Publications

Abstract

Digital health implementations and investments continue to expand. As the reliance on digital health increases, it is imperative to implement technologies with inclusive and accessible approaches. A conceptual model can be used to guide equity-focused digital health implementations to improve suitability and uptake in diverse populations. The objective of this study is expand an implementation model with recommendations on the equitable implementation of new digital health technologies. The Digital Health Equity-Focused Implementation Research (DH-EquIR) conceptual model was developed based on a rigorous review of digital health implementation and health equity literature. The Equity-Focused Implementation Research for Health Programs (EquIR) model was used as a starting point and merged with digital equity and digital health implementation models. Existing theoretical frameworks and models were appraised as well as individual equity-sensitive implementation studies. Patient and program-related concepts related to digital equity, digital health implementation, and assessment of social/digital determinants of health were included. Sixty-two articles were analyzed to inform the adaption of the EquIR model for digital health. These articles included digital health equity models and frameworks, digital health implementation models and frameworks, research articles, guidelines, and concept analyses. Concepts were organized into EquIR conceptual groupings, including population health status, planning the program, designing the program, implementing the program, and equity-focused implementation outcomes. The adapted DH-EquIR conceptual model diagram was created as well as detailed tables displaying related equity concepts, evidence gaps in source articles, and analysis of existing equity-related models and tools. The DH-EquIR model serves to guide digital health developers and implementation specialists to promote the inclusion of health-equity planning in every phase of implementation. In addition, it can assist researchers and product developers to avoid repeating the mistakes that have led to inequities in the implementation of digital health across populations.

Abstract

Objective: To identify demographic and behavioral correlates of dangerous firearm storage (i.e., unlocked and loaded) among firearm owners in nine states. Methods: Online survey data from the probability-based sample were collected using Ipsos Knowledge Panel. Participants were adults residing in nine states across the United States (n = 7785). Results: Nearly one third of the firearm owners within the sample stored at least one of their firearms unlocked and loaded. Greater threat sensitivity was associated with dangerous firearm storage. Established firearm owners who purchased an additional firearm during the firearm purchasing surge (2020–2021) had increased odds of storing at least one firearm unlocked and loaded. Those who had direct exposure to firearm violence and those whose primary reason for having a firearm at home was protection also had increased odds of storing at least one firearm unlocked and loaded. Conclusions: The results contribute to the literature on firearm storage tendencies, highlighting correlates of dangerous firearm storage within the home related to perceptions of threat and direct experiences with firearm violence. Implications include the need for broad public education on the value of secure storage targeted toward to those who have an elevated perception of danger and have been personally exposed to firearm violence.

Abstract

This chapter presents a case of a 7-month-old infant who is presented to the primary care office with complaints of cough for 2 days and “breathing heavy” since morning. She has had a fever for 2 days. Her maximum temperature at home was 101°F (rectal). She also has a runny nose. Her mother has tried an over-the-counter cough medicine without much relief. The chapter also provides essential guidance and information for understanding how to diagnose and manage this case. This includes differential diagnosis and a series of critical thinking questions ideal for the family nurse practitioner.

Abstract

Background: Efforts to reduce cesarean birth overuse have had varied success. De-implementation strategies that incorporate change to organizational characteristics (i.e. culture) can improve adoption and sustainability. This study aimed to identify culture change strategies used by hospitals that achieved significant and sustained cesarean reduction and eliminated racial disparities in cesarean birth. Methods: Hospitals in California and Florida that (1) engaged in quality initiatives to reduce cesarean births; (2) demonstrated at least a 5% cesarean birth reduction; and (3) sustained the reduction for 18 months after participation were invited to participate. Hospitals that reduced also cesarean racial disparity were prioritized for recruitment. Qualitative, semi-structured interviews were performed with leaders, obstetricians, family physicians, midwives, and nurses providing intrapartum care. Reflexive thematic analysis and values coding were used. Results: 35 participants from 6 hospitals (3 in California, 3 in Florida) participated in interviews or focus groups. Nurse-focused strategies included: leadership demonstrating support for proactive labor support (e.g., Spinning Babies, comfort measures, nursing time at bedside); enhanced communication through inter-disciplinary team huddles; clear delineation of roles; and a chain of command that assured nurses could advocate for their patients freely and without retribution. Physician-focused strategies included regular and publicly visible feedback delivered by trusted messengers, drawing attention to successful vaginal births, and highlighting the contributions of labor support. A theme of hiring/retaining for “fit” was articulated at all hospitals, most notably, the hospital that eliminated their cesarean birth racial disparity, where “fit” was conceptualized as empathy, humanism, and a desire to meet community needs. Conclusions: This study identified specific de-implementation strategies for hospitals to change implementation context, namely culture, to achieve and sustain reduction of cesarean birth. Hospitals looking to sustain culture change should adapt strategies to align with existing clinician values, change attitudes through sharing successful vaginal births, and modify beliefs through education from trusted messengers. Strategies to reduce racial disparities should emphasize designing teams that are aware of and prioritize community needs, including hiring staff from the local community, and partnering with community-based organizations.

Abstract

Objective: To explore their perceptions and attitudes toward condom use and the underlying reasons for the low usage frequency among Chinese older adults. Methods: A qualitative study design utilizing interpretive phenomenological analysis was employed. Data were collected through field observation and face-to-face in-depth interviews among older adults aged 50 years or above and having engaged in sexual activities within the previous year. Results: Three main themes emerged: perceiving unnecessary due to misconceptions and low awareness, interactive stereotypes rooted in sociocultural beliefs, and stigmatized social norms including gender inequity and economic unbalance. Conclusions: Tailored interventions focusing on addressing misconceptions, increasing awareness, and reducing culturally ingrained stereotypes and stigma surrounding condom use are essential to promote condom use among older adults in order to prevent HIV transmission in China.

Abstract

Background: Delirium is a common disorder affecting patients’ psychiatric illness, characterized by a high rate of underdiagnosis, misdiagnosis, and high risks. However, previous studies frequently excluded patients with psychiatric illness, leading to limited knowledge about risk factors and optimal assessment tools for delirium in psychiatric settings. Objectives: The scoping review was carried out to (1) identify the risk factors associated with delirium in patients with psychiatric illness; (2) synthesize the performance of assessment tools for detecting delirium in patients with psychiatric illness in psychiatric settings. Design: Scoping review. Data sources: PubMed, Web of Science, and Embase were searched to identify primary studies on delirium in psychiatric settings from inception to Dec 2023 inclusive. Two independent reviewers screened eligible studies against inclusion criteria. A narrative synthesis of the included studies was conducted. Results: A final set of 36 articles meeting the inclusion criteria, two main themes were extracted: risk factors associated with delirium in patients with psychiatric illness and assessment tools for detecting delirium in psychiatric settings. The risk factors associated with delirium primarily included advanced age, physical comorbid, types of psychiatric illness, antipsychotics, anticholinergic drug, Electroconvulsive therapy, and the combination of lithium and Electroconvulsive therapy. Delirium Rating Scale-Revised-98, Memorial Delirium Assessment Scale, and Delirium Diagnostic Tool-Provisional might be valuable for delirium assessment in patients with psychiatric illness in psychiatric settings. Conclusions: Delirium diagnosis in psychiatric settings is complex due to the overlapping clinical manifestations between psychiatric illness and delirium, as well as their potential co-occurrence. It is imperative to understand the risk factors and assessment methods related to delirium in this population to address diagnostic delays, establish effective prevention and screening strategies. Future research should focus on designing, implementing, and evaluating interventions that target modifiable risk factors, to prevent and manage delirium in patients with psychiatric illness.

Abstract

Background: Previous concept analyses have not conceptualized an evidence-based definition of the concept of dementia literacy. Methods: Rodger's evolutionary method was used to conceptualize dementia literacy among informal caregivers of persons living with dementia (PLWD) in the United States. A comprehensive search across four databases and a thorough review process resulted in 22 relevant articles between 2011 and 2023. Discussion: Dementia literacy is defined as the ability to acquire dementia-related knowledge to inform decision-making, self-identify gaps in caregiving support, and secure access to necessary resources to enable long-term care, all while maintaining relationships with an interdisciplinary team of specialized providers. Conclusion: The nursing profession can promote dementia literacy by recognizing the needs of racial and ethnic groups, the complexity of culture and language, and being mindful of potential implicit bias toward informal caregivers who are working diligently to be prepared and proactive for PLWD.

Abstract

PURPOSE: Adult day services (ADS) are a valuable resource for people living with Alzheimer’s disease and Alzheimer’s disease and related dementias (AD/ADRD) and serve a large population of late-life immigrants, often with limited English proficiency (LEP). This secondary data analysis examined potential disparities in diagnosis, dementia severity, medical complexity, and dementia-related behavioral problems in persons with AD/ADRD with LEP within the ADS setting. METHOD: The current study used data from TurboTAR, the electronic health record for ADS in California. Bivariate analyses were conducted to examine differences in clinical management for those with and without LEP. RESULTS: Of 3,053 participants included in the study, 42.3% had LEP. Participants with LEP had higher rates of emergency department use and medication mismanagement. However, due to non-standard data collection, there was a significant amount of missing data on language preference (38.1%) and race/ethnicity (46.5%). Although these findings suggest LEP may play a role in the clinical management of persons with AD/ADRD in ADS, missing data caused by lack of standardized collection compromise the results. CONCLUSION: It is essential to improve data collection practices in ADS on language, race, and ethnicity to help identify health disparities and promote equitable care for marginalized older adults. [Journal of Gerontological Nursing, 50(4), 42-47.]

Abstract

Objective: To determine what firearm policies New Jersey residents believe will prevent school shootings and the extent to which this varies by sex, firearm ownership status, and political affiliation. Methods: A representative sample of New Jersey residents (N = 1,018) was collected via the Eagleton Center on Public Interest Polling (ECPIP). Data were weighted to reflect the state's population. Participants were asked to rate how helpful they perceived different firearm-related policies to be for preventing school shootings. Results: Findings indicate that participants perceived universal and expanded background checks, increased mental health funding, and requiring a license for firearm purchases as most effective for preventing school shootings. Arming school personnel, prayer in schools, decreasing the number of entrances at schools, and secure storage requirements were viewed as less effective. Firearm ownership, sex, and political affiliation significantly influenced perceptions of the effectiveness of these policies. Conclusion: The study examined the perceived effectiveness of policies to prevent school shootings. The study highlights disparities and commonalities in policy support among different groups, emphasizing the importance of collective efforts to address gun violence in schools.

Abstract

Introduction: National data on dental caries and dental service use among immigrant children in U.S. are limited. It is not known whether race/ethnicity would interact with immigration status to increase these disparities. Using a nationally representative sample, this study assessed the interaction effects of immigrant generation status and race/ethnicity on dental caries and dental visits among children in the U.S. Methods: Data were from the 2020 and 2021 National Survey of Children's Health. All data were self-reported by parents/guardians. The 2 outcomes were (1) dental caries (yes/no) in the past 12 months and (2) preventive dental visits (yes/no) in the past 12 months. Racial/ethnic groups included non-Hispanic White, Black, Hispanics, and Asian Americans. The analytical sample included 66,167 children aged 2–17 years, including 1,243 first-generation immigrant children; 11,017 second-generation immigrant children; and 53,907 nonimmigrant children. Study authors ran separate multiple logistic regression models for the 2 outcome variables. All analyses accounted for the survey design of National Survey of Children's Health. Results: First-generation immigrant children were more likely to have dental caries than nonimmigrant children (AOR=1.44). The interaction of race/ethnicity and immigrant generation status was significant (p=0.04) in the preventive dental visits model, indicating increased challenges in getting dental visits among minority immigrant children in comparison with that among non-Hispanic White immigrant children, especially among first-generation immigrant children of Asian Americans (AOR=0.41) and non-Hispanic Black immigrant children (AOR=0.37). Conclusions: First-generation immigrant children were less likely to see a dentist and more likely to have dental caries than nonimmigrants. Moreover, first-generation immigrant children from minority racial/ethnic groups were the least likely to seek dental services. To further reduce disparities in oral health and dental use among children in the U.S., culturally sensitive health promotion is warranted to improve oral health literacy and reduce barriers to dental care for immigrants, especially immigrant children of the minority groups.

Abstract

Poor oral health has been associated with various systemic diseases (e.g., endocarditis, pneumonia, cardiovascular disease, and diabetes) and decreased quality of life. When enacted in 1965, Medicare excluded coverage for comprehensive dental services. As of 2023, Medicare has allowed coverage of limited dental services inextricably linked to specific medical conditions. Many Medicare Advantage plans (Medicare Part C) offer dental coverage. Yet in 2019, approximately 24 million Medicare beneficiaries (47% of all Medicare enrollees), lacked dental coverage. Seventy-one percent of traditional Medicare enrollees (those not enrolled in a Medicare Advantage Plan) reported that high cost was the primary reason that they did not obtain dental care. The importance of oral health for the older adults has been the main reason that a national interprofessional consortium, which includes several national nursing organizations, has been advocating for legislation to expand Medicare to include dental coverage. The consortium's efforts have been thwarted by fierce opposition from the American Dental Association and many Republican legislators. Given the vital role that nurses and advanced practice nurses play in caring for the nation's older adults and disabled, nursing's voice needs to be strengthened as leaders in advocating for inclusion of dental benefits in traditional Medicare.

Abstract

Objective: Denture use has been shown to improve nutritional intake and diet quality in people with tooth loss. Despite evidence linking tooth loss and dementia, few studies have examined the association between denture use and cognitive decline. We investigated the relationship between denture use and cognitive decline among Chinese older adults with tooth loss. Methods: We analyzed data from the Chinese Longitudinal Healthy Longevity Survey 2008–2018, including 27,708 community-dwelling dentate and edentulous (i.e., who have lost all natural teeth) older adults aged 65 and older. Cognitive function was assessed using the Mini-Mental State Examination from 2008 to 2018. Linear mixed-effect models were employed to assess the association of denture use with baseline cognitive function and rate of cognitive decline, adjusting for sociodemographic characteristics, health-related behavior, and health status. Subgroup analyses evaluated differences in associations among dentate participants with varying degrees of tooth loss (1–9, 10–19, 20–31). Results: Compared to non-denture users, dentate participants who used dentures had better baseline cognitive function (β, 1.032; 95% CI, 0.813–1.251; p < 0.001) and a slower annual decline in cognitive function (β, 0.127; 95% CI, 0.047–0.206; p < 0.01). For edentulous participants, denture use was associated with higher baseline cognitive function (β, 3.063; 95% CI, 2.703–3.423; p < 0.001) but not with the rate of cognitive decline (β, 0.011; 95% CI, –0.082 to 0.105; p = 0.818). Results remained consistent across subgroups of dentate participants with various degrees of missing teeth. Conclusions: Denture use may help protect against cognitive decline in older adults with partial tooth loss. This study highlights the potential importance of prosthodontic rehabilitation in preserving cognitive health. Further research is needed to establish a causal relationship between denture use and cognitive function.

Abstract

Background: Hypertension and diabetes are major risk factors for cardiovascular diseases, stroke, and chronic kidney disease (CKD). Disparities in hypertension control persist among Black and Hispanic adults and persons living in poverty in the United States. The “LINKED-HEARTS Program” (a Cardiometabolic Health Program LINKED with Community Health WorkErs and Mobile HeAlth TelemonitoRing To reduce Health DisparitieS”), is a multi-level intervention that includes home blood pressure (BP) monitoring (HBPM), blood glucose telemonitoring, and team-based care. This study aims to examine the effect of the LINKED-HEARTS Program intervention in improving BP control compared to enhanced usual care (EUC) and to evaluate the reach, adoption, sustainability, and cost-effectiveness of the program. Methods: Using a hybrid type I effectiveness-implementation design, 428 adults with uncontrolled hypertension (systolic BP ≥ 140 mm Hg) and diabetes or CKD will be recruited from 18 primary care practices, including community health centers, in Maryland. Using a cluster-randomized trial design, practices are randomly assigned to the LINKED-HEARTS intervention arm or EUC arm. Participants in the LINKED-HEARTS intervention arm receive training on HBPM, BP and glucose telemonitoring, and community health worker and pharmacist telehealth visits on lifestyle modification and medication management over 12 months. The primary outcome is the proportion of participants with controlled BP (<140/90 mm Hg) at 12 months. Conclusions: The study tests a multi-level intervention to control multiple chronic diseases. Findings from the study may be leveraged to reduce disparities in the management and control of chronic diseases and make primary care more responsive to the needs of underserved populations. Trial registration: ClinicalTrials.gov. Identifier: NCT05321368.

Abstract

Objectives: To examine rankings of credible sources for discussing secure storage within a representative sample of firearm-owning service members, and examine how combinations of demographic variables impact the ranking of credible sources. Methods: The probability-based sample was collected with the help of Ipsos. Participants were US service members who owned a firearm at the time of the survey (n = 719). Results: The total sample ranked service members, Veterans, and members of law enforcement as the most credible sources and faith leaders, casual acquittances, and celebrities as the least credible sources. Black men ranked the NRA as a highly credible source whereas Black females ranked the NRA as one of the least preferred sources. Regardless of political preference, those who lived in non-metropolitan rural environments ranked members of law enforcement as highly credible sources. Those who lived in non-metropolitan rural and urban settings and identified as liberal ranked the National Shooting Sports Foundation as a highly credible source. Conclusions: Law enforcement officers, military members, and Veterans are ranked as highly credible sources by most subgroups of firearm-owning service members. Leveraging these voices in firearm safety conversations is necessary, may increase adherence to secure storage recommendations, and ultimately reduce suicide.

Abstract

Background: HIV disproportionately impacts people who experience incarceration. Incarceration represents an opportunity to engage in HIV prevention care for individuals who often experience a number of barriers accessing health services in the community. The development of evidence-based practices promoting pre-exposure prophylaxis for HIV prevention (PrEP) is crucial for ending the HIV epidemic within this highly marginalized population. However, PrEP research within carceral facilities has been limited and is hampered in part by the lack of ethical guidance on conducting HIV prevention research in this unique setting where incarcerated individuals are categorized as a vulnerable population requiring specific protections. This lack of knowledge is particularly striking when considering the lack of input from incarcerated individuals themselves on the responsible conduct of research, which is critical to understanding ways to ensure participant autonomy while avoiding coercive practices in research activities. Methods: In order to gain a better understanding of ethical approaches to the conduct of HIV prevention research among incarcerated individuals, we conducted qualitative interviews with 21 incarcerated men who reported injecting drugs and met clinical criteria for PrEP use. The interview topics included HIV knowledge, PrEP knowledge, stigma, and perceptions related to ethical research practices. Results: Themes identified included how forced abstinence during incarceration can negatively affect research participation, the importance of participant comfort as it relates to ensuring autonomy in decision making, a desire for person centred approaches in research activities, study staff characteristics impacting participant experience, and perceptions of carceral staff as members of research teams. Conclusions: The results of this study indicate that conducting research focused on improving PrEP use in a carceral environment has support among those experiencing incarceration. However, researchers should place the participant experience at the center of research protocol development.

Abstract

Objective: Describe the development and testing of a web-based platform for antiretroviral treatment (ART) adherence support among HIV+ adolescents and young adults (AYA) in a randomized controlled trial (RCT). Methods: A seven-member multi-disciplinary team operationalized the flat, password protected, web-based platform. Manualized protocols guided the objectives and content for each of the eight web-based sessions. Team members evaluated usability and content validity. Client satisfaction and perceived ease of use was evaluated with the first ten HIV+ AYA participants. Results: The web-based platform was developed, evaluated, refined, implemented and pilot tested between September 2020 to April 2022. Usability was rated as high; the evaluation of content validity showed an excellent fit between session content and objectives. HIV+ AYA participants (mean age = 24.2 years) were satisfied with the quality, type, and amount of support/education received, and found the platform easy to use, operate, and navigate. Average time spent per session was 6.5 min. Conclusion: Findings support the usability, validity, acceptability, and feasibility of this web-based platform for ART adherence support among HIV+ AYA. Innovation: Our research and findings are responsive to research gaps and the need for transparency in the methodological development and testing of web-based control arms for ART adherence support among HIV+ AYA.

Abstract

This chapter explores the case of David, an 11-month-old infant, who is presented to the primary care office with complaints of watery diarrhea for 1 day. He has had at least 10 diapers with diarrhea since yesterday. David's mother is unsure of his urine output because each diaper is so full of stool. She is concerned that one of these factors may have caused or contributed to David's diarrhea. Further review of systems reveals that David has had decreased solid food and soy formula intake since yesterday and that he has been sleeping more than usual. The chapter provides essential guidance and information for understanding how to diagnose and manage this case. This includes differential diagnosis and a series of critical thinking questions ideal for the family nurse practitioner.

Abstract

Background: Mastery may shape the way individuals cope with life challenges and influence cognitive function in later life. Mastery grows out of traumatic experience and could change over the life course. This study examined the within-person and between-person associations of mastery and cognitive function, and if these associations were moderated by age in the United States. Method: Data were derived from three time points (2006–2008, 2010–2012, and 2014–2016) of the Health and Retirement Study, with 14,461 adults (aged 51 or above). Cognitive function was measured through a 27-point Telephone Interview Cognitive Screen (TICS). Mastery was measured by a modified Pearlin Mastery Scale. Multilevel modeling was employed to analyze the data. Results: Both within-person (β=0.124, SE = 0.023, p < 0.001) and between-person (β=0.089, SE = 0.029, p = 0.002) mastery were significantly associated with cognitive function. Older adults with higher between-person mastery tended to have slower cognitive decline (β=0.063, SE = 0.021, p < 0.001). Moreover, age moderated the within-person (β=0.013, SE = 0.003, p < 0.001) associations between mastery and cognition with a stronger association observed among individuals with older age. Conclusions: The current study provides evidence for within-person and between-person associations between mastery and global cognition in the United States as well as the moderating role of age. The design of the current study did not directly assess the causal direction between mastery and cognitive function. Future studies could test the directionality of associations between mastery and cognitive function.

Abstract

Introduction: Symptoms of untreated depression and anxiety during pregnancy are associated with serious adverse effects for the pregnant person, birth outcomes, and child development. However, pregnant persons are less likely to be screened and treated compared with nonpregnant people. In this systematic review, we aimed to explore individual, provider, and systems factors that impact screening, identification, and treatment patterns for depression and anxiety during pregnancy. Methods: Studies were eligible for inclusion if they were conducted within the United States and published in English between January 2012 and January 2023. Each study included analysis that compared rates of screening, identification, or treatment engagement and explicitly discussed disparities or health equity in marginalized groups. Fifteen articles met full inclusion criteria. Results: Results demonstrated variation in the screening, identification, and treatment of depression and anxiety during pregnancy among diverse groups of patients. Screening rates ranged from 51.3% in Puerto Rico to 90.7% in Alaska. Among specific clinical populations, rates were as low as 2.0%. Fewer than half of patients were referred to treatment when indicated by screening or diagnoses. Patient characteristics such as age, race, ethnicity, socioeconomic and health factors, mental health history, and obesity were associated with variation in the rates of screening, diagnoses, or treatment engagement. Language factors were the most common factor associated with lower rates of screening and treatment access. Discussion: Results suggest that many pregnant people are being overlooked and lack appropriate referrals or resources to access treatment. Results are consistent with previous findings that role confusion and lack of time, provider training, and interest contribute to low rates of screening and treatment. Future research must focus on system level factors to address perceived barriers to screening and treating depression and anxiety during pregnancy in a systematic and equitable way.

Abstract

This chapter presents a case of a 6-year-old boy who is presented in the primary care office with her mother with concerns about his increasingly disruptive behavior at home. He had some initial feeding issues as an infant with excessive irritability causing multiple formula changes. Since then he has had no food allergies or intolerances and eats a fairly well-balanced diet with the exception of excessive juice consumption. The chapter also provides essential guidance and information for understanding how to diagnose and manage this case. This includes differential diagnosis and a series of critical thinking questions ideal for the family nurse practitioner.

Abstract

Telomere length (TL) is an important indicator of cellular aging. Shorter TL is associated with several age-related diseases including coronary heart disease, heart failure, diabetes, osteoporosis, and cancer. Recently, a DNA methylation-based TL (DNAmTL) estimator has been developed as an alternative method for directly measuring TL. In this study, we examined the association of DNAmTL with cancer prevalence and mortality risk among people with and without HIV in the Veterans Aging Cohort Study Biomarker Cohort (VACS, N = 1917) and Women's Interagency HIV Study Cohort (WIHS, N = 481). We profiled DNAm in whole blood (VACS) or in peripheral blood mononuclear cells (WIHS) using an array-based method. Cancer prevalence was estimated from electronic medical records and cancer registry data. The VACS Index was used as a measure of physiologic frailty. Models were adjusted for self-reported race and ethnicity, batch, smoking status, alcohol consumption, and five cell types (CD4, CD8, NK, B cell, and monocyte). We found that people with HIV had shorter average DNAmTL than those without HIV infection [beta = −0.25, 95% confidence interval (−0.32, −0.18), p = 1.48E-12]. Greater value of VACS Index [beta = −0.002 (−0.003, −0.001), p = 2.82E-05] and higher cancer prevalence [beta = −0.07 (−0.10, −0.03), p = 1.37E-04 without adjusting age] were associated with shortened DNAmTL. In addition, one kilobase decrease in DNAmTL was associated with a 40% increase in mortality risk [hazard ratio: 0.60 (0.44, 0.82), p = 1.42E-03]. In summary, HIV infection, physiologic frailty, and cancer are associated with shortening DNAmTL, contributing to an increased risk of all-cause mortality.