Department of Emergency Medicine (UCI)

Background

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Trial registration

Human Immunodeficiency Virus (HIV) continues to be a significant public health problem, with ~1.2 million Americans living with HIV and ~14% unaware of their infection. The Centers for Disease Control and Prevention recommends that patients 13 to 64 years of age get screened for HIV at least once, and those with higher risk profiles screen at least annually. Unfortunately, screening rates are below recommendations for high-risk populations, leading to problems of delayed diagnosis. Novel technologies have been applied in HIV research to increase prevention, testing and treatment. Conversational agents, with potential for integrating artificial intelligence and natural language processing, may offer an opportunity to improve outreach to these high-risk populations. The feasibility, accessibility and acceptance of using conversational agents for HIV testing outreach is important to evaluate, especially amidst a global coronavirus disease 2019 pandemic when clinical services have been drastically affected. This viewpoint explores the application of a conversational agent in increasing HIV testing among high-risk populations.

Monkeypox 2022, a zoonotic virus similar to smallpox, presented as a rapidly escalating human outbreak with community transmission outside endemic regions of Africa. In just over one month of detection, confirmed cases escalated to over 3300, with reports of patients in at least 43 non-African nations. Mechanisms of transmission in animals and the reservoir host remain uncertain; spread from humans to wild or domestic animals risks the creation of new endemic zones. While initial cases were reported in men who have sex with men (MSM), monkeypox is not considered a sexually transmitted infection. Anyone with close contact with an infected person, aerosolized infectious material (e.g., from shaken bedsheets), or contact with fomites or infected animals is at risk. In humans, monkeypox typically presents with a non-specific prodromal phase followed by a classic rash with an incubation period of 5-21 days (usually 6-13 days). The prodrome may be subclinical, and the monkeypox virus may be transmissible from person-to-person before observed symptom onset. Most clinicians are unfamiliar with monkeypox. Information is rapidly evolving, producing an urgent need for immediate access to clear, concise, fact-based, and actionable information for frontline healthcare workers in prehospital, emergency departments/hospitals, and acute care/sexual transmitted infection clinics. This paper provides a novel Identify-Isolate-Inform (3I) Tool for the early detection and management of patients under investigation for monkeypox 2022. Patients are identified as potentially exposed or infected after an initial assessment of risk factors and signs/symptoms. Management of exposed patients includes consideration of quarantine and post-exposure prophylaxis with a smallpox vaccine. For infectious patients, providers must immediately don personal protective equipment and isolate patients. Healthcare workers must report suspected and confirmed cases in humans or animals to public health authorities. This innovative 3I Tool will assist emergency, primary care, and prehospital clinicians in effectively managing persons with suspected or confirmed monkeypox.

Monkeypox 2022 exhibits unprecedented human-to-human transmission and presents with different clinical features than those observed in prior outbreaks. Previously endemic only to West and Central Africa, the monkeypox virus spread rapidly world-wide following confirmation of a case in the United Kingdom on May 7, 2022 of an individual that had traveled to Nigeria. Detection of cases with no travel history confirms on-going community spread. Emergency Medical Services (EMS) professionals will likely encounter patients suspected or confirmed to have monkeypox, previously a rare disease and therefore unfamiliar to most clinicians. Consequently, it is critical for EMS medical directors to immediately implement policies and procedures for EMS teams - including emergency medical dispatchers - to identify potential monkeypox cases. These must include direction on actions EMS professionals should take to protect themselves and others from virus transmission. Monkeypox 2022 may manifest more subtly than it has historically. Presentations include a subclinical prodrome and less dramatic skin lesions - potentially limited to genital or anal body regions - which can be easily confused with dermatologic manifestations of common sexually transmitted infections (STIs). While most readily spread by close contact with infectious skin lesions on a patient, it is also transmissible from fomites, such as bed sheets. Additionally, droplet transmission can occur, and the virus can be spread by aerosolization under certain conditions. The long incubation period could have profound negative consequences on EMS staffing if clinicians are exposed to monkeypox. This report summarizes crucial information needed for EMS professionals to understand and manage the monkeypox 2022 outbreak. It presents an innovative Identify-Isolate-Inform (3I) Tool for use by EMS policymakers, educators, and clinicians on the frontlines who may encounter monkeypox patients. Patients are identified as potentially exposed or infected after an initial assessment of risk factors with associated signs and symptoms. Prehospital workers must immediately don personal protective equipment (PPE) and isolate infectious patients. Also, EMS professionals must report exposures to their agency infection control officer and alert health authorities for non-transported patients. Prehospital professionals play a crucial role in emerging and re-emerging infectious disease mitigation. The monkeypox 2022 3I Tool includes knowledge essential for all clinicians, plus specific information to guide critical actions in the prehospital environment.

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Digital health behavior change interventions (DHBCIs) offer users accessible support, yet their promise to improve health behaviors at scale has not been met. One reason for this unmet potential may be a failure to offer users support that is tailored to their personal characteristics and goals. We apply the concept of antifragility to propose how DHBCIs could be better designed to support diverse users' behavior change journeys. We first define antifragility as a feature of an individual's relationship to a particular challenge such that if one is antifragile to a challenge, one is well positioned to benefit from facing that challenge. Second, we introduce antifragile behavior change to describe behavior change processes that leverage person-specific antifragilities to maximize benefits and minimize risk in the behavior change process. While most existing behavior change models focus on improving one's motivation and ability to face challenges, antifragile behavior change complements these models by helping to select challenges that are most likely to produce desired outcomes. Next, we propose three principles by which DHBCIs can help users to develop antifragile behavior change strategies: providing personalized guidance, embracing variance and exploration in choosing behaviors, and prioritizing user agency. Finally, we offer an example of how a DHBCI could be designed to support antifragile behavior change.

Study design

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Introduction

Study objective

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Approximately 1.2 million people are living with HIV, with many of them unaware of their infection. Pre-exposure prophylaxis (PrEP) is available to minimize transmission among those at high risk for infection, including men who have sex with men, people who inject drugs, and female sex workers. Despite its availability, there is low usage of PrEP. To address this problem, various digital tools have been examined in HIV research. Among those, conversational agents are still underused and their capacity warrants examination to reach at-risk populations. In this paper, we discuss the potential of conversational agents in increasing uptake of PrEP by addressing barriers experienced among those at high risk for infection.

Gut bacteria influence neural circuits in addiction-related behaviors. Given the association between opioid use, gastrointestinal distress, and microbial dysbiosis in humans and mice, we test the hypothesis that interactions between gut bacteria and the brain mediate the rewarding and reinforcing properties of fentanyl. We implant rats with intravenous catheters in preparation for fentanyl intravenous self-administration (IVSA) on an escalating schedule of reinforcement to determine factors that influence fentanyl intake, including sex, dose, and gut microbiota. Our data show the impact of fentanyl IVSA on gut microbiota diversity, as well as the role of gut microbiota on fentanyl IVSA, in Sprague Dawley rats in a sex- and dose-dependent manner (n = 10-16/group). We found that the diversity of gut microbiota within females dose-dependently predicts progressive but not fixed ratio schedules of fentanyl IVSA. Depending on sex and fentanyl dose, alpha diversity (richness and evenness measured with Shannon index) is either increased or decreased following fentanyl IVSA and predicts progressive ratio breakpoint. Our findings collectively suggest a role of gut bacteria in drug-related behavior, including motivation and reinforcement. This work provides feasibility for an intravenous fentanyl self-administration model and uncovers potential factors mediating drug use, which may lead to the development of effective addiction interventions.