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      Brief Report: Supporting Access to HIV Care for Children and Youth During the COVID-19 Pandemic With Telemedicine and Rideshare

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          Abstract

          Background:

          In response to the COVID-19 pandemic, we scaled up telemedicine and rideshare services for clinic and laboratory visits for pediatric and adolescent patients with HIV.

          Setting:

          HIV subspecialty program for patients aged 0–24 years at Children's National Hospital, Washington, DC.

          Methods:

          Using the χ 2 and Wilcoxon rank sum tests, we compared demographics, visit and laboratory data, and rideshare usage among patients who scheduled telemedicine at least once (telemedicine) versus those who never scheduled telemedicine (no-telemedicine) during the pandemic (April–September 2020). We compared the number and proportion of scheduled and completed clinic visits before the pandemic (April–September 2019) with those during the pandemic.

          Results:

          We analyzed 178 pediatric and adolescent patients with HIV (median age 17.9 years, 89.3% Black, 48.9% male patients, 78.7% perinatally infected), of whom 70.2% and 28.6% used telemedicine and rideshare, respectively. Telemedicine patients scheduled more visits (236 vs 179, P < 0.0001) and completed a similar proportion of visits (81.8% vs 86.0%, P = 0.3805) compared with no-telemedicine patients. Laboratory testing rates (81.3% versus 98.5%, P = 0.0005) were lower in telemedicine patients compared with no-telemedicine patients. Rideshare usage (12.4% versus 26.5%, P = 0.0068) was lower in telemedicine versus no-telemedicine patients. During the pandemic, most of the patients (81.0%) had HIV RNA <200 copies/mL. The total number of completed visits and the proportion of visits completed were similar before and during the pandemic.

          Conclusion:

          Most of the pediatric and adolescent patients with HIV used telemedicine and maintained HIV RNA <200 copies/mL during the pandemic. Despite rideshare usage, laboratory testing rates were lower with telemedicine compared with in-person visits.

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          Most cited references22

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          Covid-19 — Implications for the Health Care System

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            Digital Health Equity and COVID-19: The Innovation Curve Cannot Reinforce the Social Gradient of Health

            Digital health innovations have been rapidly implemented and scaled to provide solutions to health delivery challenges posed by the coronavirus disease (COVID-19) pandemic. This has provided people with ongoing access to vital health services while minimizing their potential exposure to infection and allowing them to maintain social distancing. However, these solutions may have unintended consequences for health equity. Poverty, lack of access to digital health, poor engagement with digital health for some communities, and barriers to digital health literacy are some factors that can contribute to poor health outcomes. We present the Digital Health Equity Framework, which can be used to consider health equity factors. Along with person-centered care, digital health equity should be incorporated into health provider training and should be championed at the individual, institutional, and social levels. Important future directions will be to develop measurement-based approaches to digital health equity and to use these findings to further validate and refine this model.
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              Excess Deaths Associated with COVID-19, by Age and Race and Ethnicity — United States, January 26–October 3, 2020

              As of October 15, 216,025 deaths from coronavirus disease 2019 (COVID-19) have been reported in the United States*; however, this number might underestimate the total impact of the pandemic on mortality. Measures of excess deaths have been used to estimate the impact of public health pandemics or disasters, particularly when there are questions about underascertainment of deaths directly attributable to a given event or cause ( 1 – 6 ). † Excess deaths are defined as the number of persons who have died from all causes, in excess of the expected number of deaths for a given place and time. This report describes trends and demographic patterns in excess deaths during January 26–October 3, 2020. Expected numbers of deaths were estimated using overdispersed Poisson regression models with spline terms to account for seasonal patterns, using provisional mortality data from CDC’s National Vital Statistics System (NVSS) ( 7 ). Weekly numbers of deaths by age group and race/ethnicity were assessed to examine the difference between the weekly number of deaths occurring in 2020 and the average number occurring in the same week during 2015–2019 and the percentage change in 2020. Overall, an estimated 299,028 excess deaths have occurred in the United States from late January through October 3, 2020, with two thirds of these attributed to COVID-19. The largest percentage increases were seen among adults aged 25–44 years and among Hispanic or Latino (Hispanic) persons. These results provide information about the degree to which COVID-19 deaths might be underascertained and inform efforts to prevent mortality directly or indirectly associated with the COVID-19 pandemic, such as efforts to minimize disruptions to health care. Estimates of excess deaths can provide a comprehensive account of mortality related to the COVID-19 pandemic, including deaths that are directly or indirectly attributable to COVID-19. Estimates of the numbers of deaths directly attributable to COVID-19 might be limited by factors such as the availability and use of diagnostic testing (including postmortem testing) and the accurate and complete reporting of cause of death information on the death certificate. Excess death analyses are not subject to these limitations because they examine historical trends in all-cause mortality to determine the degree to which observed numbers of deaths differ from historical norms. In April 2020, CDC’s National Center for Health Statistics (NCHS) began publishing data on excess deaths associated with the COVID-19 pandemic ( 7 , 8 ). This report describes trends and demographic patterns in the number of excess deaths occurring in the United States from January 26, 2020, through October 3, 2020, and differences by age and race/ethnicity using provisional mortality data from the NVSS. § Excess deaths are typically defined as the number of persons who have died from all causes, in excess of the expected number of deaths for a given place and time. A detailed description of the methodology for estimating excess deaths has been described previously ( 7 ). Briefly, expected numbers of deaths are estimated using overdispersed Poisson regression models with spline terms to account for seasonal patterns. The average expected number, as well as the upper bound of the 95% prediction interval (the range of values likely to contain the value of a single new observation), are used as thresholds to determine the number of excess deaths (i.e., observed numbers above each threshold) and percentage excess (excess deaths divided by average expected number of deaths). Estimates described here refer to the number or percentage above the average; estimates above the upper bound threshold have been published elsewhere ( 7 ). Observed numbers of deaths are weighted to account for incomplete reporting by jurisdictions (50 states and the District of Columbia [DC]) in the most recent weeks, where the weights were estimated based on completeness of provisional data in the past year ( 7 ). Weekly NVSS data on excess deaths occurring from January 26 (the week ending February 1), 2020, through October 3, 2020, were used to quantify the number of excess deaths and the percentage excess for deaths from all causes and deaths from all causes excluding COVID-19. ¶ Deaths attributed to COVID-19 have the International Classification of Diseases, Tenth Revision code U07.1 as an underlying or contributing cause of death. Weekly numbers of deaths by age group (0–24, 25–44, 45–64, 65–74, 75–84, and ≥85 years) and race/ethnicity (Hispanic or Latino [Hispanic], non-Hispanic White [White], non-Hispanic Black or African American [Black], non-Hispanic Asian [Asian], non-Hispanic American Indian or Alaska Native [AI/AN], and other/unknown race/ethnicity, which included non-Hispanic Native Hawaiian or other Pacific Islander, non-Hispanic multiracial, and unknown) were used to examine the difference between the weekly number of deaths occurring in 2020 and the average number occurring in the same week during 2015–2019. These values were used to calculate an average percentage change in 2020 (i.e., above or below average compared with past years), over the period of analysis, by age group and race and Hispanic ethnicity. NVSS data in this report include all deaths occurring in the 50 states and DC and are not limited to U.S. residents. Approximately 0.2% of decedents overall are foreign residents. R statistical software (version 3.5.0; The R Foundation) was used to conduct all analyses. From January 26, 2020, through October 3, 2020, an estimated 299,028 more persons than expected have died in the United States.** Excess deaths reached their highest points to date during the weeks ending April 11 (40.4% excess) and August 8, 2020 (23.5% excess) (Figure 1). Two thirds of excess deaths during the analysis period (66.2%; 198,081) were attributed to COVID-19 and the remaining third to other causes †† (Figure 1). FIGURE 1 Weekly numbers of deaths from all causes and from all causes excluding COVID-19 relative to the average expected number and the upper bound of the 95% prediction interval (A), and the weekly and total numbers of deaths from all causes and from all causes excluding COVID-19 above the average expected number and the upper bound of the 95% prediction interval (B) — National Vital Statistics System, United States, January–September 2020 Abbreviation: COVID-19 = coronavirus disease 2019. The figure is a histogram, an epidemiologic curve showing the weekly numbers of deaths from all causes and from all causes excluding COVID-19 relative to the average expected number and the upper bound of the 95% prediction interval (A), and the weekly and total numbers of deaths from all causes and from all causes excluding COVID-19 above the average expected number and the upper bound of the 95% prediction interval (B), using data from the National Vital Statistics System, in United States, during January–September 2020. The total number of excess deaths (deaths above average levels) from January 26 through October 3 ranged from a low of approximately 841 in the youngest age group (<25 years) to a high of 94,646 among adults aged 75–84 years. §§ However, the average percentage change in deaths over this period compared with previous years was largest for adults aged 25–44 years (26.5%) (Figure 2). Overall, numbers of deaths among persons aged <25 years were 2.0% below average, ¶¶ and among adults aged 45–64, 65–74 years, 75–84, and ≥85 years were 14.4%, 24.1%, 21.5%, and 14.7% above average, respectively. FIGURE 2 Percentage change in the weekly number of deaths in 2020 relative to average numbers in the same weeks during 2015–2019, by age group — United States, 2015–2019 and 2020 The figure is a histogram, an epidemiologic curve showing the percentage change in the weekly number of deaths in 2020 relative to average numbers during the same weeks in 2015–2019, by age group, in the United States, during 2015–2019 and 2020. When examined by race and ethnicity, the total numbers of excess deaths during the analysis period ranged from a low of approximately 3,412 among AI/AN persons to a high of 171,491 among White persons. For White persons, deaths were 11.9% higher when compared to average numbers during 2015–2019. However, some racial and ethnic subgroups experienced disproportionately higher percentage increases in deaths (Figure 3). Specifically, the average percentage increase over this period was largest for Hispanic persons (53.6%). Deaths were 28.9% above average for AI/AN persons, 32.9% above average for Black persons, 34.6% above average for those of other or unknown race or ethnicity, and 36.6% above average for Asian persons. FIGURE 3 Percentage change in the weekly number of deaths in 2020 relative to average numbers in the same weeks during 2015–2019, by race and Hispanic ethnicity — United States, 2015–2019 and 2020 The figure is a histogram, an epidemiologic curve showing the percentage change in the weekly number of deaths in 2020 relative to average numbers in the same weeks during 2015–2019, by race and Hispanic ethnicity, in the United States, during 2015–2019 and 2020. Discussion Based on NVSS data, excess deaths have occurred every week in the United States since March 2020. An estimated 299,028 more persons than expected have died since January 26, 2020; approximately two thirds of these deaths were attributed to COVID-19. A recent analysis of excess deaths from March through July reported very similar findings, but that study did not include more recent data through September ( 5 ). Although more excess deaths have occurred among older age groups, relative to past years, adults aged 25–44 years have experienced the largest average percentage increase in the number of deaths from all causes from late January through October 3, 2020. The age distribution of COVID-19 deaths shifted toward younger age groups from May through August ( 9 ); however, these disproportionate increases might also be related to underlying trends in other causes of death. Future analyses might shed light on the extent to which increases among younger age groups are driven by COVID-19 or by other causes of death. Among racial and ethnic groups, the smallest average percentage increase in numbers of deaths compared with previous years occurred among White persons (11.9%) and the largest for Hispanic persons (53.6%), with intermediate increases (28.9%–36.6%) among AI/AN, Black, and Asian persons. These disproportionate increases among certain racial and ethnic groups are consistent with noted disparities in COVID-19 mortality.*** The findings in this report are subject to at least five limitations. First, the weighting of provisional NVSS mortality data might not fully account for reporting lags, particularly in recent weeks. Estimated numbers of deaths in the most recent weeks are likely underestimated and will increase as more data become available. Second, there is uncertainty associated with the models used to generate the expected numbers of deaths in a given week. A range of values for excess death estimates is provided elsewhere ( 7 ), but these ranges might not reflect all of the sources of uncertainty, such as the completeness of provisional data. Third, different methods or models for estimating the expected numbers of deaths might lead to different results. Estimates of the number or percentage of deaths above average levels by race/ethnicity and age reported here might not sum to the total numbers of excess deaths reported elsewhere, which might have been estimated using different methodologies. Fourth, using the average numbers of deaths from past years might underestimate the total expected numbers because of population growth or aging, or because of increasing trends in certain causes such as drug overdose mortality. Finally, estimates of excess deaths attributed to COVID-19 might underestimate the actual number directly attributable to COVID-19, because deaths from other causes might represent misclassified COVID-19–related deaths or deaths indirectly caused by the pandemic. Specifically, deaths from circulatory diseases, Alzheimer disease and dementia, and respiratory diseases have increased in 2020 relative to past years ( 7 ), and it is unclear to what extent these represent misclassified COVID-19 deaths or deaths indirectly related to the pandemic (e.g., because of disruptions in health care access or utilization). Despite these limitations, however, this report demonstrates important trends and demographic patterns in excess deaths that occurred during the COVID-19 pandemic. These results provide more information about deaths during the COVID-19 pandemic and inform public health messaging and mitigation efforts focused on the prevention of infection and mortality directly or indirectly associated with the COVID-19 pandemic and the elimination of health inequities. CDC continues to recommend the use of masks, frequent handwashing, and maintenance of social distancing to prevent COVID-19. ††† Summary What is already known about this topic? As of October 15, 216,025 deaths from COVID-19 have been reported in the United States; however, this might underestimate the total impact of the pandemic on mortality. What is added by this report? Overall, an estimated 299,028 excess deaths occurred from late January through October 3, 2020, with 198,081 (66%) excess deaths attributed to COVID-19. The largest percentage increases were seen among adults aged 25–44 years and among Hispanic or Latino persons. What are the implications for public health practice? These results inform efforts to prevent mortality directly or indirectly associated with the COVID-19 pandemic, such as efforts to minimize disruptions to health care.
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                Author and article information

                Journal
                J Acquir Immune Defic Syndr
                J Acquir Immune Defic Syndr
                qai
                Journal of Acquired Immune Deficiency Syndromes (1999)
                JAIDS Journal of Acquired Immune Deficiency Syndromes
                1525-4135
                1944-7884
                1 December 2021
                09 September 2021
                09 September 2021
                : 88
                : 4
                : 384-388
                Affiliations
                [a ]Department of Infectious Diseases, Children's National Hospital, Washington, DC;
                [b ]Department of Pediatrics, School of Medicine and Health Sciences, George Washington University, Washington, DC;
                [c ]Division of General Academic Pediatrics, Department of Pediatrics, Massachusetts General Hospital, Boston, MA; and
                [d ]Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC.
                Author notes
                Correspondence to: Wei L. A. Koay, MBBS, MSc, Department of Infectious Diseases, Children's National Hospital, 111 Michigan Avenue NW, Washington, DC 20010 (e-mail: wkoay@ 123456childrensnational.org ).
                Article
                QAIV21925 00009
                10.1097/QAI.0000000000002792
                8547581
                840fab48-db83-47e7-92bc-1a804aca0f4c
                Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

                This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the COVID-19 pandemic or until permissions are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections.

                History
                : 13 April 2021
                : 18 August 2021
                Categories
                Implementation Science

                telemedicine,hiv,rideshare,covid-19,children,youth
                telemedicine, hiv, rideshare, covid-19, children, youth

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