People living with HIV (PLHIV) have an increased risk of developing active tuberculosis (TB). To reduce the burden of TB among PLHIV, the World Health Organization (WHO) recommends systematic TB screening followed by (1) confirmatory TB testing for all who screen positive and (2) TB preventive therapy (TPT) for all TPT-eligible PLHIV who screen negative. Symptom-based screening remains the standard of care in most high TB burden settings, including Uganda. Despite having high sensitivity for active TB among antiretroviral-naïve PLHIV, symptom screening has poor specificity; as such, many high-risk PLHIV without active TB are not referred for TPT. C-reactive protein (CRP) is a promising alternative strategy for TB screening that has comparable sensitivity and higher specificity than symptom screening, and was endorsed by WHO in 2021. However, the impact of CRP-based TB screening on TB burden for PLHIV remains unclear.TB SCRIPT (TB Screening Improves Preventive Therapy Uptake) is a phase 3, multi-center, single-blinded, individual (1:1) randomized controlled trial evaluating the effectiveness of CRP-based TB screening on clinical outcomes of PLHIV. The trial aims to compare the effectiveness of a TB screening strategy based on CRP levels using a point-of-care (POC) assay on 2-year TB incidence and all-cause mortality  and prevalent TB case detection and uptake of TPT (intermediate outcomes), relative to symptom-based TB screening (current practice).This study will be critical to improving selection of eligible PLHIV for TPT and helping guide the scale-up and integration of TB screening and TPT activities. This work will enable the field to improve TB screening by removing barriers to TPT initiation among eligible PLHIV, and provide randomized evidence to inform and strengthen WHO guidelines.ClinicalTrials.gov NCT04557176. Registered on September 21, 2020.The online version contains supplementary material available at 10.1186/s13063-022-06371-0. Tuberculosis (TB) remains the leading killer of people living with HIV (PLHIV) globally, accounting for one-third of all HIV-related deaths . TB prevC-reactive protein (CRP) is a non-specific inflammatory marker whose levels rise in response to infection, including active TB. Prospective studies among individuals with advanced HIV initiating ART have shown CRP to meet the minimum thresholds for sensitivity (≥90%) and specificity (≥70%) established by WHO for an effective TB screening test –22, suggHere we describe the protocol of TB Screening Improves Preventive Therapy Uptake (TB SCRIPT), a randomized controlled trial conducted in three health centers in Uganda, which was designed to determine if TB screening based on POC CRP concentration improves clinical outcomes  among outpatients with advanced HIV initiating ART through improved TPT uptake and detection of prevalent TB cases. This work will be critical to both improving selection of eligible PLHIV for TPT and helping guide the scale-up and integration of TB screening and TPT activities in TB-endemic countries.The primary objective of TB SCRIPT is to compare the impact of POC CRP-based with symptom-based TB screening on 2-year TB disease outcomes. We will randomize participants to either POC CRP-based (intervention) or standard-of-practice symptom-based TB screening (control). All participants who screen positive will undergo confirmatory TB testing, while only participants who screen negative will initiate 12 weekly doses of isoniazid and rifapentine (3HP), a short-course TPT regimen. We will follow all eligible participants for 2 years to assess TB incidence and all-cause mortality. At the final study visit, we will collect sputum to ascertain active TB status from participants who have not been diagnosed with or treated for active TB during follow-up. The primary hypothesis for this objective is that participants randomized to POC CRP-based TB screening will have lower combined 2-year TB incidence and mortality , relative to participants randomized to symptom-based screening. The second objective is to compare the impact of POC CRP-based with symptom-based TB screening on (1) TPT uptake and (2) prevalent TB case detection, intermediate outcomes on the pathway to the combined primary trial outcome. The primary hypothesis for this objective is that participants randomized to POC CRP-based TB screening will have higher rates of TPT uptake and completion, determined via objective monitoring, and similar rates of prevalent TB case detection relative to participants randomized to symptom-based screening.The TB SCRIPT trial is a phase 3, single-blinded, multi-center, randomized superiority trial evaluating the clinical impact of POC CRP-based TB screening on immediate and longer-term outcomes of PLHIV in Uganda. Uganda is among the world’s 30 high HIV/TB burden countries with an HIV prevalence of 6.2% and an annual TB incidence of 253 cases per 100,000 ; among aWe will randomize 1720 PLHIV presenting for routine ART initiation in three clinics (two public and one non-government/non-profit) in Kampala, Uganda, to either POC CRP-based TB screening (intervention) or symptom-based TB screening (control) with a 1:1 allocation ratio over a 2-year period. After randomization, we will perform baseline TB screening in accordance with the participant’s assigned TB screening strategy. Based on the results of baseline TB screening, we will either collect clinical specimens  for confirmatory TB testing  or assess 3HP eligibility  with a confirmed HIV-positive test result and CD4 count ≤350 cells/μL and capacity to provide written  informed consent. We will exclude those who have completed treatment for active pulmonary or extra-pulmonary TB within the past 2 years; completed a full course of any approved TPT regimen within the past year; are actively taking any internationally approved medication for TB treatment  for any reason, within 2 weeks of study entry; have a prior history of combined ART for HIV treatment for any duration; or who currently reside 25 km outside the enrollment site, have plans to move 25 km outside their enrollment site in the next 2 years, or plan to transfer their HIV care from the enrollment site.The study team will obtain written informed consent in English or the local dialect (Luganda). For participants who cannot read or write, we will obtain verbal consent and obtain a thumbprint, and a witness will sign the informed consent document. We will obtain separate written informed consent for collection and storage of biological specimens.We will compare the effectiveness of two WHO-approved TB screening strategies for PLHIV: POC CRP (intervention) and the WHO 4-part symptom screen (control).For participants randomized to POC CRP-based TB screening, we will record POC CRP concentrations measured from capillary blood obtained via finger prick using a standard sensitivity POC assay . The iCHROMA CRP assay is a US Food and Drug Administration (FDA)-approved, fully quantitative, lateral flow-based fluorescence sandwich immunoassay with a detection range of 2.5–300 mg/L and excellent stability after more than 18 months of storage under the recommended conditions.Although the recent WHO TB screening guidelines recommend using a cut-point of 5 mg/L to maximize sensitivity of CRP for active TB, we selected a cut-point of 8 mg/L prior to the updated WHO recommendations based on our own previously published research demonstrating a CRP cut-point of 8 mg/L to have 90% sensitivity and 70% specificity for culture-confirmed TB , 26, 27.For participants randomized to symptom-based TB screening, we will record the presence or absence of current cough, fever, night sweats, and weight loss in the past 30 days using a standardized script. In accordance with the current WHO and Ugandan TB screening guidelines, participants with ≥1 symptom will be classified as screen-positive and participants with none of the 4 symptoms will be classified as screen-negative .In both arms, we will use the results of baseline TB screening to guide decisions regarding 3HP initiation and confirmatory TB testing Fig. .We will offer 3HP to all screen-negative participants  meeting local 3HP eligibility criteria. 3HP will be initiated no earlier than 2 weeks after ART initiation. Participants initiating 3HP will be managed in accordance with local guidelines and instructed to bring 3HP bottles at every visit during the period of 3HP prescription.We will collect spontaneously voided urine and spot sputum specimens  from all screen-positive participants  for urine LAM (Alere Determine TB-LAM) and sputum Xpert Ultra testing. In accordance with current WHO guidelines, sputum Xpert Ultra testing will be performed if (1) urine LAM is negative or (2) urine LAM is positive and the participant has risk factors for drug-resistant TB . Participants who test positive for TB by urine LAM and/or sputum Xpert Ultra will be referred to clinicians for TB treatment initiation. To maximize real-world relevance, sputum will not be submitted for mycobacterial culture because most HIV programs in high burden countries use Xpert (standard cartridge or Ultra) as the confirmatory test for TB. Participants who screen-positive but test negative by urine LAM and sputum Xpert Ultra will not be given 3HP at the time of enrollment (as their risk of active TB remains non-negligible), but will be eligible for TPT initiation at the discretion of treating (non-study) clinicians throughout the follow-up period.After baseline study procedures, routine clinic staff will provide all further care and follow-up for HIV, TPT, and/or active TB treatment. Routine clinical care for all patients initiated on ART includes blood draw for pre-ART labs, HIV viral load at 6 months and as appropriate thereafter, and clinic visits at weeks 2 and 6 and then months 3, 6, 12, 18, and 24 post-ART initiation. Patients initiated on 3HP or TB treatment have additional visits for active TB screening, medication adverse event (AE) monitoring, adherence assessments, and refills, per routine clinic protocols. To capture clinical and outcome data for this trial, we will conduct brief follow-up interviews and extract relevant data from the clinic medical record at regular intervals for 2 years . At the final (24-month) study visit, we will collect sputum specimens from all participants who have not been treated for TB during the study for the final active TB assessment. Table As this trial is comparing two WHO-endorsed TB screening strategies, the risk of study participation is no greater than routine care. People with prevalent TB may be missed by screening and/or inadvertently initiated on TPT; prevalent TB cases initiated on 3HP are at increased potential risk for developing acquired drug resistance. Missed prevalent TB cases, including all drug-resistant TB cases, will be managed by routine clinicians in accordance with local guidelines. Conversely, PLHIV without active TB may have a false-positive screen and miss the opportunity to receive study-initiated 3HP. The risk of injury to study participants is minimal. In the unlikely event of injury as a result of study participation, standard treatments will be made immediately available at the clinic site and/or Mulago National Referral Hospital; no other form of compensation for injury will be provided.To promote retention for participants in both trial arms, we will record participants’ phone numbers and home address at study entry and review/update their contact information at every study visit (with participants’ consent). We will provide phone call reminders of upcoming clinic appointments and reimbursement for transportation expenses for all scheduled study visits.The primary trial endpoint is a composite outcome of microbiologically confirmed incident TB and all-cause mortality, measured as time to first diagnosis of incident TB or death from any cause. Microbiologically confirmed incident TB is defined as active TB diagnosed by either culture, one non-trace positive Xpert Ultra result or two trace-positive Xpert Ultra results, or positive urine LAM result from 3 months after randomization to the end of follow-up . To assess active TB status at the end of follow-up, 2 spot sputum specimens will be collected from all participants who have not taken anti-TB treatment during the study at the final (24 months) study visit for sputum Xpert Ultra testing, liquid culture, and drug susceptibility testing (for participants who received any TPT). Secondary outcomes are presented in Table n = 95] to 8.1% [n = 62]). This sample size will also provide 85% and 90% power if 2-year mortality is 6.8% and 8.8%, respectively . We expect 2-year mortality of 5.2% and 2-year TB incidence of 7.3% in the control arm , 28. AssFor the secondary objective, based on published estimates of specificity from similar settings, we estimate no more than 15% of all patients in the control arm will initiate 3HP  , 17, 20.Randomization lists were generated in R using Chen’s design with a biased coin and maximum tolerated imbalance, stratified by site . Within TB SCRIPT is a single-blinded trial. We will not be blinded to intervention allocation, as we will perform baseline TB screening and subsequent procedures based on the results of screening . Participants and routine clinic staff will be blinded, as will the study principal investigators . To facilitate blinding, all participants will undergo a finger prick and have capillary blood measured for CRP (intervention) or beta-human chorionic gonadotropin . POC CRP and β-hCG assays will be provided by BodiTech, Med Inc. and measured using the iCHROMA Reader which provides analysis of more than 30 unique markers, including CRP and β-hCG. There are no procedures for unblinding, as clinicians are free to order TB testing, initiate TB treatment, or initiate TPT for study participants at any time.All participating clinics will use standardized electronic case report forms for initial and follow-up visits. At the baseline visit, we will administer a standardized questionnaire to verify relevant information in the medical record including demographic data, TB and other opportunistic infection history, current medications, and routine lab measurements. At follow-up visits, we will review the medical record to extract relevant interval medical history , new medications , and routine lab measurements  using a standardized form.For participants receiving 3HP, we will assess adherence by performing pill counts and patient-reported adherence. In addition, we will review the medical record and record the number of 3HP refill visits completed. For participants receiving active TB treatment, we will review clinic TB treatment records and record the number of treatment months recorded as complete.For all participants who screen-positive by their assigned TB screening strategy, we will collect urine and 2 spot sputum specimens for urine LAM (Alere Determine TB-LAM) and sputum Xpert Ultra testing. All urine LAM-negative participants and urine LAM-positive participants with risk factors for drug-resistant TB  will have sputum tested by Xpert Ultra for rapid detection of rifampin resistance. All participants with a positive urine LAM and/or sputum Xpert Ultra result (including trace-positives) will be referred to routine clinic staff for initiation of anti-TB treatment. Additionally, for participants with trace-positive Xpert Ultra results, we will perform repeat Xpert Ultra testing on the second spot sputum specimen. Participants with a non-trace-positive Xpert Ultra result or two trace-positive Xpert Ultra results will be classified as having active prevalent TB.M. tuberculosis complex using Ziehl-Neelsen smear microscopy for detection of acid-fast bacilli and SD MPT64  for rapid M. tuberculosis antigen detection. DST will include susceptibility testing to all first-line TB medications including isoniazid and rifamycin-based drugs. Participants will be classified as having incident TB if at least one of the following criteria are met: at least one sputum culture positive for M. tuberculosis complex, one non-trace-positive Xpert Ultra result, or two trace-positive Xpert Ultra results.For all participants who have not taken anti-TB treatment during follow-up, we will collect 2 spot sputum specimens at the final (24 months) study visit for sputum Xpert Ultra testing; repeat Xpert Ultra testing, if the initial test is trace-positive; and liquid culture and drug susceptibility testing (DST). Speciation testing will be performed on all positive cultures to confirm the presence of Data collection, entry, management, and quality assurance are conducted at each enrollment site. However, all standard operating procedures for data collection and management are identical across the enrollment sites. We have developed standardized REDCap data collection forms and implemented procedures for quality control. Data collection forms provide clear instructions to guide data entry and contain pre-programmed skip patterns, real-time range checks, and internal logic to minimize missing data and facilitate cleaner data at capture. Study data will be entered directly  into REDCap using password-protected laptop computers or tablets. Data entered in Uganda while offline will be uploaded to a secure University of California San Francisco server on a daily basis. All data will undergo weekly checks for completeness, consistency, accuracy, and range criteria. Queries performed on the database will be reviewed, verified, and corrected every 2 weeks.The primary trial outcome is a 2-year composite endpoint of microbiologically confirmed incident TB and all-cause mortality, measured as time to first diagnosis of incident TB or death from any cause. The primary analysis will be by intention-to-treat (ITT), including all participants randomized without regard to the results of baseline TB screening, and we will use a two-sided alpha (0.05 significance) in assessing the effect of the intervention on the primary outcome. Participants with prevalent TB will be included in the analysis to preserve the randomized groups (the ITT principle) but excluded from the outcome of incident TB because subsequent disease is more likely to represent relapse or failure (and these participants will not routinely receive TPT). Time from randomization to first event (diagnosis of incident TB or death from any cause) will be analyzed using the log rank test and Cox proportional hazards models, adjusted for the study site. If data are missing or a patient is lost to follow-up, a patient’s data will be censored in the analysis at the date of last known contact. We will also use the Mantel-Haenszel method to determine standardized incidence rates and incidence rate differences. Balance at baseline on all known and suspected prognostic factors will be assessed, and if important imbalances are found , a sensitivity analysis will be conducted using a Cox model to adjust for these factors. We will also assess the impact of clinician-initiated co-interventions  on the primary outcome. We will conduct a sensitivity analysis in which these participants are censored as soon as they are initiated on TPT or TB treatment by non-study clinicians. Standard checks for variation by enrollment site will also be planned. Secondary outcomes for the primary objective include the individual primary endpoints  and 2-year isoniazid-resistant TB incidence and will be analyzed using a similar approach; there will be no adjustment for multiplicity since these are pre-specified secondary outcomes.To evaluate intermediate outcomes on the pathway to the composite primary trial outcome, we will determine the proportion of randomized participants initiating TPT (prescribed TPT), the proportion of randomized participants completing TPT (≥90% TPT pills taken), the proportion of randomized participants diagnosed with prevalent TB, and the proportion of randomized participants with prevalent TB completing TB treatment (by clinic record review). The primary analysis will be by ITT, with the outcome of initiating any TPT based on actual events, irrespective of whether the algorithm was followed. Participants eligible for 3HP based on the results of baseline screening  may decline to initiate 3HP after randomization despite being prescribed 3HP; these participants will be counted as not having started TPT. Participants who were initiated on TPT during study follow-up  will be counted as having started TPT; 6 months of daily isoniazid (IPT) is currently the most common TPT regimen available for routine clinical use. We will compare the proportion of PLHIV initiating any TPT (study- and clinician-initiated TPT) and the proportion of PLHIV completing TPT , calculating the risk difference and 95% confidence intervals (CI) using standard methods, adjusted for study site using Cochran-Mantel-Haenzsel weights. If respective data on an outcome is missing or a patient is lost to follow-up, it will be assumed that the patient did not initiate nor complete TPT (depending on what data are available). Our working hypothesis is that POC CRP-based TB screening will increase the proportion of PLHIV initiating and completing TPT by at least 40%, relative to symptom-based screening. We will compare the proportion of PLHIV with screen-positive prevalent TB and the proportion of PLHIV with screen-positive prevalent TB completing TB treatment, calculating the risk difference and 95% CIs using standard methods, adjusted for study site using Cochran-Mantel-Haenszel weights. Our working hypothesis is that the proportion of PLHIV with screen-positive prevalent TB will be similar in each arm, and we expect the upper bound of the CI of the difference will be no more than 5%. We consider this margin of 5% sufficiently small to conclude equivalence.We will repeat the primary analysis in the following pre-specified sub-groups: by age, gender, enrollment site, and CD4 strata . Safety data related to missed diagnoses of prevalent TB, acquired drug-resistant TB, and TPT-related serious adverse events will be tabulated by study arm.The full protocol, participant-level dataset, and statistical code will be made available upon request if agreed upon by the principal investigators.The study will be overseen by an Administrative Core, chaired by the principal investigator and Uganda site principal investigator. In addition, a Clinical Trial Core chaired by two principal investigators will be responsible for maintaining ethics approvals, databases, and study monitoring. An Economic Modeling Core chaired by a principal investigator will be responsible for overseeing all economic and costing analyses.The study team meets bi-weekly via conference calls to monitor the progress of the study, participant enrollment, and retention. Bi-weekly conference calls include a review of trial outcomes, as well as factors external to the study  that could impact the safety of study participants and/or study activities. Additional monthly conference calls separately review all adverse events and protocol deviations.Day-to-day data and safety monitoring is the responsibility of the principal investigators and will follow guidelines established by IRBs regarding reportable adverse events (AE). Reportable AEs are reported to the IRBs within 10 days of study awareness. Reportable AEs will be attributed to the study intervention by the principal investigator with review by the physicians/co-investigators according to the following categories: definite, probably, possible, unlikely, and unrelated. A bi-annual and annual report of all reportable AEs will be presented to the Data Monitoring Committee (DMC) and National Heart, Lung and Blood and Institute, respectively. In addition, an endpoint adjudication committee will meet annually to review all deaths and determine causes of death.An independent DMC that includes experts in TB diagnostics and the analytical and regulatory aspects of clinical trials met by conference call before enrollment and will meet at 25%, 50%, 75%, and 100% enrollment and when 50% of patients have completed follow-up and when 100% have completed follow up to review safety data from the trial. They are charged with evaluating the quality of trial administration, monitoring safety issues, and providing guidance on scientific, methodological, and ethical issues. Specifically, the DMC will review administrative reports prepared by the Data Manager for each meeting of the DMC. This report will describe study progress, including the following: (1) accrual, (2) demographics, (3) subject status, (4) TB prevalence, (5) proportion of patients initiating TPT, (6) number and type of serious AEs (SAE), (7) cumulative TB incidence (including drug-resistant TB), and (8) cumulative all-cause mortality. Tables by arm will be prepared for review in the closed sessions of the DMC meetings; the DMC will have access to screening assignments. Differences in the composite primary trial outcome  between trial arms are unlikely to modify our study protocol because of the long duration of follow-up (2 years), relative to recruitment. However, differences in missed diagnoses of prevalent TB (primary risk and safety endpoint), measured as the proportion of microbiologically confirmed prevalent TB cases missed by screening, will be carefully reviewed and the decision to continue enrollment after each meeting will be made by the DMC. Although unlikely, the DMC should inform the PIs if, in their view, the results of an interim analysis are likely to convince a broad range of clinicians  that, on balance, one trial arm is clearly indicated or contraindicated for all participants or a particular category of participant. Further details of stopping guidelines and roles and responsibilities of members are included in the DMC charter.Internal monitoring will occur annually, in accordance with the trial’s Comprehensive Quality Management Plan (CQMP).TB remains a leading infectious cause of death globally and is the leading cause of death for PLHIV . DiagnosClinicalTrials.gov, NCT04557176 .Protocol version 2.1, April 26, 2021. Recruitment began on November 16, 2020, and is currently ongoing. As of October 20, 2021, 558 individuals were screened for study eligibility and 491 were enrolled. Recruitment completion is estimated in December 2022. Trial registration: Additional file 1: Biological specimens


There were significantly higher incidence (75.0% vs. 48.4%) and more severe sarcopenia in patients with wt-GIST than in patients with mu-GIST. Multivariate logistic regression analysis showed that sarcopenia score , and muscle fat index were independent predictors for higher risk of wt-GIST . Our sarcopenia nomogram achieved a promising efficiency with an AUC of 0.879 for the training cohort, and 0.9099 for the validation cohort with a satisfying consistency in the calibration curve. Favorable clinical usefulness was observed using decision curve analysis. The additional gene sequencing analysis based on both our data and the external data demonstrated aberrant signal pathways being closely associated with sarcopenia in the wt-GIST. Our study supported the use of CT-based assessment of sarcopenia in differentiating the wt-GIST from the mu-GIST preoperatively.Non-invasive prediction for KIT/PDGFRA status in GIST is a challenging problem. This study aims to evaluate whether CT based sarcopenia could differentiate KIT/PDGFRA wild-type gastrointestinal stromal tumor (wt-GIST) from the mutant-type GIST (mu-GIST), and to evaluate genetic features of GIST. A total of 174 patients with GIST (wt-GIST = 52) were retrospectively identified between January 2011 to October 2019. A sarcopenia nomogram was constructed by multivariate logistic regression. The performance of the nomogram was evaluated by discrimination, calibration curve, and decision curve. Genomic data was obtained from our own specimens and also from the open databases cBioPortal. Data was analyzed by R version 3.6.1 and clusterProfiler ( Most GISTs harbor KIT/PDGFRA mutant gene named KIT/PDGFRA mutant GIST (mu-GIST), and the remaining cases (about 10–15%) are KIT/PDGFRA wild-type GISTs (wt-GIST) which do not have mutant KIT/PDGFRA genes2. It is important to differentiate these two subtypes of GIST for selecting effective treatment3. For example, imatinib is an active multikinase inhibitor that mainly targets C-kit tyrosine-kinase receptors. Although imatinib has become the standard first-line treatment worldwide for patients with the mu-GIST, it almost ineffective for patients with the wt-GIST. Clinically, neo-adjuvant therapy with imatinib was strongly recommended for mu-GIST patients prior to surgery with the purpose of sparing important organs which may be locally invaded by tumor5. Currently, the only method for preoperative molecule identification of the GIST subtypes is through aspiration biopsy, which is invasive and may have potential risk of tumor rupture, perforation of gastrointestinal tract or needle track implantation6. There is an unmet need for developing a robust non-invasive tool for differentiating wt-GIST from mu-GIST before treatment.Gastrointestinal stromal tumor (GIST) is a common interstitial tumor occurring in gastrointestinal tract9. A recent study has identified the presence of sarcopenia in GIST patients and highlighted the predictive value of sarcopenia on treatment toxicity10. However, there is a paucity of literature regarding clinical value of pre-treatment sarcopenia for patients with GIST regarding their response to treatment and prognosis. Converging evidences have indicated that sarcopenia may possibly underline the pathogenesis of various cancers, because signal pathways involved in sarcopenia are usually anomalous in cancer11. We hypothesized that different molecular pathways for wt-GIST and mu-GIST may lead to significant differences in muscle mass of patients with different subtypes of GIST.Abdominal computed tomography (CT) is routinely used for clinic management of GIST. Sarcopenia (loss of lean muscle mass) can be evaluated on the routine abdominal CT images obtained for clinical careHere, we retrospectively analyzed the lean muscle mass on abdominal CT images of 174 patients with GIST and evaluated whether CT assessment of sarcopenia could differentiate the wt-GIST from the mu-GIST. In addition, we also performed genetic analysis on both our own data and an external dataset.This single-center retrospective study including all experimental protocols, was approved by the Institutional Review Board of Xiangya hospital (IRB#: 202009685). The written informed consents were waived by the Institutional Review Board of Xiangya hospital due to the retrospective nature of this study. All methods were carried out in accordance with relevant guidelines and regulations.Patients with pathologically proved GIST and with genotyping information were retrospectively identified and their data was collected after searching our institutional medical database from January 2011 to October 2019. This cohort was divided into two groups: the wt-GIST group and the mu-GIST group. Details of the patient recruiting process and exclusion criteria were presented in Fig. For each patient, all pathological slides were re-analyzed by two pathologists specialized in GIST . Consensus was reached by discussion if differences in opinions occurred. KIT and PDGFRA gene were amplified and sequenced by Sanger sequencing set kit according to the manufacturer’s instructions using primers designed for the c-KIT exon 9, 11, 13, 14, 17, 18 and PDGFRA exon 12, 18.10, corresponding fat area  and the area of the abdominal wall and back muscles  (between − 29 and 150 Hu) were measured by calculating the area of pixels with corresponding attenuation in demarcated areas, respectively. L3 skeletal muscle index (SMI) was calculated as the area of total L3 skeletal muscle (cm2) divided by height square (m2). Visceral or subcutaneous fat index  was calculated as the area of visceral, intramuscular or subcutaneous fat (cm2) at the navel level divided by the square (m2) of height. The details for body composition measurement was presented in Fig. Initial pre-treatment abdominal CT images were retrieved from Picture Archiving and Communication Systems (PACS) for analysis. Two axial unenhanced images were selected at the level of the third lumbar vertebra body  and at the navel level  respectively. Total body fat area, visceral fat area (VFA), fat area in muscle (MFA), subcutaneous fat area (SFA), and skeletal muscle area (SMA) were measured manually on the selected axial image by using a medical image analysis software . Bone structures, and the central spinal canal were excluded manually in the selected axial images for accurate measurement of specific areas on a workstation . According to a prior studyAll patients underwent surgery, and post-surgical follow-up was obtained for each patient. The primary endpoints of the study were disease free survival (DFS). DFS was defined as the time from surgery to recurrence of GIST or metastasis for expired patients or the last follow-up for surviving patients.Genomic DNA data for 28 patients in our cohort including 15 wt-GIST samples  and 13 KIT mu-GIST samples (sanger sequencing positive for c-KIT exon 11) were obtained from our archived formalin-fixed paraffin-embedded (FFPE) tissues. Ten peripheral blood lymphocyte (PBL) samples from the 15 wt-GIST patients were collected as germline controls. The comprehensive genetic alterations of these 28 GIST samples were analyzed using targeted deep sequencing of 1021 cancer related genes region. The Next Generation Sequencing was executed according to the manufacturer’s instructions . The somatic mutations of the wt-GISTs were investigated for genomics landscape description with the ComplexHeatmap R package.http://cbioportal.org/msk-impact). Data was analyzed by R version 3.6.1 and KEGG enrichment analysis was performed by clusterProfiler. The pathway with p-value less than 0.05 were kept for the following comparison analysis.In addition, mutational landscapes and corresponding clinical information were downloaded from cBioPortal as external data (http://www.Rproject.org). Multivariate binary logistic regression, nomograms, calibration plots, decision curve and correlation matrix plots were done with the “Caret”, “PROC”, “rmda”, “corrplot”, “forestplot”, “rms” and “corrplot” package. Decision curve was performed with the “rmda” package. And “survival” package was used for the survival analysis. KEGG analysis12 was performed by R version 3.6.1 through application of clusterProfiler. The statistical significance levels were all two-sided with statistical significance set at 0.05.Statistical analysis was implemented with SPSS 22.0, SAS9.4, and R software .We assessed body composition features and sarcopenia on the pretreatment abdominal CT images in patients with Gastrointestinal stromal tumor (GIST). Our prediction model combining sarcopenia parameters and clinical variables showed robust performance, indicating the potential for using such a non-invasive method for predicting KIT/PDGFRA status.In total, 174 consecutive patients with GIST were included into our study. The clinicopathological characteristics of the patients in the wt-GIST group and mu-GIST group were summarized in Table The VFA, VFI, MFI and SFI of patients in the wt-GIST group were all significantly larger than those of patients in the mu-GIST Group. The SMI and VFI/SFI Ratio of the wt-GIST Group were significantly lower than those in the mu-GIST Group Table .P < 0.001).Taking into considerations of the influence of age and gender on skeletal muscle index (SMI), we developed a new index termed sarcopenia score based on the three features through multivariate logistic regression. Not surprisingly, the sarcopenia score for the wt-GIST group  was significantly higher than that of the mu-GIST group  (P = 0.33). The incidence of sarcopenia and visceral obesity in the wt-GIST group was much higher than that of the mu-GIST group  (P < 0.001). Interestingly, the inconsistent diagnosis of adiposity, including obesity diagnosed based on BMI and visceral obesity based on VFA, occurred in 32.18% (56/174) of patients with GIST. BMI was normal in forty-six GIST patients with visceral obesity, while ten obese patients did not actually have visceral obesity.There was no significant difference on obesity  between the wt-GIST group and the mu-GIST Group (23.1% vs 30.3%)  and MFI  were identified as independent risk factors for wt-GIST.Single factor logistic regression analysis showed that the patients with wt-GIST were associated with NLR, VFA, MFA, SFA, VFA/SFA ratio, SMI, VFI, MFI, SFI, sarcopenia score, sarcopenia and visceral obesity. Further multivariate logistic regression analysis showed that, only sarcopenia score (A parsimonious model separating the patients with wt-GIST from the patients with mu-GIST was developed by incorporating the two independent predictors (sarcopenia score and MFI), and a nomogram was obtained Fig. A. The ROP = 0.819) and the validation cohort (P = 0.751), which suggested no departure from perfect fit.The calibration curve of the nomogram for the probability of wt-GIST showed good agreement between prediction and observation in both the training and validation cohorts Fig. E,F. The The decision curve analysis for the nomogram was presented in Fig. P = 0.561). Furthermore, two patients with visceral obesity could not be diagnosed as obesity based on their BMI values. The impact of sarcopenia and visceral obesity rather than obesity on the survival of wt patients with -GIST  were observed in the log-rank test, although there was no statistical significance  patients were lost at the median follow-up of 31.0 months (range 1.0–73.0 months). During the follow-up period, only 3  and 4  deaths were observed, respectively. The relevant prognostic analysis was not completed because the majority of patients did not have an endpoint event. However, it should be noted that all endpoints (recurrence or death) occurred in patients with sarcopenia and visceral obesity. The incidence of recurrence was higher in patients who were sarcopenic compared with those who were not (11.4% vs. 0%), although the difference was not statistically significant due to the relatively short follow-up period  analysis indicated that the pathway enriched in osteoclast differentiation and longevity regulating pathway was noted in the wt-GISTs. When compared to the mu-GISTs, higher forkhead box O (FoxO) signaling pathway and its upstream of phosphatidylinositol-3-kinase-Akt (PI3K-Akt) pathway were found in the wt-GISTs Fig. B. FurtheIn this study, we observed the incidence and severity of skeletal muscle atrophy being significantly higher in patients with wt-GIST when compared to the patients with mu-GIST. The sarcopenic nomogram constructed in our study showed the potential to be useful as a tool in predicting patients with wt-GIST before surgery. Our gene sequencing analysis of both our own data and the external data demonstrated that those aberrant gene signal pathways being closely associated with sarcopenia in the wt-GISTs more often than that in mu-GISTs. Our results indicated the potential application of CT-based sarcopenic assessment and gene analysis in pretreatment evaluation of GIST subtypes.13, and the incidence and clinical impact of sarcopenia on GIST are largely unknown. To date, the only published study on sarcopenia in GIST patients reported an incidence of 38.7% in a French cohort of GISTs (n = 31)10. However, our study showed a higher incidence of 56.32%. The reason for the discrepancy of incidence of sarcopenia between our study and their study10 was not clear. We speculate the difference in incidence might be due to different racial/ethnic background affecting body composition and muscle loss in patients with GISTs. Potential case selection bias should also be considered for both the French study and our study.The prevalence of sarcopenia varied among different type of cancers13. Although sarcopenia could also occur in mu-GIST patients, our study showed that sarcopenia was an independent predictor for wt-GIST. In other word, sarcopenia could be a potential useful predictor for identifying wt-GIST before treatment.The sarcopenic nomogram constructed in our study, with the sarcopenic score  and with the MFI incorporated, showed potential value in differentiating wt-GIST from mu-GIST. The atrophy score represented the severity of a patient’s skeletal muscle atrophy after considering the effects of age and gender. The higher the score, the more severe the muscle atrophy. MFI represented the severity of septocutaneous adipose tissue. The higher the MFI, the more serious the adipose infiltration of skeletal muscle and the worse the muscle quality. Our higher incidence of sarcopenia and more severe muscle atrophy accompanied by adipose degeneration in patients with wt-GIST suggested that patients with wild-type tumors may have a significant decrease in muscle quantity and quality when compared to patient with mu-GIST14. EGFR may be correlated with slow-twitch muscle phenotype and EGFR inhibitor may impede the loss of muscle slow-twitch fiber loss15. Fat1 is a protocadherin gene. It affects muscle patterning, regionalized muscle wasting and adult muscle fiber functions. The shape of muscle defects has been observed in adult fat1-knockout animal16. IL-6ST, also name gp130, is one of the common cytokine receptor subunits. It is shared by a series of IL-6 family which are well-known inflammatory cytokines, and function as prompting muscle wasting, stimulating protein catabolism and suppressing muscle synthesis17. Other studies have shown that TSC 2 phosphorylation activated by mTOR could be the response to the resistance training for the prevention and treatment of sarcopenia18. Collectively, these gene abnormalities involved in the total energy expenditure are correlated to food consumption and body composition, mitochondrial dysfunction, essential energy-producing processes, skeletal muscle function and cytokine-induced muscle catabolism, thus accelerating loss of muscle mass and function leading to sarcopenia19.The underlying genetic mechanism responsible for the different incidence and severity of sarcopenia between wt-GIST and mu-GIST is largely unknown. In search of the underlying molecule mechanism of sarcopenia in the wt-GIST, we analyzed the available gene data in our cohort, and extended this analysis to the external data in the Cancer Genome Atlas (TCGA). Regarding the most frequently observed genes in the wt-GIST, we identified five common genes abnormality including NF1, EGFR, BRAF, FAT1, IL-6ST and TSC2 in the wt-GIST. Patients with NF1gene deficiency have shown to have enhanced resting energy expenditure and respiratory quotient, indicating premature sarcopenia20. Our results showed patients with wt-GIST had a higher incidence of mutant pathways associated with sarcopenia than patients with mu-GIST. For example, Longevity regulating pathways consisted of a series of genes and pathways for aging process have a high rate of sarcopenia23. FoxO proteins such as FOXO1 and FOXO3) are transcription factors which regulate the expressions of various atrophy-related genes atrogin-1 and MuRF-1 muscle, contributing to the decrease in muscle size and number25. Intriguingly, our study showed that the FoxO signal pathway was present in patients with mu-GIST in our own genetic data but this pathway was only present in the wt-GISTs in the external data. The exact reason for this discrepancy is not clear. We again speculate that the racial and ethnic differences between the cohorts may play a role.The causes of sarcopenia are likely multifactorial and molecular alterations may be present in complex signaling pathways26. In advanced GIST, sarcopenia was correlated with shorter PFS and OS28. Further study with long-term follow-up is our on-going research.Our study suggested that wt-GIST patients with sarcopenia had a shorter overall survival, as well as recurrence-free survival than wt-GIST patients without sarcopenia. Patients with recurrence all had sarcopenia. Our results were consistent with the literature indicating sarcopenia being a prognostic factor in cancer patientsThere were limitations to this study. First, the retrospective nature of the study precluded the measurement of muscle strength which ought to be more important than muscle mass in terms of adverse health outcomes. Second, the absence of national cut-off points for muscle mass may hinder standardization of data and generalizability of results from sarcopenia research. Third, it was a single center study and the results may not be generalizable to other centers. Future study with a large-scale prospective multicenter approach is needed to validate our results and to expand this line of research.Our study identified higher incidence of sarcopenia, more severe muscle atrophy accompanied with more fat degeneration and more gene abnormalities in wt-GIST, than mu-GIST. Our study indicated that CT-based assessment of sarcopenia may be useful for differentiating wt-GIST from mu-GIST non-invasively before treatment. The molecule abnormalities underlying sarcopenia in wt-GIST may be potentially useful as alternative targets for detecting, mitigating and reversing sarcopenia.Supplementary Information.


Who is using HIV self-testing among men who have sex with men (MSM) in the US?In this cross-sectional study of 6563 MSM who reported HIV testing in the past year, 7.7% reported HIV self-testing within the past year. Self-testing was more common among younger MSM with higher socioeconomic status and those who reported sexual identity disclosure.The findings of this study suggest that efforts to expand HIV self-testing among MSM may need to focus on reaching vulnerable subgroups, including those with lower socioeconomic status and who have not disclosed their sexual identity. HIV self-testing (HIVST) is a promising strategy to expand the HIV care continuum, particularly among priority populations at high risk of HIV infection. However, little is known about HIVST uptake among men who have sex with men (MSM) outside of clinical trial settings.To evaluate HIVST use among urban MSM in the US who reported testing within the past 12 months.A cross-sectional study of adult MSM in the 2017 National HIV Behavioral Surveillance system, which used venue-based sampling methods to collect data related to HIV testing, receipt of prevention services, and risk factors for HIV, was conducted at 588 venues in 23 urban areas in the contiguous US and Puerto Rico. All participants were offered HIV testing. Adult cisgender MSM who reported HIV-negative or unknown HIV status and obtained HIV testing in the past 12 months were included. Data for this study were collected between June 4, 2017, and December 22, 2017, and analyzed between October 23, 2020, and August 20, 2021.Self-reported HIVST in the past year. Adjusted prevalence ratios (aPRs) using survey weights were calculated to assess factors associated with HIVST.P < .001), perceived discrimination against people with HIV , younger age , higher educational level , and higher income levels . No association was noted with condomless anal sex , sexually transmitted infections , or preexposure prophylaxis use .A total of 6563 MSM in 23 urban areas met inclusion criteria, of whom 506 (7.7%) individuals reported HIVST in the past year. The median age of self-testers was 29  years, 52.8% had completed college, and 37.9% reported non-Hispanic White race. One self-tester reported seroconverting in the prior 12 months, and an additional 10 self-testers were diagnosed with HIV during the survey. HIVST was associated with sexual orientation disclosure (aPR, 10.27; 95% CI, 3.45-30.60; In this study, HIVST was relatively uncommon in this sample of urban MSM. HIVST may not be reaching those with lower socioeconomic status or who have not disclosed their sexual identity. The findings of this study suggest that efforts to increase HIVST should focus on engaging underserved and vulnerable subgroups of MSM. This cross-sectional study examines the use of HIV self-testing among men who have sex with men. Despite interest in HIVST since the beginning of the HIV epidemic, a rapid HIVST method was not approved by the US Food and Drug Administration and was not available in the US until late 2012.4 Self-testing may be preferred by individuals who are reluctant to seek facility-based testing and may lead to increased awareness of HIV risk6 and partner testing.7 In study settings, self-testing has been associated with increased testing frequency and uptake among MSM.9 In a randomized trial evaluating internet-distributed HIV self-tests among MSM, self-testing identified more HIV infections than providing test information alone.10 In addition, studies have reported high feasibility and acceptability among MSM.14Testing for HIV is the critical first step in both HIV prevention and treatment efforts. Despite multiple interventions to increase HIV testing, novel strategies are needed to increase testing among men who have sex with men (MSM), who represent nearly two-thirds of all new HIV diagnoses in the US.However, little is known about HIVST uptake among MSM outside of clinical trial settings. Furthermore, it is unknown whether self-testing is associated with preventive behaviors and uptake of biomedical interventions, such as preexposure prophylaxis (PrEP). Understanding behaviors associated with self-testing will therefore be critical to informing implementation of HIV prevention efforts.In this study, we examined HIV self-testing uptake among participants in a national survey of MSM in 23 urban areas across the contiguous US and Puerto Rico. We assessed prevalence of self-testing, characteristics associated with self-testing, and whether self-testing was associated with risk and preventive behaviors among MSM who reported HIV testing in the past 12 months and negative or unknown status. We hypothesized that HIV self-testing would be associated with increased testing and uptake of preventive services.15 This surveillance project used venue-based sampling methods at sites frequented by MSM.16 Trained interviewers obtained informed consent and conducted face-to-face interviews, which collected data related to HIV testing behaviors, receipt of prevention services, and risk factors for HIV. In addition to completing a survey, all study participants were offered a rapid, blood-based HIV test. Each jurisdiction was allowed to select the specific type of test. If results of the first rapid test were positive or indeterminate, a second test was administered according to local public health testing procedures. These data were collected by state and local health departments and their partners with funding from the CDC. Data collection for the present study began on June 4, 2017, and was completed on December 22, 2017. This study was determined to be exempt from review by the CDC Human Research Protection Office and the University of Pennsylvania Institutional Review Board because data were collected for public health purposes and part of routine disease surveillance activity. All participants provided informed consent and were compensated for their services. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.We analyzed cross-sectional data from the Centers for Disease Control and Prevention (CDC) National HIV Behavioral Surveillance (NHBS) system conducted in 2017, which focused specifically on MSM across 23 urban areas, or metropolitan statistical areas, in the contiguous US and Puerto Rico.Individuals were eligible for the NHBS system if they reported male sex at birth and current gender identity as being a man, being at least aged 18 years, having prior oral or anal sex with a male partner, and residing in a participating metropolitan statistical area. We further restricted our analyses to individuals who reported HIV testing in the past 12 months to limit confounding by indication. We excluded individuals who reported a diagnosis of HIV infection at least 12 months prior to the survey to exclude individuals without an indication for HIV testing in the past year.Our primary outcome was reported self-testing with a rapid HIV home test at least once in the past 12 months. Individuals who did not report self-testing with a rapid HIV home test at least once in the past 12 months were considered non–self-testers. We obtained self-reported HIV status at the time of the study, date of HIV diagnosis, and HIV testing data from the NHBS database.Sociodemographic characteristics examined included age, income, educational level, and current insurance. We included race and ethnicity variables given the substantial racial and ethnic disparities in the HIV epidemic; participants self-reported Hispanic or Latino ethnicity (binary variable) and race . Sexual identity disclosure (“being out”) was a binary variable defined as telling anyone about their same-sex attraction or behavior. We obtained information on risk factors for HIV acquisition, including sexual behaviors, injection drug use, sexually transmitted infections, and information on preventive behaviors, including frequency of HIV testing, time of last HIV test, condom use, and PrEP knowledge and use. Individuals were considered to have seroconverted in the past year if they reported HIV-negative or unknown status 1 year prior to the survey and reported an HIV diagnosis date in the past 12 months prior to the survey. We defined new HIV diagnoses as those who reported HIV unknown or negative status at the time of the survey and subsequent positive rapid and confirmatory HIV tests during the NHBS survey. We defined male sex partners as having had oral or anal sex with another man. Condomless anal sex included both insertive and receptive anal sex. PrEP awareness and use were binary variables defined as having ever heard of PrEP prior to the survey, and PrEP use in the past 12 months, respectively. We also examined measures on discrimination and stigma associated with HIV and sexual identity, which may be barriers to accessing HIV testing services. Measures of perceived stigma and discrimination were based on agreement with the following statements: my community would (1) discriminate against people with HIV, (2) would not support the rights of people with HIV, (3) would not be friends with people with HIV, and (4) believe people with HIV got what they deserved. Participants answered on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree) and responses were coded as disagree/neutral (1-3) or agree (4-5). Measures of experienced discrimination due to sexual identity were binary variables and included (1) subjected to verbal discrimination, (2) received poor service, (3) treated unfairly at work or school, (4) received lower quality health care, or (5) was physically attacked or injured.2 test. We calculated crude and adjusted prevalence ratios (aPRs) and 95% CIs using Poisson multivariable regression that accounted for the survey design. We used survey interview weights based on all venue-attending MSM in the NHBS sample. Data were weighted to account for unequal selection probabilities, multiplicity, and nonresponse bias, allowing us to infer our estimates to all venue-attending MSM in these cities. We used robust sandwich variance estimation to account for clustering of survey data by venue. In adjusted models, we selected covariates based on a priori interest and on prior literature review. We adjusted for age, race and ethnicity, and city and built separate models for each covariate and the primary outcome. We assessed for linear trends for ordinal covariates. We considered a 2-tailed α level of .05 to be statistically significant. All analyses were done in Stata, version 15.1 (StataCorp LLC).We obtained weighted percentages and 95% CIs for variables of interest and compared characteristics of self-testers and non–self-testers by using the Rao and Scott χA total of 10 760 individuals were surveyed in the NHBS system across 588 venues in 23 urban areas. Of these, 435 individuals (4.0%) had never tested for HIV, 1937 (18.0%) reported an HIV diagnosis more than 1 year ago, 1762 (16.4%) had their last HIV test done more than a year ago, and 63 (0.6%) did not have HIV testing data and were excluded from the study. A total of 6563 MSM reported HIV-negative or unknown status and testing for HIV in the past year and were included in the analysis .Among the 6563 men included in the analysis, 506 individuals (7.7%) reported at least 1 HIV self-test in the past year. One self-tester reported being diagnosed with HIV in the past 12 months, compared with 114 non–self-testers who reported diagnosis of HIV in the past 12 months. An additional 10 individuals (2.0%) who self-tested tested positive for HIV during the NHBS survey, compared with 162 non–self-testers . The remP = .01) and income level , and decreased with age  (P < .001). Regarding HIV testing, we did not observe any association of self-testing with increased rates of HIV testing, testing more recently, or new HIV diagnosis during the survey.In our primary analysis, adjusted for age, race and ethnicity, and city, the prevalence of self-testing increased with educational level  . We did P = .01) but lower among those who reported verbal discrimination due to sexual identity   who reported self-testing and an HIV-negative or unknown status subsequently tested positive during the survey. Nonetheless, we did not observe a significant difference in HIV seropositivity between self-testers and non–self-based testers who reported a negative or unknown status. In addition, although self-testing was associated with discussing HIV prevention strategies with an outreach worker, we did not observe an association with PrEP awareness and use. These findings indicate the importance of frequent testing and supplementing HIV testing with other risk reduction strategies, such as PrEP.One concern with HIVST is that it may miss acute HIV infections when transmissibility is highest, prior to formation of antibodies that are detectable by current HIV self-tests.Our study has several strengths. The study draws on NHBS data from one of the largest surveillance surveys of MSM across multiple urban areas in the US, including Puerto Rico. Although literature on HIVST has been largely from randomized clinical trials, this survey presents data from a public health surveillance systems setting. The sample was racially diverse and represented a range of ages and socioeconomic status. Furthermore, although we collected self-reported HIV testing data, we were also able to verify self-reported HIV serostatus with HIV testing conducted through the NHBS system.27 However, this estimation represents one of the largest samples of MSM in the US. Second, although there was 1 self-tester who reported an HIV diagnosis in the past year, we were unable to confirm whether he was diagnosed during a self-test or a facility-based test. Third, because our study was cross-sectional, we could not evaluate longitudinal trends in HIV prevention services and behaviors. We were therefore unable to ascertain whether self-testers obtained PrEP after self-testing, used self-testing to monitor themselves on PrEP, or whether those who reported HIV diagnosis in the past 12 months identified their HIV infection through a self-test. Fourth, we were unable to assess how individuals obtained self-test kits and how much the test kits cost. Although we assessed whether MSM had contact with a prevention worker, we do not know whether MSM in the NHBS were also participants in other HIV prevention studies. Price and distribution strategy may influence whether individuals choose to use HIVST.This research has limitations. First, our study was limited to MSM sampled at venues in urban areas and therefore may not be representative of all MSM in the US, such as MSM living in rural areas or those who use dating apps. This limitation is important to acknowledge because HIVST may be particularly useful for MSM using apps or those living in rural areas who may have less access to facility-based testing.29 Additional implementation research needs to focus on identifying ideal distribution strategies to underserved, vulnerable, and medically disconnected MSM, messaging to encourage test uptake, and linkage to care to further engage priority populations in the HIV prevention and care continuum.Our findings suggest that there is an opportunity to expand implementation of HIVST in public health efforts to end the HIV epidemic. Furthermore, restrictions during the COVID-19 pandemic have demonstrated the promise of HIVST to provide more flexible and expansive testing options when access to facility-based testing is limited.


Multinomial logistic regression analyses indicated that the likelihood of reporting both daily and non-daily tobacco use (versus non-use) increased over time. Daily and non-daily tobacco use were less common at visits that occurred during COVID-19 surges, as well as among veterans vaccinated against COVID-19. Our findings provide new insight into changes of tobacco use patterns and correlates across the first two years of this pandemic, and understanding these associations may facilitate understanding of health-related behaviors and inform clinical treatment of tobacco use disorder during the COVID-19 pandemic.Because COVID-19 is a respiratory and cardiovascular disease, understanding behaviors that impact cardiopulmonary health, such as tobacco use, is particularly important. While early studies suggested no change in prevalence of tobacco use as COVID-19 emerged, pandemic fatigue, shifting levels of COVID-19 transmission, and vaccine availability have all changed since the start of the pandemic. The current study examined whether time, COVID-19 surges, and/or vaccination status were associated with likelihood of daily and non-daily tobacco use over the first 24 months of the pandemic. Data were obtained from electronic health records of healthcare visits ( COVID-19 has had a tremendous social impact, leading to more than 1 million deaths in the United States and 6.5 million internationally , Mexico Evidence suggests that some behaviors intended to protect against COVID-19 infection  have declined over time , perhapsOur group recently evaluated tobacco use in a sample of veterans during the first year of the pandemic . SignifiOther studies have suggested that people who use tobacco may have reduced or stopped use in response to COVID-19 . VaccinaThe current study aims to examine the associations of unique, COVID-19 related factors  with tobacco use reporting during the first 24 months of this pandemic. This pandemic period has been like no other in modern history, creating an opportune time to investigate tobacco use patterns and health behaviors. Based on studies cited above, we hypothesized that (1) as time progressed from the start of the pandemic, veterans would be more likely to report daily and non-daily tobacco use, (2) veterans would be less likely to report daily and non-daily tobacco use during COVID-19 surges, and (3) veterans who reported receiving at least one vaccination would be less likely to endorse daily and non-daily tobacco use.Data were obtained from electronic health records stored in the VA’s Corporate Data Warehouse and included records of visits that occurred between 18 March 2020 and 28 February 2022 at four VA healthcare system sites in Southern California . The start date was based on California Governor Gavin Newsom’s public announcement to raise COVID-19 awareness in California [To capture the effect of COVID-19 surges, we created a binary variable reflecting whether or not the visit occurred during a surge in which COVID-19 infection rates were heightened. The first surge began on 16 November 2020 , we coded whether or not veterans had received one or more vaccinations prior to the visit, resulting in a dichotomized categorization of veterans reporting being either vaccinated or non-vaccinated.We used a multinomial logistic regression model to assess associations between tobacco use and time (in months) that had elapsed since the start of the pandemic, COVID-19 prevalence rate surges, and vaccination status. Multinomial logistic regressions are useful when analyzing categorical predictor variables . Demographic and utilization variables  were included as covariates. For the outcome variable, tobacco non-use was the reference category. All analyses were conducted using SPSS 28 software with α = 0.05.n = 314,787) of veterans  across four VA Hospitals in Southern California. The mean age was 57.9 (SD = 18.0) and nearly 9 in 10 were male (89.7%). Nearly 70% of veterans reported being non-Hispanic. Over half of veterans were Caucasian (52.7%), 16.7% identified as Black or African American, 6.9% were Asian American, 2.2% were Native Hawaiian or Pacific Islander (NH/PI), 1.3% were American Indian or Alaskan Native (AI/AN), and 15.6% identified as “other” or declined to provide race data. Regarding tobacco use patterns, 10.8% of veterans reported daily use and 4.2% reported non-daily use. Nearly 40% of visits were with veterans who had reported receiving one or more COVID-19 vaccine doses prior to the visit, and 25.7% of all visits occurred during a COVID-19 surge. To address the possibility that vaccine availability would affect the association between vaccine status and tobacco use, the multinomial logistic regression was reanalyzed and included only visits  in which the vaccine was locally available . The pattern of results of the reanalysis remained unchanged ; Hispanic vs. non-Hispanic ; race ; COVID-19 surge period vs. non-surge period ; vaccinated vs. non-vaccinated ; VA location ; age ; time since the start of the pandemic ; and visit number . Multinomial model results are shown in χ2 = 6319.25, df = 26, p < 0.001).See In comparing daily tobacco use to the reference group of tobacco non-use, time since the pandemic began was a significant predictor of daily tobacco use. Over the 24-month study period, veterans were 1.5% more likely to report daily tobacco use with each passing month. In contrast, there was an inverse association between daily tobacco use and surge, such that visits that occurred during COVID-19 surges were associated with 11% lower likelihood of daily tobacco use compared to visits that had not occurred during a surge. Being vaccinated was associated with a 30% lower likelihood of reporting daily tobacco use compared to those who did not report having been vaccinated.There were also associations between daily tobacco use and several demographic variables, indicating that daily tobacco use was more likely among those who identified as Black, male, and/or non-Hispanic, and among younger veterans. Veterans who identified as Asian were less likely to be daily users.Similar to daily use reporting, there was a significant positive association between time that had elapsed from the start of the pandemic and non-daily tobacco use reporting, such that each passing month was associated with 0.8% higher likelihood of non-daily tobacco use. Whether or not the visit occurred during a COVID-19 surge was also inversely associated with non-daily tobacco use; veterans were 7% less likely to report non-daily use during COVID-19 surges. Veterans who had received any vaccine were 14% less likely to endorse non-daily tobacco use.Non-daily tobacco use was more commonly endorsed by veterans who identified as Black and male, and by younger veterans. Asian veterans were less likely than White veterans to report non-daily use. Refer to The primary aims of this study were to examine whether time, COVID-19 surges, and vaccination status were associated with self-reported tobacco use during the COVID-19 pandemic. Consistent with our primary hypothesis, time since the pandemic began was significantly positively associated with both daily and non-daily tobacco use. We speculated that initial reporting of the novel coronavirus—and the associated pulmonary issues and complications—may have motivated some initial reductions in use . HoweverWhile tobacco use reporting increased with time since the start of the pandemic, reporting of both daily and non-daily tobacco use was lower during periods of COVID-19 surges. This finding is consistent with our previous work , suggestVeterans who received at least one dose of the coronavirus vaccine were 20% and 11% less likely to report daily and non-daily use, respectively. Previous literature suggests that, relative to never and former smokers, current smokers reported significantly greater hesitancy and concerns, and were more likely to be unwilling or uncertain about receiving a COVID-19 vaccine . Health Results of our study can be used to better inform the healthcare management of our veteran population. VA providers may now be better able to evaluate tobacco use among their patients and provide information regarding associations between tobacco use and COVID-19-era factors, such as vaccination status and surges. Discussing risks of increased tobacco use  over time will help prevent the effects of pandemic fatigue and may lead to sustained efforts toward tobacco reduction or abstinence, particularly as prevalence rates continue to ebb and flow with new variant surges. Policy changes to increase patient education can serve as prevention efforts to help mitigate risks associated with continued tobacco use.There were several limitations to our study that may impact the generalizability of the findings. Data were drawn from electronic health records of veterans receiving VA care in the southwest region of the United States. Data are subject to the inherent limitations of all research capitalizing on electronic medical records, namely that data were originally collected for non-research purposes and may suffer from diagnostic inaccuracy and may fail to account for all confounding factors . AssessmThis study explored associations between the time since the start of the COVID-19 pandemic, surges, and vaccination status on daily and non-daily tobacco use. Consistent with our hypotheses, we found a significant positive association between time and tobacco use reporting, that veterans would report less tobacco use during COVID-19 surges, and that veterans who reported being vaccinated would also report less tobacco use. Future studies should explore within group differences on tobacco use status  and could include a more detailed assessment of tobacco use patterns, motives, and changes as well as further investigate the role of vaccination seeking or hesitancy on tobacco use outcomes. Additionally, future studies should evaluate factors pertaining to other substance use and mental health concerns, with a focus on subpopulation disparities and vulnerabilities, as these may have changed during the course of the pandemic. These studies of tobacco use and related factors would continue to help providers educate patients of the risks of tobacco use during the pandemic era and inform leadership to enact policy changes help to optimize the practice of treating and preventing nicotine dependence for as long as COVID-19 continues to persist.


COVID-19 has disrupted sexual behaviour and access to health systems. We adapted regular HIV behavioural surveillance of gay and bisexual men (GBM) in Australia in response to COVID-19, assessed the impact on the profile of the sample, the participants’ HIV-related behaviour, and whether COVID-19 may have accentuated existing disparities in the Australian HIV epidemic. Data collected from five states during July 2017–June 2021 were included . The emphasis on online recruitment after COVID-19 led to smaller sample sizes, greater geographic reach, and a higher proportion of bisexual-identifying participants. Most participants (88.1%) reported physical distancing and 52.1% had fewer sex partners due to COVID-19. In the COVID-19-affected rounds (July 2020–June 2021), the number of male partners, recent HIV testing and pre-exposure prophylaxis (PrEP) use all fell, and HIV risk among the smaller group of participants who reported casual sex increased. COVID-related changes were generally more pronounced among GBM aged under 25 years, participants from suburbs with fewer gay residents, and bisexual men. These groups should be prioritised when encouraging GBM to reengage with HIV testing services and effective prevention methods, like condoms and PrEP. As well as inflicting significant levels of morbidity and mortality, the COVID-19 pandemic has caused widespread disruption to health systems, including the delivery of care for people with existing health conditions. Many research and surveillance activities have had to be delayed or adjusted to comply with COVID-19-related restrictions, potentially impeding the monitoring of and response to existing epidemics such as HIV .Regular behavioural surveillance of HIV-affected populations is recommended to assess behaviours that may increase the risk of HIV, the adoption of protective practices, and engagement with health services and programs, like HIV testing and treatment , 4. BehaAustralia is one of the few countries to have maintained annual behavioural surveillance of its main HIV-affected population, gay and bisexual men (GBM), for 25 years –8. In thAustralia began imposing COVID-19 restrictions in February 2020. In most states and territories, an initial ‘lockdown’ period was imposed in March 2020, recommending that people stay at home where possible, practise physical distancing and enhanced hand hygiene . Many buCohort and clinical studies observed the impact of COVID-19 on Australian GBM during 2020, noting dramatic declines in the number of sexual partners, HIV testing and PrEP use, particularly during the first 6 months of the pandemic, and when lockdown restrictions were (re)imposed , 25–27. Here we document the way in which we adjusted HIV behavioural surveillance of gay and bisexual men to maintain ongoing monitoring and evaluation, but also to assess the impact of COVID-19 on GBM and the national HIV epidemic. We consider changes to sampling and key behavioural indicators, and whether COVID-19 has accentuated disparities in HIV testing, prevention and HIV risk. We discuss the implications of COVID-19 for the HIV response in Australia and the resilience of the behavioural surveillance system.Australia’s main behavioural surveillance system for HIV, the Gay Community Periodic Surveys, involves repeated, cross-sectional surveys of GBM at venues, events and online , 7. TheyEligible participants are Australian residents who identify as male (including cisgender and transgender men), aged 16 years or older (online recruitment), 18 years or older (in-person recruitment), who identify as gay, bisexual or queer and/or who have had sex with a man in the past 5 years. Participants are asked to complete a questionnaire about their demographic details, HIV testing and status, use of different HIV prevention methods, sex with casual and regular male partners, relationships, drug use, and sexual health testing and diagnoses. Recall periods are typically the last 6 or 12 months.https://gcpsonline.net), which provides study information and a link to the online questionnaire hosted on the Qualtrics platform . The online questionnaire uses adaptive routing to exclude ineligible participants and skip irrelevant questions. The online questionnaire is available in English, simplified and traditional Chinese, Indonesian, Portuguese, Spanish, Thai, and Vietnamese. All participants can complete the questionnaire anonymously. Completing the questionnaire is taken as evidence of consent. Participants who complete less than half the study questionnaire are considered to have withdrawn and their responses are not stored. The study has primary institutional ethics approval from the UNSW Sydney Human Research Ethics Committee (ref. HC180903), and the research ethics review panels of the community organisations ACON and Thorne Harbour Health.For in-person recruitment, trained peers approach potential participants at venues and events and provide information about the study. Consenting participants complete a paper questionnaire (in English) and return it to the recruitment staff. In online recruitment, participants are directed to the study’s website , but months before the next scheduled round (in Queensland) was due to take place. In this period, the research team consulted with our community organisation partners and jurisdictional health departments. We determined local restrictions on in-person recruitment (such as bans on large gatherings and mingling in venues), whether recruitment should be delayed or cancelled, and strategies for increasing online recruitment. We revised the procedures for in-person recruitment, including staff wearing masks, maintaining physical distance, limited handling of questionnaire materials, providing hand sanitiser for staff and participants, and using QR codes to direct participants to the online version of the questionnaire. We also added items to the questionnaire to assess the impact of COVID-19.No scheduled recruitment rounds were cancelled, although some were delayed. In November 2020, in-person recruitment was approved in South Australia (due to eased restrictions), but after recruitment started a short lockdown period was reimposed, and in-person recruitment cancelled. In most jurisdictions, advertising and recruitment were primarily conducted online. Paid Facebook advertising (primarily in English) was used in all jurisdictions, and community organisations advertised the survey through their online networks. In Queensland, New South Wales and Victoria, community organisations placed posters and flyers with QR codes linked to the online questionnaire in venues where in-person recruitment would have taken place. In the early 2021 rounds, our community partners ACON  and Thorne Harbour Health (Victoria) conducted online advertising campaigns on Facebook, and sex and dating apps and websites including Grindr, Hornet, Scruff and Squirt i.e. a greater range of online advertising than in pre-COVID-19 rounds.The survey measures have been previously described , 7. For Questions added to the survey questionnaire after COVID-19 assessed the impact of the pandemic on income or employment, whether participants had ever been tested for COVID-19, the degree to which participants had been practising physical distancing in the last 6 months, whether COVID-19 had altered the participant’s number of sex partners in the last 6 months, and whether COVID-19 had affected the frequency of PrEP use in the last 6 months .p values are reported. Selected Figures are included, particularly when COVID-19 appears to have accentuated disparities between groups.We include data collected in July 2017 to June 2021 from five states  which all had recruitment rounds affected by COVID-19. The data were grouped into four 12-month periods to include three pre-COVID-19 and one since COVID-19: July 2017–June 2018, July 2018–June 2019, July 2019–June 2020 , and July 2020–June 2021 (COVID-19 affected). Sample sizes and sociodemographic characteristics are described, as are the impacts of COVID-19 reported by participants in the 2020–2021 rounds. We report trends in recruitment source (online vs. offline), sociodemographic characteristics, self-reported HIV status of participants, and these key indicators: number of recent male sex partners, HIV testing, HIV treatment, PrEP use, and casual sex with a risk of HIV transmission, as defined above , 7. BivaA total of 31,460 survey responses were included  had lived in Australia for less than 2 years, 270 (23.9%) for 2–5 years and 708 (62.1%) for more than 5 years. Most  were in full-time employment and 246 (21.6%) were students.p < 0.001). The overall age of the sample increased slightly over time, although the proportion of younger participants (< 25 years old) was similar in the last rounds before COVID-19 (at 13.6% in 2019–2020) and the COVID-19-affected rounds (13.8%). The proportion of Australian born participants increased over time from 70.4% to 74.0% , particularly after COVID-19, while the proportion of Asian born participants remained relatively stable . The proportion of participants from suburbs with ≥ 10% gay male residents fell from 20.1 to 10.7% , as did the proportion of gay-identified participants , with the greatest year on year change occurring after COVID-19 emerged. The proportion of participants who were HIV-negative fell slightly in the COVID-19-affected rounds , while the proportion who were untested or did not know their HIV status increased to 13.8% . The proportion of participants who were HIV-positive remained stable at 7.9–8.8% .Table In the COVID-19-affected rounds (2020–2021), 6533 surveys were completed. Of these participants, 26.9% reported that they had lost income or their job because of COVID-19, 51.9% had been tested for COVID-19, and 88.1% had been practising physical distancing (staying at home or away from other people) in the previous 6 months. Over half the participants (52.1%) reported that they had had fewer sex partners in the 6 months prior to the survey because of COVID-19. Among former and current PrEP users (n = 1702), 26.3% reported that they had taken PrEP less often in the last 6 months and 11.9% had stopped using PrEP because of COVID-19.p = 0.504). Similarly, the proportion of participants reporting recent HIV testing (in the year prior to the survey) fell in the COVID-19-affected rounds (from 67.8–69.2% in 2017–2020 to 56.6% in 2020–2021), but the adjusted trend analysis indicated that the long-term trend in testing was upwards . The proportion of HIV-positive men on HIV treatment remained stable in both crude and adjusted trends , as did the proportion of HIV-positive participants on treatment who reported an undetectable viral load . The long-term trend in the proportion of participants with casual male partners who were classified as at risk of HIV infection fell over time  reaching 21.0% in 2019–2020, but increased in the rounds after COVID-19 emerged to 26.8%. However, this was in the context of participants reporting fewer male partners overall and less casual sex in the COVID-19-affected rounds. For example, in the 2019–2020 rounds 62.4% of participants (5046/8081) reported any sex with casual male partners while in the 2020–2021 this proportion fell to 55.9% (3655/6533).Table We assessed whether changes in key indicators, particularly in the COVID-19-affected rounds, were accentuated by disparities previously identified in the Australian HIV epidemic. These stratifications are shown in Table p < 0.001; suburb main effect AOR 0.76, 95% CI 0.64–0.89, p = 0.001). Partner numbers declined over time (2017–21) among younger men , Asian born participants , and bisexual men . After COVID-19 emerged, partner numbers declined more noticeably among participants from suburbs with fewer gay male residents , compared with participants from suburbs with more gay male residents, among whom partner numbers largely remained stable  and participants from suburbs with fewer < 10%) gay male residents were consistently less likely than their respective comparison groups  to report more than 10 recent male sex partners . HIV testing fell over time among younger men , Asian born participants , and bisexual men . There were steeper declines in recent HIV testing after COVID-19 emerged in younger men , participants in suburbs with fewer gay male residents  and bisexual men  than in their comparison groups, creating wider differences in levels of HIV testing.Among non-HIV-positive participants, HIV testing in the last year was consistently less likely to be reported by participants in suburbs with fewer gay male residents , nor did treatment levels change in these groups over time . Asian born HIV-positive participants were as likely as participants born elsewhere to report being on HIV treatment , and this did not change over time . HIV-positive participants from suburbs with fewer gay residents appeared to be slightly less likely to report being on treatment than participants from suburbs with more gay residents, but this difference was not statistically independent , and treatment levels did not change over time in this group .HIV-positive participants appeared to be less likely to report being on HIV treatment if they were aged under 25 years old or bisexual, but these were not statistically independent differences in the multivariate regression models , among participants from suburbs with fewer gay male residents , and bisexual men . PrEP use was reported at similar levels by Asian born participants and participants born elsewhere . PrEP use increased over time among younger men , Asian born participants  and bisexual men , but in all cases fell after COVID-19. After COVID-19 emerged, PrEP use fell in suburbs with fewer gay male residents, but it continued to increase in suburbs with more gay male residents, so the difference in levels of use between the two groups widened . After COVID-19, PrEP use by bisexual men decreased, but it decreased more among non-bisexual participants, so the difference in levels of use between the two groups narrowed; this was not a statistically independent effect .Among non-HIV-positive participants, PrEP use was consistently lower among men aged under 25 years old . Younger men became slightly less likely to report risk over time  although the gap between younger and older participants in reported levels of risk did not change after COVID-19 emerged . Asian born participants were as likely as other participants to report casual sex with a risk of HIV transmission , and became less likely to report risk over time . Participants from suburbs with < 10% gay male residents were as likely as other participants to report sex with a risk of HIV transmission , and had become less likely to report risk over time . However, after COVID-19 emerged, casual sex with a risk of infection increased more in suburbs with fewer gay male residents than in suburbs with ≥ 10% gay male residents, widening the difference in levels of risk between the two groups . Overall, bisexual men were as likely as other participants to report casual sex with a risk of transmission , and had become less likely to report risk over time . However, after COVID-19 emerged, the gap between the two groups widened, with bisexual men being more likely to report risk in the COVID-19-affected rounds .Non-HIV-positive participants under the age of 25 were consistently more likely than older participants to report condomless sex with casual partners while not using PrEP  in Australia is highly variable, with most postcodes estimated to have few gay residents and very low HIV prevalence, and a small number of mainly inner-city areas with larger gay populations and more people living with HIV , 43. In It has been previously found that bisexual men in Australia generally have fewer male partners than gay men, are much less likely to have ever been or recently tested for HIV, and use condoms more consistently during anal sex , 45. PreAlthough HIV treatment did not appear to be affected by COVID-19 in our sample, we note that treatment levels appeared to be consistently lower among HIV-positive participants aged under 25 and bisexual men. These were not statistically independent differences, probably due to the relatively small sample sizes of these groups. Low levels of HIV treatment in younger GBM living with HIV were found over 10 years ago, suggesting treatment uptake remains an issue in this group . Others Previous international reviews of behavioural surveillance studies have recommended that studies should have a backup sampling method . We wereThe Gay Community Periodic Surveys are consistent with guidelines for behavioural surveillance in allowing participants to take part anonymously, encouraging honesty , 4, but Our analysis of behavioural surveillance data collected from five states across Australia shows the varied impact of COVID-19 on GBM’s behaviour. Most GBM reduced their levels of sexual activity and risk of HIV during COVID-19, but some subgroups appeared to be at increased risk after COVID-19, if they continued or returned to having casual sex with male partners. These included GBM under the age of 25, those living in suburbs with fewer gay residents, and bisexual men. These groups should be prioritised when encouraging GBM to reengage with HIV testing services and effective prevention methods, like condoms and PrEP.