HIV transmission in the United States: considerations of viral load, risk behavior, and health disparities

Transmission clustering among newly diagnosed HIV patients in Chicago, 2008 to 2011: using phylogenetics to expand knowledge of regional HIV transmission patterns

INTRODUCTION

HIV transmission cluster analyses can inform HIV prevention efforts. We describe the first such assessment for transmission clustering among HIV patients in Chicago.

METHODS

We performed transmission cluster analyses using HIV pol sequences from newly diagnosed patients presenting to Chicago's largest HIV clinic between 2008 and 2011. We compared sequences through progressive pairwise alignment, using neighbor joining to construct an unrooted phylogenetic tree. We defined clusters as >2 sequences among which each sequence had at least 1 partner within a genetic distance of ≤1.5%. We used multivariable regression to examine factors associated with clustering and used geospatial analysis to assess geographic proximity of phylogenetically clustered patients.

RESULTS

We compared sequences from 920 patients, median age of 35 years, 75% male, 67% black, 23% Hispanic, and 8% had a rapid plasma reagin titer ≥1:16 concurrent with their HIV diagnosis. We had HIV transmission risk data for 54%; 43% identified as men who have sex with men (MSM). Phylogenetic analysis demonstrated 123 patients (13%) grouped into 26 clusters, the largest having 20 members. In multivariable regression, age <25, black race, MSM status, male gender, higher HIV viral load, and rapid plasma reagin ≥1:16 associated with clustering. We did not observe geographic grouping of genetically clustered patients.

DISCUSSION

Our results demonstrate high rates of HIV transmission clustering, without local geographic foci, among young black MSM in Chicago. Applied prospectively, phylogenetic analyses could guide prevention efforts and help break the cycle of transmission.

Loneliness, HIV-related stigma, and condom use among a predominantly rural sample of HIV-positive men who have sex with men (MSM)

Most previous studies of the sexual behaviors of men who have sex with men (MSM) living with HIV are based on samples recruited within relatively urban and suburban areas of the United States. Using an internet-based questionnaire, we assessed HIV-related stigma, loneliness, and event-level sexual behaviors in a sample of HIV positive MSM (n = 100) residing within a largely rural area in the Midwestern United States. HIV-related stigma was correlated with loneliness (r = 0.619, p < 0.01). Loneliness was negatively associated with condom usage with the most recent partner of unknown status (p < 0.05). Namely, a 1-unit increase in the UCLA loneliness score was met with a 10% decrease in odds of condom usage. Further studies are warranted that explore loneliness, within the context of HIV-related stigma, among HIV-positive MSM residing in rural areas. More refined data will inform clinical and social service practice, as they provide much-needed information on sexual health outcomes and experiences of an often underserved and under studied population.

Experiences of HIV-positive gay, bisexual and other men who have sex with men residing in relatively rural areas

Most previous studies of the sexual behaviour of gay, bisexual and other men who have sex with men living with HIV are based on samples of men recruited within relatively urban and suburban areas of the USA. The aim of the present study was to explore the potential challenges associated with HIV-related stigma and residing in a relatively rural area. We conducted a qualitative study based in south-central Indiana, a relatively rural area of the USA. Twenty-three HIV-positive gay, bisexual and other men who have sex with men, aged 21-48 years, were interviewed on topics regarding community engagement, perceived HIV-related stigma, relationship formation, sexual behaviour and HIV status disclosure. Findings indicate HIV-related stigma is commonly reported at the interpersonal and community levels. Because of this, men face complex situations on how and when to disclose their HIV status to members of their social and sexual networks. Although many participants reported many challenges associated with relationship formation, all expressed a desire for romantic and/or sexual connections with other men and/or women. Results suggest that new programmatic approaches are necessary to inform the work of social service and medical providers on mechanisms to intervene and combat stigma and discrimination inherent in communities, programmes and policies.

Understanding the HIV disparities between black and white men who have sex with men in the USA using the HIV care continuum: a modeling study

BACKGROUND

Black/white disparities in HIV incidence and prevalence among men who have sex with men (MSM) in the United States remain largely unexplained. We examined the impact on HIV prevalence and incidence of interventions that decrease disparities in HIV care. Deciding which interventions have most impact on reducing disparities is critical.

METHODS

Using available US Centers for Disease Control and Prevention (CDC) estimates, we constructed HIV care continua for black and white MSM for 2009-2010. These estimates were used as parameters in a deterministic model to yield estimated race-specific transmissions, transmission rates, incidence rates, and rate-ratios (RR). We examined the impact of changes in the care continuum for black MSM on transmission and incidence rates.

FINDINGS

Marked disparities were found throughout the care continuum: ultimately, 16% of black and 34% of white MSM achieved viral suppression. Based on these care continua, 9,833 and 9,710 new HIV transmissions were estimated annually respectively from HIV-positive black and white MSM (transmission RR=1·36 and incidence RR=7·92). In a model where black and white MSM have identical care outcomes, transmission RR=1·00 and incidence RR=5·80. Scenarios of 95% diagnosis, 95% retention, and concurrent 95% diagnosis and 95% retention respectively yield transmission RR=1·00, 1·02, 0·56, and incidence RR=5·81, 5·93, 3·28.

INTERPRETATION

Disparities in HIV transmission rates may be reduced by improving the HIV care continuum outcomes, but existing racial disparities in HIV prevalence will likely continue to drive higher incidence among black MSM for decades to come.

Infrequent HIV testing and late HIV diagnosis are common among a cohort of black men who have sex with men in 6 US cities

OBJECTIVE

US guidelines recommend at least annual HIV testing for those at risk. This analysis assessed frequency and correlates of infrequent HIV testing and late diagnosis among black men who have sex with men (BMSM).

METHODS

HIV testing history was collected at enrollment from participants in HPTN 061, an HIV prevention trial for at-risk US BMSM. Two definitions of late HIV diagnosis were assessed: CD4 cell count <200 cells per cubic millimeter or <350 cells per cubic millimeter at diagnosis.

RESULTS

HPTN 061 enrolled 1553 BMSM. HIV testing questions were completed at enrollment by 1284 (98.7%) of 1301 participants with no previous HIV diagnosis; 272 (21.2%) reported no HIV test in previous 12 months (infrequent testing); 155 of whom (12.1% of the 1284 with testing data) reported never testing. Infrequent HIV testing was associated with: not seeing a medical provider in the previous 6 months (relative risk [RR]: 1.08, 95% confidence interval [CI]: 1.03 to 1.13), being unemployed (RR: 1.04, CI: 1.01 to 1.07), and having high internalized HIV stigma (RR: 1.03, CI: 1.0 to 1.05). New HIV diagnoses were more likely among infrequent testers compared with men tested in the previous year (18.4% vs. 4.4%; odds ratio: 4.8, 95% CI: 3.2 to 7.4). Among men with newly diagnosed HIV, 33 (39.3%) had a CD4 cell count <350 cells per cubic millimeter including 17 (20.2%) with CD4 <200 cells per cubic millimeter.

CONCLUSIONS

Infrequent HIV testing, undiagnosed infection, and late diagnosis were common among BMSM in this study. New HIV diagnoses were more common among infrequent testers, underscoring the need for additional HIV testing and prevention efforts among US BMSM.

Oral pre-exposure prophylaxis (PrEP) for prevention of HIV in serodiscordant heterosexual couples in the United States: opportunities and challenges

Oral HIV pre-exposure prophylaxis (PrEP) is a promising new biomedical prevention approach in which HIV-negative individuals are provided with daily oral antiretroviral medication for the primary prevention of HIV-1. Several clinical trials have demonstrated efficacy of oral PrEP for HIV prevention among groups at high risk for HIV, with adherence closely associated with level of risk reduction. In the United States (US), three groups have been prioritized for initial implementation of PrEP-injection drug users, men who have sex with men at substantial risk for HIV, and HIV-negative partners within serodiscordant heterosexual couples. Numerous demonstration projects involving PrEP implementation among MSM are underway, but relatively little research has been devoted to study PrEP implementation in HIV-serodiscordant heterosexual couples in the US. Such couples face a unique set of challenges to PrEP implementation at the individual, couple, and provider level with regard to PrEP uptake and maintenance, adherence, safety and toxicity, clinical monitoring, and sexual risk behavior. Oral PrEP also provides new opportunities for serodiscordant couples and healthcare providers for primary prevention and reproductive health. This article provides a review of the critical issues, challenges, and opportunities involved in the implementation of oral PrEP among HIV-serodiscordant heterosexual couples in the US.

HIV prevention in clinical care settings: 2014 recommendations of the International Antiviral Society-USA Panel

IMPORTANCE

Emerging data warrant the integration of biomedical and behavioral recommendations for human immunodeficiency virus (HIV) prevention in clinical care settings.

OBJECTIVE

To provide current recommendations for the prevention of HIV infection in adults and adolescents for integration in clinical care settings.

DATA SOURCES, STUDY SELECTION, AND DATA SYNTHESIS

Data published or presented as abstracts at scientific conferences (past 17 years) were systematically searched and reviewed by the International Antiviral (formerly AIDS) Society-USA HIV Prevention Recommendations Panel. Panel members supplied additional relevant publications, reviewed available data, and formed recommendations by full-panel consensus.

RESULTS

Testing for HIV is recommended at least once for all adults and adolescents, with repeated testing for those at increased risk of acquiring HIV. Clinicians should be alert to the possibility of acute HIV infection and promptly pursue diagnostic testing if suspected. At diagnosis of HIV, all individuals should be linked to care for timely initiation of antiretroviral therapy (ART). Support for adherence and retention in care, individualized risk assessment and counseling, assistance with partner notification, and periodic screening for common sexually transmitted infections (STIs) is recommended for HIV-infected individuals as part of care. In HIV-uninfected patients, those persons at high risk of HIV infection should be prioritized for delivery of interventions such as preexposure prophylaxis and individualized counseling on risk reduction. Daily emtricitabine/tenofovir disoproxil fumarate is recommended as preexposure prophylaxis for persons at high risk for HIV based on background incidence or recent diagnosis of incident STIs, use of injection drugs or shared needles, or recent use of nonoccupational postexposure prophylaxis; ongoing use of preexposure prophylaxis should be guided by regular risk assessment. For persons who inject drugs, harm reduction services should be provided (needle and syringe exchange programs, supervised injection, and available medically assisted therapies, including opioid agonists and antagonists); low-threshold detoxification and drug cessation programs should be made available. Postexposure prophylaxis is recommended for all persons who have sustained a mucosal or parenteral exposure to HIV from a known infected source and should be initiated as soon as possible.

CONCLUSIONS AND RELEVANCE

Data support the integration of biomedical and behavioral approaches for prevention of HIV infection in clinical care settings. A concerted effort to implement combination strategies for HIV prevention is needed to realize the goal of an AIDS-free generation.

Development of year 2020 goals for the National HIV/AIDS Strategy for the United States

In July, 2010, President Barack Obama released the National HIV/AIDS Strategy (NHAS). The NHAS set forth ambitious goals for the year 2015. These goals were potentially achievable had the appropriate level of resources been invested; however, investment at the necessary scale has not been made and the 2015 goals now may well be out of reach. Therefore, we propose that an updated NHAS be developed with goals for the year 2020 clearly articulated. For the purposes of fostering discussion on this important topic, we propose bold yet achievable quantitative 2020 goals based on previously published economic and mathematical modeling analyses.

Unmet HIV service needs among Black men who have sex with men in the United States

The National HIV/AIDS Strategy (NHAS) clearly emphasized the need to provide services to black men who have sex with men (MSM). However, there are no estimates of the unmet HIV-related service delivery needs among black MSM. We estimate that of 195,313 black MSM living with HIV in the US, 50,196 were not yet diagnosed, and 145,118 were aware of their seropositivity (of whom 67,625 were not linked to care and 77,493 were linked to care). Also, of those already diagnosed, ~43,390 had undetectable viral load and 101,728 had detectable viral load. Approximately 19,545 of diagnosed black MSM engage in unprotected risk behavior in serostatus-discordant partnerships. The cost of delivering services needed to meet the NHAS goals is ~$2.475 billion in 2011 U.S. dollars. Mathematical modeling suggests that provisions of these services would avert 6213 HIV infections at an economically favorable cost of $20,032 per quality-adjusted life year saved.

The increase in global HIV epidemics in MSM

Epidemics of HIV in MSM continue to expand in most low, middle, and upper income countries in 2013 and rates of new infection have been consistently high among young MSM. Current prevention and treatment strategies are insufficient for this next wave of HIV spread. We conducted a series of comprehensive reviews of HIV prevalence and incidence, risks for HIV, prevention and care, stigma and discrimination, and policy and advocacy options. The high per act transmission probability of receptive anal intercourse, sex role versatility among MSM, network level effects, and social and structural determinants play central roles in disproportionate disease burdens. HIV can be transmitted through large MSM networks at great speed. Molecular epidemiologic data show marked clustering of HIV in MSM networks, and high proportions of infections due to transmission from recent infections. Prevention strategies that lower biological risks, including those using antiretrovirals, offer promise for epidemic control, but are limited by structural factors including, discrimination, criminalization, and barriers to healthcare. Subepidemics, including among racial and ethnic minority MSM in the United States and UK, are particularly severe and will require culturally tailored efforts. For the promise of new and combined bio-behavioral interventions to be realized, clinically competent healthcare is necessary and community leadership, engagement, and empowerment are likely to be key. Addressing the expanding epidemics of HIV in MSM will require continued research, increased resources, political will, policy change, structural reform, community engagement, and strategic planning and programming, but it can and must be done.

Alcohol use and HIV disease management: the impact of individual and partner-level alcohol use among HIV-positive men who have sex with men

Alcohol use among HIV-positive (HIV+) individuals is associated with decreased adherence to antiretroviral therapy (ART) and consequently poorer HIV treatment outcomes. This study examined the independent association of individual and partner-level alcohol use with HIV disease management among men who have sex with men (MSM) in primary partnerships. In total, 356 HIV+ MSM and their male primary partners completed a baseline visit for a longitudinal study examining the role of couple-level factors in HIV treatment. The Alcohol Use Disorders Identification Test (AUDIT) was administered to assess the individual and the partner-level alcohol use. Primary outcome variables included self-reported ART adherence, ART adherence self-efficacy, and HIV viral load. Results demonstrated that abstainers, compared to hazardous drinkers, had higher self-efficacy to integrate and persevere in HIV treatment and a lower odds of having a detectable viral load. Participants with a partner-abstainer, versus a partner-hazardous drinker, had less self-efficacy to persevere in HIV treatment, a lower odds of 100% three-day adherence and a higher viral load. Together, these findings suggest that assessment and treatment of both the patient's and the patient's primary partner's pattern of alcohol consumption is warranted when attempting to optimize HIV care among MSM.

Substance use and HIV risk behavior among men who have sex with men: the role of sexual compulsivity

The relationship between substance use, sexual compulsivity and sexual risk behavior was assessed with a probability-based sample of men who have sex with men (MSM). Stimulant, poppers, erectile dysfunction medication (EDM), alcohol use, and sexual compulsivity were independently associated with higher odds of engaging in any serodiscordant unprotected anal intercourse (SDUAI). The association of sexual compulsivity with SDUAI was moderated by poppers and EDM use. Behavioral interventions are needed to optimize biomedical prevention of HIV among substance using MSM.

Finding those at risk: acute HIV infection in Newark, NJ

BACKGROUND

A screening strategy combining rapid HIV-1/2 (HIV) antibody testing with pooled HIV-1 RNA testing increases identification of HIV infections, but may have other limitations that restrict its usefulness to all but the highest incidence populations.

OBJECTIVE

By combining rapid antibody detection and pooled nucleic acid amplification testing (NAAT) testing, we sought to improve detection of early HIV-1 infections in an urban Newark, NJ hospital setting.

STUDY DESIGN

Pooled NAAT HIV-1 RNA testing was offered to emergency department patients and outpatients being screened for HIV antibodies by fingerstick-rapid HIV testing. For those negative by rapid HIV and agreeing to NAAT testing, pooled plasma samples were prepared and sent to the University of Washington where real-time reverse transcription-polymerase chain reaction (RT-PCR) amplification was performed.

RESULTS

Of 13,226 individuals screened, 6381 had rapid antibody testing alone, and 6845 agreed to add NAAT HIV screening. Rapid testing identified 115 antibody positive individuals. Pooled NAAT increased HIV-1 case detection by 7.0% identifying 8 additional cases. Overall, acute HIV infection yield was 0.12%. While males represent only 48.1% of those tested by NAAT, all samples that screened positive for HIV-1 RNA were obtained from men.

CONCLUSION

HIV-1 RNA testing of pooled, HIV antibody-negative specimens permits identification of recent infections. In Newark, pooled NAAT increased HIV-1 case detection and provided an opportunity to focus on treatment and prevention messages for those most at risk of transmitting infection. Although constrained by client willingness to participate in testing associated with a need to return to receive further results, use of pooled NAAT improved early infection sensitivity.

Engagement in HIV Medical Care and Technology Use among Stimulant-Using and Nonstimulant-Using Men who have Sex with Men

Aims of this study were to assess the associations between stimulant use and attitudes toward and engagement in HIV medical care and to examine technology use among stimulant-using and nonstimulant-using men who have sex with men (MSM). HIV-positive MSM (n = 276; mean age = 42 years; 71% white, non-Hispanic; 43% with college degree) completed an online survey in 2009. Most men (69%) had not missed any scheduled HIV medical appointments in the past year, while 23% had missed at least one, and 9% had not attended any appointments. Stimulant use was significantly associated with not attending any HIV medical appointments in the unadjusted model (relative risk ratio (RRR) = 2.84, 95% CI [1.07, 7.58]), as well as in models adjusted for demographic (RRR = 3.16, 95% CI [1.13, 8.84]) and psychosocial (RRR = 3.44, 95% CI [1.17, 10.15]) factors (Ps < 0.05). Fewer stimulant-using than non-stimulant-using men rated HIV medical care a high priority (57% versus 85%; P < 0.01). Few significant differences were found in online social networking or mobile phone use between stimulant-using and non-stimulant-using MSM, even when stratified by engagement in HIV care. Findings indicate that stimulant use is uniquely associated with nonengagement in HIV medical care in this sample, and that it may be possible to reach stimulant-using MSM using online social networking and mobile technologies.