, coronavirus and other infectious diseases.

Rachel Lutz

Low-income essential workers had a concentration of COVID-19 variant infections similar to the disproportionate incidence observed in wildtype COVID-19 earlier this year, according to a research letter published in 

Investigators from Canada created a retrospective cohort of the two areas most affected by COVID-19 variants in order to determine the impact of the variants on essential workers. The study authors noted that these variants emerged at the end of 2020, but before they appeared, transmission and incidence of COVID-19 was concentrated in neighborhoods of low socioeconomic status–home to a large proportion of frontline essential workers and their contact networks. By studying the city of Toronto and the bordering town of Peel in Ontario, Canada, the investigators organized the residents by income and essential work status, and tracked COVID-19 variant emergence.

The investigators employed a public health reportable database between February 3 and March 10, 2021, and used PCR testing to confirm COVID-19 status. They identified nearly 20,000 COVID-19 cases in the area, of which 12,860 were screened for a variant identification. Of that group, 5084 screened positive for a variant, the study authors reported. This pattern of about 25 percent being positive for a variant remained similar throughout each income tertiles. For example, of all the cases within the study period, 43 percent were in tertile 1, 35 percent were in tertile 2, and 20 percent were in tertile 3.

The study authors also found that essential work tertiles of total cases, about half were in tertile 1, 32 percent were in tertile 2, and 19 percent were in tertile 3. For variant cases among essential work tertiles, the study authors reported that half were in tertile 1, 30 percent were in tertile 2, and 18 percent were in tertile 3.

As time went on, COVID-19 cases in all income tertiles increased, as well as among those employed in essential work, the study authors observed. This was also true for variants, where all 3 tertiles were impacted across the study period.

Similarly to wildtype COVID-19 infections, the study authors wrote, variants of COVID-19 are disproportionately associated with neighborhood with lower income and a higher proportion of essential workers.

“Given the rapid mirroring of wildtype epidemics, these results suggest an association between essential work, income, and COVID-19 burden, which may be magnified by more transmissible variants,” the study authors concluded. “Reducing SARS-CoV-2 transmission and the associated morbidity and mortality necessitates tailored and equitable intervention strategies including vaccine prioritization and outreach services.”

However, the study authors noted that their report included limitations. For example, they used an ecological design instead of individual-level data on income and/or employment for their analysis, and the fact that different COVID-19 testing may have been available across the different tertiles. The study authors also noted a limitation may have come from the fact that not all samples were screened for variants, so they are unsure if there was a selection bias or there were different testing taking place from region to region.

“Less testing in low-income neighborhoods and essential work communities may result in underreporting both wildtype and VOC cases,” they added.

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Investigators retrospectively observed 2 communities of essential workers in Toronto, Canada.

Neighborhoods with Low Income, Essential Workers Carry COVID-19 Variant Burden

HIV care was impacted across the world during the COVID-19 crisis but clinics responded with several effective mitigation strategies to continue to care for patients, according to an original research paper 

Investigators from Brazil conducted a retrospective cohort study that spanned 4 continents in order to determine and describe the impact of the COVID-19 pandemic on HIV testing and treatment. Additionally, the investigators aimed to describe strategies used to mitigate the impact of the pandemic on HIV care, they said. Using secondary data from the AIDS Healthcare Foundation (AHF) Global Quality Program, the investigators identified the number of HIV tests and the percentage of positive tests, the number of in-person appointments, and the number of new enrollments for HIV care. The investigators compared data from January to August 2020 to a period in 2019.

All 4 continents showed a dip in the number of HIV tests when comparing 2020 with 2019, the study authors said. The reduction ranged from 26 percent in Europe to 44 percent in Latin America and the Caribbean, they found, noting an overall reduction of 35 percent. All European countries showed a decrease in the number of tests; in Africa, all countries except Ethiopia and Mozambique showed a decrease in the number of tests, the study authors determined.

The overall increase in percentage of positive tests was about 10 percent, the study authors said, with a low point of 2 percent in Africa and 44 percent in Europe. They wrote that this suggests targeted testing strategies may have been used during the pandemic that prioritized individuals at higher risks or symptomatic individuals. The investigators also said that MSM, transgender people, migrants, sex workers, and persons who inject drugs (PWID) had reductions in the number of tests, but among inmates, there were an increase in the number of tests performed when comparing 2020 to 2019.

In-person consultations dropped in Africa and Latin America between 2020 and 2019, the study authors said (7 percent and 24 percent, respectively). But for European and Asian countries, the investigators observed a slight increase in consultations in 2020.

The study authors additionally found that African, Asian and Latin American countries had reductions in the number of new enrollments that varied between 33 and 56 percent, but European countries saw an increase in 2020 compared to 2019. Despite the increase in in-person consultations in the European countries between January and August, there still remained a reduction of consultations in the months of March, April, and May in Europe, according to the investigators. They noted this corresponded with the highest occurrence of COVID-19 cases and severe social distancing measures were in place at that time. A similar trend was observed in Asia and Latin America, where consultations were boosted after local, severe breakouts had passed.

Mitigation strategies to increase access to care during the pandemic were numerous, depending on the type of barrier faced. For example, when there was decreased access to clinics due to lockdown restrictions, health care providers took actions such as telephone and video conference clinical consultations, pre-packed medications, extended clinic hours, alternative drug delivery, and mobile clinics. Clinics also underwent reorganizations to help physically distance, use PPE and schedule appointments; staff who worked from home were asked to call clients and encourage attendance, too, the study authors said.

Looking at other barriers, like reduced income due to the pandemic, the study authors saw that clinics provided food and hygienic packages free for vulnerable clients. When the number of people tested for HIV was reduced, clinics encouraged HIV self-testing methods and enhanced testing strategies for key populations. When it was clear that they were facing a lower retention in care, the study authors observed that clinics expanded hours, implemented video and telephone consults, and personnel encouraged continuation and resumption of care.

“The negative impact of COVID-19 on HIV care could have been even worse if client-centered strategies prioritized by AHF had not been used,” the study authors concluded. “Restrictions caused by COVID-19 accelerated innovations in HIV care services such as HIV self-testing, multiple months’ dispensation of antiretrovirals, community-led services, and alternative drug delivery. Such innovations proved to be essential, yet insufficient to mitigate the detrimental effect of the ongoing pandemic.”

Comparing 2020 to 2019, investigators saw a reduction in the number of HIV tests, the number of in-person consultations, and new enrollments in care, due to the disruption in HIV care throughout the COVID-19 pandemic.

HIV Care Disrupted by COVID-19 Pandemic

 indications strongly predicted current PrEP use among men who have sex with men (MSM) in the United States, according to a 

Journal of the International AIDS Society

Investigators from Emory University in Atlanta identified 3508 HIV-negative MSM from a web-based network of participants between 2017 and 2019 in order to determine whether the association between PrEP indications and PrEP use differed by demography or geography. The study authors also wanted to estimate PrEP use among MSM and assess if their PrEP use aligned with their current indications for PrEP. 

From the database, the investigators were able to measure PrEP usage and see if the respondents met indications for PrEP, which include self-reported behaviors such as the number of recent sexual partners, whether the partnership was with a main, casual, or one-time partner, the dates of the partnership, what sexual activities occurred, whether the participant and partner were using PrEP or antiretroviral therapy or condoms, and the responder and partner’s histories of STI diagnoses.

Then, the study authors matched South, Midwest, Northeast, West designations to participant-reported zip codes and race/ethnicity data, including non-Hispanic Black, non-Hispanic White, Hispanic, other race/ethnicity. Age groups were also considered: 15-17 years; 18-24; 25-34; 35-44; 45-54 and 55-65.

A majority of the responders who were eligible reported using PrEP (82 percent), the study authors determined. Of the 631 who reported using PrEP, more than half met indications for PrEP use but 40 percent did not. The study authors found that a third of PrEP-indicated MSM reported currently using PrEP.

Of the group who did not meet indications for PrEP, 10 percent were currently using PrEP, the authors learned.

Nearly a third of all the men who were eligible for PrEP (the larger group) had PrEP usage misaligned with their current indications, and a further 7 percent of PrEP-eligible MSM were currently using PrEP despite not meeting its indications, the study authors observed. Furthermore, the study authors wrote that nearly a quarter of PrEP eligible MSM were not using PrEP despite meeting indications for PrEP.

The lowest PrEP use was found in the South, and was greatest in the West. The study authors also found that PrEP use increased with age, with the lowest use in the youngest age groups (15-17 and 18-24-year-olds) and the highest use among 45-54-year-old MSM.

The study authors did not find a significant variation in current PrEP use by race/ethnicity, they said, but found the lowest use among Hispanic MSM. Despite not meeting indications for PrEP, usage was greatest among non-Hispanic White, Northeast, and 45-54-year-old MSM the study authors said.

“We found evidence of substantial misalignment between the US Public Health Service indications for PrEP and current PrEP use among PrEP-eligible MSM,” the study authors concluded. They also wrote that monitoring of PrEP uptake is needed in order to measure progress toward closing the gaps in PrEP coverage. Currently, PrEP uptake among MSM tracked with prior estimates and meeting PrEP indications was linked to current usage; however, there are populations who are indicated for PrEP that do not use it and those who use it while not meeting the indications, they wrote.

“The relative importance of behavioral indications and demographic differences in PrEP uptake highlight potential barriers to and gaps in implementing PrEP, both in the United States and globally, which will need to be addressed to meet PrEP's full potential to reduce new infections, particularly given efforts to both scale-up and address structural barriers to accessing PrEP in the United States.”

There are MSM who are indicated for PrEP use that don’t use it, and vice versa, the study authors found.

Predicting PrEP Use Based on PrEP Indications Among MSM 

 GG produced no significant difference compared to placebo for critically-ill patients in terms of the prevention of ventilator-assisted pneumonia (VAP), according to a 

Investigators from Canada enrolled 2650 adult patients across 44 intensive care units who required mechanical ventilation for at least 72 hours in order to determine the effect of 

 GG on preventing VAP and/or additional infections. Between October 2013 and March 2019, patients were randomized to receive enteral 

GG (1 × 1010 colony-forming units) or placebo twice daily in the ICU, the study authors wrote.

Probiotics are being theorized as a potential strategy for treatment or prevention of various infectious, inflammatory, or autoimmune conditions, the study authors explained. They noted that some literature has suggested probiotics can reduce infection rates by 20 percent and VAP specifically by 25 to 30 percent.

The mean age of the participants was 59.8 years and 40 percent were women, while 76 percent had a medical admitting diagnosis, the study authors said. All were receiving mechanical ventilation at baseline (for a median of 7 days), while a further 61 percent were receiving inotropes or vasopressors, and 8 percent were receiving kidney replacement therapy, the investigators noted. Other characteristics between the probiotic vs. placebo groups were not statistically different, though the study authors did say that antimicrobials were prescribed or ongoing for a majority of the patients (82 percent) on the day of randomization. Seventy percent of patients had infection at the admission, and 60 percent had pneumonia as a concurrent or primary admitting diagnosis, they also said.

For the group that received probiotics, 21.9 percent developed VAP compared to 21.3 percent of patients in the placebo group, the investigators determined. When the investigators conducted further subgroup analyses, a modifying effect was not revealed after looking at diagnostic category (such as medical, surgical, or trauma), age, frailty status, prior receipt of antimicrobials, or prevalent pneumonia at baseline.

Secondary outcomes were also similar between the intervention and placebo groups, including development of 

GG group vs. 2.1 percent in the placebo group) or diarrhea occurrences.

Median duration of ICU stay and mean hospital stay also did not differ significantly between the 2 groups, the study authors found. Deaths in the ICU were similar among the groups (279 vs. 296 patients, respectively) as well as hospital deaths (363 vs. 381, respectively), the study authors added.

There were 16 patients that experienced an adverse event or serious adverse event, the study authors said, which included 12 from the 

“In this trial involving critically ill patients, the probiotic 

GG did not significantly reduce the risk of VAP, 

, or other infections,” the study authors wrote, while concluding that their findings do not support the use of the probiotic 

GG for prevention of VAP. “Furthermore, no effects on diarrhea, antimicrobial use, length of stay or mortality were identified. In this broad population of ICU patients with high illness severity, life support dependence, antimicrobial exposure, and propensity for ICU-acquired infection, 

Investigators found no significant difference among hospitalized patients in the ICU being administered probiotics vs placebo. 