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For marginalized populations, county health departments may be important PrEP access points; however, there are little data on successful PrEP programs at these venues outside of incentivized demonstration projects. Therefore, we implemented an open-access, free PrEP clinic at a county health department in Atlanta, GA to promote PrEP uptake among high-risk clients. The Fulton County Board of Health PrEP clinic launched in October 2015, and eligible clients who expressed interest initiated PrEP and attended follow-up visits per CDC guidelines. Clients engaged in quarterly follow-up and seen within the last 6 months were defined as “persistent”, whereas clients with a lapse in follow-up of > 6 months were defined as “not persistent.” Factors associated with PrEP persistence were assessed with unadjusted odds ratios. Between October 2015 and June 2017, 399 clients were screened for PrEP, almost all were eligible [392/399 (98%)]; however, 158/392 (40%) did not return to start PrEP after screening. Of 234 patients, 216 (92%) received a prescription for PrEP. As of June 2017, only 69/216 (32%) clients remained persistent in PrEP care, and the only evaluated factor significantly associated with PrEP persistence was age ≥ 30 years (OR 1.86, 95% CI 1.02, 3.42). Implementation of PrEP in the county health department setting is feasible; however, we have identified significant challenges with PrEP uptake and persistence in our setting. Further research is needed to fully understand mediators of PrEP persistence and inform interventions to optimize health department-based PrEP services.

Latent tuberculosis infection (LTBI) treatment in persons at increased risk of disease progression is a key strategy with the strong potential to increase rate of tuberculosis (TB) decline in the United States. However, LTBI treatment in homeless persons, a population at high-risk of active TB disease, is usually associated with poor adherence. We describe the impact of using directly observed treatment (DOT) versus self-administered treatments (SAT) as an adherence-improving intervention to administer four months of daily rifampin regimen for LTBI treatment among homeless adults in Atlanta. Retrospective analysis of clinical care data on 274 homeless persons who initiated daily rifampin treatment for LTBI treatment at a county health department between January 2014 and December 2016 was performed. To reduce bias from non-random assignment of treatment, an inverse probability of treatment weighted (IPTW) logistic regression model was used to assess the effect of treatment type on treatment completion. Subgroup analyses were performed to assess heterogeneity of treatment effect on LTBI completion. Of 274 LTBI treatment initiators, 177 (65%) completed treatment [DOT 118/181 (65%), SAT 59/93 (63%)]. In the fully adjusted and weighted analysis, the odds of completing LTBI treatment on DOT was 40% higher than the odds of completing treatment by SAT [adjusted odds ratio (95% CI), aOR: 1.40 (1.07, 1.82), p = 0.014]. The unstable nature of homeless persons' lifestyle makes LTBI treatment difficult for many reasons. Our study lends support to the use of DOT to improve LTBI treatment completion among subgroups of homeless persons on treatment with daily rifampin.

People experiencing homelessness are at increased risk of tuberculosis (TB) and HIV. We examined the impact of integrating HIV testing and mandatory TB screening on HIV test uptake (HTU) during a multishelter TB outbreak in Atlanta, Georgia (2008–2018). Overall HTU was low; however, the intervention led to a reversal of declining HTU trend (rate ratio = 1.11; 95% confidence interval = 1.04, 1.19). Concerted efforts to increase HIV testing access and uptake alongside robust TB control efforts may increase progress toward the goals of End TB and Ending the HIV Epidemic. (Am J Public Health. 2022;112(6):881–885. https://doi.org/10.2105/AJPH.2022.306801 )

We evaluated the impact of test-order frequency per diarrheal episodes on difficile infection (CDI) incidence estimates in a sample of hospitals at 2 CDC Emerging Infections Program (EIP) sites. Observational survey. Inpatients at 5 acute-care hospitals in Rochester, New York, and Atlanta, Georgia, during two 10-workday periods in 2020 and 2021. We calculated diarrhea incidence, testing frequency, and CDI positivity (defined as any positive NAAT test) across strata. Predictors of CDI testing and positivity were assessed using modified Poisson regression. Population estimates of incidence using modified Emerging Infections Program methodology were compared between sites using the Mantel-Hanzel summary rate ratio. Surveillance of 38,365 patient days identified 860 diarrhea cases from 107 patient-care units mapped to 26 unique NHSN defined location types. Incidence of diarrhea was 22.4 of 1,000 patient days (medians, 25.8 for Rochester and 16.2 for Atlanta; < .01). Similar proportions of diarrhea cases were hospital onset (66%) at both sites. Overall, 35% of patients with diarrhea were tested for CDI, but this differed by site: 21% in Rochester and 49% in Atlanta ( < .01). Regression models identified location type (ie, oncology or critical care) and laxative use predictive of CDI test ordering. Adjusting for these factors, CDI testing was 49% less likely in Rochester than Atlanta (adjusted rate ratio, 0.51; 95% confidence interval [CI], 0.40-0.63). Population estimates in Rochester had a 38% lower incidence of CDI than Atlanta (summary rate ratio, 0.62; 95% CI, 0.54-0.71). Accounting for patient-specific factors that influence CDI test ordering, differences in testing practices between sites remain and likely contribute to regional differences in surveillance estimates.

Healthcare providers whom people see regularly (e.g., primary care providers [PCPs]) are likely to interact with individuals at risk of human immunodeficiency virus (HIV). However, most PCPs report never prescribing pre-exposure prophylaxis (PrEP), a medication that prevents HIV infection. This study examined the association between having a regular healthcare provider and PrEP use among men who have sex with men (MSM). We analyzed health survey data from Black (n = 151) and White (n = 113) MSM in Atlanta, GA using log binomial regressions. Among Black MSM, the proportion who used PrEP was nearly three times higher for those with a regular provider compared to those without one (aPR 2.58; 95% CI: 0.96, 6.93). Conversely, the proportion of White MSM who used PrEP was slightly lower among those with a regular provider (aPR 0.67; 95% CI: 0.36, 1.27). Findings suggest having a regular provider may be more strongly associated with PrEP among Black MSM.

Assessing pre-exposure prophylaxis (PrEP) coverage and identifying reasons for disproportionate uptake among the varied social and cultural sub-groups of men who have sex with men (MSM) and transgender women who have sex with men (TWSM) are necessary precursors to setting attainable local PrEP. We report on findings of a cross-sectional survey among MSM/TWSM attending Gay pride events in Atlanta, Georgia, in 2018. Associations between PrEP awareness, uptake, and respondent characteristics were assessed using logistic regression. PrEP awareness did not differ by race, but current use was significantly lower among Blacks at substantial risk of HIV ( p  = .008). In multivariate analysis, clinician encounter in the past year was associated with awareness while age, income, drug use, sero-discordant sex, and multiple male partners were associated with current use. Among PrEP-naïve MSM/TWSM, the most common reasons for nonuse differed by race (poor knowledge of PrEP: Black—45% vs. non-Black—27%, p  = .010, low perception of risk: Black—26% vs. non-Black—52%, p  = .001). Key racial and socioeconomic disparities in active PrEP use and reasons for nonuse remain despite the recent increases in PrEP awareness and use among MSM/TWSM in Atlanta. Achieving overall improvement in uptake among all MSM/TWSM sub-groups will require tailoring PrEP educational messaging, optimizing communication modalities, expanding provider outreach, and identifying ways to defray costs for high-risk, underserved sub-groups in these populations.

Among inpatients, peer-comparison of prescribing metrics is challenging due to variation in patient-mix and prescribing by multiple providers daily. We established risk-adjusted provider-specific antibiotic prescribing metrics to allow peer-comparisons among hospitalists. Using clinical and billing data from inpatient encounters discharged from the Hospital Medicine Service between January 2020 through June 2021 at four acute care hospitals, we calculated bimonthly (every two months) days of therapy (DOT) for antibiotics attributed to specific providers based on patient billing dates. Ten patient-mix characteristics, including demographics, infectious disease diagnoses, and noninfectious comorbidities were considered as potential predictors of antibiotic prescribing. Using linear mixed models, we identified risk-adjusted models predicting the prescribing of three antibiotic groups: broad spectrum hospital-onset (BSHO), broad-spectrum community-acquired (BSCA), and anti-methicillin-resistant Staphylococcus aureus (Anti-MRSA) antibiotics. Provider-specific observed-to-expected ratios (OERs) were calculated to describe provider-level antibiotic prescribing trends over time. Predictors of antibiotic prescribing varied for the three antibiotic groups across the four hospitals, commonly selected predictors included sepsis, COVID-19, pneumonia, urinary tract infection, malignancy, and age >65 years. OERs varied within each hospital, with medians of approximately 1 and a 75th percentile of approximately 1.25. The median OER demonstrated a downward trend for the Anti-MRSA group at two hospitals but remained relatively stable elsewhere. Instances of heightened antibiotic prescribing (OER >1.25) were identified in approximately 25% of the observed time-points across all four hospitals. Our findings indicate provider-specific benchmarking among inpatient providers is achievable and has potential utility as a valuable tool for inpatient stewardship efforts.

Background:Primary care providers are regarded as trustworthy sources of information about COVID-19 vaccines. Although primary care practices often provide information about common medical and public health topics on their practice websites, little is known about whether they also provide information about COVID-19 vaccines on their practice websites.Objective:This study aimed to investigate the prevalence and correlates of COVID-19 vaccine information on family medicine practices’ website home pages in the United States.Methods:We used the Centers for Medicare and Medicaid National Provider Identifier records to create a sampling frame of all family medicine providers based in the United States, from which we constructed a nationally representative random sample of 964 family medicine providers. Between September 20 and October 8, 2021, we manually examined the practice websites of these providers and extracted data on the availability of COVID-19 vaccine information, and we implemented a 10% cross-review quality control measure to resolve discordances in data abstraction. We estimated the prevalence of COVID-19 vaccine information on practice websites and website home pages and used Poisson regression with robust error variances to estimate crude and adjusted prevalence ratios for correlates of COVID-19 vaccine information, including practice size, practice region, university affiliation, and presence of information about seasonal influenza vaccines. Additionally, we performed sensitivity analyses to account for multiple comparisons.Results:Of the 964 included family medicine practices, most (n=509, 52.8%) had ≥10 distinct locations, were unaffiliated with a university (n=838, 87.2%), and mentioned seasonal influenza vaccines on their websites (n=540, 56.1%). In total, 550 (57.1%) practices mentioned COVID-19 vaccines on their practices’ website home page, specifically, and 726 (75.3%) mentioned COVID-19 vaccines anywhere on their practice website. As practice size increased, the likelihood of finding COVID-19 vaccine information on the home page increased (n=66, 27.7% among single-location practices, n=114, 52.5% among practices with 2-9 locations, n=66, 56.4% among practices with 10-19 locations, and n=304, 77.6% among practices with 20 or more locations, P<.001 for trend). Compared to clinics in the Northeast, those in the West and Midwest United States had a similar prevalence of COVID-19 vaccine information on website home pages, but clinics in the south had a lower prevalence (adjusted prevalence ratio 0.8, 95% CI 0.7 to 1.0; P=.02). Our results were largely unchanged in sensitivity analyses accounting for multiple comparisons.Conclusions:Given the ongoing COVID-19 pandemic, primary care practitioners who promote and provide vaccines should strongly consider utilizing their existing practice websites to share COVID-19 vaccine information. These existing platforms have the potential to serve as an extension of providers’ influence on established and prospective patients who search the internet for information about COVID-19 vaccines.

Background In 2019, Fulton County, GA was named one of 48 priority “hotspots” to target in renewed efforts to end the HIV epidemic in the United States. To more accurately predict women at greatest risk for HIV, we conducted an individually matched case–control study among women who attended a Fulton County health clinic to identify risk factors associated with HIV seroconversion. Methods We obtained data about women who sought care at Fulton County Board of Health Sexual Health Clinic (SHC) between 2011 and 2016. Cases were women with at least one clinician-assisted visit (CAV) at the SHC prior to HIV diagnosis date. Controls were women who visited the clinic in this same period but remained HIV negative. Controls were individually matched to cases in a 2:1 matching ratio on race, age at first CAV, and date of first CAV. Conditional logistic regression was used to develop a model for predicting probability of and identifying risk factors for HIV seroconversion. Results Of 18,281 women who were HIV negative at their first visit to the SHC between 2011 and 2016, 110 (0.6%) seroconverted before 2018. Of these, 80 (73%) had a CAV prior to HIV diagnosis. Using these 80 cases and 160 matched controls, having a history of gonorrhea, multiple gonorrhea episodes, a history of syphilis, a greater number of sex partners in the past 2 months, anal sex, history of injection drug or crack cocaine use, a history of exchanging drugs/money for sex, and heterosexual sex with more than one sex partner in the last month were associated with HIV seroconversion in bivariate analyses. After conducting backward selection from a fully adjusted model, predictors remaining were: having a history of syphilis (OR = 4.9, 95% CI: 1.4, 16.9), anal sex (OR = 2.9, 95% CI: 1.0, 8.3), and injection drug or crack cocaine use (OR = 34.8, 95% CI: 3.7, 328.1). Women having all three risk factors were six times more likely to seroconvert compared with matched controls without these risk factors. Conclusion Our results offer clinical insights into which women are most at-risk for HIV and are therefore best candidates for initiating HIV prevention interventions like pre-exposure prophylaxis (PrEP) within a HIV “hotspot” in the South. Disclosures All Authors: No reported Disclosures.

Background: Provider-specific prescribing metrics can be used for benchmarking and feedback to reduce unnecessary antibiotic use; however, metrics must be credible. To improve credibility of a recently described risk-adjusted antibiotic prescribing metric for hospital medicine service (HMS) providers, we assessed whether providers who initially prescribed excess antibiotics continued to prescribe antibiotics excessively. Methods: We linked administration and billing data among patients at 4 acute-care hospitals (1,571 beds) to calculate days of therapy (DOT) ordered by individual hospitalists for each of 3 NHSN antibiotic groupings: broad-spectrum hospital onset (BS-HO), broad-spectrum community-onset (BS-CO), or anti-MRSA for each patient day billed from January 2020 to June 2021. To incorporate repeated measures by provider, mixed models adjusted for patient-mix characteristics (eg, % encounters with urinary tract infection, etc) were used to calculate serial, bimonthly, provider-specific, observed-to-expected ratios (OERs). An OER of 1.25 indicates that the prescribing rate observed was 25% higher than predicted, adjusting for patient mix. We then used log binomial generalized estimating equations to assess whether a high prescribing rate (defined as an OER ≥ 1.25) for an individual provider in an earlier bimonthly period was associated with a persistent high rate for that provider in the following period. Results: Overall, 975 bimonthly periods were evaluated from 136 hospitalists. Most (58%) contributed data the entire 18-month study period. Median OERs were similar between hospitals: 0.94 (IQR, 0.65–1.28) for BS-HO antibiotic use, 0.99 (IQR, 0.73–1.24) for BS-CO antibiotic use, and 0.95 (IQR, 0.65–1.28) for anti-MRSA antibiotic use. At the individual prescriber level, roughly one-quarter of bimonthly OERs (range varied by group and hospital from 21% to 31%) were categorized as high. At 3 of the 4 hospitals, a provider with a high OER for either BS-HO or BS-CO antibiotic use in any bimonthly period was more likely to have a high OER in the subsequent period (Fig. 1). These observed risk ratios were statistically significant for BS-HO antibiotic use at only 2 hospitals: hospital A risk ratio (RR) was 1.54 (95% CI, 1.10–2.16); hospital B RR was 1.28 (95% CI, 0.90–1.82); hospital C RR was 0.76 (95% CI, 0.39–1.48); and ospital D RR was 1.71 (95% CI, 1.09–2.68). Conclusions: Our findings suggest that hospitalists with a higher than expected 2-month period of antibiotic prescribing are likely to continue to have elevated prescribing rates in the following period, particularly for BS-HO antibiotics. These findings increase the credibility of using a 2-month prescribing metric for BS-HO antibiotic stewardship efforts; further work is needed to evaluate utility for other antibiotic groupings. Funding: None Disclosures: None