The Development and Implementation of an Outreach Program to Identify Acute and Recent HIV Infections in New York City

Acute and early HIV infection screening among men who have sex with men, a systematic review and meta-analysis

INTRODUCTION

Screening for acute and early HIV infections (AEHI) among men who have sex with men (MSM) remains uncommon in sub-Saharan Africa (SSA). Yet, undiagnosed AEHI among MSM and subsequent failure to link to care are important drivers of the HIV epidemic. We conducted a systematic review and meta-analysis of AEHI yield among MSM mobilized for AEHI testing; and assessed which risk factors and/or symptoms could increase AEHI yield in MSM.

METHODS

We systematically searched four databases from their inception through May 2020 for studies reporting strategies of mobilizing MSM for testing and their AEHI yield, or risk and/or symptom scores targeting AEHI screening. AEHI yield was defined as the proportion of AEHI cases among the total number of visits. Study estimates for AEHI yield were pooled using random effects models. Predictive ability of risk and/or symptom scores was expressed as the area under the receiver operator curve (AUC).

RESULTS

Twenty-two studies were identified and included a variety of mobilization strategies (eight studies) and risk and/or symptom scores (fourteen studies). The overall pooled AEHI yield was 6.3% (95% CI, 2.1 to 12.4; I2  = 94.9%; five studies); yield varied between studies using targeted strategies (11.1%; 95% CI, 5.9 to 17.6; I2  = 83.8%; three studies) versus universal testing (1.6%; 95% CI, 0.8 to 2.4; two studies). The AUC of risk and/or symptom scores ranged from 0.69 to 0.89 in development study samples, and from 0.51 to 0.88 in validation study samples. AUC was the highest for scores including symptoms, such as diarrhoea, fever and fatigue. Key risk score variables were age, number of sexual partners, condomless receptive anal intercourse, sexual intercourse with a person living with HIV, a sexually transmitted infection, and illicit drug use. No studies were identified that assessed AEHI yield among MSM in SSA and risk and/or symptom scores developed among MSM in SSA lacked validation.

CONCLUSIONS

Strategies mobilizing MSM for targeted AEHI testing resulted in substantially higher AEHI yields than universal AEHI testing. Targeted AEHI testing may be optimized using risk and/or symptom scores, especially if scores include symptoms. Studies assessing AEHI yield and validation of risk and/or symptom scores among MSM in SSA are urgently needed.

High HIV risk and syndemic burden regardless of referral source among MSM screening for a PrEP demonstration project in Toronto, Canada

Background

To maximize public health impact and cost-effectiveness, HIV pre-exposure prophylaxis (PrEP) must reach individuals at high HIV risk. Referrals for PrEP can be self- or provider-initiated, but there are several challenges to both. We assessed whether HIV risk differed by referral source among gay, bisexual and other men who have sex (gbMSM) screening for an HIV PrEP demonstration project.

Methods

PREPARATORY-5 was an open-label PrEP demonstration project enrolling gbMSM at high risk of HIV acquisition in Toronto, Canada. Study eligibility criteria related to high risk was defined as scoring ≥10 on the HIV Incidence Risk Index for MSM (HIRI-MSM) and engaging in at least 1 act of condomless receptive anal sex within the past 6 months. Recruitment was promoted through self-referrals (ads in a sexual networking app and gay newspaper/website) and provider-referrals (10 community-based organizations, CBOs). HIV risk score (HIRI-MSM) and syndemic health burden were measured among gbMSM screened for study participation and compared according to referral source.

Results

Between October 16 and December 30, 2014, online ads generated 1518 click-throughs and CBOs referred 115 individuals. Overall, 165 men inquired about the trial, of which 86 underwent screening. The majority of screened men were self-referrals (60.5%), scored ≥10 on HIRI-MSM (96.5%), and reported condomless receptive anal sex in the past 6 months (74.2%). Self- and provider-referrals had similarly high HIV risk profiles, with a median (IQR) HIRI-MSM score of 26.0 (19.0–32.5) and 28.5 (20.0–34.0) (p = 0.3), and 75.0% and 73.5% reporting condomless receptive anal sex (p = 0.9), respectively. The overall burden of syndemic health problems was also high, with approximately one-third overall identified as having depressive symptoms (39.5%), alcohol-related problems (39.5%), multiple drug use (31.4%), or sexual compulsivity (31.4%). There were no significant differences in syndemic health problems by referral source.

Conclusions

HIV risk and syndemic burden were high among gbMSM presenting for this PrEP demonstration project regardless of referral source. Self-referral may be a useful and efficient strategy for identifying individuals suitable for PrEP use. Online strategies and CBOs working in gay men’s health may play important roles in connecting individuals at high HIV risk to PrEP services.

Trial registration

ClinicalTrials.gov NCT02149888. Registered May 12th 2014.

Rationale, Design and Methods of the Ecological Study of Sexual Behaviors and HIV/STI among African American Men Who Have Sex with Men in the Southeastern United States (The MARI Study)

BACKGROUND

This paper describes the rationale, design, and methodology of the Ecological Study of Sexual Behaviors and HIV/STI among African American Men Who Have Sex with Men (MSM) in the Southeastern United States (U.S.; known locally simply as the MARI Study).

METHODS

Participants are African American MSM aged 18 years and older residing in the deep South.

RESULTS

Between 2013 and 2015, 800 African American MSM recruited from two study sites (Jackson, MS and Atlanta, GA) will undergo a 1.5-hour examination to obtain anthropometric and blood pressure measures as well as to undergo testing for sexually transmitted infections (STI), including HIV. Intrapersonal, interpersonal, and environmental factors are assessed by audio computer-assisted self-interview survey. Primary outcomes include sexual risk behaviors (e.g., condomless anal sex) and prevalent STIs (HIV, syphilis, gonorrhea, and Chlamydia).

CONCLUSION

The MARI Study will typify the HIV environmental 'riskscape' and provide empirical evidence into novel ecological correlates of HIV risk among African American MSM in the deep South, a population most heavily impacted by HIV. The study's anticipated findings will be of interest to a broad audience and lead to more informed prevention efforts, including effective policies and interventions, that achieve the goals of the updated 2020 U.S. National HIV/AIDS Strategy.

Knowledge and awareness of acute human immunodeficiency virus infection among mobile app-using men who have sex with men: a missed public health opportunity

In a national online survey, we assessed awareness and knowledge of acute human immunodeficiency virus (HIV) infection manifestation among 1748 men who have sex with men (MSM). Only 39% of respondents were aware that acute HIV infection may be accompanied by symptoms. Education and increased access to acute HIV testing may facilitate MSM to appropriately seek acute HIV testing.

Targeting screening and social marketing to increase detection of acute HIV infection in men who have sex with men in Vancouver, British Columbia

OBJECTIVES

The contribution of acute HIV infection (AHI) to transmission is widely recognized, and increasing AHI diagnosis capacity can enhance HIV prevention through subsequent behavior change or intervention. We examined the impact of targeted pooled nucleic acid amplification testing (NAAT) and social marketing to increase AHI diagnosis among men who have sex with men (MSM) in Vancouver.

DESIGN

Observational study.

METHODS

We implemented pooled NAAT following negative third-generation enzyme immunoassay (EIA) testing for males above 18 years in six clinics accessed by MSM, accompanied by two social marketing campaigns developed by a community gay men's health organization. We compared test volume and diagnosis rates for pre-implementation (April 2006-March 2009) and post-implementation (April 2009-March 2012) periods. After implementation, we used linear regression to examine quarterly trends and calculated diagnostic yield.

RESULTS

After implementation, the AHI diagnosis rate significantly increased from 1.03 to 1.84 per 1000 tests, as did quarterly HIV test volumes and acute to non-acute diagnosis ratio. Of the 217 new HIV diagnoses after implementation, 54 (24.9%) were AHIs (25 detected by pooled NAAT only) for an increased diagnostic yield of 11.5%. The average number of prior negative HIV tests (past 2 years) increased significantly for newly diagnosed MSM at the six study clinics compared to other newly diagnosed MSM in British Columbia, per quarter.

CONCLUSION

Targeted implementation of pooled NAAT at clinics accessed by MSM is effective in increasing AHI diagnoses compared to third-generation EIA testing. Social marketing campaigns accompanying pooled NAAT implementation may contribute to increasing AHI diagnoses and frequency of HIV testing.

Counselor-based rapid HIV testing in community pharmacies

The purpose of this study was to examine the results of implementing a rapid counselor-based HIV testing program in community pharmacies. A prospective cross-sectional study was conducted on a convenience sample of clients at five community pharmacies in New York City (NYC). In 294 days of pharmacy testing, 2805 clients were eligible to receive testing, and 2030 individuals agreed to test. The average age was 33±15 years, 41% were male, 59% were Hispanic, 77% had been previously tested for HIV, and 34% were uninsured. HIV incidence was 0.3%, median CD4 cell count was 622.0, and the average age of the newly diagnosed positives was 36.0±13.9 years. Participants were satisfied with a counselor-based rapid HIV testing program in community-based pharmacies.

ru2hot?: A public health education campaign for men who have sex with men to increase awareness of symptoms of acute HIV infection

OBJECTIVES

Teach HIV-negative men who have sex with men (MSM) symptoms of acute HIV infection (AHI) and direct them to nucleic acid amplification testing (NAAT) though Public Health--Seattle & King County (PHSKC).

DESIGN

Cross-sectional surveys, retrospective database analysis and chart review.

METHODS

Beginning in June 2009, the ru2hot? campaign described AHI symptoms and NAAT. Two preintervention and two postintervention surveys assessed campaign visibility, symptom knowledge, and healthcare-seeking behaviour. Regression analyses evaluated secular trends in case-finding.

RESULTS

366 MSM completed surveys. In survey 4, 23% of 100 men reported seeing the campaign, and 25% knew 'ru2hot?' referred to AHI. From survey 1 to survey 4, the proportion of subjects who knew ≥2 symptoms or that AHI was a 'flu-like' illness was unchanged (61% vs 57%, p=0.6). However, in survey 4, 13 (72%) of 18 subjects who saw the campaign named fever as a symptom of AHI compared with 19 (35%) of 55 subjects who had not seen the campaign (p=0.005). From 9/2003 to 12/2010, 622 (2.2%) of 27 661 MSM tested HIV-positive, and 111 (18%) were identified by the Public Health--Seattle & King County NAAT programme. In terms of the impact of the campaign on case-finding, diagnosis of EIA-negative/NAAT-positive and OraQuick-negative/EIA-positive cases increased from six in 2004 to 20 in 2010 (p=0.01), but postcampaign numbers were unchanged. 23 (51%) of 45 cases identified before and 8 (44%) of 18 cases identified after the campaign reported symptoms at initial testing (p=0.6).

CONCLUSIONS

Although a quarter of MSM surveyed saw the campaign and knowledge of fever (the symptom of emphasis) was high, case-finding was unchanged. Increasing campaign visibility could have had greater impact.

Towards targeted screening for acute HIV infections in British Columbia

BACKGROUND

Our objective was to describe the characteristics of acute and established HIV infections diagnosed in the Canadian province of British Columbia. Province-wide HIV testing and surveillance data were analyzed to inform recommendations for targeted use of screening algorithms to detect acute HIV infections.

METHODS

Acute HIV infection was defined as a confirmed reactive HIV p24 antigen test (or HIV nucleic acid test), a non-reactive or reactive HIV EIA screening test and a non-reactive or indeterminate Western Blot. Characteristics of unique individuals were identified from the British Columbia HIV/AIDS Surveillance System. Primary drug resistance and HIV subtypes were identified by analyzing HIV pol sequences from residual sera from newly infected individuals.

RESULTS

From February 2006 to October 2008, 61 individuals met the acute HIV infection case definition, representing 6.2% of the 987 newly diagnosed HIV infections during the analysis period. Acute HIV infection cases were more likely to be men who have sex with men (crude OR 1.71; 95% CI 1.01-2.89], to have had a documented previous negative HIV test result (crude OR 2.89; 95% CI 1.52-5.51), and to have reported a reason for testing due to suspected seroconversion symptoms (crude OR 5.16; 95% CI 2.88-9.23). HIV subtypes and rates of transmitted drug resistance across all classes of drugs were similar in persons with both acute and established HIV infections.

CONCLUSIONS

Targeted screening to detect acute HIV infection is a logical public health response to the HIV epidemic. Our findings suggest that acute HIV infection screening strategies, in our setting, are helpful for early diagnosis in men who have sex with men, in persons with seroconversion symptoms and in previously negative repeat testers.