Background: Depression affects 25–30% of people with HIV (PWH) in South Africa (RSA) and is associated with both antiretroviral therapy (ART) nonadherence and increased mortality. We evaluated the cost-effectiveness of task-shifted, cognitive behavioral therapy (CBT) for PWH with diagnosed depression and virologic failure from a randomized trial in RSA. Setting: RSA. Methods: Using the Cost-Effectiveness of Preventing AIDS Complications model, we simulated both trial strategies: Enhanced treatment as usual (ETAU) and ETAU plus CBT for ART adherence and depression (CBT-AD; eight sessions plus two follow-ups). In the trial, viral suppression at one year was 20% with ETAU and 32% with CBT-AD. Model inputs included mean initial age (39 years) and CD4 count (214/μL), ART costs ($7.5–22/month), and CBT costs ($29/session). We projected 5- and 10-year viral suppression, quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (ICERs: $/QALY [discounted 3%/year]; cost-effectiveness threshold: ≤$2,545/QALY [0.5x per-capita GDP]). In sensitivity analyses, we determined how input parameter variation affected cost-effectiveness. Results: Model-projected 5- and 10-year viral suppression were 18.9% and 8.7% with ETAU and 21.2% and 9.7% with CBT-AD. Compared with ETAU, CBT-AD would increase discounted life expectancy from 4.12 to 4.68 QALYs and costs from $6,210/person to $6,670/person (ICER: $840/QALY). CBT-AD would remain cost-effective unless CBT-AD cost >$70/session and simultaneously improved one-year viral suppression by ≤4% compared with ETAU. Conclusions: Cognitive behavioral therapy for PWH with depression and virologic failure in RSA could improve life expectancy and be cost-effective. Such targeted mental health interventions should be integrated into HIV care.

In the United States, racial disparities have been observed in complications following total joint arthroplasty (TJA), including readmissions and mortality. It is unclear whether such disparities also exist for periprosthetic joint infection (PJI). The clinical data registry of a large New England hospital system was used to identify patients who underwent TJA between January 2018 and December 2021. The comorbidities were evaluated using the Elixhauser Comorbidity Index (ECI). We used Poisson regression to assess the relationship between PJI and race by estimating cumulative incidence ratios (cIRs) and 95% confidence intervals (CIs). We adjusted for age and sex and examined whether ECI was a mediator using structural equation modeling. The final analytic dataset included 10,018 TJAs in 9681 individuals [mean age (SD) 69 (10)]. The majority (96.5%) of the TJAs were performed in non-Hispanic (NH) White individuals. The incidence of PJI was higher among NH Black individuals (3.1%) compared with NH White individuals (1.6%) [adjusted cIR = 2.12, 95%CI = 1.16–3.89; p = 0.015]. Comorbidities significantly mediated the association between race and PJI, accounting for 26% of the total effect of race on PJI incidence. Interventions that increase access to high-quality treatments for comorbidities before and after TJA may reduce racial disparities in PJI.

The association between neighborhood-built environment and body mass index (BMI) is well-characterized, whereas fewer studies have explored the mechanisms underlying the relationship between neighborhood social environment and obesogenic behaviors. Using data from a random sample of 16,820 residents ≥18 years from all 169 Connecticut towns and seven ZIP Codes in New York, this study examines the influence of neighborhood social environment on residents’ mental wellbeing, physical activity, and BMI. Structural equation modeling was conducted to estimate direct and indirect effects of neighborhood social environment on BMI, using mental wellbeing and physical activity as intermediate variables. There were significant total [β(SE) = 0.741 (0.170), p < 0.0001], direct [β(SE) = 0.456 (0.1890), p = 0.016], and indirect [β(SE) = 0.285 (0.061), p < 0.0001] effects of neighborhood social environment on BMI. Low physical activity was a partial mediator of the effect of non-favorable neighborhood social environment on BMI [β(SE) = −0.071 (0.011), p < 0.0001]. The association between neighborhood social environment and BMI was also mediated by mental wellbeing [β(SE) = 0.214 (0.060), p < 0.0001], and by mental wellbeing through physical activity [β(SE) = 0.071 (0.011), p < 0.0001]. Study findings provide further support for building strong social environments to improve population health and suggest that strategies prioritizing mental wellbeing may benefit behavioral interventions aimed at reducing obesity risk and should be a focus of prevention efforts in and of itself.

Background: New diagnoses of HIV increasingly occur among people who fall outside traditional transmission risk categories. This group remains poorly defined, and HIV prevention efforts for this group lag behind efforts for patients in other risk groups. Methods: We conducted a retrospective review of patient visits at sexual health clinics in Boston, MA, over a 14-month period. Patients were classified into Centers for Disease Control and Prevention–defined HIV transmission risk categories. We compared frequencies of sexually transmitted infections (STIs), HIV, preexposure prophylaxis (PrEP) indications, and PrEP prescriptions. Predictors of HIV or STI among patients in the undetermined risk category were assessed with logistic regression. Results: There were 4723 clinic visits during the study period. Patients in the undetermined risk group constituted the largest proportion (55.8%), followed by men who have sex with men (MSM; 42.7%). The proportion of visits by patients in the undetermined risk group with an indication for PrEP was low (28.0%) compared with MSM (91.3%) and MSM who also inject drugs (93.8%); however, the absolute number was high (737). Among patients with an indication for PrEP, those in the undetermined risk group were least likely to receive a prescription. Behavioral risk factors were poorly predictive of STI or HIV among patients in the undetermined risk group. Conclusions: Patients with undetermined risk for HIV constituted a large proportion of clinic visits and had a large volume of sexual health needs but rarely received PrEP when indicated. To end the HIV epidemic in the United States, prevention efforts must include people who fall outside traditional risk categories.