Last week in @CDCMMWR: #HIV among PWID in the US and young women in Africa

Monday, January 15, 2018

This week's edition of MMWR features two analyses on HIV. The first is on infection prevalence and risk among persons who inject drugs in 20 U.S. cities. The data comes from the National HIV Behavioral Surveillance system:
In 2015, National HIV Behavioral Surveillance found a 7% prevalence of HIV infection among persons who inject drugs which was lower than in 2012 (11%). Among HIV-negative respondents, 27% reported sharing syringes and 67% reported having vaginal sex without a condom in the previous 12 months; only 52% received syringes from a syringe services program and 34% received all syringes from sterile sources. HIV infection prevalence was higher among blacks (11%) than whites (6%) but more white persons who inject drugs shared syringes (white: 39%; black: 17%) and injection equipment (white: 61%; black: 41%) in the previous 12 months.
What I find interesting is that the prevalence of unsafe injection practices is so much higher among whites than blacks, although this may be related to there being so many new white PWID due to the opioid crisis (i.e., more black PWID have been injecting for longer). What does not surprise me, sadly, is that so few PWID were able to access sterile syringes from a syringe exchange program (SEP). Even after Congress lifted the federal funding ban on SEPs, states and other jurisdictions have been reluctant to operate them.

The second article (which boasts a jaw-dropping 82 co-authors from 22 institutions) reports HIV status and treatment cascade metrics for women aged 15-24 in seven countries in eastern and southern Africa:
Analysis of data from Population-based HIV Impact Assessment surveys conducted during 2015–2017 in seven countries in Eastern and Southern Africa found that the prevalence of HIV infection among adolescent girls and young women was 3.6%. Among those who were HIV-positive, 46.3% reported being aware of their status, and among those aware of their HIV-positive status, 85.5% reported current antiretroviral treatment (ART) use. Overall, viral load suppression among HIV-infected adolescent girls and young women, regardless of status awareness or current use of ART, was 45.0%, well below the UNAIDS target of 73%.
While low levels of awareness of status and viral suppression are pretty depressing, I was encouraged to see that so many who are aware of their infection are on ART. I was also fascinated to learn that the PHIA survey used is funded by PEPFAR:
The PHIA surveys are nationally representative, household-based surveys funded by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and conducted under the leadership of the respective countries’ ministries of health, CDC, and ICAP at Columbia University). The objectives of the PHIA surveys are to provide national estimates of HIV incidence and subnational estimates of HIV prevalence and viral load suppression to assess the HIV epidemic and the impact of HIV prevention and ART programs in each country. During 2015–2017, PHIA surveys were conducted in Lesotho, Malawi, Swaziland, Uganda, Tanzania Zambia, and Zimbabwe.
Also super cool: the survey takers conduct HIV, CD4, and viral load testing on the spot:
The surveys included home-based HIV counseling and testing conducted in private locations within or around the home, using each country’s national HIV rapid testing algorithm, and employing CD4 testing technology, with results immediately returned to participants. Awareness of HIV status and current ART use (an indicator of ART coverage at the population level) were determined based on responses provided in the survey questionnaire. HIV viral load testing was conducted using plasma specimens or dried blood spots.

@CDCgov researchers report increases in HCV infection and #opioid admissions in @AMJPublicHealth

Friday, January 12, 2018

Just before Christmas, researchers from the CDC's Division of Viral Hepatitis published an article in the American Journal of Public Health reporting an increase in both acute hepatitis C (HCV) cases and admissions for injection drug use in substance abuse treatment centers:
The annual incidence rate of acute HCV infection increased more than 2-fold (from 0.3 to 0.7 cases/100 000) from 2004 to 2014, with significant increases among select demographic subgroups. Admissions for substance use disorder attributed to injection of heroin and prescription opioid analgesics increased significantly, with an almost 4-fold increase in prescription opioid analgesic injection. Significant increases in opioid injection mirrored those for reported cases of acute HCV infection among demographic subgroups.
CDC featured the article, along with several related graphics, in a press release. As a side note, HCV infection is considered a highly reliable proxy for injection drug use, although I would advise caution when looking at "acute" HCV figures. HCV infection is frequently asymptomatic (i.e., not acute), and surveillance for acute cases is spotty in some states. Overall HCV infection rates are most likely much higher, however, meaning that these numbers point to what is most likely a much larger overall infection rate.

The authors used national surveillance data for HCV infection and substance use treatment data from SAMHSA for IDU admissions:
We obtained confirmed cases of acute HCV infection and associated demographic and risk characteristics from the National Notifiable Disease Surveillance System (NNDSS) for 2004 to 2014.
...
TEDS is a national data system administered by SAMHSA. It collects information on annual admissions to SUD treatment facilities in the United States. TEDS contains data on admissions to publicly funded and state-certified SUD treatment facilities by year and by state of treatment facility for all persons aged 12 years or older. By state law, treatment facilities provide data to TEDS. TEDS is estimated to include 67% of all SUD treatment admissions and 83% of TEDS-eligible admissions in the United States.
Despite limitations of the data, this should add to the list of rather loud alarm bells that we have a serious injection drug use problem. HIV looms.

Interestingly, the same issue of AJPH featured a commentary on the national opioid crisis, co-authored by HIV/IDU heavyweight Daniel Ciccarone at UCF. After a brief historical overview that separates the crisis into three phases, the piece criticizes what it calls the "vector model" - the focus on supply of opioid prescription drugs as the root of the crisis - and argues that appropriate policy responses should instead consider the reasons behind the demand for such drugs. The authors present several related possiblities to explain demand, including "diseases of despair" and the structural aspects of poverty:
The “reversal of fortunes” in life expectancy saw rapid diffusion, going from largely limited to Appalachia and the Southwest in 2000 to nationwide by 2015. The unprecedented 20-year difference in life expectancy between the healthiest and least healthy counties is largely explained by socioeconomic factors correlated with race/ethnicity, behavioral and metabolic risk, and health care access. These indicators are the most recent evidence of a long-term process of decline: a multidecade rise in income inequality and economic shocks stemming from deindustrialization and social safety net cuts. The 2008 financial crisis along with austerity measures and other neoliberal policies have further eroded physical and mental well-being.
It's an excellent piece that looks at the data on structural factors behind other forms of substance use (e.g., alcoholism), issues of racism, and the inability of the current U.S. health care system to adequately address the problem. It urges a human-centered approach to the problem and says that we should "focus on suffering."

More #opendata highlights: @CDCgov's 500 Cities project!

Thursday, January 11, 2018

The 500 Cities project was featured in Data is Plural this week!
Local health metrics.The CDC’s 500 Cities Project provides “city and census tract-level data, obtained using small area estimation methods, for 27 chronic disease measures for the 500 largest American cities.” The metrics range from cancer prevalence to binge drinking to dental health to undersleeping. The latest data release was published in December and covers more than 28,000 Census tracts.
I'm irrationally excited about this initiative and the potential for discovery in the data. So much so that I mentioned it in an upcoming installment of an open data series I am working on for Cadence Group.

#Opendata highlights: Mammographies

Tuesday, January 9, 2018

The very last edition of Data is plural in 2017 featured an improved database of mammographies, overhauled by researchers at Stanford:
A better mammography database. The Digital Database for Screening Mammography was first released two decades ago, in 1997. It contains data and images from 2,620 mammographies — a mix of normal, benign, and malignant cases. In a Scientific Data article published last week, a team of Stanford University researchers describe a series of improvements they’ve made to the original database; their Curated Breast Imaging Subset of DDSM has modernized the database’s image formatting, added detailed “region-of-interest” annotations, and converted the metadata into CSV files.
This one hit home for me because my mother's sister goes in for surgery today for a lump they found in her mammary duct. Va com Deus, Tia.

@LancetGH looks at data collection on deaths from the war in #Syria

Thursday, December 14, 2017

The January 2018 issue of Lancet Global Health features an article (and associated commentary) on an analysis of civilian and combatant deaths using data from the Violations Documentation Center (VDC, which until now I didn't even know existed).
This study makes use of the systematic recording of violent deaths from the Syrian civil war by the Violation Documentation Center over 6 years of conflict to provide a systematic analysis of civilian and opposition combatant violent deaths, their demographic characteristics, the causative method or weapon, and spatial and temporal patterns of direct deaths during the conflict. We relate patterns and causes of death to possible violations of international humanitarian law.
The authors don't mince words - they are explicit in their conclusion that the results of the analysis indicate possible war crimes. Of course, pretty much everyone who still cares about Syria already knows that, but additional evidence never hurts - even if it will never make the UN move. What is particularly horrifying is the effect that the increasing use of aerial bombardment in general, and barrel bombs in particular, on civilian deaths - over a quarter of which were children.

Unfortunately, the VDC data only contains deaths that occurred in areas outside of government control (as “information on victims in government-controlled areas can be difficult to obtain”), so the analysis is geographically incomplete and does not include any deaths among Syrian government forces. But the data that is available is incredibly detailed and valuable:
Documentation of the health impact of war and conflict is one of the most difficult yet important public health challenges....Yet, the health and population impact of conflicts is dramatic and their effects long lasting. Any attempt to understand these events requires careful data collection and contemporaneous analysis to capture data that would otherwise be lost. Only through collection efforts such as those mounted by the VDC and analyses like the one presented by Guha-Sapir and colleagues can propel researchers and policymakers into recognising the true costs of current wars and the need to mitigate such consequences in the future.