Undiagnosed HIV prevalence among adults and adolescents in the United States at the end of 2006

The Girlfriends Project: Results of a pilot study assessing feasibility of an HIV testing and risk reduction intervention developed, implemented, and evaluated in community settings

African American women in the United States experience significant HIV health disparities. The majority of evidence-based risk reduction interventions do not incorporate HIV testing, and most are targeted only to narrow segments of the population such as women who are pregnant or seen in STI clinics. This pilot study assessed the feasibility and efficacy of The Girlfriends Project (TGP), a community developed and community evaluated HIV risk reduction and testing intervention. A group randomized wait-list design was used to recruit 149 women and to compare findings for intervention group versus control group participants. Women in the intervention group demonstrated statistically-significant increases in HIV knowledge scores and in condom use during vaginal sex. Eighty-seven percent of participants accessed HIV testing with a 100% return rate for results. Study findings suggest that TGP has the potential to be an effective intervention and to increase number of African American women who access HIV testing.

HIV-1 transmission during early infection in men who have sex with men: a phylodynamic analysis

BACKGROUND

Conventional epidemiological surveillance of infectious diseases is focused on characterization of incident infections and estimation of the number of prevalent infections. Advances in methods for the analysis of the population-level genetic variation of viruses can potentially provide information about donors, not just recipients, of infection. Genetic sequences from many viruses are increasingly abundant, especially HIV, which is routinely sequenced for surveillance of drug resistance mutations. We conducted a phylodynamic analysis of HIV genetic sequence data and surveillance data from a US population of men who have sex with men (MSM) and estimated incidence and transmission rates by stage of infection.

METHODS AND FINDINGS

We analyzed 662 HIV-1 subtype B sequences collected between October 14, 2004, and February 24, 2012, from MSM in the Detroit metropolitan area, Michigan. These sequences were cross-referenced with a database of 30,200 patients diagnosed with HIV infection in the state of Michigan, which includes clinical information that is informative about the recency of infection at the time of diagnosis. These data were analyzed using recently developed population genetic methods that have enabled the estimation of transmission rates from the population-level genetic diversity of the virus. We found that genetic data are highly informative about HIV donors in ways that standard surveillance data are not. Genetic data are especially informative about the stage of infection of donors at the point of transmission. We estimate that 44.7% (95% CI, 42.2%-46.4%) of transmissions occur during the first year of infection.

CONCLUSIONS

In this study, almost half of transmissions occurred within the first year of HIV infection in MSM. Our conclusions may be sensitive to un-modeled intra-host evolutionary dynamics, un-modeled sexual risk behavior, and uncertainty in the stage of infected hosts at the time of sampling. The intensity of transmission during early infection may have significance for public health interventions based on early treatment of newly diagnosed individuals.

The effect of churn on "community viral load" in a well-defined regional population

BACKGROUND

The concept of community viral load (CVL) was introduced to quantify the pool of transmissible HIV within a community and to monitor the potential impact of highly active antiretroviral therapy (HAART) on reducing new infections. The implications of churn (patient movement in/out of care in a community) on CVL have not been studied.

METHODS

The annual CVL was determined in the entire geographic HIV population receiving care in southern Alberta from 2001 to 2010; the CVL for specific subpopulations was analyzed for 2009. CVL was determined for patients under continuous care, newly diagnosed, new to the region, moved away, returned, and lost to follow-up (LTFU). Viral loads (VLs) <50 or <200 copies per milliliter were deemed undetectable and suppressed, respectively. The mean VL per patient and total VL were used to determine CVL.

RESULTS

From 2001 to 2010, the HAART uptake for all patients increased from 62% to 81%, undetectability from 32% to 66%, and suppression from 49% to 72%. The annual total CVL however did not vary significantly after 2003. Incidence rates for new locally diagnosed infections increased from 4.4 to 5.8/100,000 per year. In 2009, newly diagnosed HIV patients (6.6%) contributed 37.5% to the CVL, whereas patients transferring in/out of the region or lost to follow-up contributed 33% to the CVL. Patients in continuous care (79% of all patients) contributed 29.5% to the total CVL.

CONCLUSIONS

Increasing HAART coverage did not reduce the CVL or reduce new HIV diagnoses in our population. The effect of churn significantly limited CVL use as a measure for evaluating the impact of HAART in reducing HIV transmissions in our population.

Committee Opinion No. 572: Reproductive health care for adolescents with human immunodeficiency virus

Adolescents make up an increasing percentage of the U.S. population with human immunodeficiency virus (HIV). Adolescent-focused care is critical to identify and reduce at-risk behavior, comorbidities, and partner transmission. Optimal medical and reproductive health care, both now and in the future, with an adolescent-focused approach, are important for HIV-infected adolescents. Adolescents who are infected with HIV should receive care that allows them to realize their sexual and reproductive goals while maximizing their personal health and minimizing the risk of unintended pregnancy, acquisition of new sexually transmitted infections, and transmission of infection to partners or offspring. Key strategies for preventing the spread of infection include, early diagnosis, guideline-based treatment, and partner notification of HIV status.

Church attendance in men who have sex with men diagnosed with HIV is associated with later presentation for HIV care

We demonstrate an interdependent relationship between sexual behavior and church attendance on timing of human immunodeficiency virus (HIV) diagnosis and presentation for care. Men who have sex with men (MSM) and who attend church are more likely to present with lower CD4(+) T-lymphocyte counts than MSM who do not attend church.

Optimizing care for HIV-infected people who use drugs: evidence-based approaches to overcoming healthcare disparities

Substance use disorders (SUDs) and human immunodeficiency virus (HIV) are pervasive epidemics that synergize, resulting in negative outcomes for HIV-infected people who use drugs (PWUDs). The expanding epidemiology of substance use demands a parallel evolution of the HIV specialist-beyond HIV to diagnosis and management of comorbid SUDs. The purpose of this paper is to describe healthcare disparities for HIV-infected PWUDs along each point of a continuum of care, and to suggest evidence-based strategies for overcoming these healthcare disparities. Despite extensive dedicated resources and availability of antiretroviral therapy (ART) in the United States, PWUDs continue to experience delayed HIV diagnosis, reduced entry into and retention in HIV care, delayed initiation of ART, and inferior HIV treatment outcomes. Overcoming these healthcare disparities requires integrated packages of clinical, pharmacological, behavioral, and social services, delivered in ways that are cost-effective and convenient and include, at a minimum, screening for and treatment of underlying SUDs.

Effect of risk-reduction counseling with rapid HIV testing on risk of acquiring sexually transmitted infections: the AWARE randomized clinical trial

IMPORTANCE

To increase human immunodeficiency virus (HIV) testing rates, many institutions and jurisdictions have revised policies to make the testing process rapid, simple, and routine. A major issue for testing scale-up efforts is the effectiveness of HIV risk-reduction counseling, which has historically been an integral part of the HIV testing process.

OBJECTIVE

To assess the effect of brief patient-centered risk-reduction counseling at the time of a rapid HIV test on the subsequent acquisition of sexually transmitted infections (STIs).

DESIGN, SETTING, AND PARTICIPANTS

From April to December 2010, Project AWARE randomized 5012 patients from 9 sexually transmitted disease (STD) clinics in the United States to receive either brief patient-centered HIV risk-reduction counseling with a rapid HIV test or the rapid HIV test with information only. Participants were assessed for multiple STIs at both baseline and 6-month follow-up.

INTERVENTIONS

Participants randomized to counseling received individual patient-centered risk-reduction counseling based on an evidence-based model. The core elements included a focus on the patient's specific HIV/STI risk behavior and negotiation of realistic and achievable risk-reduction steps. All participants received a rapid HIV test.

MAIN OUTCOMES AND MEASURES

The prespecified outcome was a composite end point of cumulative incidence of any of the measured STIs over 6 months. All participants were tested for Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum (syphilis), herpes simplex virus 2, and HIV. Women were also tested for Trichomonas vaginalis.

RESULTS

There was no significant difference in 6-month composite STI incidence by study group (adjusted risk ratio, 1.12; 95% CI, 0.94-1.33). There were 250 of 2039 incident cases (12.3%) in the counseling group and 226 of 2032 (11.1%) in the information-only group.

CONCLUSION AND RELEVANCE

Risk-reduction counseling in conjunction with a rapid HIV test did not significantly affect STI acquisition among STD clinic patients, suggesting no added benefit from brief patient-centered risk-reduction counseling.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01154296.

Housing stability, residential transience, and HIV testing among low-income urban African Americans

The association between housing and HIV has been widely demonstrated, although inquiry into HIV testing has been largely limited to the homeless. This study examines correlates of HIV testing within the past 6 months with housing stability and residential transience (moving two or more times in the past 6 months) among 620 low-income urban African Americans. Unstably housed and transient participants were more likely to participate in high-risk sex behaviors than stably housed participants and non-transient participants, respectively. In multivariate analyses, residential transience was positively associated with recent HIV testing; however, persons unstably housed were not more likely to have recently been tested for HIV despite their increased vulnerability and risk. While structural interventions are necessary to address the HIV disparities related to housing, increased community-based and mobile testing centers may be able to improve access to HIV testing among unstably housed.

Central implementation strategies outperform local ones in improving HIV testing in Veterans Healthcare Administration facilities

BACKGROUND

Pilot data suggest that a multifaceted approach may increase HIV testing rates, but the scalability of this approach and the level of support needed for successful implementation remain unknown.

OBJECTIVE

To evaluate the effectiveness of a scaled-up multi-component intervention in increasing the rate of risk-based and routine HIV diagnostic testing in primary care clinics and the impact of differing levels of program support.

DESIGN

Three arm, quasi-experimental implementation research study.

SETTING

Veterans Health Administration (VHA) facilities.

PATIENTS

Persons receiving primary care between June 2009 and September 2011 INTERVENTION: A multimodal program, including a real-time electronic clinical reminder to facilitate HIV testing, provider feedback reports and provider education, was implemented in Central and Local Arm Sites; sites in the Central Arm also received ongoing programmatic support. Control Arm sites had no intervention

MAIN MEASURES

Frequency of performing HIV testing during the 6 months before and after implementation of a risk-based clinical reminder (phase I) or routine clinical reminder (phase II).

KEY RESULTS

The adjusted rate of risk-based testing increased by 0.4 %, 5.6 % and 10.1 % in the Control, Local and Central Arms, respectively (all comparisons, p < 0.01). During phase II, the adjusted rate of routine testing increased by 1.1 %, 6.3 % and 9.2 % in the Control, Local and Central Arms, respectively (all comparisons, p < 0.01). At study end, 70-80 % of patients had been offered an HIV test.

CONCLUSIONS

Use of clinical reminders, provider feedback, education and social marketing significantly increased the frequency at which HIV testing is offered and performed in VHA facilities. These findings support a multimodal approach toward achieving the goal of having every American know their HIV status as a matter of routine clinical practice.

A degenerative retinal process in HIV-associated non-infectious retinopathy

HIV retinopathy is the most common non-infectious complication in the eyes of HIV-positive individuals. Oncotic lesions in the retinal nerve fiber layer, referred to as cotton wool spots (CWS), and intraretinal (IR) hemorrhages are frequently observed but are not unique to this pathology. HIV-positive patients have impaired color vision and contrast sensitivity, which worsens with age. Evidence of inner-retinal lesions and damage have been documented ophthalmoscopically, however their long term structural effect has not been investigated. It has been hypothesized that they may be partially responsible for loss of visual function and visual field. In this study we utilized clinical data, retinal imaging and transcriptomics approaches to comprehensively interrogate non-infectious HIV retinopathy. The methods employed encompassed clinical examinations, fundus photography, indirect ophthalmoscopy, Farmsworth-Munsell 100 hue discrimination testing and Illumina BeadChip analyses. Here we show that changes in the outer retina, specifically in the retinal pigment epithelium (RPE) and photoreceptor outer segments (POS) contribute to vision changes in non-infectious HIV retinopathy. We find that in HIV-positive retinae there is an induction of rhodopsin and other transcripts (including PDE6A, PDE6B, PDE6G, CNGA1, CNGB1, CRX, NRL) involved in visual transduction, as well as structural components of the rod photoreceptors (ABCA4 and ROM1). This is consistent with an increased rate of renewal of rod outer segments induced via increased phagocytosis by HIV-infected RPE previously reported in culture. Cone-specific transcripts (OPN1SW, OPN1LW, PDE6C, PDE6H and GRK7) are uniformly downregulated in HIV positive retina, likely due to a partial loss of cone photoreceptors. Active cotton wool spots and intraretinal hemorrhages (IRH) may not affect photoreceptors directly and the interaction of photoreceptors with the aging RPE may be the key to the progressive vision changes in HIV-positive patients.

Initiation of antiretroviral therapy in youth with HIV: a U.S.-based provider survey

In 2009, the Department of Health and Human Services (DHHS) recommended initiating antiretroviral therapy (ART) for youth with HIV at higher CD4 counts (≤500 cells/mm³) than previously recommended (≤350 cells/mm³). Barriers experienced by providers regarding ART initiation in this population have not been assessed. From 12/2011-01/2012, we asked providers from the American Academy of HIV Medicine (AAHIVM) [corrected] listserv who prescribed ART to youth (ages 13-25 years) with behaviorally-acquired HIV to complete a web-based survey. We presented a clinical vignette to explore potential barriers for initiating ART. Overall, 274/290 (94%) respondents completed the survey. Most felt confident that evidence supported initiating ART at higher CD4 counts (94%), and that benefits outweighed the risks of long-term toxicity (98%) or developing resistance (88%). Most (96%) initiated ART in the patient vignette (age 19 years, CD4 count ~400). Patient characteristics (e.g., unstable housing or drug use) were perceived as large barriers to ART initiation. Low response rate (13%) was a limitation. Respondents were knowledgeable about relevant DHHS guidelines, believed sufficient evidence supported ART initiation at higher CD4 counts, and would provide treatment to those with CD4 counts ≤500cells/mm³. Understanding and overcoming barriers to initiation of ART perceived by providers is important to ensure implementation of ART treatment guidelines.

Epidemiology, sexual risk behavior, and HIV prevention practices of men who have sex with men using GRINDR in Los Angeles, California

Young men who have sex with men (YMSM) are at alarming risk for HIV acquisition, demonstrating the highest rates of incident infection of any age-risk group. GRINDR is a global positioning service-based social networking application popular with YMSM for sexual partnering. To assess the characteristics of YMSM who use GRINDR, we conducted a computer-assisted self-interview-based survey of 375 YMSM using GRINDR in metropolitan Los Angeles, recruited using the GRINDR platform. The median age was 25 (interquartile range, 22-27) years old, 42.4 % caucasian, 6.4 % African American, 33.6 % Latino, and 14.1 % Asian/Pacific Islander. Participants reported high rates of sexual partnering and unprotected anal intercourse (UAI). The majority (70 %) of those reporting unprotected anal intercourse reported low perception of HIV-acquisition risk. Of the participants, 83.1 % reported HIV testing within the past 12 months; 4.3 % had never been HIV tested. Of the participants, 4.5 % reported HIV-positive serostatus; 51.7 % indicated that they would be interested in participating in a future HIV prevention trial. Latinos were more likely than either caucasians or African Americans to endorse trial participation interest (odds ratio, 1.9; 95 % confidence interval [1.1-3.3]). HIV-positive test results were associated with increased number of anal sex partners in the past 3 months (adjusted odds ratio (AOR), 1.53 [0.97-2.40]), inconsistent inquiry about partners' serostatus (AOR, 3.63 [1.37-9.64]), reporting the purpose for GRINDR use including "friendship" (AOR, 0.17 [0.03-1.06), and meeting a sexual partner in a bookstore in the past 3 months (AOR, 33.84 [0.99-1152]). Men recruited via GRINDR were high risk for HIV acquisition or transmission and interested in clinical trial participation, suggesting potential for this method to be used for recruitment of YMSM to HIV prevention trials.

Social network approaches to recruitment, HIV prevention, medical care, and medication adherence

This article reviews the current issues and advancements in social network approaches to HIV prevention and care. Social network analysis can provide a method to understand health disparities in HIV rates, treatment access, and outcomes. Social network analysis is a valuable tool to link social structural factors to individual behaviors. Social networks provide an avenue for low-cost and sustainable HIV prevention interventions that can be adapted and translated into diverse populations. Social networks can be utilized as a viable approach to recruitment for HIV testing and counseling, HIV prevention interventions, optimizing HIV medical care, and medication adherence. Social network interventions may be face-to-face or through social media. Key issues in designing social network interventions are contamination due to social diffusion, network stability, density, and the choice and training of network members. There are also ethical issues involved in the development and implementation of social network interventions. Social network analyses can also be used to understand HIV transmission dynamics.

A survey of a small sample of emergency department and admitted patients asking whether they expect to be tested for HIV routinely

OBJECTIVES

Many US HIV-positive patients are unaware of their infection. Although there are multiple studies assessing the acceptance of testing, there are none that assess the patient's expectations of routine HIV testing.

METHODS

Through a prospective, cross-sectional, unfunded, convenience sample survey, we assessed the patient's expectation of testing at a regional medical center serving an indigent population. Also, we compared the providers' predictions of the proportion of patients expecting a test.

RESULTS

Of the 69 patients, 23% expected a test. The only factor that correlated with this was their desire to be tested (P = .004). Providers' (N = 59) mean prediction was that 21% of the patients expected a test (range: 0%-100%). The proportion of emergency department (ED) patients wanting a test was 52% (of 30) and internal medicine inpatients were 44% (of 39).

CONCLUSIONS

Nearly a quarter of patients expected routine HIV testing. This finding should encourage a review of policies promoting HIV testing, especially within the ED.

Short communication: lack of occult HIV infection among non-AIDS-defining cancer patients in three academic oncology clinics in the United States

The Centers for Disease Control (CDC) testing recommendations suggest universal opt-out testing in all health care settings, including cancer clinics. The incidence of non-AIDS-defining cancers (NADCs) is on the rise among HIV patients. However, to date, no data exist on the prevalence of HIV infection among NADC patients in the United States. Knowledge of HIV infection may affect clinical management, prognosis, and overall patient survival and decrease new infections in the population. The purpose of this study was to determine the point seroprevalence of HIV infection in cancer patients being seen in medical oncology clinics. A total of 634 individuals (mean age=53.2 years) participated and were tested for HIV. None of the participants tested positive for HIV in any of the three clinics. Using a futility analysis, the upper end of the 95% confidence interval for prevalence of undiagnosed HIV in cancer patients was less than 0.3%. Most participants were female (59.2%) and non-Hispanic (96.6%). The majority of study participants were white (76.5%) or African-American (17.7%). Breast cancer (19.7%), colon cancer (10.3%), and melanoma (9.7%) were the most commonly reported non-AIDS-defining cancers. While our study suggested that there was no occurrence of undiagnosed HIV among NADC patients, it is important to note that our population was largely white, females with insurance and with a different distribution of cancer than the most prevalent NADC among HIV patients. Furthermore, one-third of the patients did not consent to participate and further studies are needed to assess reasons for their unwillingness along with other populations, specifically minorities and individuals with low socioeconomic status (SES).

Temporal trends in sexual behavior among men who have sex with men in the United States, 2002 to 2006-2010

Little is known about national trends in sexual behavior among MSM in the US. Data from the 2002 and 2006-2010 National Survey of Family Growth were used to compare sexual behaviors of sexually active MSM. Mean number of recent male partners significantly decreased from 2.9 in 2002 to 2.1 in 2006-2010 (P = 0.027), particularly among young MSM. Other sexual risk behaviors did not change or decrease over time. Our findings that sexual risk decreased as HIV and syphilis increased among MSM suggest that factors in addition to individual-level sexual risk should also be examined in relation to recent disease increases.

Trends in the spectrum of engagement in HIV care and subsequent clinical outcomes among men who have sex with men (MSM) at a Boston community health center

Despite known benefits, only 19-28% of HIV-infected Americans are virologically suppressed (defined as ≤200 copies/mL). Engagement in HIV care represents a continuum from patients unaware they are infected to virological suppression. The electronic medical record of all newly diagnosed HIV-infected MSM seen at Fenway Health between 2000 and 2010 were reviewed. Patients were "engaged" if they had one negative HIV test and/or one physical exam within 24 months prior to their HIV diagnosis (n=291). All others were considered "new" (n=463). MSM engaged in care prior to HIV diagnosis were more often identified in acute retroviral syndrome or on routine screening, more rapidly linked to care, and less often diagnosed with a concomitant STI than those who were not engaged in care. Nearly 19% of all patients were diagnosed with AIDS the same time they were diagnosed with HIV. Blacks and those with higher CD4 counts at diagnosis were less likely to be virologically suppressed at 1 year. Between 2000 and 2010, patients retained in care were more likely to initiate ART and be virologically suppressed within 1 year independent of initial HIV viral load and CD4 count. Engagement in care prior to seroconversion influences important HIV outcomes. Programs that care for at risk populations should institute routine opt-out HIV testing and test-and-treat programs to optimize HIV care and prevention.

Human immunodeficiency virus testing practices among buprenorphine-prescribing physicians

BACKGROUND

Despite the Centers for Disease Control and Prevention recommendations for annual HIV testing of at-risk populations, including those with substance use disorders, there are no data on the human immunodeficiency virus (HIV) testing practices of buprenorphine-prescribing physicians.

OBJECTIVE

To describe HIV testing practices among buprenorphine-prescribing physicians.

METHODS

We conducted a cross-sectional survey of physicians enrolled in a national system to support buprenorphine prescribing between July and August 2008. The electronic survey included questions on demographics; clinical training and experience; clinical practice; patient characteristics; and physician screening practices, including HIV testing.

RESULTS

Only 46% of 382 respondent physicians conducted HIV testing. On univariate analysis, physicians who conducted HIV testing were more likely to report addiction specialty training (33% vs 19%, P = 0.001), practicing in addiction settings (28% vs 16%, P = 0.006), and having treated more than 50 patients with buprenorphine (50% vs 31%, P < 0.0001) than those who did not. Compared with physicians who did not conduct HIV testing, physicians who conducted HIV testing had a lower proportion of buprenorphine patients who were white (75% vs 82%, P = 0.01) or dependent upon prescription opioids (57% vs 70%, P < 0.0001). In multivariate analysis, physicians who conducted HIV testing were more likely to have treated more than 50 patients with buprenorphine (odds ratio = 1.777, 95% CI 1.011-3.124) and had fewer patients dependent upon prescription opioids (odds ratio = 0.986 95% CI 0.975-0.998) than physicians who did not.

CONCLUSIONS

Interventions to increase HIV testing among physicians prescribing buprenorphine are needed.

Same-sex cohabitors and health: the role of race-ethnicity, gender, and socioeconomic status

A legacy of research finds that marriage is associated with good health. Yet same-sex cohabitors cannot marry in most states in the United States and therefore may not receive the health benefits associated with marriage. We use pooled data from the 1997 to 2009 National Health Interview Surveys to compare the self-rated health of same-sex cohabiting men (n = 1,659) and same-sex cohabiting women (n = 1,634) with that of their different-sex married, different-sex cohabiting, and unpartnered divorced, widowed, and never-married counterparts. Results from logistic regression models show that same-sex cohabitors report poorer health than their different-sex married counterparts at the same levels of socioeconomic status. Additionally, same-sex cohabitors report better health than their different-sex cohabiting and single counterparts, but these differences are fully explained by socioeconomic status. Without their socioeconomic advantages, same-sex cohabitors would report similar health to nonmarried groups. Analyses further reveal important racial-ethnic and gender variations.

HIV testing practices among black primary care physicians in the United States

BACKGROUND

The Centers for Disease Control and Prevention recommends routine HIV testing in all healthcare settings, but it is unclear how consistently physicians adopt the recommendation. Making the most of each interaction between black physicians and their patients is extremely important to address the HIV health disparities that disproportionately afflict the black community. The goal of this survey-based study was to evaluate the perceptions and practices of black, primary care physicians regarding HIV testing.

METHODS

A physician survey was administered at the 2010 National Medical Association Annual Convention, via online physician panels, and by email. Physician eligibility criteria: black race; practicing at least 1 year in the US; practice comprised of at least 60% adults and 20% black patients. Contingency tables and ordinary least squares regression were used for comparisons and statistical analyses. A Chi-square test compared percentages of physicians who gave a particular response and a t-test compared the means of values provided by physicians.

RESULTS

Physicians over-estimated HIV prevalence and believed that HIV is a crisis in the black community, yet reported that only 34% of patients were HIV tested in the past year. Physicians reported that 67% of those patients tested did so due to a physician recommendation. Physicians who were younger, female, obstetricians/gynecologists, and had a higher proportion of black, low-socioeconomic status, and Medicaid patients reported higher testing rates. Most testing was risk-based rather than routine, and three of the five most commonly reported barriers to testing were related to disease stigma and perceived value judgments. Physicians reported that in-office patient informational materials, increased media attention, additional education and training on HIV testing, government mandates requiring routine testing, and accurate pre-packed tests would most help them test more frequently for HIV.

CONCLUSIONS

In this sample of black, primary care physicians, HIV testing practices differed according to physician characteristics and practice demographics, and overall reported testing rates were low. More physician education and training around testing guidelines is needed to enable more routine testing, treatment, and long-term management of patients with HIV.

Health care and HIV testing experiences among Black men in the South: implications for "Seek, Test, Treat, and Retain" HIV prevention strategies

Few studies have explored how overall general health care and HIV/STI testing experiences may influence receipt of "Seek, Test, Treat, and Retain" (STTR) HIV prevention approaches among Black men in the southern United States. Using in-depth qualitative interviews with 78 HIV-negative/unknown Black men in Georgia, we explored factors influencing their general health care and HIV/STI testing experiences. The Andersen behavioral model of health care utilization (Andersen model) offers a useful framework through which to examine the general health care experiences and HIV testing practices of Black men. It has four primary domains: Environment, Population characteristics, Health behavior, and Outcomes. Within the Andersen model framework, participants described four main themes that influenced HIV testing: access to insurance, patient-provider communication, quality of services, and personal belief systems. If STTR is to be successful among Black men, improving access and quality of general health care, integrating HIV testing into general health care, promoting health empowerment, and consumer satisfaction should be addressed.

Late diagnosis, delayed presentation and late presentation in HIV: proposed definitions, methodological considerations and health implications

Contemporary literature emphasizes HIV treatment across multiple stages of the care continuum, beginning with HIV testing, followed by linkage and retention in medical care. As a sizeable global population remains undiagnosed or not engaged in medical care, researchers must evaluate the earliest phases of the HIV treatment cascade in order to optimize individual health outcomes and treatment-as-prevention initiatives. Because ambiguity persists for classification of these early stages of HIV care, the aim of this review is to propose a congruous approach to defining the constructs of late diagnosis, delayed presentation and late presentation for HIV medical care, as well as focus attention on methodological considerations and associated clinical and public health implications for these entities.

HIV testing beliefs in a predominantly Hispanic community health center during the routine HIV testing era: does English language ability matter?

The Hispanic population in the U.S. carries a disproportionate burden of HIV. Despite the high prevalence of HIV, many Hispanics remain untested for HIV. The purpose of this study conducted in a predominantly Hispanic-serving community health center in a high HIV prevalence area was to understand patient beliefs of who should be tested for HIV in the routine HIV testing era. Survey participants were presented with nine populations of people that should be tested for HIV based on CDC HIV testing recommendations. Of the 90 participants (67.1% Hispanic) who answered the HIV testing beliefs question, only approximately 45% were aware that all adults and teenagers should be HIV tested. Only 30% correctly identified all nine populations of people that should be tested for HIV based on CDC HIV testing recommendations. Our study suggests that Hispanics are either unaware of or disagree with the latest CDC recommendations for routine HIV testing of all persons ages 13-64 in high HIV prevalence areas. Improving knowledge of the current HIV epidemiologic profile in the U.S. and the most recent routine HIV testing recommendations may improve HIV testing rates in Hispanic communities.

Delayed entry into and failure to remain in HIV care among HIV-infected adolescents

Prompt entry into care and retention in care are critical for improving outcomes among HIV-infected individuals. This study identified factors associated with HIV-infected adolescents who delayed entry into HIV care (DEC) after diagnosis of HIV or who fail to remain in care afterward (FRC). We reviewed clinical, demographic, and social data from the records of 202 HIV-positive adolescents (13-21 years old) infected via high-risk behaviors. Strength of association between clinical and social factors and DEC or FRC were estimated with log-linear regression models. DEC occurred in 38% (76/202) of adolescents. Factors independently associated with DEC were unstable residence (RR 1.5; CI: 1.0-2.1) and, compared with less education, college attendance (RR 2.1; CI: 1.5-3.2). FRC occurred in 29% (52/177) of adolescents established in care. Compared with college attendees, high school students (RR: 4.5; CI: 1.2-17.3) and those who dropped out of high school (RR: 4.0; CI: 1.1-15) were more likely to FRC. Compared with adolescents with private insurance, adolescents without insurance (despite access to free care) were more likely to FRC (RR: 2.8; CI: 1.1-6.9). Controlling for sex, adolescents with children were more likely to FRC (RR: 1.8; CI: 1.0-3.1). Interventions to avoid DEC that target HIV-infected adolescents with unstable residences or those diagnosed while attending college are warranted. Among patients engaged in care, those with only high school education or without insurance-which may be markers for socioeconomic status-need additional attention to keep them in care.

Evolution of HIV incubation times in AIDS patients

Since introduction of highly active antiretroviral therapy (HAART), the incidence of AIDS has gradually declined, although the incidence of HIV infection is largely unknown. We have studied a sample with 10,571 patients whose data were recorded by Spain's public health system, in the Andalusian Register of Cases of AIDS. The diagnoses correspond to the period January 1981 to June 2008. For this period, AIDS incubation times were analyzed by means of the survival and risk functions, using R survival and DTDA libraries. We have studied the evolution of incubation mean times according to specific variables from database. The obtained results show that the mean times of viral incubation presented a growing trend that was greater among women when the study was limited to heterosexual transmission. Stratifying by category of transmission, the longest incubation period was seen for intravenous drug users (IDU). Both gender and IDU transmission were associated with significantly greater survival without AIDS. In contrast, heterosexual transmission or pneumonia diagnosis were associated with lower survival without AIDS.

Assessing the impact of a community-wide HIV testing scale-up initiative in a major urban epidemic

BACKGROUND

The Bronx, one of 5 boroughs in New York City (NYC), bears a high burden of HIV. We evaluated the impact of HIV testing initiatives in the Bronx, including the 2008 The Bronx Knows campaign.

METHODS

We used data from an annual telephone survey representative of NYC adults to compare 2005 and 2009 estimates of HIV testing prevalence among Bronx residents and to identify correlates of testing. We used NYC HIV surveillance data to evaluate changes in the percentage of persons concurrently being diagnosed with HIV and AIDS, an indicator of delayed HIV diagnosis.

RESULTS

Between 2005 and 2009, relative increases of 14% and 32% were found in the proportion of Bronx adults who have ever been HIV tested and who have been tested in the past year, respectively (P < 0.001). The largest increases were among those aged 24-44 years, men, non-Hispanic blacks and Hispanics, and those with low income or education, nonheterosexual identity, a personal doctor/provider, or health insurance. Factors independently associated with being recently tested included black or other race, Hispanic ethnicity, and bisexual identity. The proportion concurrently diagnosed with HIV and AIDS fell 22% from 2005 to 2009, and decreases generally occurred among subgroups experiencing increases in testing.

CONCLUSION

Community-wide testing in the Bronx increased the proportion of people with known HIV status and reduced the proportion with delayed diagnoses.

Impact of the HIV epidemic on the incidence rates of anal cancer in the United States

BACKGROUND

The risk of anal cancer is substantially increased in HIV-infected individuals. Thus, the HIV epidemic may have influenced the increasing anal cancer trends in the United States. We estimated the impact of the HIV epidemic on trends in anal cancer incidence in the United States during 1980-2005.

METHODS

Data on anal cancer cases with and without AIDS were obtained from the HIV/AIDS Cancer Match Study. The number of HIV-infected anal cancer cases without AIDS was estimated from the number of anal cancers occurring before diagnosis of AIDS. The proportion of anal cancer cases with HIV infection in the general population was calculated. We estimated temporal trends in the incidence rates of anal cancer in the general population overall and after exclusion of HIV-infected cancer cases by calculating annual percent changes and 95% confidence intervals (CIs) using a Joinpoint log-linear model. All incidence rates were standardized to the 2000 US population by age, sex, and race.

RESULTS

During 1980-2005, of the 20 533 estimated anal cancer cases, 1665 (8.1%) were HIV-infected. During 2001-2005, the proportion of anal cancer cases with HIV infection was the highest-1.2% (95% CI = 0.93 to 1.4%) among females and 28.4% (95% CI = 26.6 to 29.4%) among males. During 1980-2005, HIV infection did not have an impact on the trends in anal cancer among females (incidence rates increased by 3.3% [95% CI = 3.0 to 3.7%] annually overall, and by 3.3% [95% CI = 2.9 to 3.6%] annually without HIV-infected anal cancer cases) but had a strong impact on the trends in anal cancer among males (incidence rates increased by 3.4% [95% CI = 2.9 to 3.9%] annually overall, and by 1.7% [95% CI = 1.2 to 2.3%] annually without HIV infection).

CONCLUSION

During 1980-2005, the increasing anal cancer incidence rates in the United States were strongly influenced by the HIV epidemic in males but were independent of HIV infection in females.

Adolescent STIs for primary care providers

PURPOSE OF REVIEW

Sexually transmitted infections (STIs) remain a significant source of morbidity among adolescents, who bear a disproportionate burden of disease. Many infections are asymptomatic, but pose significant risk for long-term sequelae in this at-risk population.

RECENT FINDINGS

Recommendations published within the last 5 years from the Centers for Disease Control, United States Preventive Services Task Force, and American Academy of Pediatrics are available to aid providers in appropriate screening, treatment, and prevention of common STIs. However, recent data indicate that many adolescents at risk for STIs are not being appropriately screened. In this review, we summarize screening and treatment recommendations for chlamydia and gonorrhea; prevention and screening recommendations for human papilloma virus (HPV); and appropriate testing for HIV and syphilis.

SUMMARY

Primary care providers are in a unique position to address STIs with adolescents. Improved adherence to screening, treatment, and vaccination recommendations by primary care providers is imperative to reduce prevalence, complications, and transmission of STIs in the adolescent population.

Use of HIV case surveillance system to design and evaluate site-randomized interventions in an HIV prevention study: HPTN 065

INTRODUCTION

Modeling studies suggest intensified HIV testing, linkage-to-care and antiretroviral treatment to achieve viral suppression may reduce HIV transmission and lead to control of the epidemic. To study implementation of strategy, population-level data are needed to monitor outcomes of these interventions. US HIV surveillance systems are a potential source of these data.

METHODS

HPTN065 (TLC-Plus) Study is evaluating the feasibility of a test, linkage-to-care, and treat strategy for HIV prevention in two intervention communities - the Bronx, NY, and Washington, DC. Routinely collected laboratory data on diagnosed HIV cases in the national HIV surveillance system were used to select and randomize sites, and will be used to assess trial outcomes.

RESULTS

To inform study randomization, baseline data on site-aggregated study outcomes was provided from HIV surveillance data by New York City and Washington D.C. Departments of Health. The median site rate of linkage-to-care for newly diagnosed cases was 69% (IQR 50%-86%) in the Bronx and 54% (IQR 33%-71%) in Washington, D.C. In participating HIV care sites, the median site percent of patients with viral suppression (<400 copies/mL) was 57% (IQR 53%-61%) in the Bronx and 64% (IQR 55%-72%) in Washington, D.C.

CONCLUSIONS

In a novel use of site-aggregated surveillance data, baseline data was used to design and evaluate site randomized studies for both HIV test and HIV care sites. Surveillance data have the potential to inform and monitor sitelevel health outcomes in HIV-infected patients.

HIV screening in the health care setting: status, barriers, and potential solutions

Thirty years into the human immunodeficiency virus (HIV) epidemic in the United States, an estimated 50,000 persons become infected each year: highest rates are in black and Hispanic populations and in men who have sex with men. Testing for HIV has become more widespread over time, with the highest rates of HIV testing in populations most affected by HIV. However, approximately 55% of adults in the United States have never received an HIV test. Because of the individual and community benefits of treatment for HIV, in 2006 the Centers for Disease Control and Prevention recommended routine screening for HIV infection in clinical settings. The adoption of this recommendation has been gradual owing to a variety of issues: lack of awareness and misconceptions related to HIV screening by physicians and patients, barriers at the facility and legislative levels, costs associated with testing, and conflicting recommendations concerning the value of routine screening. Reducing or eliminating these barriers is needed to increase the implementation of routine screening in clinical settings so that more people with unrecognized infection can be identified, linked to care, and provided treatment to improve their health and prevent new cases of HIV infection in the United States.

Update and review of racial disparities in sepsis

BACKGROUND

Sepsis is an excessive systemic inflammatory response activated by invasive infection. There has been substantial epidemiologic literature addressing perceived disparities in sepsis by demographic factors such as gender and race. There also have been multiple examinations of the disparities of sepsis with regard to environmental and socioeconomic factors. This paper reviews the current epidemiologic literature evaluating the association of race with the development of sepsis and its associated outcomes.

METHODS

Review of pertinent English-language literature.

RESULTS

Race is a marker of poverty, preexisting conditions, increased allostatic loads, and decreased access to health systems. Racial disparities and the incidence of sepsis likely are explained by a multiplicity of environmental factors that are not captured by administrative data.

CONCLUSION

Race is a surrogate for many intangible factors that lead to the development of sepsis and inferior outcomes.

Undiagnosed HIV prevalence based on nontargeted screening in emergency departments

To estimate the 2009-2010 undiagnosed HIV prevalence in the Paris metropolitan region, where half of France's new HIV cases are diagnosed annually, we used a direct method based on a large sample of emergency department patients unaware of their HIV status. The overall expected prevalence was 0.09% (95% confidence interval 0.04-0.13). Undiagnosed infections were exclusively found in high-risk groups. This prevalence is below the 0.1% threshold suggested by regulatory authorities for implementing universal screening.

Evolving epidemiology of hepatitis C virus in the United States

The impact of hepatitis C virus (HCV) infection on health and medical care in the United States is a major problem for infectious disease physicians. Although the incidence of HCV infection has declined markedly in the past 2 decades, chronic infection in 3 million or more residents now accounts for more disease and death in the United States than does human immunodeficiency virus (HIV)/AIDS. Current trends in the epidemiology of HCV infection include an apparent increase in young, often suburban heroin injection drug users who initiate use with oral prescription opioid drugs; infections in nonhospital healthcare (clinic) settings; and sexual transmission among HIV-infected persons. Infectious disease physicians will increasingly have the responsibility of diagnosing and treating HCV patients. An understanding of how these patients were infected is important for determining whom to screen and treat.

Return on public health investment: CDC's Expanded HIV Testing Initiative

BACKGROUND

Over a 3-year period, the Centers for Disease Control and Prevention invested $102.3 million in a large-scale HIV testing program, the Expanded HIV Testing Initiative for populations disproportionally affected by HIV. Policy makers, who must optimize public health given a set budget, are interested in the financial return on investment (ROI) of large-scale HIV testing.

METHODS

We conducted an ROI analysis using expenditure and outcome data from the program. A health system perspective was used that included all program expenditures including medical costs of treating newly diagnosed patients. We incorporated benefits of HIV transmissions averted from persons diagnosed of their infection through the Initiative compared with when, on average, those persons would have been diagnosed without the Initiative (3 years later in the base case). HIV transmissions were derived from a published mathematical model of HIV transmission. In sensitivity analysis, we tested the effect of 1-year to 5-year alternate testing intervals and differences in the prevalence of undiagnosed HIV infection.

RESULTS

Under the Initiative, 2.7 million persons were tested for HIV, there was a newly diagnosed HIV positivity rate of 0.7%, and an estimated 3381 HIV infections were averted. It achieved a return of $1.95 for every dollar invested. ROI ranged from $1.46 to $2.01 for alternative testing intervals of 1-5 years and remained above $1 (positive return on investment) with a prevalence of undiagnosed HIV infection as low as 0.12%.

CONCLUSIONS

The expanded testing Initiative yielded ROI values of >$1 under a broad range of sensitivity analyses and provides further support for large-scale HIV testing programs.

Retention in care of adults and adolescents living with HIV in 13 U.S. areas

BACKGROUND

Monitoring immunologic and virologic responses to antiretroviral therapy in HIV-1-infected patients is an important component of treatment in the United States. However, little population-based information is available on whether HIV-infected persons receive the recommended tests or continuous care.

METHODS

Using data from 13 areas reporting relevant HIV-related tests to national HIV surveillance, we determined retention in care in persons older than 12 years living with HIV at the end of 2009. We assessed retention in care, defined as ≥2 CD4 or viral load tests at least 3 months apart in the past year, by demographic, clinical, and risk characteristics and calculated prevalence ratios and 95% confidence intervals. We also assessed the percentage established in care within 12 months after HIV diagnosis in 2008 (≥2 tests, ≥3 months apart).

RESULTS

Among 100,375 persons living with HIV, 45% had ≥2 tests at least 3 months apart. A higher percentage of whites were retained in care (50%) compared with blacks/African Americans (41%, prevalence ratio: 0.83, 95% confidence interval: 0.82 to 0.84) and Hispanics/Latinos (40%, prevalence ratio: 0.90, 95% CI: 0.87 to 0.92). Compared with heterosexual women (50%), fewer men who have sex with men (48%), heterosexual men (45%), and male (37%) and female (43%) injection drug users had ≥2 tests. Approximately 64% established care within 12 months of diagnosis.

CONCLUSIONS

Less than half of persons living with HIV had laboratory evidence of ongoing clinical care and only two thirds established care after diagnosis. Further assessments determining modifiable barriers to accessing care could assist with achieving public health targets.

Allocating HIV prevention funds in the United States: recommendations from an optimization model

The Centers for Disease Control and Prevention (CDC) had an annual budget of approximately $327 million to fund health departments and community-based organizations for core HIV testing and prevention programs domestically between 2001 and 2006. Annual HIV incidence has been relatively stable since the year 2000 [1] and was estimated at 48,600 cases in 2006 and 48,100 in 2009 [2]. Using estimates on HIV incidence, prevalence, prevention program costs and benefits, and current spending, we created an HIV resource allocation model that can generate a mathematically optimal allocation of the Division of HIV/AIDS Prevention’s extramural budget for HIV testing, and counseling and education programs. The model’s data inputs and methods were reviewed by subject matter experts internal and external to the CDC via an extensive validation process. The model projects the HIV epidemic for the United States under different allocation strategies under a fixed budget. Our objective is to support national HIV prevention planning efforts and inform the decision-making process for HIV resource allocation. Model results can be summarized into three main recommendations. First, more funds should be allocated to testing and these should further target men who have sex with men and injecting drug users. Second, counseling and education interventions ought to provide a greater focus on HIV positive persons who are aware of their status. And lastly, interventions should target those at high risk for transmitting or acquiring HIV, rather than lower-risk members of the general population. The main conclusions of the HIV resource allocation model have played a role in the introduction of new programs and provide valuable guidance to target resources and improve the impact of HIV prevention efforts in the United States.

HIV testing and management: findings from a national sample of Asian/Pacific islander men who have sex with men

OBJECTIVES

We examined reasons for and barriers to participating in HIV voluntary counseling and testing for Asian/Pacific Islander (A/PI) men who have sex with men (MSM) in the U.S.

METHODS

We collected data between June 2007 and September 2009 in a study known as Men of Asia Testing for HIV, using a cross-sectional community-based participatory design. This national study was conducted in seven U.S. metropolitan cities through a coalition of seven community-based organizations.

RESULTS

Participants included 445 self-identified A/PI MSM aged ≥18 years. Perception of being at risk was the number one reason for testing behaviors. For first-time testers, structural barriers (e.g., language barriers with health professionals) and fear of disclosure (e.g., sexual orientation not known to parents) were deterrents for nontesting in the past. Among previously known HIV-positive men, 22% were not seeing a doctor and 19% were not taking any HIV medications.

CONCLUSIONS

HIV testing, care, and treatment policies would be less than optimal without addressing barriers to testing, including stigma related to sexual orientation, among A/PI MSM.

Circular migration by Mexican female sex workers who are injection drug users: implications for HIV in Mexican sending communities

Circular migration and injection drug use increase the risk of HIV transmission in sending communities. We describe female sex workers who are injection drug users' (FSW-IDUs) circular migration and drug use behaviors. Between 2008-2010, 258 migrant FSW-IDUs residing in Tijuana and Ciudad Juarez, Mexico responded to questionnaires. 24% of FSW-IDUs were circular migrants. HIV prevalence was 3.2% in circular migrants and 6.1% in non-circular migrants; 50% of circular and 75% of non-circular migrants were unaware of their HIV infection. Among circular migrants, 44% (n = 27) consumed illicit drugs in their birthplace; 74% of these (n = 20) injected drugs and one-half of injectors shared injection equipment in their birthplace. Women reporting active social relationships were significantly more likely to return home. Circular migrant FSW-IDUs exhibit multiple HIV risks and opportunities for bridging populations. Regular HIV testing and treatment and access to substance use services is critical for FSW-IDUs and their sexual/drug-using contacts.

Rapid HIV screening: missed opportunities for HIV diagnosis and prevention

BACKGROUND

Although rapid HIV tests increase the number of persons who are aware of their HIV status, they may fail to detect early HIV infection.

OBJECTIVES

To evaluate the sensitivity for early HIV infection of several rapid tests and third- and fourth-generation assays compared with nucleic acid amplification testing (NAAT).

STUDY DESIGN

Sensitivity for early HIV infection was evaluated using 62 NAAT-positive/WB-negative or indeterminate specimens from the CDC Acute HIV Infection study. Specimens underwent third-generation testing with Genetic Systems 1/2+O(®) and rapid testing with Multispot HIV-1/HIV-2. A subset was also tested with four FDA-approved rapid tests and Determine HIV-1 Antigen/Antibody Rapid Test(®) and Architect HIV Antigen/Antibody Combo(®), both fourth-generation tests.

RESULTS

Of 99,111 specimens screened from April 2006 to March 2008, 62 met the definition for early HIV infection (60 NAAT-positive/seronegative and 2 NAAT-positive/Western blot indeterminate). Third-generation testing correctly detected antibody in 34 specimens (55%; 95% confidence interval (CI): 42-67); Multispot detected antibody in 16 (26%; 95% CI: 16-38). Of the 62 specimens, 33 (53%) had sufficient quantity for further testing. Rapid test sensitivities for early HIV infection ranged from 22-33% compared with 55-57% for the third-generation assay and 76-88% for the fourth-generation tests.

CONCLUSIONS

Many rapid HIV tests failed to detect half of the early HIV infection cases in whom antibody was present. Programs that screen high-incidence populations with rapid tests should consider supplemental testing with NAAT or other antigen-based tests. These data support the need for more sensitive antigen-based point-of-care screening tests for early HIV infection.

Supporting the integration of HIV testing into primary care settings

OBJECTIVES

We examined the efforts of the US network of AIDS Education and Training Centers (AETCs) to increase HIV testing capacity across a variety of clinical settings.

METHODS

We used quantitative process data from 8 regional AETCs for July 1, 2008, to June 30, 2009, and qualitative program descriptions to demonstrate how AETC education helped providers integrate HIV testing into routine clinical care with the goals of early diagnosis and treatment.

RESULTS

Compared with other AETC training, HIV testing training was longer and used a broader variety of strategies to educate more providers per training. During education, providers were able to understand their primary care responsibility to address public health concerns through HIV testing.

CONCLUSIONS

AETC efforts illustrate how integration of the principles of primary care and public health can be promoted through professional training.

Implementing rapid HIV testing with or without risk-reduction counseling in drug treatment centers: results of a randomized trial

OBJECTIVES

We examined the effectiveness of risk reduction counseling and the role of on-site HIV testing in drug treatment.

METHODS

Between January and May 2009, we randomized 1281 HIV-negative (or status unknown) adults who reported no past-year HIV testing to (1) referral for off-site HIV testing, (2) HIV risk-reduction counseling with on-site rapid HIV testing, or (3) verbal information about testing only with on-site rapid HIV testing.

RESULTS

We defined 2 primary self-reported outcomes a priori: receipt of HIV test results and unprotected anal or vaginal intercourse episodes at 6-month follow-up. The combined on-site rapid testing participants received more HIV test results than off-site testing referral participants (P<.001; Mantel-Haenszel risk ratio=4.52; 97.5% confidence interval [CI]=3.57, 5.72). At 6 months, there were no significant differences in unprotected intercourse episodes between the combined on-site testing arms and the referral arm (P=.39; incidence rate ratio [IRR]=1.04; 97.5% CI=0.95, 1.14) or the 2 on-site testing arms (P=.81; IRR=1.03; 97.5% CI=0.84, 1.26).

CONCLUSIONS

This study demonstrated on-site rapid HIV testing's value in drug treatment centers and found no additional benefit from HIV sexual risk-reduction counseling.

Computerized assessment facilitates disclosure of sensitive HIV risk behaviors among African Americans entering substance abuse treatment

BACKGROUND

Individuals entering substance abuse treatment are at elevated risk for HIV infection, and clinicians must generally rely on patient self-report to gauge their involvement in risk behaviors. Strategies to improve accurate reporting of personally sensitive or stigmatizing risk behaviors are needed.

OBJECTIVE

This study compared computerized and face-to-face interview methods in eliciting self-disclosure of HIV risk behaviors among a high-risk sample of urban African Americans entering substance abuse treatment (N = 146).

METHODS

Participants completed a standardized HIV risk behavior screening as a face-to-face interview. Several days later, the same participants completed a computerized self-interview with the same measure, covering the same time frame.

RESULTS

Disclosure rates for many sensitive risk behaviors were considerably higher on the computerized interview. Participants had significantly higher odds of disclosure on the computerized interview compared to the face-to-face interview on 2 of 6 drug risk behaviors examined (ORs between 2.75 and 3.15) and 9 of 13 sex risk behaviors examined (ORs between 1.60 and 6.45). The advantage of the computerized interview was most evident for highly stigmatized behaviors, such as unprotected sex with someone other than a spouse or main partner (OR = 3.93; p < .001), unprotected sex during a commercial sex transaction (OR = 5.63; p < .001), unprotected anal sex (OR = 6.45; p < .001), and using unsterilized syringes (OR = 3.15; p < .05).

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Findings support the utility of computerized risk behavior assessment with African Americans entering substance abuse treatment. Computerized assessment of HIV risk behaviors may be clinically useful in substance abuse treatment and other healthcare venues serving high-risk populations.

Operational research to improve HIV prevention in the United States

The HIV/AIDS epidemic in the United States continues despite several recent noteworthy advances in HIV prevention. Contemporary approaches to HIV prevention involve implementing combinations of biomedical, behavioral, and structural interventions in novel ways to achieve high levels of impact on the epidemic. Methods are needed to develop optimal combinations of approaches for improving efficiency, effectiveness, and scalability. This article argues that operational research offers promise as a valuable tool for addressing these issues. We define operational research relative to domestic HIV prevention, identify and illustrate how operational research can improve HIV prevention, and pose a series of questions to guide future operational research. Operational research can help achieve national HIV prevention goals of reducing new infections, improving access to care and optimization of health outcomes of people living with HIV, and reducing HIV-related health disparities.

HIV and club drugs in emerging adulthood

PURPOSE OF REVIEW

To evaluate the incidence of club drug use in pediatric patients, especially those aged 13-25, and how it relates to the spread of HIV.

RECENT FINDINGS

Transmission of HIV among younger patients has become largely associated with risky sexual behaviors, as the rate of transmission from vertical infection and intravenous drug use has decreased. Use of club drugs in emerging adult populations contributes to the HIV epidemic through a combination of decreased inhibitions as well as physiological effects that increase high-risk sexual practices. Robust data exists linking the use of club drugs by the men who have sex with men population with spread of HIV, but this data in other at-risk populations (e.g. African Americans) is not as robust. Additional research is needed to identify the rates of transmission among adolescents and emerging adults, as well as knowledge, attitudes, beliefs, and practices that affect HIV transmission in this population.

SUMMARY

Use of club drugs by adolescents and emerging adults contributes to the current rate of HIV transmission among this age group.

Deportation experiences of women who inject drugs in Tijuana, Mexico

Deportation from the United States for drug offenses is common, yet the consequences of deportation for women drug users are poorly documented. In 2008, in Tijuana, Mexico, we conducted an exploratory qualitative study of migration, deportation, and drug abuse by interviewing 12 Mexican injection-drug-using women reporting U.S. deportation. Women reported heavy drug use before and after deportation, but greater financial instability and physical danger following deportation than when in the United States. We identified an unmet need for health and social services among deported drug-using women, including HIV prevention, drug treatment, physical and mental health services, and vocational training. Binational coordination is needed to help deported women resettle in Mexico.

Long-term follow-up after voluntary human immunodeficiency virus/sexually transmitted infection counseling, point-of-service testing, and referral to substance abuse treatment from the emergency department

OBJECTIVES

Public health initiatives have lowered human immunodeficiency virus (HIV) transmission risk associated with injection drug use in the United States, making sexual risk behaviors a greater source of transmission. Strategies are therefore needed to reduce these risk behaviors among all emergency department (ED) patients who use drugs, regardless of route of administration. Although recent articles have focused on the opportunity for early HIV detection and treatment through an array of ED screening and testing strategies, the effect of voluntary HIV testing and brief counseling (VT/C) on the sexual behaviors of out-of-treatment drug users over time has not yet been reported.

METHODS

From November 2004 to May 2008, the study screened 46,208 urban ED patients aged 18 to 54 years; 2,148 (4.6%) reported cocaine or heroin use within 30 days, 1,538 met eligibility criteria (Drug Abuse Severity Test [DAST] scores ≥3 and were either English- or Spanish-speaking), and 1,030 were enrolled. These data were obtained in the course of a randomized, controlled trial (Project SAFE) of a brief motivational intervention focused on reducing risky sexual behaviors. Although the intervention itself did not demonstrate any differential effect on the number or percentage of unprotected sexual acts, both control and intervention group participants received baseline VT/C and referral for drug treatment as part of the study protocol. This study is a report of a secondary analysis of cohort data to describe changes in sexual behaviors over time among drug users after the VT/C and referral.

RESULTS

The mean (±SD) age of enrollees was 35.8 (±8.4) years; 67% were male, 39% were non-Hispanic black or African American, 41% were white non-Hispanic, and 19% were Hispanic. Half injected drugs, and 53% met criteria for posttraumatic stress disorder (PTSD). At baseline testing, 8.8% were HIV-positive on enzyme-linked immunosorbent assay. Follow-ups were conducted at 6 and 12 months, with an attrition rate of 22%. Known HIV-positive patients accounted for 84 of 1,030 cases (8.1%), and 13 new cases were discovered: 7 of 946 at were discovered at the baseline contact (0.74%), 2 of 655 were discovered at 6 months (0.3%), and 4 of 706 (0.57%) were discovered at the 12-month contact. Twelve of the 13 returned for confirmatory testing and were actively enrolled in our infectious disease clinic. For all partners, there was a reduction in the percentage of unprotected sex acts over time (p < 0.0001), with decreases at 6 months versus baseline (odds ratio [OR] = 0.70, 95% confidence interval [CI] = 0.60 to 0.83), sustained at 12 months versus baseline (OR = 0.69, 95% CI = 0.58 to 0.82). For the outcome of percentage of sex acts while high, there was also a significant reduction over time (p < 0.0001), with a drop-off at 6 months versus baseline (OR = 0.31, 95% CI = 0.25 to 0.37) that was sustained at 12 months (OR vs. baseline 0.25, 95% CI = 0.20 to 0.30). In an adjusted model, male sex, older age, and HIV positivity predicted significant declines over time in the likelihood of unprotected sexual acts. Older age and higher baseline drug severity predicted significant decreases over time in the likelihood of sex acts while high.

CONCLUSIONS

Voluntary testing and counseling for HIV or sexually transmitted infections, accompanied by referral to drug treatment, for this population of ED cocaine and heroin users was associated with reduction in unprotected sex acts and fewer sex acts while high.

Cost savings associated with testing of antibodies, antigens, and nucleic acids for diagnosis of acute HIV infection

Efforts to identify all persons infected with HIV in the United States are driven by the hope that early diagnosis will lower risk behaviors and decrease HIV transmission. Identification of HIV-infected people earlier in the course of their infection with HIV antigen/antibody (Ag/Ab) combination assays (4th-generation HIV assays) should help achieve this goal. We compared HIV RNA nucleic acid test (NAT) results to the results of a 4th-generation Ag/Ab assay (Architect HIV Ag/Ab Combo [HIV Combo] assay; Abbott Diagnostics) in 2,744 HIV antibody-negative samples. Fourteen people with acute HIV infection (HIV antibody negative/NAT positive) were identified; the HIV Combo assay detected nine of these individuals and was falsely negative in the remaining five. All five persons missed by the HIV Combo assay were in the stage of exponential increase in plasma virus associated with acute HIV infection (3, 7, 20, 35, 48). In contrast, most acutely infected persons detected by the HIV Combo assay demonstrated either a plateauing or decreasing plasma viral load. The HIV Combo assay also classified as positive five other samples which were negative by NAT. Taken together, the HIV Combo assay had a sensitivity of 73.7% and a specificity of 99.8%. Using published data, we estimated secondary transmission events had HIV infection in these five individuals remained undiagnosed. Screening of our population with NAT cost more than screening with the HIV Combo assay but achieved new diagnoses that we predict resulted in health care savings that far exceed screening costs. These findings support the use of more sensitive assays, like NAT, in HIV screening of populations with a high prevalence of acute HIV infection.