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

Patterns of drug and sexual HIV transmission risk behaviors: A latent class analyses of men and women who inject drugs and are living with HIV in Kazakhstan

INTRODUCTION

Central Asia has one of the fastest-growing HIV epidemics globally. Suboptimal anti-retroviral treatment (ART) coverage and viral suppression among people who inject drugs (PWID) and are living with HIV increase transmission risk to injection and sexual partners. Men and women may have distinct patterns of HIV transmission risk behaviors, but little is known about how these behaviors co-occur. This paper identifies HIV transmission risk typologies among PWID and examines associated health outcomes by sex.

METHODS

Between February 2017 and June 2019, we recruited 450 men and 166 women (N = 616) PWID living with HIV in Kazakhstan. Latent class analysis identified heterogenous patterns of injection and sexual risk behaviors. Multinomial logistic regression examined how criminal-justice involvement, drug use and health outcomes varied by risk patterns.

RESULTS

ART coverage was 71 % and viral suppression was 43 %, with little variation by sex. Among men, latent classes included: No injection & Low Sexual Risk (41.8 %), Injection & Sexual Risk (36.4 %), and Low Injection & High Injection Risk (21.8 %) behaviors. Both injection risk classes were associated with higher odds of detention, drug use, and overdose. Among women, classes included: Low Injection & Sexual Risk (60.7 %), Sex Work Behaviors & Injection Risk (8.4 %), High Injection & Sexual Risk (30.7 %) behaviors. Sex Work Behaviors & Injection Risk was associated with higher odds of detention, heroin use, and verbal police harassment.

CONCLUSION

PWID living with HIV in Kazakhstan exhibit high-risk behaviors and low viral suppression. Distinct patterns by sex underscore the need for tailored harm reduction strategies and retention in HIV care.

Association between substance use disorders and sustained viral suppression: a longitudinal analysis among people with HIV in South Carolina

OBJECTIVES

Substance use disorders (SUDs) are a significant public health concern across the United States and may pose a risk to achieving sustained viral suppression (SVS) in people with HIV (PWH). This study aims to examine the association between SUDs and SVS among PWH.

DESIGN

Using electronic health records from the South Carolina Department of Health, we conducted a retrospective study of adults with HIV who were diagnosed between January 2006 and December 2019.

METHODS

The impact of SUDs on SVS was assessed using generalized linear mixed model. Potential confounders included age, sex, chronic diseases history, etc. Stepwise selection was performed to decide the confounders included in the final model, and the optimal correlation structure was determined by Akaike information criterion.

RESULTS

Of the 9412 eligible participants, 7481 (79.48%) had reached SVS status during their follow-up periods. SUDs related to alcohol [adjusted odds ratio (AOR) = 1.70, 95% confidence interval (CI): 1.46-1.98], cannabis (AOR = 1.62, 95% CI: 1.35-1.95), cocaine (AOR = 1.95, 95% CI: 1.60-2.37), opioid (AOR = 1.91, 95% CI: 1.13-3.23), and tobacco (AOR = 1.80, 95% CI: 1.69-1.92) were negatively associated with SVS. Individuals with chronic conditions such as cardiovascular disease (AOR = 0.31, 95% CI: 0.29-0.33), diabetes (AOR = 0.49, 95% CI: 0.41-0.59), and cancer (AOR = 0.47, 95% CI: 0.38-0.58) showed a higher likelihood of maintaining SVS.

CONCLUSION

This large cohort study of PWH with extended follow-up highlights the negative impact of SUDs on maintaining SVS. Long-term strategies for reducing substance use could support SVS in PWH.

Viral Breakthrough Episodes Among Persons with HIV in Care in Alberta, Canada: Clinical and Public Health Implications

Unsuppressed HIV viremia damages immunity and increases the risk for secondary HIV transmission. Successful engagement of persons with HIV (PWH) into care resulting in viral suppression is vital. PWH already engaged in care, who, after achieving viral suppression, experience viral breakthrough episodes (VBEs) with a sequence of suppressed/unsuppressed/suppressed viral loads remain problematic. We examined the frequency and outcomes of PWH experiencing VBE. HIV care is provided at no cost to all patients under Alberta's universal health program. All PWH followed at Southern Alberta Clinic, Canada, with two or more viral load tests between January 1, 2010, and January 1, 2020, were evaluated. Sociodemographic, clinical, and lifestyle variables were determined along with health outcomes (CD4 levels, HIV-related hospitalizations, and HIV/AIDS-related mortality). Descriptive and multi-variable analyses were performed comparing PWH with and without VBEs. Of 2096 PWH, 386 (18%) experienced one or more VBEs. A higher risk of VBEs was seen in adjusted analyses in those diagnosed age ≤40 years. Increased risk of VBE was seen with injection drug use (46%) and in heterosexuals (56%) compared with MSM. Experience of intimate partner violence, unstable housing, homelessness, and past incarceration also increased risks by 36%, 44% 79%, and 51%, respectively. PWH with VBEs experienced lower CD4 counts (median -417/mm³ vs. 576/mm³), higher rates of HIV-related hospitalizations (16% vs. 5%), and a 67% increased risk of death (95% confidence interval 1.17-2.39) over the study period. Nearly 20% of all PWH, after achieving viral suppression, experienced VBEs. Distinct clinical, lifestyle, and life experiences predict PWH at greatest risk for more than one VBEs. Serious negative health outcomes of VBEs were identified, suggesting that novel customized care programming is required for PWH at greatest risk.

Trends of late HIV presentation and advance HIV disease among newly diagnosed HIV cases in Jiangsu, China: A serial cross-sectional study from 2008 to 2020

Background

This study aimed to assess the trends and determine the factors associated with late presentation (LP) and advanced HIV disease (AHD) among newly diagnosed people living with HIV (PLWH) from 2008 to 2020 in Jiangsu, China.

Methods

Newly diagnosed PLWH registered in the HIV surveillance system from 2008 to 2020 were included. Multivariable logistic regression models were used to analyze the factors associated with LP and AHD. The LP and AHD trends were assessed using Joint-point analysis.

Results

Of 37,251 newly diagnosed PLWH identified, 30,251(81.2%) patients met the inclusion criteria. Among those, 16,672 (55.1%) were considered LP, and 8,691 (28.7%) had AHD. LP trends steadily increased from 2008 (39.0%) to 2020 (59.4%), but AHD trends decreased visibly from 2016 (32.3%) to 2020 (23.4%). The overall median CD4 trends decreased slowly from 389 to 305 cells/mm³ between 2008 and 2020. Married patients and those older than 35 years were more likely to be LP and have AHD. Patients infected via heterosexual transmission had a higher risk of being classified as AHD (aOR: 1.13, 95%CI: 1.06-1.21) than patients infected via homosexual transmission. Patients that were diagnosed at sexually transmitted infections (STIs) clinics (aOR: 1.10, 95%CI: 1.01-1.20) and in hospitals (aOR: 1.69, 95%CI: 1.59-1.79) were more likely to be classified as LP compared with patients diagnosed at voluntary counseling and testing (VCT) centers. Similar, patients diagnosed at STIs clinics (aOR: 1.23, 95%CI: 1.11-1.36) and hospitals (aOR: 2.27, 95%CI: 2.12-2.43) were more likely to have AHD than patients diagnosed in VCT.

Conclusion

Our findings indicate an alarming burden of LP in Jiangsu, suggesting the need for more attention toward HIV diagnosis at early CD4 stages. National HIV control programs must strengthen comprehensive interventions for HIV prevention and promote HIV services. Also, strategies for HIV prevention (PrEP and PEP), testing, and treatment must be extended, especially among the general population.

Racial and Ethnic Disparities in HIV Testing in People Who Use Drugs Admitted to a Tertiary Care Hospital

Ending the HIV epidemic requires increased testing, diagnosis, and linkage to care. In the past 10 years, rates of HIV have increased among people with substance use disorder (SUD). HIV testing is recommended during hospitalization. Despite rising rates of infections and recommendations, HIV testing remains suboptimal. This study sought to detect differences in HIV testing by race and ethnicity in people who use drugs (PWUD) admitted to Tufts Medical Center (TuftsMC). This study is a retrospective review of hospitalized PWUD admitted from January 1, 2017 to December 31, 2020. PWUD were identified through toxicology results, medication prescribed for SUD, and nursing intake questions. The primary outcome of interest was whether an HIV test was ordered during hospitalization. The indicator of interest was race and ethnicity. Of 13,486 PWUD admitted to TuftsMC, only 10% had an HIV test ordered. Compared with White patients, Black patients [adjusted odds ratio (AOR): 0.69, 95% confidence interval (CI) (0.59-0.83)] and Hispanic patients [AOR: 0.68, 95% CI (0.55-0.84)] had decreased odds of receiving an HIV test. Our report is the first to show racial and ethnic differences in HIV testing ordering for hospitalized PWUD. Without access to harm reduction tools and expanded systems-based testing strategies, the HIV epidemic will continue and disproportionately impact minoritized communities.

Client-Centered Care Coordination (C4™) for HIV/STI Prevention: a Theoretical, Conceptual, and Methodological Overview-HIV Prevention Trials Network (HPTN) 073

Introduction

There are few culturally informed, theory-driven evidence-based strategies to support PrEP use among Black MSM. This paper describes the theoretical foundation and conceptual development of C4™ to support the prevention of HIV and other STIs.

Methods

C4™ integrates self-determination theory with comprehensive risk counseling and services using an integrative anti-racism lens. C4™ was implemented in a 52-week HIV prevention demonstration project to facilitate PrEP use and adherence among Black MSM (N=225) in three US cities from 2014-2017.

Results

PrEP use was 79%, with 91% of PrEP users starting within 30-days. 12-month retention in C4™ was 92%. Care coordination encounters focused primarily on clients' needs related to PrEP adherence (43%) and sexual health (19%). Over the 12-month period, a substantial proportion of the men made progress towards their PrEP adherence goals at the 8-week (83%), 26-week (75%) and 52-week (81%) study visits.

Conclusions

C4™ is a multi-level, multi-component intervention that dually targets individual-level motivations and capacities of Black MSM and the healthcare facility-level attitudes, behaviors and processes that characterize the climates where Black MSM receive services.

Policy Implications

Public health policy efforts to scale-up PrEP may consider C4™ as a tool to optimize the use of PrEP and PrEP program retention with Black MSM. C4™ is also a tool for healthcare facilities to transform their models of service delivery towards improving the implementation PrEP services, including ensuring racial equity in the prevention impact of novel PrEP formulations such as long-acting injectable and potential future long-acting oral regimens.

Study protocol: a pilot randomised waitlist-controlled trial of a dyadic mobile health intervention for black sexual-minority male couples with HIV in the USA

INTRODUCTION

HIV care engagement is lower among black sexual-minority men relative to other racial/ethnic groups of sexual-minority men. Being in a primary relationship is generally associated with more successful HIV care engagement across various populations. However, among black sexual-minority men, the association between primary relationship status and HIV-related outcomes is inconsistent across the HIV care continuum. Given the ubiquity of mobile technology access and use among racial/ethnic minority communities, leveraging mobile technology for HIV care engagement appears a promising intervention strategy. This paper outlines the protocol of the LetSync study, a pilot randomised controlled trial of a mobile health app intervention developed using the Framework of Dyadic HIV Care Engagement to improve care-engagement outcomes among black sexual-minority male couples living with HIV.

METHODS AND ANALYSIS

Eighty black sexual-minority men in couples (n=160) will be enrolled to pilot test the LetSync app. At least one member of each dyad must be both HIV-positive and self-identify as black/African-American. Couples will be randomised to either a waitlist-control arm or an intervention that uses relationship-based approach to improve HIV care engagement. We will assess feasibility and acceptability of trial procedures and intervention protocols based on predefined metrics of feasibility and acceptability. Execution of the study will yield the opportunity to conduct analyses to test the measurement and analysis protocol on antiretroviral therapy adherence by comparing the intervention and waitlist-control arms on self-reported and biological (hair sample) measures of adherence.

ETHICS AND DISSEMINATION

Study staff will obtain electronic consent from all participants. This study has been approved by the University of California (UCSF) Institutional Review Board. Study staff will work with the Community Advisory Board at the UCSF Center for AIDS Prevention Studies Board to disseminate results to participants and the community via open discussions, presentations, journal publications and/or social media.

TRIAL REGISTRATION NUMBER

NCT04951544.

HIV knowledge, attitudes and practices amongst patients with severe mental illnesses and chronic medical illnesses in Durban, South Africa

BACKGROUND

Studies exploring HIV knowledge, attitudes and practices (KAP) of individuals with severe mental illness (SMI) have suggested their poorer knowledge about HIV. In KwaZulu-Natal (KZN) province, South Africa (SA), the epicentre of the country's HIV epidemic, improving KAP is essential for reduce its incidence amongst individuals with SMI. Comparing the KAP related to HIV between those with SMI and chronic medical illnesses (CMI) such as hypertension and diabetes may expose gaps in KAP related to HIV in the mentally ill who are more vulnerable to HIV.

AIM

This study aimed to compare the KAP related to HIV between people living with SMI and CMI.

SETTING

Outpatient clinics in Durban, SA.

METHODS

A cross-sectional structured questionnaire survey was conducted amongst 214 adult outpatients with SMI and CMI attending two general public sector hospitals in Durban, KZN. The KAP questionnaire consisted of three sections: general information, prevention and transmission of HIV.

RESULTS

Interviews were conducted with 124 patients with SMI and 90 with CMI. Most were female (69.5%), single (57.5%) and unemployed (59.4%). The diagnosis of SMI was associated with poorer general information of HIV (p = 0.02), but not with its prevention and transmission compared with those with CMI. Educational level was associated with poorer performance in all three domains: general information of HIV (p = 0.01), prevention (p = 0.01) and transmission (p = 0.02) amongst all the participants.

CONCLUSION

Gaps in the KAP of HIV amongst individuals with SMI compared with those with CMI suggested a need to provide focused health promotion regarding sexual health and HIV to the mentally ill at psychiatric facilities.

Increasing HIV/AIDS knowledge among urban ethnic minority youth: Findings from a community-based prevention intervention program

HIV (Human Immunodeficiency Virus)/AIDs (Acquired immunodeficiency syndrome) prevention and research are imperative. Prevention-intervention programming is minimal in low-income communities of color. Additional research is needed that uncovers points of support and prevention to increase HIV knowledge and awareness and limit new HIV infections among adolescents of color. This study presents preliminary findings from a community-based HIV/AIDS, substance abuse, and viral hepatitis (VH) prevention education intervention for ethnic minority youth in a northeastern urban community. We evaluated HIV/AIDS knowledge and factors associated with knowledge. Participants (N = 599) completed a baseline survey followed by an exit survey measuring HIV/AIDS knowledge. Exit survey findings indicated that there was an increase in HIV/AIDs knowledge. Multivariate regression analyses showed that change scores in VH knowledge accuracy, sexual negotiation skills, risk perception, and ethnic identity were positively associated with change in HIV/AIDs knowledge score. The development and implementation of HIV/AIDS knowledge interventions can be crucial in alleviating new infections in the U.S.

Examining stigma, social support, and gender differences in unsuppressed HIV viral load among participants in HPTN 065

Successful navigation of the HIV care continuum is necessary to maintain viral suppression. We explored gender-stratified correlates of being virally unsuppressed in the Prevention for Positives (P4P) component of HPTN 065. The outcome of interest was unsuppressed viral load (> 40 copies/mL) among individuals already living with HIV. Correlates included medication adherence factors, social support and stigma. Logistic regression models were stratified by gender (N = 673). Men-specific correlates of being virally unsuppressed included opposite-sex partners, older age and HIV disclosure stigma. Women-specific correlates included time since diagnosis, and personal-level barriers to medication adherence. When more individuals knew about their HIV status, women had over twice the likelihood of being virally unsuppressed; no such association was seen among men. Additionally, higher levels of social support were not associated with viral suppression among women. Interventions should consider gender-specific approaches to engaging social support in de-stigmatization of HIV and promotion of medication adherence and subsequent viral suppression.

Characteristics of Sexual Partnerships Among Men With Diagnosed HIV Who Have Sex With Men, United States and Puerto Rico-2015-2019

BACKGROUND

Understanding sexual partnerships of HIV-positive persons, particularly at the dyad level, can help in quantifying HIV transmission risk. We described sexual partnerships among HIV-positive men who have sex with men (MSM), including partnerships with a high risk for sexual HIV transmission.

SETTING

The Medical Monitoring Project is an annual, cross-sectional study that reports representative estimates on U.S. HIV-positive adults.

METHODS

During 2015-2019, we assessed sexual behaviors by interview, and viral load results from medical records. Among sexually active HIV-positive MSM (n = 4923), we described prevalence of high-risk sex, defined as: (1) not having sustained viral suppression, and (2) having condomless sex with an HIV-negative partner not known to be taking pre-exposure prophylaxis or an HIV-unknown partner. We described sexual partnerships among HIV-positive MSM (n = 13,024 partnerships among 4923 MSM). For HIV-discordant partnerships (n = 7768), we reported the proportion involved in high-risk sex, and associations with high-risk sex using prevalence ratios with predicted marginal means, controlling for age of the HIV-positive partner (P < 0.05).

RESULTS

More than half (66%) of sexually active HIV-positive MSM had condomless sex; 11% had high-risk sex. Blacks were more likely to have detectable viral loads, but less likely to have condomless sex, making prevalence of high-risk sex comparable between racial/ethnic groups. Dyad-level analyses among HIV-discordant partnerships indicated that prevalence of high-risk sex was higher among partnerships with HIV-positive white MSM, which was not observed using person-level data alone.

CONCLUSIONS

In the context of ending the HIV epidemic, behavioral and clinical surveillance data can help monitor HIV transmission risk and target prevention efforts to reduce transmission among populations at disproportionate risk.

A Surveillance Data-Based Model System for Assessing the Effects of HIV Intervention and Prevention Strategies

OBJECTIVE

Build a dynamic model system to assess the effects of HIV intervention and prevention strategies on future annual numbers of new HIV infections, newly diagnosed cases of HIV infection, and deaths among persons infected with HIV.

DESIGN AND SETTING

Model parameters are defined to quantify the putative effects of HIV prevention strategies that would increase HIV testing, thereby diagnosing infection earlier; increase linkage to care and viral suppression, thereby reducing infectiousness; and increase the use of preexposure prophylaxis, thereby protecting persons at risk of infection. Surveillance data are used to determine the initial values of the model system's variables and parameters, and the impact on the future course of various outcome measures of achieving either specified target values or specified rates of change for the model parameters is examined.

PARTICIPANTS

A hypothetical population of persons with HIV infection and persons at risk of acquiring HIV infection.

MAIN OUTCOME MEASURES

HIV incidence, HIV prevalence, proportion of persons infected with HIV whose infection is diagnosed, and proportion of persons with diagnosed HIV infection who are virally suppressed.

RESULTS

A model system based on the basic year-to-year algebraic relationships among the model variables and relying almost exclusively on HIV surveillance data was developed to project the course of HIV disease over a specified time period. Based on the most recent HIV surveillance data in the United States-which show a relatively high proportion of infections having been diagnosed but a relatively low proportion of diagnosed persons being virally suppressed-increasing the proportion of diagnosed persons who are virally suppressed and increasing preexposure prophylaxis use appear to be the most effective ways of reducing new HIV infections and accomplishing national HIV prevention and care goals.

CONCLUSIONS

Both having current and accurate information regarding the epidemiologic dynamics of HIV infection and knowing the potential impact of prevention strategies are critical in order for limited HIV prevention resources to be optimally allocated.

Disparities in Care Outcomes in Atlanta Between Black and White Men Who Have Sex With Men Living With HIV: Protocol for a Prospective Cohort Study (Engage[men]t)

BACKGROUND

The US HIV epidemic is driven by infections in men who have sex with men and characterized by profound disparities in HIV prevalence and outcomes for Black Americans. Black men who have sex with men living with HIV are reported to have worse care outcomes than other men who have sex with men, but the reasons for these health inequities are not clear. We planned a prospective observational cohort study to help understand the reasons for worse HIV care outcomes for Black versus White men who have sex with men in Atlanta.

OBJECTIVE

The aim of this study is to identify individual, dyadic, network, neighborhood, and structural factors that explain disparities in HIV viral suppression between Black and White men who have sex with men living with HIV in Atlanta.

METHODS

Black and White men who have sex with men living with HIV were enrolled in a prospective cohort study with in-person visits and viral suppression assessments at baseline, 12 months, and 24 months; additional surveys of care and risk behaviors at 3, 6, and 18 months; analysis of care received outside the study through public health reporting; and qualitative interviews for participants who experienced sentinel health events (eg, loss of viral suppression) during the study. The study is based on the Bronfenbrenner socioecological theoretical model.

RESULTS

Men who have sex with men (n=400) were enrolled between June 2016 and June 2017 in Atlanta. Follow-up was completed in June 2019; final study retention was 80% at 24 months.

CONCLUSIONS

Health disparities for Black men who have sex with men are hypothesized to be driven by structural racism and barriers to care. Observational studies are important to document and quantify the specific factors within the socioecological framework that account for disparities in viral suppression. In the meantime, it is also critical to push for steps to improve access to care, including Medicaid expansion in Southern states, such as Georgia, which have not yet moved to expand Medicaid.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/21985.

Acceptability of HIV self-testing is low among men who have sex with men who have not tested for HIV: a study with respondent-driven sampling in Brazil

BACKGROUND

Brazil has many people living with HIV (PLWH) who are unaware of their serostatus. The public health system has recently added HIV self-testing (HIVST) for key populations such as men who have sex with men (MSM). This study estimates HIVST acceptability among Brazilian MSM and explores factors associated with acceptability among MSM who have never tested for HIV or who had a previous negative result.

METHODS

Respondent-driven sampling (RDS) was used to recruit 4176 MSM in 12 Brazilian cities in 2016 to this biological and behavioral surveillance study. We excluded from this analysis all MSM who were aware of their positive HIV serostatus. Descriptive, bivariate and multivariate analyses were conducted. Overall proportions were weighted with Gile's estimator in RDS Analyst software and 95% confidence intervals were calculated. The analyses of HIVST acceptability were stratified by prior HIV testing (never or one or more times).

RESULTS

For this analysis, 3605 MSM were included. The acceptability of HIVST was 49.1%, lower among those who had never tested for HIV (42.7%) compared to those who had a previous HIV negative test (50.1%). In the subgroup of MSM who had never tested for HIV, those who reported discrimination or who had a medical appointment in the last 12 months reported higher HIVST acceptability. Among MSM who had a previous negative HIV test, only those reporting condomless receptive anal sex reported higher HIVST acceptability. In addition, we observed that high levels of knowledge of HIV/AIDS, taking part in lesbian, gay, bisexual, and transgender nongovernmental organizations (LGBT-NGO), or complete secondary or incomplete higher undergraduate education reported higher acceptability.

CONCLUSIONS

The acceptability of HIVST was low among MSM, especially among those who never tested for HIV. Given access to HIVST in Brazil, we point to the need for programs that enhance promotion of testing addressed to MSM.

Substantial gap in primary care: older adults with HIV presenting late to care

BACKGROUND

Late diagnosis of human immunodeficiency virus (HIV) is associated with increased morbidity and mortality, and represents a serious public health concern.

METHODS

A retrospective medical record review was conducted on 188 patients with newly diagnosed HIV at a large academic center's HIV clinic from 1/2010 to 12/2019. Patient demographic data, HIV staging, and response to combination antiretroviral therapy (cART) as measured by HIV viral suppression at 12 weeks (HIV RNA < 50 copies) were collected. Bivariate analyses were applied to compare patients ≥50 years old to those < 50 years old.

RESULTS

Over two-thirds of the older patients with a new diagnosis of HIV presented with a CD4 count < 200, or an AIDS-defining illness. Though not statistically significant, this same group also had a delay to viral suppression with only 59% achieving viral suppression after 12-weeks of cART initiation.

CONCLUSIONS

This study suggests that older patients are presenting to care with advanced stages of HIV, and may also have a delay in achieving viral suppression after cART initiation. Future studies should aim to target HIV testing and treatment strategies for this at-risk older adult group.

Information and Motivation Predict HIV-Serostatus Among a Population of High-Risk Men and Transgender Women Who Have Sex with Men

Two constructs from the information-motivation-behavioral skills model were used to predict HIV-serostatus among a sample of men and transgender women who have sex with men. Hypotheses were that lower levels of HIV knowledge and lower levels of motivation to remain HIV-negative would be associated with an increased likelihood of receiving a positive HIV test result at a study eligibility-screening session. Results of a backwards stepwise logistic regression analysis demonstrated that lower levels of HIV knowledge, lower levels of motivation to remain HIV-negative, lower levels of education, and identifying as Hispanic/Latinx were associated with greater odds of receiving a positive HIV test result. These findings are consistent with the broader HIV-prevention literature that demonstrates that information and motivation are fundamental determinants of HIV preventive behavior. This work has implications for informing the development and improvement of HIV-prevention interventions.

Predictors of Condomless Anal Intercourse in Young HIV-Positive Men Who Have Sex With Men With Detectable Viral Loads

PURPOSE

A minority of young, gay, bisexual, and other men who have sex with men (YGBMSM) living with HIV in the U.S. achieve viral suppression, thus increasing the likelihood of viral transmission during condomless anal intercourse (CAI). The purpose of this study was to explore potential risk factors for CAI and serodiscordant CAI (SD-CAI) among YGBMSM with detectable viremia.

METHODS

A total of 146 YGBMSM (aged 16-24 years) with a detectable viremia enrolled in a mobile health adherence intervention. Baseline characteristics, stratified by any CAI and any SD-CAI (past 3 months), were computed. Random Forests and regression methods were used to assess factors associated with each type of CAI. Adjusted prevalence rate ratios (aPRR) and 95% confidence intervals (CIs) were calculated.

RESULTS

Half (51.9%) reported engaging in CAI; 57.1% of those reported SD-CAI. There was strong agreement between the Random Forests and regression methods. Significant risk factors of CAI included marijuana use (aPRR = 1.97, 95% CI: 1.21-3.21), problematic substance use (aPRR = 1.56, 95% CI: 1.11-2.20), and being in a committed relationship (aPRR = 1.66, 95% CI: 1.21-2.27). Only 47% believed they were less likely to transmit HIV through CAI when virally suppressed.

CONCLUSION

High rates of CAI, including engagement in SD-CAI in a population of YGBMSM with detectable viral loads, pose significant concerns for onward transmission. Individual, dyadic, and structural predictors of CAI were associated with engagement in risk in this priority population. Addressing these factors in concert with ensuring viral suppression will be key to ending the epidemic among youth.

Evaluation of Sex Positive! A Video eHealth Intervention for Men Living with HIV

Sex Positive!^[+] is a two-arm, video-based web intervention aimed at reducing condomless anal sex (CAS) with partners of known and unknown serostatus that was delivered online to a racially and ethnically diverse sample of 830 gay, bisexual, and other men who have sex with men living with HIV. Men in each arm received 6 weekly videos after completing a baseline assessment and 4 weekly booster videos following a 6-month assessment. Follow-up assessments were conducted every 3 months for 1 year. At 3-month follow-up, men in the intervention arm reported significantly reduced risk of having unknown serodiscordant CAS partners than men in the control arm (RR 0.60, 95% CI 0.39-0.92), partially supporting study hypotheses. Aside from this finding, similar reductions in sexual risk behaviors were observed in both arms over the study period. There is much to be learned about video-based web interventions in terms of methodological development and intervention delivery, including frequency and duration of intervention components.

Racial and Ethnic Differences in Viral Suppression Among HIV-Positive Women in Care

BACKGROUND

Women with HIV diagnoses are less likely to be virally suppressed than men. Women of different racial/ethnic groups may be differentially affected by sociodemographic factors. We examined differences in viral suppression among women by race/ethnicity and associated variables to inform prevention interventions.

METHODS

We used data from the 2010-2014 cycles of the Medical Monitoring Project, a cross-sectional survey of HIV-positive adults in care. We limited analyses to black, Hispanic, and white women. We calculated weighted prevalences of recent viral suppression (undetectable or <200 copies/mL) and sustained viral suppression (consistent viral suppression during the past 12 months) among women by race/ethnicity. We computed adjusted prevalence differences (aPDs) and 95% confidence intervals (CIs) for viral suppression by racial/ethnic group, controlling for selected variables, including available social determinants of health variables.

RESULTS

Among women, 62.9% were black, 19.8% Hispanic, and 17.3% white. Overall, 74.3% had recent viral suppression, and 62.3% had sustained viral suppression. Compared with white women (79.7%, CI: 77.2 to 82.2), black (72.5%, CI: 70.3 to 74.7; PD: 7.2) and Hispanic (75.4%, CI: 72.6 to 78.3; PD: 4.3) women were less likely to have recent viral suppression. In multivariable analyses, after adjusting for antiretroviral therapy adherence, HIV disease stage, age, homelessness, and education, black-white aPDs remained significant for recent (aPD: 4.8, CI: 1.6 to 8.1) and sustained (aPD: 5.0, CI: 1.1 to 9.0) viral suppression.

CONCLUSION

Viral suppression was suboptimal for all women, but more for black and Hispanic women. Differences between black, Hispanic, and white women may be partially due to antiretroviral therapy adherence, HIV disease stage, and social determinants of health factors.

Trends and Racial Disparities of Late-Stage HIV Diagnosis: Hawaii, 2010-2016

OBJECTIVES

To examine racial/ethnic disparities in Hawaii in stage 3 classification at HIV diagnosis and trends in such disparities from 2010 through 2016.

METHODS

We analyzed data including patients' demographic information, behavioral risk factors, residential county at HIV diagnosis, and type of facility where HIV was diagnosed. Multivariable logistic regression modeling was used to examine racial/ethnic disparities in late-stage diagnoses after adjustment for known or possible confounders.

RESULTS

About 30% of HIV diagnoses were classified as late-stage (stage 3) diagnoses, and there were significant racial/ethnic disparities in stage 3 classification at diagnosis. Relative to Whites, the odds of being diagnosed at stage 3 were 3.7 times higher among Native Hawaiians and other Pacific Islanders (NHPIs; odds ratio [OR] = 3.69; 95% confidence interval [CI] = 1.89, 7.22) and more than twice as high among Asians (OR = 2.46; 95% CI = 1.16, 5.20). Older age and being diagnosed in an inpatient setting were associated with stage 3 classification.

CONCLUSIONS

Targeted preventive services need to be strengthened for Asians and NHPIs in Hawaii.

HIV Screening and Early Referral in the Trauma Population: The Experience of a Large Safety Net Hospital

BACKGROUND

While the prevalence of HIV infection in the population is 0.5%, it is higher among trauma patients as are rates of unknown seropositivity. Routine HIV screening for all trauma evaluations was implemented at our urban level I center in 2009. We aimed to evaluate use and results of the program in our trauma population.

METHODS

This was a retrospective analysis of all trauma evaluations between July 2015 and February 2018. After passage of legislation rescinding the requirement for consent to perform HIV testing, our trauma service instituted an order set which automatically tested for HIV unless the ordering physician opted out. Patients found to be infected with HIV were to be counseled and referred to specialty care.

RESULTS

Of 6175 consecutive trauma evaluations during the study period, 449 (7.3%) patients had been screened within the prior year and were excluded. Of the remaining cohort, 2024 (35.3%) patients were screened with 27 (1.3%) testing positive. Among those testing positive for infection, 100% were male, 77% white, 63% non-Hispanic, and 70% lacked insurance. Twenty-five (92.6%) patients received counseling and 19 were referred to specialty care. Age, gender, race, ethnicity, Injury Severity Score, trauma activation level, and payor type were not significant predictors for positive HIV screen on logistic regression analysis.

CONCLUSIONS

Despite a significantly higher rate of HIV in the trauma population, only a third of patients are screened. Such high infection rates justify the existence of this screening program but steps must be taken to increase screening rate.

LEVEL OF EVIDENCE

Level 3.

Barriers to HIV Testing: Patient and Provider Perspectives in the Deep South

Although CDC guidelines call for universal, "opt-out" HIV testing, barriers to testing continue to exist throughout the United States, with the rural South particularly vulnerable to both HIV infection and decreased awareness of status. Therefore, the objectives of this study were to evaluate uptake of "opt-out" HIV testing and barriers to testing within the primary care setting in the South. A concurrent triangulation design guided the collection of quantitative data from patients (N = 250) and qualitative data from providers (N = 10) across three primary health clinics in Alabama. We found that 30% of patients had never been tested for HIV, with the highest ranked barrier among patients being perceived costs, access to specialty care, and not feeling at risk. Significant differences existed in perceived barriers between patients and providers. Increased provider-patient engagement and the routine implementation of "opt-out" HIV testing would effectively reveal and mitigate barriers to testing, thus, increasing awareness of status.

Pre-exposure prophylaxis initiation and adherence among Black men who have sex with men (MSM) in three US cities: results from the HPTN 073 study

INTRODUCTION

Randomized clinical trials have demonstrated the efficacy of antiretroviral pre-exposure prophylaxis (PrEP) in preventing HIV acquisition among men who have sex with men (MSM). However, limited research has examined initiation and adherence to PrEP among Black MSM (BMSM) in the United States (US) who are disproportionately represented among newly HIV infected and late to care individuals. This research reports on the HIV Prevention Trials Network 073 (HPTN 073) study aimed to examine PrEP initiation, utilization and adherence among Black MSM utilizing the theoretically principled, culturally informed and client-centered care coordination (C4) model.

METHODS

The HPTN 073 study enrolled and followed 226 HIV-uninfected Black MSM in three US cities (Los Angeles, CA; Washington DC; and Chapel Hill, NC) from February 2013 through September 2015. Study participants were offered once daily oral emtricitabine/tenofovir (FTC/TDF) PrEP combined with C4 and followed up for 52 weeks. Participants received HIV testing, risk reduction education and clinical monitoring.

RESULTS

Of the 226 men enrolled, 178 participants initiated PrEP (79%), and of these 64% demonstrated PrEP utilization at week 26 (mid-point of the study) based on pharmacokinetic testing. Condomless anal sex with an HIV-infected or unknown status casual male partner was statistically significantly associated with a greater likelihood of PrEP initiation (adjusted odds ratio (OR) 4.4, 95% confidence interval (CI) 1.7, 11.7). Greater age (≥25 vs. <25, OR 2.95, 95% CI 1.37 -6.37), perception of having enough money (OR 3.6, 95% CI 1.7 to 7.7) and knowledge of male partner taking PrEP before sex (OR 2.22, 95% CI 1.03 to 4.79) were statistically significantly associated with increased likelihood of PrEP adherence at week 26. Annualized HIV incidence was 2.9 (95% CI 1.2 to 7.9) among those who initiated PrEP, compared to 7.7 (95% CI 2.5 to 24.1) among those who did not initiate PrEP (p = 0.18).

CONCLUSIONS

Results suggest a high level of PrEP initiation among at-risk Black MSM, a group historically characterized as hard to reach. The data support the importance of addressing contextual factors that affect PrEP initiation and adherence, and of additional research on the ultimate benefit of PrEP in HIV prevention among Black MSM.

Changes of sexual risk behaviors and sexual connections among HIV-positive men who have sex with men along their HIV care continuum

BACKGROUND

While HIV incidence among men who have sex with men (MSM) is increasing in Hong Kong, unprotected sex apparently remains prevalent among those infected but virally non-suppressed. Little is known about how sexual behaviours and sexual connections may change among MSM along their HIV care continuum.

METHODS

In this retrospective cross-sectional study, HIV-positive MSM attending the largest HIV specialist clinic in Hong Kong between October and December 2014 were invited to complete a self-administrated structured questionnaire. Their behavioural profile and partner sourcing patterns during the one-year period respectively (a) before HIV diagnosis, (b) after HIV diagnosis, (c) after initiation of antiretroviral treatment and (d) preceding the survey were examined.

RESULTS

Of 345 recruited MSM, 304 (88.1%) had treatment initiated and 272 (78.8%) had viral load suppressed. In the first year after HIV diagnosis, the proportion reporting inconsistent condom use dropped from 47.0% to 17.5% (p<0.05) and from 49.6% to 17.8% (p<0.01) for anal sex with main and casual partners respectively. Except for mobile applications, usage of most sex-networking venues decreased significantly after diagnosis. Inconsistent condom usage rate remained at around 20% after treatment initiation and viral load suppression, but the frequency of use of sex-networking venues further varied among virally suppressed MSM.

CONCLUSIONS

Most HIV-positive MSM had persistently low level of sexual risk behaviours along their care continuum and achieved viral load suppression, conferring a general reduction of secondary transmission risk in Hong Kong. To increase the effectiveness of Treatment as Prevention strategy, uptake of HIV testing for undiagnosed HIV-positive MSM shall be emphasised.

Mobile Technology for Healthy Aging Among Older HIV-Positive Black Men Who Have Sex with Men: Qualitative Study

Background

People living with HIV are living longer in the United States as a result of antiretroviral therapy. Black men who have sex with men (MSM) are disproportionally affected by HIV and have low rates of engagement in HIV care and treatment. Mobile technology holds promise as an intervention platform; however, little is known regarding its use among older black MSM living with HIV.

Objective

The goal of this study was to explore mobile technology use and narratives of aging with HIV among older black MSM to inform mobile health intervention development.

Methods

A total of 12 black MSM living with HIV, aged 50 years or older, completed in-person, semistructured interviews exploring the issues of aging, HIV care engagement, and mobile technology use. The interviews were audiotaped, transcribed, and analyzed using qualitative research methods.

Results

Men appreciated having survived the AIDS epidemic, but some expressed discomfort and ambivalence toward aging. Men described various levels of engagement in HIV care and treatment; challenges included social isolation and need for support that was not focused on HIV. Almost all described using mobile technology to engage in health care, whereas some referenced important barriers and challenges to technology use.

Conclusions

Findings highlighted a high level of interest toward a mobile technology–based intervention targeting older black men but also identified barriers and challenges to using mobile technology for health care engagement. Mobile technology is well incorporated into older black MSM’s lives and shows potential as an intervention platform for addressing aging issues to enhance engagement in HIV care and treatment.

Correlates of Serodiscordant Condomless Anal Intercourse Among Virologically Detectable HIV-Positive Young Men Who Have Sex with Men

Sexual transmission risk occurs in the context of serodiscordant condomless anal intercourse (CAI) where the seropositive partner is virologically detectable (VL+) and/or seronegative partner is not on PrEP. We analyzed correlates of serodiscordant CAI among 688 VL+ young men who have sex with men (YMSM). In multivariable analyses, serodiscordant CAI was associated with a receiving a HIV diagnosis in the past 6 months, greater depressive symptoms, and cocaine use during the past 90 days. Although HIV+ YMSM currently experience disparities across the continuum of care, those new to care may need support adopting risk reduction strategies with their sexual partners.

Cost-Utility of Access to Care, a National HIV Linkage, Re-engagement and Retention in Care Program

Linkage to HIV medical care and on-going engagement in HIV medical care are vital for ending the HIV epidemic. However, little is known about the cost-utility of HIV linkage, re-engagement and retention (LRC) in care programs. This paper presents the cost-utility analysis of Access to Care, a national HIV LRC program. Using standard methods from the US Panel on Cost-Effectiveness in Health and Medicine, we calculated the cost-utility ratio. Seven Access to Care programs were cost-effective and two were cost-saving. This study adds to a small but growing body of evidence to support the cost-effectiveness of LRC programs.

Couple-Level Dynamics and Multilevel Challenges Among Black Men Who Have Sex with Men: A Framework of Dyadic HIV Care

The primary romantic relationship may offer critical opportunities for improving HIV care among key populations affected by high rates of HIV infection and low rates of care engagement, such as black men who have sex with men. A conceptual framework is needed to identify dyadic processes involved in addressing challenges in retention in care and adherence to antiretroviral therapy. This study conducted dyadic and individual-level qualitative analyses of individual interviews with men living with HIV from 14 black gay couples (n = 28). Interviews explored each partner's perspectives on challenges to and supportive strategies for retention in care and medication adherence. Findings highlighted challenges at various levels of care engagement and patterns of dyadic interactions that impeded or facilitated HIV care. Couple-level processes (i.e., couple's resilience, interdependence) underlined a joint problem-solving approach toward addressing challenges in care engagement. Findings support a conceptual framework of dyadic HIV care that highlights the impacts of dyadic and individual factors on coordination of care and treatment to influence retention and adherence. The generalizability of study findings is limited by the small sample size. Implications for intervention design include leveraging drivers of partner support, including couples' resilience, in enhancing joint problem-solving in HIV care among black gay couples.

Universal Screening for HIV and Hepatitis C Infection: A Community-Based Pilot Project

INTRODUCTION

Black men in the Deep South have been disproportionally affected by high HIV and hepatitis C virus infection rates. Conventional clinic-based screening approaches have had limited success in reaching those with undiagnosed HIV or hepatitis C virus infection. The purpose of this study was to evaluate the acceptability, feasibility, and best practices of an integrated HIV and hepatitis C virus community-based health screening approach.

METHODS

The study used a mixed methods approach: focus group discussion, individual interviews, and surveys that assessed perceptions, perspectives, and HIV and hepatitis C virus awareness among six communities across Alabama and Mississippi. Data were collected and analyzed in 2014-2017.

RESULTS

Although HIV and hepatitis C virus knowledge was limited among community members surveyed, the results of this study suggest that (1) using an integrated, community-based HIV and hepatitis C virus testing approach is acceptable and feasible; (2) formation of a community advisory board is a key element of successful community mobilization; (3) education and training of community members on disease-specific topics and overcoming stigma are essential; and (4) focus on and inclusion of young community members will be critical for the sustainability of screening efforts.

CONCLUSIONS

Including and engaging communities at risk for HIV and hepatitis C virus infection in prevention research is a promising strategy to overcome existing barriers of stigma and discrimination. Integration of HIV and hepatitis C virus testing in universal health screening efforts utilizing a Community Health Advisors model encourages unbiased communication with a focus on overall community health. Community health advisors are recognized as important agents in this effort.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health.

Prevalence of HIV Viral Load Suppression Among Psychiatric Inpatients with Comorbid Substance Use Disorders

A consistently suppressed viral load enables HIV (+) patients to live longer, healthier lives and reduces the probability of transmitting the virus. Since the prevalence of HIV is four times higher among those with psychiatric disorders than in the general population, it is likely that this group would also have greater difficulty remaining in care and achieving viral suppression. A secondary data analysis utilizing screening data from the Preventing AIDS Through Health (PATH) for Triples (PFT) Study were examined to assess HIV load suppression among 254 psychiatric inpatients with comorbid substance use disorders in Philadelphia. Viral load results from the past 12 months were obtained from medical records for 63 inpatients identified as HIV (+). The sample was predominately African American (76%), male (56%), and the average age was 43 years. Psychiatric disorders included depression (64%), schizophrenia (21%), and bipolar disorder (13%) with patients reporting use of alcohol (73%), cocaine (64%), cannabis (29%) and opioids (16%) prior to admission. Among this high risk sample of HIV (+) patients, about one-half (52%) achieved viral suppression, with recent opioid users six times more likely to have a detectable viral load than non-opioid users (OR 6.0; CI 1.1-31.7, p = .035). The 52% viral load suppression rate among psychiatric inpatient was higher than expected, given that the CDC's national suppression rate among those diagnosed with HIV in the general population is 58%. However, individuals with mental illness and substance use disorders require constant surveillance, monitoring, and supportive services to achieve viral suppression. Many of those who were virally suppressed were engaged in Philadelphia's extensive treatment network, whereas those who were detectable and enrolled in the PFT intervention were often homeless with unstable psychiatric symptoms and current substance use disorders, particularly opioid abuse.

Psychiatric Illness, Substance Use, and Viral Suppression Among HIV-Positive Men of Color Who Have Sex with Men in Los Angeles

For individuals living with human immunodeficiency virus (HIV), viral suppression positively affects quality and length of life and reduces risks for HIV transmission. Men of color who have sex with men (MoCSM) who have been diagnosed with HIV have disproportionately low rates of viral suppression, with concomitant increases in incidence. We identified specific social, structural, and psychiatric factors associated with viral suppression among a sample of 155 HIV-positive MoCSM. Cigarette smoking and biological markers of recent drug use were significantly associated with detectable viral load. In contrast, individuals reporting a history of psychiatric illness during medical examination were more likely to be virally suppressed. Further analyses demonstrated that psychiatric illness may affect virologic outcomes through increased probability of being prescribed HIV medications. Alternatively, cigarette smoking and drug use appear to negatively affect subsequent HIV Care Continuum milestones such as medication adherence. Findings provide support for comprehensive intervention programs that emphasize prevention and treatment of cigarette, methamphetamine, and other drug use, and promote improved connection to psychiatric care. Continual achievement of this goal may be a crucial step to increase rates of viral suppression and slow HIV incidence in communities of MoCSM in Los Angeles and other urban areas.

A Multilevel Tailored Web App-Based Intervention for Linking Young Men Who Have Sex With Men to Quality Care (Get Connected): Protocol for a Randomized Controlled Trial

Background

HIV epidemic among young men who have sex with men (YMSM) is characterized by strong racial disparities and concerns about the availability and access to culturally appropriate HIV prevention and care service delivery. Get Connected, a Web-based intervention that employs individual- and system-level tailoring technology to reduce barriers to HIV prevention care (eg, HIV or sexually transmitted infection [STI] testing, pre-exposure prophylaxis [PrEP]), was developed for YMSM (age 15-24 years). This protocol details the design and procedures of a 2-phase project that includes mystery shopping and a randomized controlled trial (RCT) to test the efficacy of Get Connected among YMSM in Philadelphia, Atlanta, and Houston.

Objective

The objective of mystery shopping is to examine the quality of HIV test counseling and PrEP-related referrals for YMSM within local HIV or STI testing sites. The objective of the RCT is to test the efficacy of Get Connected for increasing HIV-negative or HIV-unknown YMSM’s successful uptake of HIV prevention services (eg, routine HIV or STI testing), PrEP awareness, and likelihood to start PrEP (PrEP willingness), compared with those in the control condition, over a 12-month period.

Methods

For Phase 1, we will create a master list of HIV and STI testing sites in each city. We will enroll and train 10-15 mystery shoppers per city; each testing site will be separately visited and assessed by 2 mystery shoppers. After each site visit, the mystery shoppers will complete a site evaluation to record their perceptions of various measures including lesbian, gay, bisexual, transgender, queer visibility and inclusivity, privacy and confidentiality, provider-patient interactions, and clinic environment. For Phase 2, we will enroll 480 YMSM for 12 months across the 3 iTech cities into a 2-arm prospective RCT. Participants randomized to the control condition are directed to the AIDSVu.org testing site locator. Participants randomized to the intervention condition will be granted access to a Web app with content tailored to their specific demographic characteristics (eg, age, race or ethnicity, location, and relationship status), HIV and STI risk behaviors (eg, HIV and STI testing history, substance use, communication with partners regarding status) and sociocultural context (eg, homelessness, incarceration). Study assessments will occur at enrollment and at 1, 3, 6, 9, and 12 months postenrollment.

Results

Get Connected research activities began in September 2016 and are ongoing. To date, institutional review board (IRB) submission is complete and IRB authorization agreements are pending at several other universities.

Conclusions

The deployment of Get Connected through a mobile-optimized Web app seeks to optimize the intervention’s acceptability, accessibility, availability, and long-term affordability among YMSM.

Trial Registration

ClinicalTrials.gov (NCT03132415); https://clinicaltrials.gov/ct2/show/NCT03132415 (Archived by WebCite at http://www.webcitation.org/70j4gSFbZ)

Registered Report Identifier

RR1-10.2196/10444

Influence of Substance Use Disorders on 2-Year HIV Care Retention in the United States

Substance use disorders (SUDs) are thought to predict care discontinuity, though magnitude and substance-specific variance of effects are unclear. This report of analytic work undertaken with a multi-regional American cohort of 9153 care enrollees addresses these gaps. Care retention was computed from 24-month post-linkage clinic visit documentation, with SUD cases identified from patient-report screening instruments. Two generalized estimating equations tested binary and hierarchial SUD predictors of retention, and potential effect modification by patient age-group, sex, and care site. Findings demonstrate: (1) detrimental SUD effect, equivalent to a nine percentage-point decrease in retention, with independent effects of age-group and care site; (2) substance-specific effect of marijuana UD associated with lower retention; and (3) age-modification of each effect on care discontinuity, with SUDs serving as a risk factor among 18-29 year-olds and protective factor among 60+ year-olds. Collective findings document patient attributes as influences that place particular subgroups at-risk to discontinue care.

The effect of prevention methods on reducing sexual risk for HIV and their potential impact on a large-scale: a literature review

A spectrum of diverse prevention methods that offer high protection against HIV has posed the following challenge: how can national AIDS policies with high coverage for prevention and treatment make the best use of new methods so as to reverse the current high, and even rising, incidence rates among specific social groups? We conducted a narrative review of the literature to examine the prevention methods and the structural interventions that can have a higher impact on incidence rates in the context of socially and geographically concentrated epidemics. Evidence on the protective effect of the methods against sexual exposure to HIV, as well as their limits and potential, is discussed. The availability and effectiveness of prevention methods have been hindered by structural and psychosocial barriers such as obstacles to adherence, inconsistent use over time, or only when individuals perceive themselves at higher risk. The most affected individuals and social groups have presented limited or absence of use of methods as this is moderated by values, prevention needs, and life circumstances. As a result, a substantial impact on the epidemic cannot be achieved by one method alone. Programs based on the complementarity of methods, the psychosocial aspects affecting their use and the mitigation of structural barriers may have the highest impact on incidence rates, especially if participation and community mobilization are part of their planning and implementation.

Prevalence and Predictors of Substance Use Disorders Among HIV Care Enrollees in the United States

Prior efforts to estimate U.S. prevalence of substance use disorders (SUDs) in HIV care have been undermined by caveats common to single-site trials. The current work reports on a cohort of 10,652 HIV-positive adults linked to care at seven sites, with available patient data including geography, demography, and risk factor indices, and with substance-specific SUDs identified via self-report instruments with validated diagnostic thresholds. Generalized estimating equations also tested patient indices as SUD predictors. Findings were: (1) a 48 % SUD prevalence rate (between-site range of 21-71 %), with 20 % of the sample evidencing polysubstance use disorder; (2) substance-specific SUD rates of 31 % for marijuana, 19 % alcohol, 13 % methamphetamine, 11 % cocaine, and 4 % opiate; and (3) emergence of younger age and male gender as robust SUD predictors. Findings suggest high rates at which SUDs occur among patients at these urban HIV care sites, detail substance-specific SUD rates, and identify at-risk patient subgroups.

The association between symptoms of mental disorders and health risk behaviours in Vietnamese HIV positive outpatients: a cross-sectional study

Background

A high prevalence of symptoms of mental disorders (SOMD) has been found among people living with HIV/AIDS (PLHIV). Additionally, SOMD may impact on the prevalence of high-risk health behaviours (HRB). This study investigates the relationship between SOMD and HRB in a large sample of Vietnamese HIV positive outpatients.

Methods

A cross-sectional study was conducted with 400 outpatients at two HIV/AIDS clinics in Ho Chi Minh City, Vietnam, selected using a systematic sampling technique. Validated scales were used to measure SOMD, specifically symptoms of depression, anxiety, alcohol use disorder (AUD), substance use disorder (SUD) and HIV associated dementia (HAD). Participants completed a self-report questionnaire assessing HRB during the preceding 12 months including unsafe sexual practices and illicit drug use. Multivariable logistic regression models were used to evaluate associations between SOMD and HRB.

Results

The majority of participants (63.5%) were male and the median age was 34.0 years. Unsafe sexual practices and illicit drug use were reported by 13.8 and 5.5% of participants. The prevalences of HAD, depression, AUD, anxiety and SUD symptoms were 39.8, 36.5, 13.3 10.5, 3.3% respectively. There was no association between SOMD and HRB either with or without adjusting for correlates of HRB, except between symptoms of SUD and illicit drug use. PLHIV who had symptoms of SUD were more likely to use illicit drugs (adjusted Odds Ratio 81.14, 95% CI 12.55–524.47).

Conclusions

While the prevalence of SOMD among HIV positive outpatients was high, most SOMD were not associated with increased HRB. Only illicit drug use was predicted by symptoms of SUD. Screening PLHIV for symptoms of SUD may be useful for detecting people likely to be engaging in illicit drug use to reduce the risk of secondary disease transmission.

Cost-utility of HIV Testing Programs Among Men Who Have Sex with Men in the United States

Few groups in the United States (US) are as heavily affected by HIV as men who have sex with men (MSM), yet many MSM remain unaware of their infection. HIV diagnosis is important for decreasing onward transmission and promoting effective treatment for HIV, but the cost-effectiveness of testing programs is not well-established. This study reports on the costs and cost-utility of the MSM Testing Initiative (MTI) to newly diagnose HIV among MSM and link them to medical care. Cost and testing data in 15 US cities from January 2013 to March 2014 were prospectively collected and combined to determine the cost-utility of MTI in each city in terms of the cost per Quality Adjusted Life Years (QALY) saved from payer and societal perspectives. The total venue-based HIV testing costs ranged from $18,759 to $564,284 for nine to fifteen months of MTI implementation. The cost-saving threshold for HIV testing of MSM was $20,645 per new HIV diagnosis. Overall, 27,475 men were tested through venue-based MTI, of whom 807 (3 %) were newly diagnosed with HIV. These new diagnoses were associated with approximately 47 averted HIV infections. The cost per QALY saved by implementation of MTI in each city was negative, indicating that MTI venue-based testing was cost-saving in all cities. The cost-utility of social network and couples testing strategies was, however, dependent on whether the programs newly diagnosed MSM. The cost per new HIV diagnosis varied considerably across cities and was influenced by both the local cost of MSM testing implementation and by the seropositivity rate of those reached by the HIV testing program. While the cost-saving threshold for HIV testing is highly achievable, testing programs must successfully reach undiagnosed HIV-positive individuals in order to be cost-effective. This underscores the need for HIV testing programs which target and engage populations such as MSM who are most likely to have undiagnosed HIV to maximize programmatic benefit and cost-utility.

Demographic Trends in New HIV Diagnoses in the U.S., 2009-2013

INTRODUCTION

HIV testing is key to achieving the National HIV/AIDS Strategy goals. A new diagnosis metric evaluated whether testing services are reaching the remaining undiagnosed people living with HIV (PLWH), by subpopulation.

METHODS

Centers for Disease Control and Prevention surveillance data from 2008 to 2013 were obtained for: (1) new HIV diagnoses; (2) HIV prevalence; and (3) percentage of PLWH aware of serostatus. The number of new HIV diagnoses in a given year divided by the number of undiagnosed PLWH in the previous year was determined. Trends were evaluated by calculating net percentage change in this measure from 2009 to 2013 for all new diagnoses and stratified by subpopulation. Analyses were conducted during 2015-2016.

RESULTS

The proportion of all undiagnosed PLWH who achieve serostatus awareness was 26.0%, 25.9%, 26.1%, 27.7%, and 30.4% from 2009 to 2013, respectively. The absolute net change was 4.3% (5.2% for men and 0.5% for women). There was an absolute net change of 5.0%, 3.1%, and 5.5% for the black, Hispanic, and men who have sex with men communities, respectively. An absolute net change >10% was observed only for those aged 13-24 years (10.9%) and ≥65 years (17.8%), and for men who inject drugs (11.7%).

CONCLUSIONS

The proportion of undiagnosed PLWH who achieve serostatus awareness increased minimally from 2009 to 2013, especially for blacks, Hispanics, and men who have sex with men. Redirecting HIV testing efforts and funds to disproportionately affected communities is essential.

Behavioral and Other Characteristics Associated with HIV Viral Load in an Outpatient Clinic

Persons living with HIV (PLWH) who are engaged in care, yet not virally suppressed, represent a risk for transmission and opportunity for risk reduction interventions. This study describes characteristics of an outpatient clinic cohort of PLWH by laboratory confirmed viral suppression status and examines associations with demographics and sexual and drug use behaviors gathered through questionnaire. From a sample of 500 clinic patients, 438 were prescribed antiretroviral treatment (ART) and 62 were not. Among the 438 on ART, 72 (16.4%) were not virally suppressed at the most recent lab draw. Compared to individuals with a suppressed viral load, those that were unsuppressed were more likely to: be black (79.2% vs. 64.2%; p = 0.014); earn below $25,000/year (88.9% vs. 65.0%; p < 0.001); be of a younger age (47.8 vs. 50.0 mean years; p = 0.009); be on opiate substitution (14.1% vs. 6.3%; p = 0.023); and acknowledge poly-substance (38.9% vs. 24.4%; p = 0.012) and excessive alcohol use (13.9% vs. 6.0%; p = 0.019). Conversely, a smaller proportion of those with an unsuppressed viral load had multiple sex partners in the previous 30 days (39.8% vs. 58.5%; p = 0.003). In multivariable regression of those on ART, the prevalence of an unsuppressed viral load was 3% lower with each increasing year of age (aPR: 0.97; 95% CI: 0.95, 0.99) and 47% lower with income over $25,000/year (aPR: 0.33; 95% CI: 0.16, 0.70). In a separate analysis of all 500 subjects, ART was less frequently prescribed to blacks compared to whites, heterosexuals, those with lower education and income, and persons with active substance use. Findings confirm that a large proportion of PLWH and engaged in care were not virally suppressed and continued behaviors that risk transmission, indicating the need for screening, prevention counseling and access to ancillary services to lower the incidence of HIV infections.

Unmet HIV Service Needs Among Hispanic Men who Have Sex with Men in the United States

The National HIV/AIDS Strategy (NHAS) originally issued in 2010 targets the reduction of HIV-related health disparities. Hispanic men who have sex with men (MSM) have the third highest burden of incident HIV in the US, but there are no estimates of the unmet HIV service needs for Hispanic MSM. We estimate that of approximately 204,800 Hispanic MSM living with HIV, roughly 46,900 were undiagnosed. 157,900 were diagnosed, and of those, 75,700 were not linked to care and 82,200 were linked. Among diagnosed individuals, 48,800 had undetectable viral loads, and 109,100 had detectable viral loads. An estimated 30,000 of diagnosed Hispanic MSM engage in unprotected, serodiscordant risk behaviors. Total cost to meet service needs and achieve NHAS goals is ~$2.511 billion in 2011 US dollars. Transmission rate modeling suggests this investment would avert 3656 new HIV infections at an economically favorable cost of $61,202 per quality-adjusted life year saved.

Evaluating the Impact of the US National HIV/AIDS Strategy, 2010-2015

The 2010 US National HIV/AIDS Strategy (NHAS) set key targets for the reduction of HIV incidence (25 %) and the transmission rate (30 %) by 2015. We utilized published CDC data on HIV prevalence and mortality for 2007-2012, and literature-based incidence estimates for 2008-2012, along with mathematical modeling to evaluate whether the original NHAS incidence and transmission rate goals were achieved. From 2010 to 2015, a decrease was estimated from about 37,366 to 33,218 (11.1 % net decrease) for HIV incidence, and from 3.16 to 2.61 (17.4 % net decrease) for the HIV transmission rate. Over the same period, estimated all-cause mortality decreased from 17,866 to 16,085, while HIV prevalence increased from 1,181,300 to 1,270,755 persons living with HIV. At the conclusion of the original NHAS time period, important incremental but ultimately insufficient progress was made in attempting to reach key incidence and transmission rate targets for the NHAS. HIV prevention efforts must be reinvigorated in the NHAS's second era.

Developing a Video-Based eHealth Intervention for HIV-Positive Gay, Bisexual, and Other Men Who Have Sex with Men: Study Protocol for a Randomized Controlled Trial

BACKGROUND

Gay, bisexual, and other men who have sex with men (GBMSM) accounted for 67% of new US human immunodeficiency virus (HIV) infections in 2012; however, less than 40% of HIV-positive GBMSM are virally suppressed. Preventing transmission from virally unsuppressed men who have condomless anal sex (CAS) with serodiscordant partners is a public health imperative. New HIV infections in GBMSM are attributed in part to online access to sex partners; therefore, low-cost eHealth interventions are a unique opportunity to reach men where they meet partners.

OBJECTIVE

To describe the protocol of a randomized controlled trial evaluating whether video-based messaging delivered online may lead to reductions in serodiscordant CAS and increased HIV disclosure.

METHODS

Sex Positive!([+]) is a two-arm, phase III, video-based randomized controlled trial delivered online to GBMSM living with HIV. Participants in the intervention arm receive 10 video vignettes grounded in social learning and social cognitive theories that are designed to elicit critical thinking around issues of HIV transmission and disclosure. Participants in the attention control arm receive 10 video vignettes that focus on healthy living. All videos are optimized for mobile viewing. The study protocol includes five online assessments conducted over a 1-year period among 1500 US white, black, or Hispanic/Latino GBMSM living with HIV who report suboptimal antiretroviral therapy (ART) adherence or a detectable viral load in the past 12 months and recent CAS (past 6 months) with HIV-negative or unknown status male partners. Compared to the control arm, we hypothesize that men who watch the intervention videos will report at 12-month follow-up significantly fewer serodiscordant CAS partners, increased HIV disclosure, and improved social cognition (eg, condom use self-efficacy, perceived responsibility).

RESULTS

Participant recruitment began in June 2015 and ended in December 2015.

CONCLUSIONS

This protocol describes the underlying theoretical framework and measures, study design, recruitment challenges, and antifraud measures for an online, video-based randomized controlled trial that has the potential to decrease HIV transmission risk behaviors among HIV-positive GBMSM who struggle with ART adherence. The Sex Positive!([+]) intervention allows for participation through multiple Internet-based mediums and has the potential to reach and engage a broader population of HIV-positive GBMSM who are virally unsuppressed.

CLINICALTRIAL

ClinicalTrials.gov NCT02023580; https://clinicaltrials.gov/ct2/show/NCT02023580 (Archived by WebCite at http://www.webcitation.org/6iHzA8wRG).

Cost-Utility Analysis of Three U.S. HIV Linkage and Re-engagement in Care Programs from Positive Charge

Linking and retaining people living with HIV in ongoing, HIV medical care is vital for ending the U.S. HIV epidemic. Yet, 41-44 % of HIV+ individuals are out of care. In response, AIDS United initiated Positive Charge, a series of five HIV linkage and re-engagement projects around the U.S. This paper investigates whether three Positive Charge programs were cost effective and calculates a return on investment for each program. It uses standard methods of cost utility analysis and WHO-CHOICE thresholds. All three projects were found to be cost effective, and two were highly cost effective. Cost utility ratios ranged from $4439 to $137,271. These results suggest that HIV linkage to care programs are a productive and efficient use of public health funds.

Running Backwards: Consequences of Current HIV Incidence Rates for the Next Generation of Black MSM in the United States

Black men who have sex with men (MSM) in the United States are disproportionately impacted by HIV. To better understand this public health problem, we reviewed the literature to calculate an estimate of HIV incidence among Black MSM. We used this rate to model HIV prevalence over time within a simulated cohort, which we subsequently compared to prevalence from community-based samples. We searched all databases accessible through PubMed, and Conference on Retroviruses and Opportunistic Infections abstracts for HIV incidence estimates among Black MSM. Summary HIV incidence rates and 95 % confidence intervals (CIs) were calculated using random effects models. Using the average incidence rate, we modeled HIV prevalence within a simulated cohort of Black MSM (who were all HIV-negative at the start) from ages 18 through 40. Based on five incidence rates totaling 2898 Black MSM, the weighted mean incidence was 4.16 % per year (95 % CI 2.76-5.56). Using this annual incidence rate, our model predicted that 39.94 % of Black MSM within the simulated cohort would be HIV-positive by age 30, and 60.73 % by 40. Projections were similar to HIV prevalence found in community-based samples of Black MSM. High HIV prevalence will persist across the life-course among Black MSM, unless effective prevention and treatment efforts are increased to substantially reduce HIV transmission among this underserved and marginalized population.

A SWOT Analysis of the Updated National HIV/AIDS Strategy for the U.S., 2015-2020

In July 2015, President Barack Obama released an updated National HIV/AIDS Strategy (NHAS) for the United States to guide HIV efforts through the year 2020. A federal action plan to accompany the updated NHAS will be released in December 2015. In this editorial, we offer a strengths, weaknesses, opportunities and threats analysis with the aim of increasing discussion of ways to truly fulfill the promise of the updated NHAS and to address barriers that may thwart it from achieving its full potential.

Correlates of Seroadaptation Strategies Among Black Men Who have Sex with Men (MSM) in 4 US Cities

We assessed associations of demographic, psychosocial, and substance use factors with seroadaptation strategies among 835 BMSM in four US cities. Seroadaptation strategies were practiced by 59.8 % of men, with 10.5 % practicing 100 % condom use, 26.5 % serosorting, 7.2 % condom serosorting, and 15.6 % seropositioning. In multivariable analyses, compared to men who used no seroadaptation strategies, serosorters were older, were less likely to be HIV infected, had fewer male sex partners, and had higher levels of social support and sexual self-efficacy. Condom serosorters had less psychological distress, were more likely to use methamphetamine, and had higher levels of sexual self-efficacy. Seropositioners were older, were less likely to be HIV infected, to have a main partner, and report alcohol/drug use with sex, while having higher levels of sexual self-efficacy. Seroadaptation practices among BMSM need to be considered to address perceived safer sex strategies and strengthen access to a broader reach of culturally-relevant prevention efforts.

HIV Prevalence and Awareness of Positive Serostatus Among Men Who Have Sex With Men and Transgender Women in Bogotá, Colombia

OBJECTIVES

We estimated HIV prevalence among men who have sex with men (MSM) and transgender women in Bogotá, Colombia, and explored differences between HIV-positive individuals who are aware and unaware of their serostatus.

METHODS

In this cross-sectional 2011 study, we used respondent-driven sampling (RDS) to recruit 1000 MSM and transgender women, who completed a computerized questionnaire and received an HIV test.

RESULTS

The RDS-adjusted prevalence was 12.1% (95% confidence interval [CI] = 8.7, 15.8), comparable to a previous RDS-derived estimate. Among HIV-positive participants, 39.7% (95% CI = 25.0, 54.8) were aware of their serostatus and 60.3% (95% CI = 45.2, 75.5) were unaware before this study. HIV-positive-unaware individuals were more likely to report inadequate insurance coverage, exchange sex (i.e., sexual intercourse in exchange for money, goods, or services), and substance use than other participants. HIV-positive-aware participants were least likely to have had condomless anal intercourse in the previous 3 months. Regardless of awareness, HIV-positive participants reported more violence and forced relocation experiences than HIV-negative participants.

CONCLUSIONS

There is an urgent need to increase HIV detection among MSM and transgender women in Bogotá. HIV-positive-unaware group characteristics suggest an important role for structural, social, and individual interventions.

Identifying opportunities to increase HIV testing among mexican migrants: a call to step up efforts in health care and detention settings

HIV testing and counseling is a critical component of HIV prevention efforts and core element of current “treatment as prevention” strategies. Mobility, low education and income, and limited access to health care put Latino migrants at higher risk for HIV and represent barriers for adequate levels of HIV testing in this population. We examined correlates of, and missed opportunities to increase, HIV testing for circular Mexican migrants in the U.S. We used data from a probability-based survey of returning Mexican migrants (N=1161) conducted in the border city of Tijuana, Mexico. We estimated last 12-months rates of HIV testing and the percentage of migrants who received other health care services or were detained in an immigration center, jail, or prison for 30 or more days in the U.S., but were not tested for HIV. Twenty-two percent of migrants received HIV testing in the last 12 months. In general, utilization of other health care services or detention for 30 or more days in the U.S. was a significant predictor of last 12-months HIV testing. Despite this association, we found evidence of missed opportunities to promote testing in healthcare and/or correctional or immigration detention centers. About 27.6% of migrants received other health care and/or were detained at least 30 days but not tested for HIV. Health care systems, jails and detention centers play an important role in increasing access to HIV testing among circular migrants, but there is room for improvement. Policies to offer opt-out, confidential HIV testing and counseling to Mexican migrants in these settings on a routine and ethical manner need to be designed and pilot tested. These policies could increase knowledge of HIV status, facilitate engagement in HIV treatment among a highly mobile population, and contribute to decrease incidence of HIV in the host and receiving communities.

What we know and what we do not know about factors associated with and interventions to promote antiretroviral adherence

Antiretroviral therapy (ART) adherence remains critical for achieving successful outcomes. Factors affecting ART adherence can occur at the individual level or be related to the treatment regimen, daily schedule, and/or interpersonal relationships. While treatment-related barriers have diminished with recent simplified ART regimens, guidelines still recommend considering regimen simplicity. ART readiness should be assessed prior to starting ART, with follow-up adherence assessments once ART is initiated, and at all subsequent clinical visits. Adherence interventions work best when multifaceted, targeted for at-risk and nonadherent participants, and tailored to individuals' needs. Successful interventions have included education and counseling, provision of social support, directly observed therapy, and financial incentives. Pillboxes and two-way short-text messaging service (SMS) reminders have been shown to be effective and are widely recommended tools for promoting ART adherence. Further research is needed to determine the optimal combination of adherence interventions, as well as generalizability, implementation, and cost-effectiveness.

Transmission risk behaviour at enrolment in participants in the INSIGHT Strategic Timing of AntiRetroviral Treatment (START) trial

OBJECTIVES

A proportion of HIV-positive people have condomless sex. Antiretroviral treatment (ART) reduces infectiousness, but a substantial proportion of HIV-diagnosed people are not yet on ART. We describe baseline self-reported risk behaviours in ART-naïve Strategic Timing of AntiRetroviral Treatment (START) trial participants.

METHODS

All START participants completed a risk behaviour questionnaire. Data were collected on sociodemographics, lifestyle factors, health and wellbeing status and clinical status. Recent sexual behaviour and HIV transmission beliefs in the context of ART were also assessed. The primary interest was in condomless sex with serodifferent partners (CLS-D) in the past two months.

RESULTS

A total of 4601 of 4685 HIV-positive participants (98%) completed the questionnaire [2559 men who have sex with men (MSM), 803 heterosexual men and 1239 women]. Region of recruitment was Europe/Israel, 33%; South America/Mexico, 25%; Africa, 22%; other, 21%. Median age was 36 years [interquartile range (IQR) 29, 44 years]. Forty-five per cent reported white ethnicity and 31% black ethnicity. Two per cent had HIV viral load < 50 HIV-1 RNA copies/mL. Seventeen per cent (767 of 4601) reported CLS-D; 20% of MSM compared with 10% of heterosexual men and 14% of women. MSM were also more likely to report multiple CLS-D partners. Possible risk limitation measures (reported by more than half of those who had CLS-D) were seropositioning (receptive anal CLS-D only) or withdrawal (insertive anal CLS-D always without ejaculation). CLS-D was more commonly reported by participants from South America/Mexico and North America compared with Europe; among heterosexual men and women CLS-D was also more commonly reported among participants from Africa compared with Europe. Knowledge of ART impact on transmission risk was low.

CONCLUSIONS

A substantial minority recruited to the START study reported CLS-D at baseline. CLS-D reporting was higher in MSM than heterosexuals and varied significantly according to region of recruitment. A substantial proportion of MSM reporting CLS-D appear to take transmission risk limitation measures.