios of 4 neuroAIDS conditions for baseline regimens with high and medium CPE scores compared with regimens with a low score. We used inverse probability weighting to adjust for potential bias due to infrequent follow-up. RESULTS A total of 61,938 individuals were followed for a median (interquartile range) of 37 (18, 70) months. During follow-up, there were 235 cases of HIV dementia, 169 cases of toxoplasmosis, 128 cases of cryptococcal meningitis, and 141 cases of progressive multifocal leukoencephalopathy. The hazard ratio (95% confidence interval) for initiating a combined antiretroviral therapy regimen with a high vs low CPE score was 1.74 (1.15, 2.65) for HIV dementia, 0.90 (0.50, 1.62) for toxoplasmosis, 1.13 (0.61, 2.11) for cryptococcal meningitis, and 1.32 (0.71, 2.47) for progressive multifocal leukoencephalopathy. The respective hazard ratios (95% confidence intervals) for a medium vs low CPE score were 1.01 (0.73, 1.39), 0.80 (0.56, 1.15), 1.08 (0.73, 1.62), and 1.08 (0.73, 1.58). CONCLUSIONS We estimated that initiation of a combined antiretroviral therapy regimen with a high CPE score increases the risk of HIV dementia, but not of other neuroAIDS conditions.
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Affiliation(s)
| | - Lauren E Cain
- Authors' affiliations are listed at the end of the article
| | - Amy Justice
- Authors' affiliations are listed at the end of the article
| | - Janet Tate
- Authors' affiliations are listed at the end of the article
| | - Roger Logan
- Authors' affiliations are listed at the end of the article
| | - Caroline Sabin
- Authors' affiliations are listed at the end of the article
| | - Alan Winston
- Authors' affiliations are listed at the end of the article
| | - Ard van Sighem
- Authors' affiliations are listed at the end of the article
| | - Jose M Miro
- Authors' affiliations are listed at the end of the article
| | | | - Ashley Olson
- Authors' affiliations are listed at the end of the article
| | | | | | - Laurence Meyer
- Authors' affiliations are listed at the end of the article
| | | | - François Dabis
- Authors' affiliations are listed at the end of the article
| | | | | | - Georgia Vourli
- Authors' affiliations are listed at the end of the article
| | | | - Emilie Lanoy
- Authors' affiliations are listed at the end of the article
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