Background: Approximately 80% of gonorrhea (GC) and chlamydia (CT) infections are missed when healthcare providers do not screen for pharyngeal and rectal (extra-genital) GC and CT infections among men who have sex with men (MSM). Some factors may include under-identification of MSM as a high-risk population, implicit biases, and under-appreciation of the problem’s magnitude in this population. Undiagnosed and poor treatment of GC and CT infections in MSM may result in further spread and poor clinical outcomes for index and subsequent cases. Objectives: Measure knowledge, perceptions, and beliefs about screening and acceptability of an electronic medical record (EMR) dot-phrase template for clinician history taking. Methods: This observational study compared self-reported baseline knowledge and comfort for GC and CT screening for MSM, and approval of the dot-phrase template over eight weeks between training and availability of the EMR tool. Northern California federally-qualified health center adult primary care providers were enrolled in the study. We gathered self-report for sociodemographic characteristics, practice-specific knowledge, perceptions, and beliefs about extra-genital screening in MSM patient populations using online administered, anonymous, linked surveys over the study period. Results: Nine participants participated in the initial training and six completed the follow-up evaluation. Physicians comprised the largest group: 6 family medicine, 1 internal medicine, 2 family nurse practitioners, of whom 56% reported 3 to 5 years of clinical experience. Most were female (77%). 33% of initial participants (3/9) believe that consistent condom use does not put a patient at risk for GC or CT. While 55% initially disagreed that GC can be transmitted via kissing, most agreed following in-service education (1 “strongly disagreed” vs. 3.5 “slightly to strongly agree”). 83% of subjects who participated in both surveys report feeling more compelled to offer extra-genital screening upon completion of the training and introduction of the dot-phrase. No provider reported being able to implement the dot-phrase protocol over the study period. Conclusion: A six week in-service education and structured dot-phrase history taking tool intervention improved evidence-based understanding of GC/CT transmission risk factors. Participants completing the program expressed that they felt more compelled to offer extra-genital screening in applicable patient encounters following the educational intervention.

Background: Time-trend Hispanic population data spanning 2007-2012 shows a stronger association between obesity trends and a higher prevalence of Type 2 Diabetes Mellitus (T2DM) in Hispanic than non-Hispanic Whites (NHW): 40.1% and 44.4% for male and female Hispanic adults, respectively, and 32.4% and 32.8 % for male and female NHW adults. Patients with T2DM have 2-3-fold higher mortality than unaffected adults, and the disease is strongly correlated with obesity1. Obesity, insulin resistance, and abnormal glucose metabolism are strongly associated with diabetes. Reducing the incidence of T2DM depends upon body weight control. The Center for Disease Control and Prevention (CDC)'s Diabetes Prevention Program (DPP) strategies evidence 58% reduced incidence of T2DM over three years of study2. Objectives: The purpose of this quality improvement (QI) project is to implement a modified Diabetes Prevention Program (DPP) curriculum in the underserved, uninsured Hispanic patient population by imposing health-promoting behaviors through weight loss, diet, and exercise. One of the main objectives of this QI is to demonstrate to clinic leadership the efficacy of this modified DPP curriculum in preventing diabetes so it may be adopted as a standard of care across all prediabetic patients within the clinic's healthcare system. Methods: We modified the DPP curriculum to better reflect the culture and language represented by Spanish-speaking adults with prediabetes and obesity. A fluent Spanish-speaking diabetic educator implemented this QI project at a Federally Qualified Health Center (FQHC) over 13 weekly sessions covering 16 DPP core concepts. Pretests and posttests were administered to 18 participants to measure knowledge before and after the intervention. Bodyweight was measured at the pretest and each weekly session, as well as self-reported minutes of exercise. Waist circumference and point of care HbA1c were evaluated at week 1 and week 13. Each measure was discussed with participants for personal reflection. Results: Of 18 planned, 61% (=11/18) enrolled and completed the program; all the participants were female. Nutritional and diabetes prevention knowledge increased (p<0.003), and waist circumference decreased (p=0.005), but no change in HbA1c, weight loss, or BMI change were noted over the period compared to baseline data. The week 13, HbA1c is inversely associated with an absolute change in waist circumference over the period (p=0.043); however, a low-sample size limited associations of change in HbA1c with either weight loss or BMI trend. Conclusion: Over the relatively short period of 13 weeks, those Hispanic women received linguistically and culturally competent education therapy to change their T2DM-associated behaviors, and the absolute changes in waist circumference were inversely accompanied by lower levels of post-DPP HbA1c. Improving the appeal of DPP to male Hispanics is an important next step. Also, developing a culturally competent follow-on approach to promoting further adherence to evidence-based exercise and dietary recommendations is essential to improving the public’s health. (1) Fryar, C. D., Carroll, M. D., & Ogden, C. L. (2014). Prevalence of Overweight, Obesity, and Extreme Obesity Among Adults: United States, 1960–1962 Through 2011–2012 https://www.cdc.gov/nchs/data/hestat/obesity_adult_11_12/obesity_adult_11_12.pdf (2) La Sala, L., & Pontiroli, A. E. (2020). Prevention of diabetes and cardiovascular disease in obesity. International Journal of Molecular Sciences, 21(21), 1-17. https://doi.org/10.3390/ijms21218178

Background. Every year, approximately 2.5 million individuals sustain traumatic physical injuries that require admission to an acute care facility. Several studies suggest that physical injury increases the risk for the development of Post-Traumatic Stress Disorder (PTSD). Nationally, 20% to 40% of acutely injured patients had symptoms consistent with PTSD. Most studies describe the prevalence of PTSD and other mental health conditions post-injury. However, there is limited attention to the effect of pre-existing mental health condition as pre-injury factor, and conclusions from these studies were limited by their small sample sizes, lack of population comparison group, and non-population based. The overall objective of this study was to examine the association between physical injury and PTSD and other mental health conditions in adult patients >18 years who were admitted in ED between 2009-2011. More specifically, those patients who were admitted with physical injury were compared with patients

who had a concurrent diagnosis of PTSD, or concurrent diagnosis of other mental health conditions with patients who did not have these concurrent conditions. The interaction between presenting diagnoses, patient characteristics, hospital setting, location, and risk for outcomes such as mortality rates, and costs were also explored.

Method. This is a cross-sectional, descriptive study that compares the prevalence of Injury (ICD-9-CM 800-999) for patients with and without PTSD (ICD-9-CM 308.91) and patients with and without other mental health diagnoses other than PTSD (ICD-9-CM 290-320) using the National Emergency Department Sample (NEDS) databases who were admitted to a US Emergency Department (ED) between January 1, 2009, through December 31, 2011. The interaction between presenting diagnoses, patient characteristics, hospital setting, location and risk for outcomes such as mortality rates, and costs were explored using univariate, bivariate, and

multivariate analyses.

Results. Adjusted analyses suggested that for the period 2009 to 2011, there were 308, 078,546 ED visits among adults in the US Approximately 22% (N=66,936, 140) of these ED visits had injury-related diagnoses, 0.25% (N=758,528) had PTSD diagnoses, and 25% (N=77,536,048) had mental health diagnoses other than PTSD. There were 133,243 adult patients that were diagnosed with both PTSD and Injury for this period. Adult patients with a diagnosis of PTSD had 1.03-fold higher odds of having injury diagnosis compared to those who are otherwise similar but unaffected adults. Adult patients with mental health diagnoses had

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1.30-fold higher odds of having injury-related ED visits compared to those that are unaffected.

Results from a survey-adjusted multivariate logistic regression analysis indicated that PTSD diagnosis increased the odds of injury-related ED visits to 1.30-fold compared to those that are unaffected. In comparison to adults aged 45-64, those who were aged 18-44 had 1.10-

fold higher odds of an injury, while aged 65-84 had 1.10-fold lesser odds. Males, compared to females, had 1.40-fold higher odds of having injury-related ED visits. Compared to patients with Medicare insurance, those that have private and other insurances had 1.50 and 2.60c-fold higher odds to have injury-related ED visits.

There were significant differences in mortality rates across the studied groups. Injured adult patients compared to otherwise similar but uninjured counterparts had significantly lower mortality rates (0.79% vs. 0.37%, p<0.0001). PTSD diagnosed adults had lower mortality rates in comparison to those that were unaffected (0.20% vs. 0.56%, p<0.0001). PTSD diagnosed patients with injury diagnoses also had a slightly lower mortality rate compared to their uninjured counterparts (0.19% vs. 0.20%, p<0.001). The mortality rates among adults with other mental health diagnoses compared to those that were unaffected were also lower (0.53% vs. 0.70%, p<0.0001). Adult patients with concurrent diagnoses of other mental health and injury showed a lesser mortality rate compared to those without injuries (0.25% vs. 0.61%, p<0.0001). There were significant differences in cost across the groups. Adult patients with injury had higher mean costs compared to those without injury ($45,271 vs. $33,197, p <0.001). Uninjured PTSD diagnosed adults showed lower costs compared to those that did not have PTSD ($21,061 vs. $33,272, p<0.001). Similarly, adults with mental health conditions without injury had lower costs compared to those who did not ($30,269 vs. $35,196, p<0.001). There was incremental

iv

increase in costs for ED patients with concurrent diagnoses. The mean cost for patients with a diagnosis of PTSD was $21,061. The cost increased by 26% when there was concurrent diagnoses of PTSD and Injury ($28, 319). The costs increased by 54% when there was concurrent diagnoses of PTSD, Injury, and other mental health conditions ($45,431).

Conclusion. These findings indicate that when investigating injury as an outcome, the

presence of PTSD and other mental health conditions is a potential confounder and effect modifier. For example, this study showed that PTSD diagnosis didn't increase the odds of dying among those who were diagnosed with injury. Likewise, diagnoses of injury didn't increase the odds of dying among those diagnosed with PTSD. In regards to hospital costs, adult patients with injury or PTSD diagnoses incurred more hospital costs compared to similar but unaffected patients. Results also showed that there were incremental costs incurred with the increased number of diagnoses. For example, combined diagnoses of Injury and PTSD increased the cost by 23% compared to just having PTSD diagnosis alone. Having concurrent diagnoses of PTSD, Injury, and other mental health disorder increased the cost further by 54% compared to just having a diagnosis of PTSD. Based from these findings, it is suggested that mental health and PTSD screening needs to be evaluated upon entry to ED, and immediate referral to mental health services must be considered a priority for patients with an injury. Strategies for injury prevention need to include mental health evaluation and management at the primary, secondary, and tertiary care service settings.

Soccer-related injuries are a health and healthcare concern in the United States (U.S.), and while interest dates to 1994, injuries continue to be a health concern with increased participation. Consequently, to describe baseline characteristics for future comparisons, it is important to describe the breadth and scope of health and healthcare outcomes that are attributed to soccer (injuries) among visiting U.S. EDs, including hospitalization, cost, and length of stay, with special interest in patient-level and hospital-level features, as well as geographic region, population density, mechanism of injury, and place of injury effects on outcomes. Our aim was to determine features of soccer-related injuries amenable to injury prevention strategies to reduce cost and healthcare utilization across the US ED’s. We evaluated a weighted sample of 480,580 for child, adolescent and adult soccer-related injuries in U.S. EDs to address the following aims:

Aim 1 (First publication): Describe soccer-related concussions, intracranial injuries (ICI), and all-other soccer injuries. We also aimed to describe healthcare utilization, cost and length of hospital stay of soccer-related injuries. A third aim was to determine independent predictors (e.g. age, gender, and other individual and well as hospital-level) of concussions, ICI, and all-other soccer injuries leading to ED visits. Study methods and findings are presented and discussed in “Soccer-related injuries utilization of U.S. emergency departments for concussions, intracranial injuries, and other-injuries in a national representative probability sample: Nationwide Emergency Department Sample, 2010 to 2013” submitted for peer review on March 2, 2021.

Findings Summary for Aim 1: Generally, 98% of soccer-related ED visits resulted in routine (treat-and-release) visits. However, the odds of transfer to a short-term hospital following ED evaluation and treatment was more than 37-fold higher for soccer-injured youth and adults diagnosed with ICI when compared to all-other soccer injuries; additionally, these patients showed 28-fold higher odds of being admitted for inpatient care at the ED-affiliated hospital. For concussion, soccer-injured patients with concussion showed nearly 1.5-fold higher odds of being transferred to a short-term hospital than did those with any other soccer injury. Soccer-related ED visits cost more than 700 million in U.S. dollars from 2010 to 2013.

Aim 2 (Second publication): Describe soccer-related injuries evaluated in U.S. ED’s by age. We also analyzed ED disposition and total healthcare charges for ED visits and inpatient care and resources, by age category. Study methods and findings are presented and discussed in “Soccer-related injuries in U.S. emergency departments across the age spectrum: Nationwide Emergency Department Sample, 2010 to 2013” submitted for peer review on March 28, 2021Findings Summary for Aim 2: Males accounted for the majority of the ED visits across the age spectrum, from youth to older age, but the difference narrowed among 12 to 17 years of age. Private insurance payers significantly comprised >50% of payers for soccer-related injury ED care across all age groups; and the patients in the highest income brackets had significantly higher proportional distribution of ED visits in each age group, ranging from 29.6% in 25 to 34 years of age to 67.4% in those 45+ years of age. Of the $700 million dollars charged, youth players 12 to 17 year olds account for nearly half of all soccer related ED visits and total charges, with most of the charges (83%) from the ED (rather than inpatient charges, 17%). In older players 45+ years of age, inpatient charges (rather than ED charges) account for approximately half of all charges. To conclude, socioeconomic indicators, such as income and access to private insurance, may drive decisions to attend to the ED in U.S. soccer players after an injury. Players 12 to 17 years of age account for the greatest impact of ED utilization and cost, while cost for those 45+ years of age may be costly given the disproportional inpatient charges.

Aim 3 (Third publication): Describe and establish independent predictors of soccer-related injury ED visits resulting in hospitalization (vs not) across individual cofactors, treatment centers characteristics, geographic regions and population density, as well as mechanism of injury and place of injury. We also aimed to describe ED charges, inpatient charges, and hospital length of stay in soccer injuries. Study methods and findings are presented and discussed in “Soccer-related injuries disposition in U.S. emergency departments: Nationwide Emergency Department Sample, 2010 to 2013” pending submission for peer review.

Findings Summary for Aim 3: Males were nearly 2-fold more likely to be hospitalized compared to females. Soccer players with other form of payment where 68% more likely to be hospitalized compared to those with private insurance; once models were adjusted, differences were not noted between public insurance and uninsured compared to private insurance. Injury diagnoses more likely to be hospitalized compared to not having that diagnosis were concussions (68%), intracranial injuries (59-fold), fractures (5.74-fold), and internal injuries (86-fold); least likely to be hospitalized were sprains and strains (3.44-fold), wounds (58%), and contusions (2.12-fold). Upper extremities were 3.7-fold less likely to be hospitalized than those without upper extremity injuries. Soccer players that experienced an injury due to a fall, struck by hit or thrown ball with subsequent fall, or in a residential institution were more likely to be hospitalized than those without a fall, not struck by hit or thrown ball with subsequent fall, or not in a residential institution, 2.33-fold, 2.71-fold, and 7.04-fold respectively. From >$700 million, nearly 75% of the cost, over U.S. $521 million in the 4-year period, of soccer-related injuries resulted from treat-and-release ED visits. The mean of total ED charges was highest among hospitalized ED soccer-injured patients, compared to those not hospitalized from 2010 to 2013: ranging from US$2,117-US$2,425 (Hospitalized) and US$1,415-US$1,770 (Not-hospitalized), respectively.

In conclusion, given that soccer-related injuries have become a health, healthcare utilization, and cost concern, the current studies allowed insight into soccer related injuries in meaningful ways, including (Aim 1) concussions, ICI, and all-other injury; (Aim 2) a lifespan analysis, from childhood to older age; and (Aim 3) the differences between those hospitalized (vs not). Generally, the studies looked at descriptors, hospitalization, ED and inpatient charges, and hospital length of stay, across individual-level, hospital-level, and multiple injuries in soccer-related injuries. The finding helped determine multi-level features susceptible to targeted injury prevention intervention to minimize the price on human suffering, healthcare cost, and utilization, within soccer injuries leading to an ED visit.

Purpose: Incidence of HIV diagnoses is higher in Black men who have sex with men (BMSM) than any other socio-demographic population in the United States. BMSM account for 26% of all new HIV diagnoses in the U.S. yet make up an estimated 1% of the U.S population. In 2017, Centers for Disease Control and Prevention (CDC) predicted 50% of BMSM would be diagnosed with HIV in their lifetime. Oral HIV pre-exposure prophylactic (PrEP) medications developed to prevent sexual transmission of HIV are 95-99% effective. However, Blacks represent only 10% of PrEP prescriptions. Targeted Social Marketing initiatives on Instagram need to be explored as a potential channel for informing BMSM about the benefits of PrEP and encouraging use.

Methods: To evaluate interest in a social marketing campaign to increase PrEP interest and use, we systematically deployed an advertisement on the online social media platforms Facebook and Instagram targeting user accounts that show high engagement with lesbian, gay, bisexual, transgender, and queer (LGBTQ), Black LGBTQ, queer-identified, and Black queer-identified (Instagram) accounts. Those accessing the ad by either taping on the link through their mobile device or clicking the link with their computer mouse and agreeing to participate in the survey, completed up to 26 sociodemographic and sexual behavior questions adapted from other surveys of men who have sex with men. Thereafter, respondents were separately invited to follow @The_InstaPrEP_Project on Instagram where followers received 31 educational images developed by the U.S. Centers for Disease Control and Prevention released individually over six weeks. Followers that engaged the Instagram account (@The_InstaPrEP_Project) could view the 31 social marketing interventions as they became available and throughout the intervention. Followers were asked to complete a post-test survey at completion of the intervention. Descriptive, and parametric and non-parametric statistics explored associations between race, age, geography, and sexual-behavioral characteristics and in relationship to engagement of and perceptions of PrEP-specific social marketing campaign materials distributed on Instagram. The study protocol was evaluated as not representing human research by the UCLA Institutional Review Board (IRB#20-000123, South Campus) and declared exempt.

Results: Fifteen users completed the pre-intervention survey. Of the 550 followers gained through the six-week intervention, six (1%) completed the post-intervention survey. Among pre-survey respondents, fewer than half reported themselves as African American (27%, 4/15) or non-white (20%, 3/15), but most stated they were cis-males (93%, 14/15) who have sex with men or mostly men (80%, 12/15). Most reported their age to be between 18 and 39 years (73%) and the majority stated they never used PrEP to prevent HIV (60%). Overall, most reported being HIV-uninfected (73%) at the outset of the intervention.

The intervention account generated 550 followers,19,601 content views by unique user accounts, and 1,326 indications of a favorable opinion (likes) over the six-week intervention. Post-survey data suggested the intervention should be recommended to people like me, is a good addition to regular health care, and increased access to care. Interestingly, the intervention did not invade personal privacy, daily routines, or cause feelings of discomfort.

Conclusion: Greater engagement in the content, given the absence of robust survey participation, suggests Instagram may be an effective tool to engage MSM at high risk for primary HIV infection to use PrEP. Optimized content and engagement strategies may allow for primary prevention strategies using Instagram to improve PrEP uptake and adherence.

Problem Statement: Non-alcoholic fatty liver disease (NAFLD) is rapidly increasing in health and economic burden and necessitates the introduction of preventive and treatment measures in high-risk subpopulations to reduce NAFLD-related morbidity and mortality. Studies have shown that following a healthier lifestyle, losing weight, and treating individual metabolic syndromes can proactively help prevent, postpone, or reverse liver damage caused by NAFLD.Methods: This scholarly project was a single-group, pre- and post-test pilot quality-improvement study designed to improve our understanding of the findings for 26 participants diagnosed with NAFLD within the past year without recent progression. The focus was on lifestyle changes, evidenced by a change in behavior, slowing down the progression of NAFLD to severe liver disease. Eight weekly individual coaching sessions, each lasting 30 to 60 minutes, taught, guided, and supported participants to initiate lifestyle changes in diet and exercise. Individual coaching sessions utilized motivational interviewing, followed by a semi-structured curriculum that included questions designed to elicit participants' responses to inquiries intended to assess their progress. Findings: Study participants were enrolled and underwent baseline measurements. Throughout the course of the study, five subjects dropped out leaving a total of 21participants. The sample's average baseline waist circumference was 41.2 inches (95% CI: 28.8, 54). The final waist circumference measurement was 39.3 (95% Cl: 27.6, 51.1) inches, which displayed a trend in the correct direction. At baseline, individuals weighed 206.5 (141.8–271.1) pounds. The average weight at week eight was 194.8 (95% CI: 133.4, 256.1) pounds. Adjusting for height, individuals' baseline BMI was 34.8 kg/m2 (95% Cl: 26.3, 43.1). The average BMI at week 8 was 32.6 kg/m2 (95% Cl: 23.7, 41.4) kg/m2. The three-factor eating questionnaire (TFEQ) is one of the most commonly used instruments to measure dietary restraint characteristics (Stunkard et al., 1985). The TFEQ data suggests a trend toward overall improvement in uncontrolled eating behaviors, cognitive restraint, and emotional eating behaviors. Conclusion: Participants on average showed a modest reduction in weight over the intervention period, which suggests that the intervention may have been successful. The waist circumference measurements and data indicate the intervention reduced the waist circumference. The results are not statistically significant with the BMI data suggesting that the intervention contributed to a decreased BMI at the post-intervention visit. However, these findings suggest improvements in NAFLD as well with the emphasis placed on weight-reduction as a principal treatment for NAFLD.

ABSTRACT OF THE DISSERTATION

Sinusoidal Obstruction Syndrome Among Pediatric Hematopoietic Stem Cell Transplant Patients

by

Tracy Ono Doctor of Philosophy in Nursing University of California, Los Angeles, 2024 Professor Dorothy J. Wiley, Chair

Evidence strongly supports hematopoietic stem cell transplants (HSCTs) for the treatment of malignancy. HSCT carries risks, including fatality, that are associated with intensive conditioning radiation and chemotherapy that optimize the bone marrow for stem-cell implantation. Hepatic sinusoidal obstruction syndrome (SOS) is a rare complication that disproportionately affects children where progression to severe SOS requires advanced life support and carries high mortality (>80%). A historical literature review and two quantitative studies explored nurse-sensitive predictors for SOS and the association between SOS and malignancy relapse. The literature review targeted people aged 19 and younger receiving HSCT treatment. Five themes emerged: diagnostic and severity grading; pharmacotherapy, primarily concentrated on defibrotide; biologic indicators; advances in diagnostic imaging; and clinical SOS treatment and management variability. We evaluated the associations between heart rate patterns and SOS using routine, clinically recorded electronically-measured heart rates for 0.5 to 19-year-olds following HSCT. While SOS-affected youth consistently showed increasing mean heart rates across 14 and 28 days following HSCT, unaffected minors showed flat patterns. For example, among 0.5 to 2.5-year-olds, mean heart rates increased 1.37-fold over the first 14 days, compared to no change observed among unaffected same-aged children. These and other acute changes in heart rate patterns surrounding HSCT may be new biomarkers for SOS. The associations between SOS and malignancy relapse following HSCT evaluated follow-up data for 180 pediatric HSCT recipients, 0.5 to 19 years of age. Twenty-eight diagnosed with SOS showed a shorter time to relapse in bivariate analysis. Multivariable adjusted models showed SOS was associated with a 3.2-fold higher odds of relapse than observed among youth without SOS. Alkylating chemotherapy was independently associated with lower odds of relapse in these analyses. These analyses underscore a critical need to evaluate routinely collected EMR data, especially data electronically evaluated (vs. counts by many personnel), as risk factors for disease outcomes that drive care and prescriptive interventions among people treated with HSCT. Evaluating nurse-sensitive indicators for early diagnosis of SOS and malignancy relapse prevention may improve patient care, survival, and quality of life.

Human papillomaviruses (HPVs) are common sexually transmitted infections in the epithelium, some genotypes of which are oncogenic and capable of causing cervical and anal cancers. While HPV-associated cervical cancer rates have declined among U.S. women as a result of effective screening and treatment of cervical precancers, anal cancer is increasing in incidence nationwide and is quickly becoming a new threat to public health. While anal cancer is rare in the general U.S. population with an annual incidence rate of 1.8 cases per 100,000 men and women, gay, bisexual, and other men who have sex with men (MSM) have exponentially higher anal cancer incidence rates: 78-137 cases per 100,000 HIV-infected MSM and 5-35 cases per 100,000 HIV-uninfected MSM. The highest estimates for anal cancer in MSM exceed the incidence of the most common cancer in the world (prostate cancer: 120 cases per 100,000), emphasizing the disparate cancer risk in this population. Older MSM are at the highest risk since they have often gone their whole lives without screening, allowing disease to progress unchecked. Risk factors and screening protocols for cervical cancer have long been established and informs anal cancer practices, though for anal cancer, more information is needed and a standard of care remains a work in progress. The purpose of this dissertation is to increase the knowledge and data surrounding anal HPV infections and resulting anal cancer precursors, to inform anal cancer screening and prevention protocols.

This dissertation uses data from the Multicenter AIDS Cohort Study (MACS), the longest running longitudinal study tracking the natural history of HIV/AIDS in MSM, and an independent clinical trial for anal cancer screening in MSM (“Improving Screening Tools for Anal cancer” (ISTA)). Chapter 2 analyzes longitudinal anal HPV data to characterize HPV infection in older MSM, and uses multivariable time-to-event proportional hazards models to identify predictors for incidence and clearance of anal HPV16 and 18, the high-risk HPVs (hrHPVs) accounting for up to 90% of anal cancers. Chapter 3 examines a sample of men with anal biopsy data, to compare anal cytology and hrHPV testing strategies to identify the most effective screening tool to predict histological high-grade squamous intraepithelial lesions (hHSILs): the precursors of anal cancer. Lastly, Chapter 4 assesses self-reported data on testosterone replacement therapy (TRT) and associations with anal cytology test performance and risk for hHSIL. Findings from this dissertation may provide invaluable information to develop standardized anal cancer screening and prevention protocols.

Background

Methods

Results

Conclusions