Risk network approaches to locating undiagnosed HIV cases in Odessa, Ukraine

Comparison of a novel expanded social network recruitment intervention with risk network recruitment to HIV testing: locating undiagnosed cases in South Africa

OBJECTIVE

To ascertain whether a novel expanded social network recruitment to HIV testing (E-SNRHT) intervention recruits men and individuals with previously undiagnosed HIV at higher rates than risk network recruitment.

DESIGN

Initial "seed" participants were prospectively randomly assigned to the E-SNRHT intervention or to risk network recruitment. Their network members were included in the study arm of their recruiter.

SETTING

Three Department of Health clinics and two drug treatment centers (DTCs) in the Msunduzi municipality of KwaZulu-Natal, South Africa.

PARTICIPANTS

Clinics and DTCs referred 110 newly HIV-diagnosed adult "seeds" to the study from June 2022 to February 2023. E-SNRHT seeds were asked to recruit network members as described below; risk network recruitment arm seeds were asked to recruit recent sex and/or injection partners. Presenting a recruitment coupon (from clinic/DTC staff or another participant) was required for eligibility.

INTERVENTION

E-SNRHT seeds were shown educational material about HIV transmission risks and then asked to recruit anyone they know (e.g., friends, family) whom they thought could benefit from HIV testing.

MAIN OUTCOME MEASURES

Rates of recruiting men to HIV testing and locating individuals with previously undiagnosed HIV.

RESULTS

E-SNRHT recruited significantly higher proportions of men to HIV testing (70.3 vs. 40.4%; χ2  = 16.33; P  < 0.0005) and located significantly more previously undiagnosed cases of HIV per seed than risk network recruitment (rate ratio = 9.40; P  < 0.0001). E-SNRHT also recruited significantly higher proportions of women with previously undiagnosed HIV (29.0 vs. 10.7%; χ2  = 3.87; P  = 0.049).

CONCLUSION

E-SNRHT is an important strategy to expand the reach of HIV testing among men and undiagnosed cases of HIV in KwaZulu-Natal.

Changes in Stigma and Social Support among Participants in a Randomized Trial of a Novel Expanded Social Network-based HIV Testing Intervention in KwaZulu-Natal, South Africa

HIV-related stigma is a well-documented barrier to HIV testing in South Africa, and may be particularly likely to create reluctance to test among South African men, who have reported feeling blamed for HIV by their partners and communities. The present study presents a novel expanded social network recruitment to HIV testing (E-SNRHT) intervention explicitly designed to reduce stigma as a barrier to testing by asking people to recruit anyone they know to testing, thus allowing them to avoid the potential for increased stigma and/or blame associated with direct risk partner recruitment, and helping to normalize openly discussing HIV among social networks. We examined baseline and 6-10-week follow-up data from a 2022-2023 randomized trial in KwaZulu-Natal, South Africa that recruited 110 individuals who had been newly diagnosed with HIV and randomly assigned them to recruit people to HIV testing either via the E-SNRHT intervention or via risk network recruitment. Participants in the E-SNRHT intervention reported significant decreases in anticipated and enacted HIV-related stigma between baseline and follow-up; and the E-SNRHT intervention was more effective at decreasing enacted HIV-related stigma than was risk network recruitment. Individuals newly diagnosed with HIV by the E-SNRHT intervention reported significant increases in social support between intervention enrollment and follow-up, and all of these individuals reported participating in positive conversations about HIV services with peers in the 6-10 weeks after intervention enrollment. These findings suggest that E-SNRHT is a potentially important strategy to reduce HIV-related stigma as a barrier to HIV testing among peer networks in KwaZulu-Natal.

Pilot Testing Two Versions of a Social Network Intervention to Increase HIV Testing and Case-finding among Men in South Africa's Generalized HIV Epidemic

Locating undiagnosed HIV infections is important for limiting transmission. However, there is limited evidence about how best to do so. In South Africa, men have been particularly challenging to reach for HIV testing due, in part, to stigma. We pilot-tested two versions of a network-based case-finding and care-linkage intervention. The first, TRIP, asked "seeds" (original participants) to recruit their sexual and/or injection partners. The second, TRIPLE, aimed to circumvent some stigma-related issues by asking seeds to recruit anyone they know who might be at risk of being HIV-positive-unaware. We recruited 11 (18% male) newly diagnosed HIV-positive (NDP) seeds from two clinics in KwaZulu-Natal, South Africa and randomly assigned them to either TRIP or TRIPLE. Network members were recruited two steps from each seed. The TRIP arm recruited 12 network members; the TRIPLE arm recruited 62. Both arms recruited NDPs at higher rates than local clinic testing, with TRIP (50.0%) outperforming (p = 0.012) TRIPLE (14.5%). However, TRIPLE (53.2%) was far superior to clinics (27.8%) and to TRIP (25.0%) at recruiting men. Given challenges around testing and treating men for HIV in this context, these findings suggest that the TRIPLE expanded network-tracing approach should be tested formally among larger samples in multiple settings.

Effects of a social network intervention on HIV seroconversion among people who inject drugs in Ukraine: moderation by network gender composition

BACKGROUND

Women who inject drugs in Ukraine are disproportionately burdened by HIV. To help address the needs of this population, a greater understanding of how interventions may uniquely benefit women who inject drugs is needed.

METHODS

Data come from a randomized controlled trial of a social network intervention targeting people who inject drugs in Ukraine (N = 1195). Indexes, plus two of their injection network members, received HIV testing and counseling (control arm) or HIV testing and counseling plus a social network intervention (intervention arm), in which indexes were trained to influence network members' risk behaviors. We used Cox regressions with interaction terms to assess differences in time to HIV seroconversion between arms by network gender composition and gender of the index. For significant interaction terms, we calculated simple effects, generated survival functions using Kaplan-Meier methods, and compared survival curves using log-rank tests.

RESULTS

At 12 months, there were 45 seroconversions among women (40.0 [28.3, 51.7] per 100 person years) and 111 among men (28.4 [23.1, 33.6] per 100 person years) in the control arm; there were 27 seroconversions among women (17.1 [10.7, 23.6] per 100 person years) and 77 among men (18.7 [14.5, 22.9] per 100 person years) in the intervention arm. Network gender composition (but not gender of the index) moderated the intervention effect on HIV incidence (p < 0.05). Specifically, the intervention appeared to be even more protective against HIV acquisition as female gender composition increased. In the intervention arm, the HIV seroconversion hazard rate was 44% lower with 1 network female; 61% lower with 2 network females; and 72% lower with 3 network females.

CONCLUSIONS

A greater number of women in an injection network, coupled with the provision of risk-reduction strategies, is associated with HIV risk-mitigation, though the mechanisms through which this occurs remain unclear. Findings can support new research and practice directions that prioritize women who inject drugs and more thoughtfully support their health and wellbeing.

Distinctive model for HIV index testing (IT) in Eastern Europe: results of Ukraine's physician-led, integrated IT programme

OBJECTIVES

The effectiveness of HIV index testing (IT) in Eastern Europe has not been described. This study reports the performance of a scaled IT programme in Ukraine.

DESIGN

This observational study included clients enrolled in IT services in 2020, and used routinely collected data from programme registers and the national electronic health record system.

SETTING

The study covered 39 public-sector health facilities where IT services were integrated into medical visits for persons living with HIV (PLHIV) already enrolled in HIV care.

PARTICIPANTS

Participants included PLHIV with both recent (<6 months) and previously established (≥6 months) HIV diagnoses.

INTERVENTION

Ukraine's physician-led IT model involves a cascade of steps including voluntary informed consent, partner elicitation, selection of partner notification method and follow-up with clients to ensure partners are notified, tested for HIV and linked to HIV prevention and treatment services, as needed.

PRIMARY AND SECONDARY OUTCOME MEASURES

Outcomes included contact index, testing, index and HIV case-finding index disaggregated by index client (IC) subgroups, including people with current or past injection drug use (PWID) and men who have sex with men (MSM).

RESULTS

Of 14 525 ICs offered index testing, 51.9% accepted, of whom 98.3% named at least one sexual, injection or biological child partner. In total, 14.9% of ICs were PWID and 3.5% were MSM. Clients named 8448 unique partners (contact index=1.14). HIV case finding averaged 0.14 cases per client, and was highest among clients with recent HIV diagnosis (0.29) and among PWID (0.23), and lower among clients with established HIV diagnosis (0.07). More than 90% of all partners with new HIV diagnoses were linked to care.

CONCLUSIONS

There was a high case-finding index among ICs with recent HIV and high linkage to care for all partners, demonstrating the effectiveness of this integrated, physician-led model implemented in 39 health facilities in Ukraine.

[Estimate of undiagnosed HIV cases in the Cajamarca region of Peru: probabilistic linkage between databases]

Undiagnosed HIV cases contribute to the increase in new infections, therefore estimating this figure is important in order to assess strategies in HIV control programs. The objective of this study was to estimate the number of undiagnosed HIV cases in the Cajamarca region in Peru between 2015 and 2021. HIV cases were obtained from three sources of information: The Regional Health Strategy for HIV Prevention and Control (ESPC-HIV); the HIV epidemiological notification application (Noti-HIV), and the laboratory information system (Netlab). The three databases were linked; a capture-recapture analysis using a log-linear model provided estimates of the number of undiagnosed HIV cases, taking into account interactions and the Akaike information criterion. After linkage, 991 registered HIV cases were obtained. An estimated 1388 cases (95%CI: 1265.6-1542.8) of people living with HIV were estimated, of which 393 (28.4%) were not diagnosed. The underreporting of each source was: 51.9% in the ESPC-HIV; 63.6% in Netlab; and 88% in Noti-HIV. The conclusion drawn was that a high number of HIV cases went undiagnosed, and strategies need to be reconsidered to increase the systematic detection of HIV cases.

Integration of a geospatially targeted community-based testing approach with respondent-driven sampling to identify people who inject drugs living with HIV and HCV in Patti and Gorakhpur, India

BACKGROUND

Respondent-driven sampling (RDS), a network recruitment approach, is effective at reaching people who inject drugs (PWID), but other strategies may be needed to reach PWID at risk or living with HIV and/or Hepatitis C (HCV). We examined the impact of integrating geospatially targeted community-based HIV/HCV testing with an RDS survey.

METHODS

PWID were recruited between 2019 and 2021 in Patti and Gorakhpur, India, in a two-phased approach for identifying PWID living with HIV/HCV. Phase 1 was an RDS survey, in which participants reported injection venues. Venues with the highest prevalence of HIV/HCV viremia were selected for Phase 2: community-based testing. All participants underwent rapid HIV and HCV testing and viral load quantification. Using Pearson's chi-squared test, two-sided exact significance tests, and t-tests, we compared prevalence and identification rates for each of the primary outcomes: the number of PWID 1) living with HIV/HCV, 2) undiagnosed, and 3) viremic.

RESULTS

Both approaches identified large numbers of PWID (n∼500 each; N=2011) who were living with HIV/HCV and had transmission potential (i.e., detectable viremia). The community-based approach identified a higher proportion of individuals living with HCV (76.4% vs. 69.6% in Gorakhpur and 36.3% vs. 29.0% in Patti). Community-based testing was also faster at identifying PWID with detectable HIV viremia. Both approaches identified PWID with varying demographic characteristics.

CONCLUSIONS

Community-based testing was more efficient than RDS overall, but both may be required to reach PWID of varying characteristics. Surveillance should collect data on injection venues to facilitate community-based testing and maximize case identification.

HIV Continuum of Care Among People Who Inject Drugs in Iran: A Cross-sectional Study

ABSTRACT

People living with HIV who inject drugs may have lower access to treatment services. We aimed to assess the HIV continuum of care among people who inject drugs (PWID) in Iran. Data were collected from 2,663 PWID who were recruited via respondent-driven sampling from 11 cities of Iran between June 2019 and March 2020. Participants who tested positive for HIV infection were asked questions to calculate the status of HIV cascade of care. Of 95 PWID living with HIV, 67% were aware of their HIV status, 57% were linked to care service and initiated ART, 49% retained on ART, and only 15% had viral load less than 1,000 copies/ml. About half of the PWID diagnosed with HIV ever started ART and less than one in six were virally suppressed. Strategies to improve linkage to ART programs and ART retention may improve HIV care outcomes among PWID in Iran.

Phylodynamics and migration data help describe HIV transmission dynamics in internally displaced people who inject drugs in Ukraine

Internally displaced persons are often excluded from HIV molecular epidemiology surveillance due to structural, behavioral, and social barriers in access to treatment. We test a field-based molecular epidemiology framework to study HIV transmission dynamics in a hard-to-reach and highly stigmatized group, internally displaced people who inject drugs (IDPWIDs). We inform the framework by Nanopore generated HIV pol sequences and IDPWID migration history. In June-September 2020, we recruited 164 IDPWID in Odesa, Ukraine, and obtained 34 HIV sequences from HIV-infected participants. We aligned them to publicly available sequences (N = 359) from Odesa and IDPWID regions of origin and identified 7 phylogenetic clusters with at least 1 IDPWID. Using times to the most recent common ancestors of the identified clusters and times of IDPWID relocation to Odesa, we infer potential post-displacement transmission window when infections likely to happen to be between 10 and 21 months, not exceeding 4 years. Phylogeographic analysis of the sequence data shows that local people in Odesa disproportionally transmit HIV to the IDPWID community. Rapid transmissions post-displacement in the IDPWID community might be associated with slow progression along the HIV continuum of care: only 63% of IDPWID were aware of their status, 40% of those were in antiviral treatment, and 43% of those were virally suppressed. Such HIV molecular epidemiology investigations are feasible in transient and hard-to-reach communities and can help indicate best times for HIV preventive interventions. Our findings highlight the need to rapidly integrate Ukrainian IDPWID into prevention and treatment services following the dramatic escalation of the war in 2022.

Methods for Assessing Spillover in Network-Based Studies of HIV/AIDS Prevention among People Who Use Drugs

Human Immunodeficiency Virus (HIV) interventions among people who use drugs (PWUD) often have spillover, also known as interference or dissemination, which occurs when one participant's exposure affects another participant's outcome. PWUD are often members of networks defined by social, sexual, and drug-use partnerships and their receipt of interventions can affect other members in their network. For example, HIV interventions with possible spillover include educational training about HIV risk reduction, pre-exposure prophylaxis, or treatment as prevention. In turn, intervention effects frequently depend on the network structure, and intervention coverage levels and spillover can occur even if not measured in a study, possibly resulting in an underestimation of intervention effects. Recent methodological approaches were developed to assess spillover in the context of network-based studies. This tutorial provides an overview of different study designs for network-based studies and related methodological approaches for assessing spillover in each design. We also provide an overview of other important methodological issues in network studies, including causal influence in networks and missing data. Finally, we highlight applications of different designs and methods from studies of PWUD and conclude with an illustrative example from the Transmission Reduction Intervention Project (TRIP) in Athens, Greece.

Ending the HIV Epidemic: Identifying Barriers and Facilitators to Implement Molecular HIV Surveillance to Develop Real-Time Cluster Detection and Response Interventions for Local Communities

The rapid implementation of molecular HIV surveillance (MHS) has resulted in significant challenges for local health departments to develop real-time cluster detection and response (CDR) interventions for priority populations impacted by HIV. This study is among the first to explore professionals' strategies to implement MHS and develop CDR interventions in real-world public health settings. Methods: Semi-structured qualitative interviews were completed by 21 public health stakeholders in the United States' southern and midwestern regions throughout 2020-2022 to identify themes related to the implementation and development of MHS and CDR. Results for the thematic analysis revealed (1) strengths and limitations in utilizing HIV surveillance data for real-time CDR; (2) limitations of MHS data due to medical provider and staff concerns related to CDR; (3) divergent perspectives on the effectiveness of partner services; (4) optimism, but reluctance about the social network strategy; and (5) enhanced partnerships with community stakeholders to address MHS-related concerns. Conclusions: Enhancing MHS and CDR efforts requires a centralized system for staff to access public health data from multiple databases to develop CDR interventions; designating staff dedicated to CDR interventions; and establishing equitable meaningful partnerships with local community stakeholders to address MHS concerns and develop culturally informed CDR interventions.

Recent HIV Infection: Diagnosis and Public Health Implications

The early period of infection with human immunodeficiency virus (HIV) has been associated with higher infectiousness and, consequently, with more transmission events. Over the last 30 years, assays have been developed that can detect viral and immune biomarkers during the first months of HIV infection. Some of them depend on the functional properties of antibodies including their changing titers or the increasing strength of binding with antigens over time. There have been efforts to estimate HIV incidence using antibody-based assays that detect recent HIV infection along with other laboratory and clinical information. Moreover, some interventions are based on the identification of people who were recently infected by HIV. This review summarizes the evolution of efforts to develop assays for the detection of recent HIV infection and to use these assays for the cross-sectional estimation of HIV incidence or for prevention purposes.

Challenges of sexually transmitted infections and sexual health among people who inject drugs

PURPOSE OF REVIEW

This review provides a summary of recently published research on sexually transmitted infections (STI) and related behaviors among people who inject drugs (PWID), covering three major areas: sexual behavior and its role in STI transmission among PWID, multilevel factors associated with STI risk, and strategies addressing sexual health of PWID. This review is timely given the growing priority of combination prevention approaches and integrated care for PWID.

RECENT FINDINGS

Modern research improves the understanding that PWID have an increased risk of STI, which varies by gender, setting, type of substance used, and presence of mental disorders. Major socioeconomic and structural factors, specific and nonspecific to PWID, facilitate inequality and sexual risk behavior. Sexual transmission continues to contribute substantially to the spread of bloodborne infections among PWID, accounting for at least 10% of new HIV cases according to epidemiological modeling. Despite the substantial evidence that behavioral interventions can improve sexual health and reduce sex-related risks among PWID, there is a research-practice gap, reflected in the scarcity of implementation studies published recently.

SUMMARY

Integration of sexual health into prevention programs for PWID is essential to curb transmission of STI, including HIV, among PWID and their sexual partners.

Effect of community-based interventions targeting female sex workers along the HIV care cascade in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Female sex workers are extremely vulnerable and highly susceptible to being infected with human immunodeficiency virus. As a result, community-based targeted interventions have been recommended as one of the models of care to improve access to HIV services and continued engagement in care. We conducted a systematic review to (1) assess the effect of FSW-targeted community interventions on the improvement of HIV services access along the treatment cascade and (2) describe community-based interventions that positively affect continuation in HIV care across the HIV treatment cascade for FSWs in sub-Saharan Africa.

METHODS

We defined the 5 steps that make up the HIV care cascade and categorized them as outcomes, namely, HIV testing and diagnosis, linkage to care, receipt of ART, and achievement of viral suppression. We conducted a systematic search of randomized controlled trials, cohort, and cross-sectional studies done in sub-Saharan African countries and published from 2004 to 2020. The period was selected based on the time span within which ART was scaled up through widespread roll-out of comprehensive HIV programs in sub-Saharan Africa. We reviewed studies with data on the implementation of community interventions for any of the HIV care cascade stage. The data were analyzed using random effects meta-analysis where possible, and for the rest of the studies, data were synthesized using summary statistics.

RESULTS

The significant impact of the community interventions was observed on HIV testing, HIV diagnosis, and ART use. However, for HIV testing and ART use, the improvement was not sustained for the entire period of implementation. There were minimal interventions that had impact on HIV diagnosis, with only one community service delivery model showing significance. Generally, the interventions that had reasonable impact are those that implemented targeted and comprehensive package of HIV services provided at one location, and with unique strategies specific to each cascade stage.

CONCLUSIONS

The evidence brought forward from this review shows that the effect of community-based interventions varies across the different stages of HIV care cascade. A broad package of interventions including a combination of behavioral, biomedical, and structural, designed with specific strategies, unique to each cascade stage appears to be more effective, although information on long-term treatment outcomes and the extent to which FSWs remain engaged in care is sparse. There is need to conduct a further research to deepen the assessment of the effectiveness of community-based interventions on HIV care cascade for FSWs. This will enhance identification of evidence-based optimal interventions that will guide effective allocation of scarce resources for strategies that would have a significant impact on HIV service delivery.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020157623.

Access to HIV-prevention in female sex workers in Ukraine between 2009 and 2017: Coverage, barriers and facilitators

The provision of comprehensive prevention services is vital for reducing the high burden of HIV amongst Ukrainian female sex workers (FSWs). To identify barriers and facilitators that influence access to HIV prevention amongst this population between 2009 and 2017, we developed a literature-informed conceptual framework and conducted a document analysis to identify the components of the Ukrainian prevention package (PP). Using the Integrated Bio Behavioural Surveillance Surveys, we then conducted descriptive analyses to explore PP coverage from 2009 to 2017 and the influence of factors, identified by our conceptual framework. After increasing over four years, a drop in PP coverage was observed from 2013 onwards. Being a client of a non-governmental organisation, street and highway solicitation, non-condom use, and knowledge of HIV may influence access to HIV prevention in the Ukrainian context. Future interventions should consider barriers and facilitators to HIV prevention and the multiple structural levels on which they operate.

``Now it is mostly done through stashes, to do it in person one has to trust you'': Understanding the retail injection drug market in Dnipro, Ukraine

Little research has been conducted in Ukraine since the 1990s to understand the organization of drug market and its implications for people who inject drugs (PWID). In this study, we explore how PWID perceive the retail drug market in a large Ukrainian city. Qualitative data were obtained during in-depth interviews and analyses included open coding, coding tree development and revision, axial coding, and identification of higher-level domains. Participants' narratives focused on types and forms of drugs available, perceptions about drug quality, methods of buying drugs, and the relationships that are formed and maintained by participating in the drug economy. The described technical organization of the drug market, with multiple contingent combinations of drug types, forms and means of obtaining drugs (hand-to-hand vs stash-based) resulted from diversification and digitalization of the retail injection drug market. The social organization of the drug market in the form of relationships with sellers and drug use partners represented the response to the fundamental problem of uncertainty. The lens of ``transaction cost'' helps explain strategies PWID used to manage uncertainties, including finding reliable and suitable sellers, sending money and picking up the stash under the threat of being stiffed or caught by the police, choosing the product itself, using the intermediaries to outsource risky operations and forming groups to procure and inject together. Our results indicate that the technical and social organization of drug distribution in Ukraine stimulates formation and continuation of relationships and impacts the choices of what, how, and when to inject beyond individual preferences. The policy and practice implications include the need to monitor and understand the retail drug market to develop and deliver more efficient and client-oriented services, incorporate and leverage social networks structure for information sharing and behavior change, pilot and implement drug testing services to assist with management of uncertainties.

HIV treatment cascade among people who inject drugs in Ukraine

The HIV treatment cascade is an effective tool to track progress and gaps in the HIV response among key populations. People who inject drugs (PWID) remain the most affected key population in Ukraine with HIV prevalence of 22% in 2015. We performed secondary analysis of the 2017 Integrated Bio-Behavioral Surveillance (IBBS) survey data to construct the HIV treatment cascade for PWID and identify correlates of each indicator achievement. The biggest gap in the cascade was found in the first "90", HIV status awareness: only 58% [95% CI: 56%-61%] of HIV-positive PWID reported being aware of their HIV-positive status. Almost 70% [67%-72%] of all HIV-infected PWID who were aware of their status reported that they currently received antiretroviral therapy (ART). Almost three quarters (74% [71%-77%]) of all HIV-infected PWID on ART were virally suppressed. Access to harm reduction services in the past 12 months and lifetime receipt of opioid agonist treatment (OAT) had the strongest association with HIV status awareness. Additionally, OAT patients who were aware of HIV-positive status had 1.7 [1.2-2.3] times the odds of receiving ART. Being on ART for the last 6 months or longer increased odds to be virally suppressed; in contrast, missed recent doses of ART significantly decreased the odds of suppression. The HIV treatment cascade analysis for PWID in Ukraine revealed substantial gaps at each step and identified factors contributing to achievement of the outcomes. More intensive harm reduction outreach along with targeted case finding could help to fill the HIV awareness gap among PWID in Ukraine. Scale up of OAT and community-level linkage to care and ART adherence interventions are viable strategies to improve ART coverage and viral suppression among PWID.

Grindr Users Take More Risks, but Are More Open to Human Immunodeficiency Virus (HIV) Pre-exposure Prophylaxis: Could This Dating App Provide a Platform for HIV Prevention Outreach?

BACKGROUND

Technology has changed the way that men who have sex with men (MSM) seek sex. More than 60% of MSM in the United States use the internet and/or smartphone-based geospatial networking apps to find sex partners. We correlated use of the most popular app (Grindr) with sexual risk and prevention behavior among MSM.

METHODS

A nested cohort study was conducted between September 2018 and June 2019 among MSM receiving community-based human immunodeficiency virus (HIV) and sexually transmitted infection (STI) screening in central San Diego. During the testing encounter, participants were surveyed for demographics, substance use, risk behavior (previous 3 months), HIV pre-exposure prophylaxis (PrEP) use, and Grindr usage. Participants who tested negative for HIV and who were not on PrEP were offered immediate PrEP.

RESULTS

The study included 1256 MSM, 1090 of whom (86.8%) were not taking PrEP. Overall, 580 of 1256 (46%) participants indicated that they used Grindr in the previous 7 days. Grindr users reported significantly higher risk behavior (greater number of male partners and condomless sex) and were more likely to test positive for chlamydia or gonorrhea (8.6% vs 4.7% of nonusers; P = .005). Grindr users were also more likely to be on PrEP (18.7% vs 8.7% of nonusers; P < .001) and had fewer newly diagnosed HIV infections (9 vs 26 among nonusers; P = .014). Grindr users were also nearly twice as likely as nonusers to initiate PrEP (24.6% vs 14%; P < .001).

CONCLUSIONS

Given the higher risk behavior and greater acceptance of PrEP among MSM who used Grindr, Grindr may provide a useful platform to promote HIV and STI testing and increase PrEP uptake.

Risk-Taking Behaviors and Adherence to HIV Pre-Exposure Prophylaxis in Users of Geosocial Networking Apps: Real-World, Multicenter Study

Background

Over half of men who have sex with men (MSM) use geosocial networking (GSN) apps to encounter sex partners. GSN apps’ users have become a unique large subpopulation among MSM for interventions concerning HIV prevention and control. Pre-exposure prophylaxis (PrEP) is a promising measure for HIV prevention, especially for MSM, but its effectiveness largely depends on medication adherence. However, little is known about PrEP adherence among GSN apps’ users, which is critical to addressing the overall optimization of PrEP compliance outside of clinical trials in the context of large-scale implementation.

Objective

The objective of this study is to understand the correlation between GSN apps’ use and medication adherence among MSM receiving PrEP, with the aim to increase their awareness about PrEP use in order to increase adherence.

Methods

This study based on the China Real-world Oral intake of PrEP (CROPrEP) project, a multicenter, real-world study of Chinese MSM on daily and event-driven PrEP. Eligible participants completed a detailed computer-assisted self-interview on sociodemographic, GSN apps’ use, and sexual behavior. Then participants were followed up for 12 months and assessed for various characteristics (eg, PrEP delivery, adherence assessment, PrEP coverage of sexual activities, and regimens switch). A generalized estimation equation was used to analyze the predictors of medication adherence and regimen conversion among GSN apps’ users and nonusers.

Results

At baseline, 756 of the 1023 eligible participants (73.90%) reported primarily using GSN apps to seek sexual partners, and GSN apps’ users are more likely to have high-risk behaviors such as multiple sex partners and condomless anal intercourse than other nonusers (all P<.05). During follow-up, GSN apps’ users had a significantly low level of pill-counting adherence than nonusers (adjusted odds ratio [aOR] 0.8, 95% CI 0.6-1.0, P=.038). In the event-driven group, GSN apps’ users had marginally lower levels of self-reported adherence (aOR 0.7, 95% CI 0.4-1.0, P=.060) and lower PrEP coverage of sexual practices (aOR 0.6, 95% CI 0.4-1.0, P=.038). Additionally, GSN apps’ users seemed more likely to switch from event-driven to daily regimen (aOR 1.8, 95% CI 0.9-3.3, P=.084).

Conclusions

GSN apps’ users are highly prevalent among MSM, despite their higher sexual risk and lower adherence levels, suggesting that eHealth needs to be introduced to the GSN platform to promote PrEP adherence.

Trial Registration

Chinese Clinical Trial Registry ChiCTR-IIN-17013762; https://tinyurl.com/yy2mhrv4.

International Registered Report Identifier (IRRID)

RR2-10.1186/s12879-019-4355-y

Comparison of effectiveness and cost for different HIV screening strategies implemented at large urban medical centre in the United States

INTRODUCTION

Incident HIV infections persist in the United States (U.S.) among marginalized populations. Targeted and cost-efficient testing strategies can help in reaching HIV elimination. This analysis compares the effectiveness and cost of three HIV testing strategies in a high HIV burden area in the U.S. in identifying new HIV infections.

METHODS

We performed a cost analysis comparing three HIV testing strategies in Chicago: (1) routine screening (RS) in an inpatient and outpatient setting, (2) modified partner services (MPS) among networks of the recently HIV infected and diagnosed, and (3) a respondent drive sampling (RDS)-based social network (SN) approach targeting young African-American men who have sex with men. All occurred at the same academic medical centre during the following times: routine testing, 2011 to 2016; MPS, 2013 to 2016; SN: 2013 to 2014. Costs were in 2016 dollars and included personnel, HIV testing, training, materials, overhead. Outcomes included cost per test, HIV-positive test and new diagnosis. Sensitivity analyses were performed to assess the impact of population demographics.

RESULTS

The RS programme completed 57,308 HIV tests resulting in 360 (0.6%) HIV-positive tests and 165 new HIV diagnoses (0.28%). The MPS completed 146 HIV tests, resulting in 79 (54%) HIV-positive tests and eight new HIV diagnoses (5%). The SN strategy completed 508 HIV tests, resulting in 210 (41%) HIV-positive tests and 37 new HIV diagnoses (7.2%). Labour accounted for the majority of costs in all strategies. The estimated cost per new HIV diagnosis was $16,773 for the RS programme, $61,418 for the MPS programme and $15,683 for the SN testing programme. These costs were reduced for the RS and MPS strategies in sensitivity analyses limiting testing efficacy to the highest prevalence patient populations ($2,841 and $33,233 respectively).

CONCLUSIONS

The SN strategy yielded the highest proportion of new diagnoses, followed closely by the MPS programme. Both the SN strategy and RS programme were comparable in the cost per new diagnosis. A simultaneous approach that consists of RS in combination with SN testing may be most effective for identifying new HIV infections in settings with heterogeneous epidemics with both high rates of HIV prevalence and HIV testing.

Optimizing HIV prevention and treatment outcomes for persons with substance use in Central Asia: what will it take?

Purpose of review

To summarize the status of HIV and substance use in Central Asia and discuss potential ways to move forward to effective epidemic control among people who inject drugs (PWID) in the region and beyond.

Recent findings

PWID and their partners remain the population most affected by HIV in Central Asia. Lack of effective substance use prevention and treatment options and limited involvement of PWID-led community-based organizations in HIV programs, combined with the requirement for official registration, stigma and discrimination of PWID, and criminalization of drug use remain key barriers to effective HIV prevention and treatment.

Summary

Sustainable HIV epidemic control among PWID will not be feasible without decriminalization of drug use, addressing stigma and discrimination and policy changes to enhance uptake of HIV-related prevention, treatment and support services by PWID. It is also critical to ensure adoption of innovations, particularly those that combine evidence-based biomedical, behavioral and structural interventions tailored to the needs of the PWID.

Phylodynamics Helps to Evaluate the Impact of an HIV Prevention Intervention

Assessment of the long-term population-level effects of HIV interventions is an ongoing public health challenge. Following the implementation of a Transmission Reduction Intervention Project (TRIP) in Odessa, Ukraine, in 2013-2016, we obtained HIV pol gene sequences and used phylogenetics to identify HIV transmission clusters. We further applied the birth-death skyline model to the sequences from Odessa (n = 275) and Kyiv (n = 92) in order to estimate changes in the epidemic's effective reproductive number (Re) and rate of becoming uninfectious (δ). We identified 12 transmission clusters in Odessa; phylogenetic clustering was correlated with younger age and higher average viral load at the time of sampling. Estimated Re were similar in Odessa and Kyiv before the initiation of TRIP; Re started to decline in 2013 and is now below Re = 1 in Odessa (Re = 0.4, 95%HPD 0.06-0.75), but not in Kyiv (Re = 2.3, 95%HPD 0.2-5.4). Similarly, estimates of δ increased in Odessa after the initiation of TRIP. Given that both cities shared the same HIV prevention programs in 2013-2019, apart from TRIP, the observed changes in transmission parameters are likely attributable to the TRIP intervention. We propose that molecular epidemiology analysis can be used as a post-intervention effectiveness assessment tool.

People with high HIV viral load within risk networks: who are these people and who refers them best?

Introduction:

Viral load is one of the most important determinants for HIV transmission. Identification of people with high viral load (PHVL) can be effective in limiting onward HIV transmission. In order to improve the identification of these individuals within risk networks, we determined a) the number of PHVL recruited through risk networks b) their socio-demographic, behavioural and clinical characteristics and c) the characteristics of individuals who referred these PHVL to the study.

Methodology:

From November 2013 to March 2016, in Odessa, Ukraine, Transmission Reduction Intervention Project (TRIP) was implemented to identify people recently infected with HIV within the risk networks of “seeds” and “venues” where they engaged in risk behaviour.

Results:

TRIP identified 53 PHVL, of whom 32 (60%) injected drugs; 42 (79%) were unaware of their HIV status; 25 (47%) had more than one sex partner, and only 14 (26%) were using condoms. There were 164 people who referred individuals into the study; 33 of them (20%) referred PHVL. In terms of referrers, those with lower than secondary level of education, not living with a sex partner, and reporting regular condom use were significantly more likely (p < 0.05) to refer PHVL. Most PHVL (38, 72%) and their referrers (27, 82%) were found through venues.

Conclusions:

In Odessa city, PHVL are at high risk of transmitting HIV as the majority inject drugs, do not know their HIV status, and have unprotected sex and/or multiple partners. Targeting these individuals for HIV prevention, harm reduction and initiation of antiretroviral treatment (ART) is urgent.

Exploring HIV-1 Transmission Dynamics by Combining Phylogenetic Analysis and Infection Timing

HIV-1 pol sequences obtained through baseline drug resistance testing of patients newly diagnosed between 2013 and 2017 were analyzed for genetic similarity. For 927 patients the information on genetic similarity was combined with demographic data and with information on the recency of infection. Overall, 48.3% of the patients were genetically linked with 11.4% belonging to a pair and 36.9% involved in a cluster of ≥3 members. The percentage of early diagnosed (≤4 months after infection) was 28.6%. Patients of Belgian origin were more frequently involved in transmission clusters (49.7% compared to 15.3%) and diagnosed earlier (37.4% compared to 12.2%) than patients of Sub-Saharan African origin. Of the infections reported to be locally acquired, 69.5% were linked (14.1% paired and 55.4% in a cluster). Equal parts of early and late diagnosed individuals (59.9% and 52.4%, respectively) were involved in clusters. The identification of a genetically linked individual for the majority of locally infected patients suggests a high rate of diagnosis in this population. Diagnosis however is often delayed for >4 months after infection increasing the opportunities for onward transmission. Prevention of local infection should focus on earlier diagnosis and protection of the still uninfected members of sexual networks with human immunodeficiency virus (HIV)-infected members.

Risk network approaches to locating undiagnosed HIV cases in Odessa, Ukraine

INTRODUCTION

Providing HIV healthcare and Treatment as Prevention both depend on diagnosing HIV cases, preferably soon after initial infection. We hypothesized that tracing risk networks recruits higher proportions of undiagnosed positives than outreach-based testing or respondent-driven sampling (RDS) in Odessa, Ukraine.

METHODS

The Transmission Reduction Intervention Project (TRIP) used risk network tracing to recruit sexual and injection networks of recently-infected and longer-term infected (LTs) seeds (2013 to 2016). Integrated Biobehavioural Surveillance (IBBS) (2013) used RDS to recruit people who inject drugs (PWID). Outreach Testing tested PWID for HIV at community outreach sites (2013 to 2016). Proportions of undiagnosed positives among those tested were compared TRIP versus IBBS; TRIP versus Outreach Testing and between TRIP arms. Costs were compared across the projects.

RESULTS

TRIP tested 1252 people (21% women) in seeds' risk networks; IBBS tested 400 (18% women); Outreach Testing 13,936 (31% women). TRIP networks included a higher proportion of undiagnosed positives (14.6%) than IBBS (5.0%) or Outreach Testing (2.4%); odds ratio (OR) 3.25 (95% CI 2.07, 5.12) versus IBBS and 7.03 (CI 5.95, 8.31) versus Outreach Testing respectively. Findings remained significant in analyses stratified by sex and when PWID in TRIP networks were compared with Outreach Testing and IBBS. Within TRIP, recently-infected participants' networks contained higher proportions of undiagnosed positives (16.3%) than LTs' networks (12.2%); OR 1.41 (CI 1.01, 1.95). TRIP located undiagnosed positives less expensively than did RDS or Outreach Testing.

CONCLUSIONS

TRIP's recruiting techniques, including prioritizing networks of the recently infected, find undiagnosed HIV-positive people efficiently. They should be integrated with standard practice to improve case-finding. Research should test these techniques in other socio-epidemiologic contexts.

CLINICAL TRIAL REGISTRY

Registered ClinicalTrials.gov: NCT01827228.

HIV testing behaviour and HIV prevalence among female sex workers in Ukraine: findings from an Integrated Bio-Behavioural Survey, 2013-2014

OBJECTIVES

Ukraine has one of the largest HIV epidemics in Europe, with high prevalence among female sex workers (FSWs). We aimed to identify factors associated with HIV testing and receipt of the test result in the last 12 months, HIV prevalence and self-reported positive status among FSWs in Ukraine.

METHODS

We used data from an Integrated Bio-Behavioural Survey among FSWs conducted in 2013-2014. The survey methodology combined three sampling strategies: time and location sampling, respondent-driven sampling and key informant recruitment. We used multivariable regression to identify factors associated with self-reported HIV testing in the last 12 months, HIV prevalence and self-reported positive status among FSWs living with HIV. Explored factors included: age, age at first sex, age at entry into sex work, education, marital status, employment status beside sex work, condom use with last paying or non-paying sexual partner, drug or alcohol consumption and sex work venue.

RESULTS

Recent HIV testing was low overall with only 63.2% of FSWs reported having tested and received their test result in the last 12 months prior to the survey. HIV prevalence was 7.1% overall, but only 45.0% of FSWs living with HIV were aware of their HIV status. Testing in the last 12 months with receipt of test result was less common among FSWs who used drugs ever in life (adjusted OR (AOR) 0.7, 95% CI 0.6 to 0.9), women soliciting clients indoors (AOR 0.8, 95% CI 0.7 to 0.9) and those not using a condom with last paying sexual partner (AOR 0.3, 95% CI 0.2 to 0.5). HIV positivity was associated with history of ever using drugs (AOR 2.3, 95% CI 1.4 to 3.6) and soliciting clients outdoors (AOR 1.5, 95% CI 1.1 to 2.0). Women working indoors were less aware of their positive status (AOR 0.1, 95% CI 0.1 to 0.9).

CONCLUSION

HIV prevalence is high among FSWs in Ukraine, and testing and knowledge of one's status remain insufficient. HIV testing programmes need to expand with strategies to reach specific subgroups of FSWs.

Experiences of Stigma and Support Reported by Participants in a Network Intervention to Reduce HIV Transmission in Athens, Greece; Odessa, Ukraine; and Chicago, Illinois

A growing body of evidence suggests that network-based interventions to reduce HIV transmission and/or improve HIV-related health outcomes have an important place in public health efforts to move towards 90-90-90 goals. However, the social processes involved in network-based recruitment may pose a risk to participants of increasing HIV-related stigma if network recruitment causes HIV status to be assumed, inferred, or disclosed. On the other hand, the social processes involved in network-based recruitment to HIV testing may also encourage HIV-related social support. Yet despite the relevance of these processes to both network-based interventions and to other more common interventions (e.g., partner services), there is a dearth of literature that directly examines them among participants of such interventions. Furthermore, both HIV-related stigma and social support may influence participants' willingness and ability to recruit their network members to the study. This paper examines (1) the extent to which stigma and support were experienced by participants in the Transmission Reduction Intervention Project (TRIP), a risk network-tracing intervention aimed at locating recently HIV-infected and/or undiagnosed HIV-infected people and linking them to care in Athens, Greece; Odessa, Ukraine; and Chicago, Illinois; and (2) whether stigma and support predicted participant engagement in the intervention. Overall, experiences of stigma were infrequent and experiences of support frequent, with significant variation between study sites. Experiences and perceptions of HIV-related stigma did not change significantly between baseline and six-month follow-up for the full TRIP sample, and significantly decreased during the course of the study at the Chicago site. Experiences of HIV-related support significantly increased among recently-HIV-infected participants at all sites, and among all participants at the Odessa site. Both stigma and support were found to predict participants' recruitment of network members to the study at the Athens site, and to predict participants' interviewer-rated enthusiasm for naming and recruiting their network members at both the Athens and Odessa sites. These findings suggest that network-based interventions like TRIP which aim to reduce HIV transmission likely do not increase stigma-related risks to participants, and may even encourage increased social support among network members. However, the present study is limited by its associational design and by some variation in implementation by study site. Future research should directly assess contextual differences to improve understanding of the implications of site-level variation in stigma and support for the implementation of network-based interventions, given the finding that these constructs predict participants' recruitment of network members and engagement in the intervention, and thereby could limit network-based interventions' abilities to reach those most in need of HIV testing and care.

Reaching the unreached: Performance of an enhanced peer outreach approach to identify new HIV cases among female sex workers and men who have sex with men in HIV programs in West and Central Africa

Finding new HIV-positive cases remains a priority to achieve the UNAIDS goals. An enhanced peer outreach approach (EPOA) was implemented to expand the delivery of HIV services to female sex workers (FSWs) and men who have sex with men (MSM) in three countries in West and Central Africa. The aim of EPOA is to identify new HIV-positive cases. EPOA was implemented in Burundi among FSWs, and in Cote d'Ivoire and Democratic Republic of the Congo (DRC) among both FSWs and MSM. Implementation ranged from five to nine weeks and was nested within a three-month reporting period. Standard outreach was suspended for the duration of EPOA implementation but was resumed thereafter. Summary service statistics were used to compare HIV seropositivity during standard outreach and EPOA. Trends were analyzed during the quarter in which EPOA was implemented, and these were compared with the two preceding quarters. Differences in proportions of HIV seropositivity were tested using Pearson's chi-square test; p-values of less than 0.05 were considered statistically significant. Overall, EPOA resulted in a higher proportion of new HIV-positive cases being found, both within and between quarters. In Burundi, HIV seropositivity among FSWs was significantly higher during EPOA than during standard outreach (10.8% vs. 4.1%, p<0.001). In Cote d'Ivoire, HIV seropositivity was significantly higher during EPOA among both populations (FSWs: 5.6% vs. 1.81%, p<0.01; MSM: 15.4% vs. 5.9%; p<0.01). In DRC, HIV seropositivity was significantly higher during EPOA among MSM (6.9% vs. 1.6%; p<0.001), but not among FSWs (5.2% vs. 4.3%; p = 0.08). Trends in HIV seropositivity during routine outreach for both populations were constant during three successive quarters but increased with the introduction of EPOA. EPOA is a public health approach with great potential for reaching new populations and ensuring that they are aware of their HIV status.

Identifying, linking, and treating people who inject drugs and were recently infected with HIV in the context of a network-based intervention

Identifying and linking people to care soon after HIV infection could limit viral transmission and protect their health. This work aims at describing the continuum of care among recently HIV-infected people who inject drugs (PWID) and participated in an intervention in the context of an HIV outbreak in Athens, Greece. The Transmission Reduction Intervention Project (TRIP) conducted risk network-based contact tracing and screened people for recent HIV infection. A comprehensive approach with a case management component that aimed to remove barriers to accessing care was adopted. Follow-up data on antiretroviral treatment (ART) and HIV-RNA levels were obtained from HIV clinics. TRIP enrolled 45 recently HIV-infected PWID (80% male) with a median viral load at recruitment of 5.43 log₁₀ copies/mL. Of the recently infected persons in TRIP, 87% were linked to care; of these, 77% started ART; and of those on ART, 89% achieved viral load <200 copies/mL. TRIP and its public health allies managed to get most of the recently HIV-infected PWID who were identified by the program into care and many of them onto ART. This resulted in very low HIV-RNA levels. Treatment as prevention can work if individuals are aided in overcoming difficulties in entry to, or attrition from care.

Strategies for Identifying and Linking HIV-Infected Infants, Children, and Adolescents to HIV Treatment Services in Resource Limited Settings

Many children living with HIV in resource-limited settings remain undiagnosed and at risk for HIV-related mortality and morbidity. This article describes 5 key strategies for strengthening HIV case finding and linkage to treatment for infants, children, and adolescents. These strategies result from lessons learned during the Accelerating Children's HIV/AIDS Treatment Initiative, a public-private partnership between the President's Emergency Plan for AIDS Relief (PEPFAR) and the Children's Investment Fund Foundation (CIFF). The 5 strategies include (1) implementing a targeted mix of HIV case finding approaches (eg, provider-initiated testing and counseling within health facilities, optimization of early infant diagnosis, index family testing, and integration of HIV testing within key population and orphan and vulnerable children programs); (2) addressing the unique needs of adolescents; (3) collecting and using data for program improvement; (4) fostering a supportive political and community environment; and (5) investing in health system-strengthening activities. Continued advocacy and global investments are required to eliminate AIDS-related deaths among children and adolescents.

Social network methods for HIV case-finding among people who inject drugs in Tajikistan

INTRODUCTION

HIV testing programmes have struggled to reach the most marginalized populations at risk for HIV. Social network methods such as respondent-driven sampling (RDS) and peer-based active case-finding (ACF) may be effective in overcoming barriers to reaching these populations. We compared the client characteristics, proportion testing HIV positive (yield), and number of new cases found through two RDS strategies and an ACF approach to HIV case-finding among people who inject drugs (PWID) in Tajikistan.

METHODS

Routine programme data from adult PWID recruited to testing under the HIV Flagship Project in Tajikistan were analysed to compare client demographic and clinical characteristics across the three approaches. We also compared the number of previously untested clients, the number of new HIV cases found, and the yield across the case-finding strategies, and evaluated predictors of new HIV diagnosis using fixed-effects logistic regression.

RESULTS

From 24 October 2016 to 30 June 2017, Flagship tested 10,300 PWID for HIV, including 2143 under RDS with unrestricted waves (RDS1, yield: 1.5%), 3517 under restricted RDS (RDS2, yield: 2.6%), and 4640 under ACF (yield: 1.5%). Clients recruited under ACF were similar in age (35.8 vs. 36.8) and gender (91% vs. 90% male) to those recruited through RDS, though ACF clients were more likely to report being a first-time tester (85.1% vs. 68.3%, p < 0.001). After controlling for age, sex, previous testing history and accounting for clustering at the site level, we found that clients tested under both RDS1 (aOR: 1.74, 95% CI: 1.04 to 2.90) and RDS2 (aOR: 1.54, 95% CI: 1.11 to 2.15) had higher odds of testing newly positive for HIV relative to clients recruited through ACF. We did not find significant differences in the odds of new HIV infection between those recruited from RDS1 versus RDS2 (aOR: 1.12, 95% CI: 0.67 to 1.86).

CONCLUSIONS

RDS-based interventions resulted in higher yields and overall case-finding, especially when recruitment was restricted. However, ACF identified a higher proportion of first-time testers. To find at least 90% of PWID living with HIV in Tajikistan, it may be necessary to implement multiple case-finding approaches concurrently to maximize testing coverage.

Syringe Sharing in Drug Injecting Dyads: A Cross-Classified Multilevel Analysis of Social Networks

We examined the association of dyadic-level factors with syringe sharing among people who inject drugs (PWID) in Kerman, Iran. In a cross-sectional study, we collected data on 329 drug-injecting dyads by individual face-to-face interviews. An injecting dyad was defined as 2 PWID who knew each other and injected drugs together during the last 6 months. If they reported at least 1 occasion of syringe sharing, the dyad was considered high-risk. Dyadic-level factors associated with syringe sharing were assessed using cross-classified multilevel logistic regression. The rate of syringe sharing was significantly higher for dyads who were more intimate (adjusted odds ratio [AOR] 4.5, CI 95%, 2.3-8.6), who had instrumental support (AOR 2.1, 95% CI 1.1-4.5), and who pooled money for drugs (AOR 4.1, 95% CI 2.0-8.3). The rate was lower in same-sex dyads (AOR 0.4, 95% CI 0.2-0.9) and in dyads who shared health information (AOR 0.5, 95% CI 0.2-0.9). Findings highlight close-peer influences on syringe-sharing behavior.

Network Research Experiences in New York and Eastern Europe: Lessons for the Southern US in Understanding HIV Transmission Dynamics

PURPOSE

This paper presents an overview of different kinds of risk and social network methods and the kinds of research questions each can address.

RECENT FINDINGS

It also reviews what network research has discovered about how network characteristics are associated with HIV and other infections, risk behaviors, preventive behaviors, and care, and discusses some ways in which network-based public health interventions have been conducted. Based on this, risk and social network research and interventions seem both feasible and valuable for addressing the many public health and social problems raised by the widespread use of opioids in the US South.