Ending the HIV Epidemic: A Plan for the United States

Assessment of Bias in Estimates of Sexual Network Degree using Prospective Cohort Data

BACKGROUND

Sexual network degree, a count of ongoing partnerships, plays a critical role in the transmission dynamics of human immunodeficiency virus and other sexually transmitted infections. Researchers often quantify degree using self-reported cross-sectional data on the day of survey, which may result in bias because of uncertainty about future sexual activity.

METHODS

We evaluated the bias of a cross-sectional degree measure with a prospective cohort study of men who have sex with men (MSM). At baseline, we asked men about whether recent sexual partnerships were ongoing. We confirmed the true, ongoing status of those partnerships at baseline at follow-up. With logistic regression, we estimated the partnership-level predictors of baseline measure accuracy. With Poisson regression, we estimated the longitudinally confirmed degree as a function of baseline predicted degree.

RESULTS

Across partnership types, the baseline ongoing status measure was 70% accurate, with higher negative predictive value (91%) than positive predictive value (39%). Partnership exclusivity and racial pairing were associated with higher accuracy. Baseline degree generally overestimated confirmed degree. Bias, or number of ongoing partners different than predicted at baseline, was -0.28 overall, ranging from -1.91 to -0.41 for MSM with any ongoing partnerships at baseline. Comparing MSM of the same baseline degree, the level of bias was stronger for black compared with white MSM, and for younger compared with older MSM.

CONCLUSIONS

Research studies may overestimate degree when it is quantified cross-sectionally. Adjustment and structured sensitivity analyses may account for bias in studies of human immunodeficiency virus or sexually transmitted infection prevention interventions.

The Health Resources and Services Administration (HRSA) Ryan White HIV/AIDS Program's Response to the Opioid Epidemic

BACKGROUND

The United States is in the midst of an unprecedented opioid crisis with increasing injection drug use (IDU)-related human immunodeficiency virus (HIV) outbreaks, particularly in rural areas. The Health Resources and Services Administration (HRSA)'s Ryan White HIV/AIDS Program (RWHAP) is well positioned to integrate treatment for IDU-associated HIV infections with treatment for drug use disorders. These activities will be crucial for the "Ending the HIV Epidemic: A Plan for America" (EHE) initiative, in which 7 southern states were identified with rural HIV epidemics.

METHODS

The RWHAP Services Report data were used to assess the IDU population and substance use services utilization among RWHAP clients in 2017, nationally and in the 7 EHE-identified states. THe HRSA held a 1-day Technical Expert Panel (TEP) to explore how RWHAP can best respond to the growing opioid crisis.

RESULTS

During the TEP, 8 key themes emerged and 11 best practices were identified to address opioid use disorder (OUD) among people with HIV. In 2017, among RWHAP clients with reported age and transmission category, 6.7% (31 683) had HIV attributed to IDU; among IDU clients, 6.3% (1988) accessed substance use services.

CONCLUSIONS

The TEP results and RWHAP data were used to develop implementation science projects that focus on addressing OUD and integrating behavioral health in primary care. These activities are critical to ending the HIV epidemic.

Ending the HIV Epidemic Among Persons Who Inject Drugs: A Cost-Effectiveness Analysis in Six US Cities

BACKGROUND

Persons who inject drugs (PWID) are at a disproportionately high risk of HIV infection. We aimed to determine the highest-valued combination implementation strategies to reduce the burden of HIV among PWID in 6 US cities.

METHODS

Using a dynamic HIV transmission model calibrated for Atlanta, Baltimore, Los Angeles, Miami, New York City, and Seattle, we assessed the value of implementing combinations of evidence-based interventions at optimistic (drawn from best available evidence) or ideal (90% coverage) scale-up. We estimated reduction in HIV incidence among PWID, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) for each city (10-year implementation; 20-year horizon; 2018 $ US).

RESULTS

Combinations that maximized health benefits contained between 6 (Atlanta and Seattle) and 12 (Miami) interventions with ICER values ranging from $94 069/QALY in Los Angeles to $146 256/QALY in Miami. These strategies reduced HIV incidence by 8.1% (credible interval [CI], 2.8%-13.2%) in Seattle and 54.4% (CI, 37.6%-73.9%) in Miami. Incidence reduction reached 16.1%-75.5% at ideal scale.

CONCLUSIONS

Evidence-based interventions targeted to PWID can deliver considerable value; however, ending the HIV epidemic among PWID will require innovative implementation strategies and supporting programs to reduce social and structural barriers to care.

Use of Population-Based Surveys for Estimating the Population Size of Persons Who Inject Drugs in the United States

BACKGROUND

In the United States, injection is an increasingly common route of administration for opioids and other substances. Estimates of the number of persons who inject drugs (PWID) are needed for monitoring risk-specific infectious disease rates and health services coverage.

METHODS

We reviewed design and instruments for 4 national household surveys, 2012-2016, for their ability to produce unbiased injection drug use (IDU) prevalence estimates. We explored potential analytic adjustments for reducing biases through use of external data on (1) arrest, (2) narcotic overdose mortality, and (3) biomarker-based sensitivity of self-reported illicit drug use.

RESULTS

Estimated national past 12 months IDU prevalence ranged from 0.24% to 0.59% across surveys. All surveys excluded unstably housed and incarcerated persons, and estimates were based on <60 respondents reporting IDU behavior in 3 surveys. No surveys asked participants about nonmedical injection of prescription drugs. Analytic adjustments did not appreciably change IDU prevalence estimates due to suboptimal specificity of data points.

CONCLUSIONS

PWID population size estimates in the United States are based on small numbers and are likely biased by undercoverage of key populations and self-report. Novel methods as discussed in this article may improve our understanding of PWID population size and their health needs.

A mentor training workshop focused on fostering diversity engenders lasting impact on mentoring techniques: Results of a long-term evaluation

INTRODUCTION

Trainees and investigators from underrepresented minority (URM) backgrounds face unique challenges to establishing successful careers in clinical and translational research. Structured training for mentors is an important mechanism to increase the diversity of the research workforce. This article presents data from an evaluation of the University of California, San Francisco (UCSF) Center for AIDS Research (CFAR) Mentoring the Mentors program aimed at improving mentors' competency in working with diverse mentees in HIV research.

METHODS

Mentors from around the USA who had in one of seven separate 2-day training workshops conducted from 2013 to 2020 were invited to participate in an online evaluation survey of their experiences with the training and their subsequent mentoring activities.

RESULTS

There was a high response rate (80%) among the 226 mentors invited to complete the survey. The 180 respondents were diverse in demographics, professional disciplines, and geographic distribution. Quantitative and qualitative data indicate a lasting positive impact of the training, with sustained improvements documented on a validated measure of self-appraised mentoring competency. Respondents also endorsed high interest in future, follow-up training with continued focus on topics related to mentoring in the context of diversity.

CONCLUSION

The evaluation of the UCSF CFAR Mentoring the Mentors program showed lasting impact in improving mentoring practices, coupled with high interest in continued in-depth training in areas focused on diversity, equity, and inclusion.

Refocusing Research on Sexually Transmitted Infections

This article highlights biomedical research goals for the development of critical tools, including innovative diagnostics, safe and effective vaccines, and new and improved therapeutics, necessary to achieve an end to the global epidemic of sexually transmitted infections. The incidence of sexually transmitted infections (STIs), including gonorrhea, syphilis, chlamydia, and trichomoniasis, is increasing by over 1 million new cases daily and represents a global public health crisis. There is an alarming increase of gonorrhea and syphilis among men who have sex with men and bisexual men, 2 key populations also at high risk for human immunodeficiency virus. A refocused, dedicated, and intensive biomedical research program is needed targeting development of innovative diagnostics, safe and effective vaccines, and new and improved therapeutics. This article highlights biomedical research goals providing critical tools necessary to achieve an end to the global STIs epidemic.

Progression and transmission of HIV (PATH 4.0)-A new agent-based evolving network simulation for modeling HIV transmission clusters

We present the Progression and Transmission of HIV (PATH 4.0), a simulation tool for analyses of cluster detection and intervention strategies. Molecular clusters are groups of HIV infections that are genetically similar, indicating rapid HIV transmission where HIV prevention resources are needed to improve health outcomes and prevent new infections. PATH 4.0 was constructed using a newly developed agent-based evolving network modeling (ABENM) technique and evolving contact network algorithm (ECNA) for generating scale-free networks. ABENM and ECNA were developed to facilitate simulation of transmission networks for low-prevalence diseases, such as HIV, which creates computational challenges for current network simulation techniques. Simulating transmission networks is essential for studying network dynamics, including clusters. We validated PATH 4.0 by comparing simulated projections of HIV diagnoses with estimates from the National HIV Surveillance System (NHSS) for 2010-2017. We also applied a cluster generation algorithm to PATH 4.0 to estimate cluster features, including the distribution of persons with diagnosed HIV infection by cluster status and size and the size distribution of clusters. Simulated features matched well with NHSS estimates, which used molecular methods to detect clusters among HIV nucleotide sequences of persons with HIV diagnosed during 2015-2017. Cluster detection and response is a component of the U.S. Ending the HIV Epidemic strategy. While surveillance is critical for detecting clusters, a model in conjunction with surveillance can allow us to refine cluster detection methods, understand factors associated with cluster growth, and assess interventions to inform effective response strategies. As surveillance data are only available for cases that are diagnosed and reported, a model is a critical tool to understand the true size of clusters and assess key questions, such as the relative contributions of clusters to onward transmissions. We believe PATH 4.0 is the first modeling tool available to assess cluster detection and response at the national-level and could help inform the national strategic plan.

HIV Care Continuum and Meeting 90-90-90 Targets: Cascade of Care Analyses of a U.S. Military Cohort

INTRODUCTION

The new initiative by the Department of Health and Human Services (DHHS) aims to decrease new HIV infections in the U.S. by 75% within 5 years and 90% within 10 years. Our objective was to evaluate whether the U.S. military provides a good example of the benefits of such policies.

MATERIALS AND METHODS

We conducted an analysis of a cohort of 1,405 active duty military personnel with HIV enrolled in the Natural History Study who were diagnosed between 2003 and 2015 at six U.S. military medical centers. The study was approved by institutional review boards at the Uniformed Services University of the Health Sciences and each of the sites. We evaluated the impact of Department of Defense (DoD) HIV care policies, including screening, linkage to care, treatment eligibility, and combined antiretroviral therapy (cART) initiation on achieving viral suppression (VS) within 3 years of diagnosis. As a secondary outcome, we evaluated the DoD's achievement of UNAIDS 90-90-90 targets.

RESULTS

Nearly all (99%) were linked to care within 60 days. Among patients diagnosed in 2003-2009, 77.5% (95% confidence intervals (CI) 73.9-80.6%) became eligible for cART within 3 years of diagnosis, 70.6% (95% CI 66.6-74.1%) overall initiated cART, and 64.2% (95% CI 60.1-68.0%) overall achieved VS. Among patients diagnosed in 2010-2015, 98.7% (95% CI 96.7-99.5%) became eligible for cART within 3 years of diagnosis, 98.5% (95% CI 96.4-99.4%) overall initiated cART, and 89.8% (95% CI 86.0-92.5%) overall achieved VS.

CONCLUSIONS

U.S. military HIV policies have been highly successful in achieving VS goals, exceeding the UNAIDS 90-90-90 targets. In spite of limitations, including generalizability, this example demonstrates the feasibility of the DHHS initiative to decrease new infections through testing, early treatment, and retention in care.

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.

Missed Opportunity Encounters for Early Diagnosis of HIV Infection in Adolescents

BACKGROUND

Early diagnosis of HIV infection improves patient outcomes and reduces transmission. Adolescents make up one-fifth of new HIV diagnoses in the United States. We sought to quantify the number of missed opportunity encounters (MOEs) before HIV diagnosis for adolescents at a pediatric hospital (PediHosp) and a proximate adult hospital which employs universal HIV screening in its emergency department (ED) (CountyHosp).

METHODS

An observational study at 2 academic tertiary care hospitals in the United States that included all adolescents 13-20 years old with a new diagnosis of behaviorally-acquired HIV infection from 2006 to 2017. MOE were defined as any encounter at PediHosp or CountyHosp after the latter of the individual's 13th birthday or the date 3 months after the individual's most recent negative HIV screen, and before the encounter of HIV diagnosis. Comparisons were made by site of diagnosis and location of MOE.

RESULTS

Two-hundred five subjects met inclusion criteria: 68% male, 76% Black and 81% men who have sex with men. There were 264 MOE, the proportion of adolescent ED encounters that were MOE at the PediHosp ED was 8.3 MOE per 10,000 encounters and the proportion at the CountyHosp ED was 1.2 (relative risk = 6.7; 95% CI: 4.1-11.0; P < 0.001).

CONCLUSIONS

MOE for HIV diagnosis in adolescents occur frequently and are greater in number at a PediHosp as compared with a similar adult setting with universal screening. Universal HIV screening protocols at PediHosp may identify HIV-positive adolescents earlier.

Barriers, Facilitators, and Cost of Integrating HIV-Related Activities Into Sexually Transmitted Disease Partner Services in Jackson, Mississippi

BACKGROUND

Many US health departments now integrate HIV-related outcomes (e.g., relinkage to HIV care and preexposure prophylaxis [PrEP]) into sexually transmitted disease (STD) partner services (PS) programs. We sought to determine the barriers, facilitators, and cost of integrating these activities into PS.

METHODS

From 2016 to 2018, the Mississippi State Department of Health integrated 3 new activities into STD PS: HIV testing for partners of HIV-negative men who have sex with men with gonorrhea/chlamydia, relinkage to HIV care for STD PS recipients previously diagnosed with HIV, and PrEP referrals. We conducted direct observations and interviews with disease intervention specialists (DIS) in Jackson to assess barriers and facilitators to implementing these activities. We completed time and motion studies with 8 DIS and case tracking forms for 90 unique cases to estimate the incremental staff time and associated personnel cost of added services compared with a standard PS case.

RESULTS

Disease intervention specialists were optimistic about integrating HIV-related activities but noted disparate data systems, nonsystematic documentation, and lack of training as barriers. The mean time for a standard STD PS case without HIV-related activities was 195 minutes (cost, $77.69/case). The cost to conduct PS for HIV-negative men who have sex with men with gonorrhea/chlamydia was 36% higher than a standard case. Integrating relinkage to care and PrEP referrals resulted in a 44% and 20% increase in cost, respectively.

CONCLUSIONS

Integrating HIV care relinkage and PrEP referrals into STD partner services was generally acceptable by DIS and added marginal cost per case. Coupling these cost metrics with an assessment of the effectiveness of these activities can inform prioritization of partner services activities.

Expansion of Preexposure Prophylaxis Capacity in Response to an HIV Outbreak Among People Who Inject Drugs-Cabell County, West Virginia, 2019

From January 1, 2018, through October 9, 2019, 82 HIV diagnoses occurred among people who inject drugs (PWID) in Cabell County, West Virginia. Increasing the use of HIV preexposure prophylaxis (PrEP) among PWID was one of the goals of a joint federal, state, and local response to this HIV outbreak. Through partnerships with the local health department, a federally qualified health center, and an academic medical system, we integrated PrEP into medication-assisted treatment, syringe services program, and primary health care settings. During the initial PrEP implementation period (April 18-May 17, 2019), 110 health care providers and administrators received PrEP training, the number of clinics offering PrEP increased from 2 to 15, and PrEP referrals were integrated with partner services, outreach, and testing activities. The number of people on PrEP increased from 15 in the 6 months before PrEP expansion to 127 in the 6 months after PrEP implementation. Lessons learned included the importance of implementing PrEP within existing health care services, integrating PrEP with other HIV prevention response activities, adapting training and material to fit the local context, and customizing care to meet the needs of PWID. The delivery of PrEP to PWID is challenging but complements other HIV prevention interventions. The expansion of PrEP in response to this HIV outbreak in Cabell County provides a framework for expanding PrEP in other outbreak and non-outbreak settings.

Preexposure prophylaxis strategies for African-American women affected by mass incarceration

OBJECTIVE

We aimed to determine the effectiveness of various preexposure prophylaxis (PrEP) prescription strategies for African-American women impacted by mass incarceration within an urban setting.

DESIGN

An agent-based model was utilized to evaluate prevention strategies in an efficient, ethical manner. By defining agents, their characteristics and relationships, we assessed population-level effects of PrEP on HIV incidence.

METHODS

We tested hypothetical PrEP prescription strategies within a simulation representing the African-American population of Philadelphia, Pennsylvania. Four strategies were evaluated: PrEP for women meeting CDC indicators regarding partner characteristics, PrEP for women with a recently incarcerated male partner, PrEP for women with a recently released male partner and couples-based PrEP at time of release. Interventions occurred alongside scale-up of HAART. We evaluated reductions in HIV transmissions, the number of persons on PrEP needed to avert one HIV transmission (NNT) and the resulting proportions of people on PrEP.

RESULTS

Scenarios prescribing PrEP based on criminal justice system involvement reduced HIV transmissions. The NNT ranged from 147 (couples-based scenario) to 300 (recently released scenario). The percentage of the female population covered by PrEP at any one time ranged from 0.14% (couples-based) to 10.8% (CDC-based). CDC-guideline scenarios were consistently less efficient compared to the justice-involved interventions.

CONCLUSION

Expanding PrEP for African-American women and their male partners affected by incarceration should be considered in national HIV prevention goals and correctional facilities leveraged as intervention sites. Partner characteristics in the current CDC indications may be more effective and efficient if guidelines considered criminal justice involvement.

Longitudinal Cohort Study of Gender Affirmation and HIV-Related Health in Transgender and Gender Diverse Adults: The LEGACY Project Protocol

Background

Transgender and gender diverse (TGD) adults in the United States experience health disparities, especially in HIV infection. Medical gender affirmation (eg, hormone therapy and gender-affirming surgeries) is known to be medically necessary and to improve some health conditions. To our knowledge, however, no studies have assessed the effects of gender-affirming medical care on HIV-related outcomes.

Objective

This study aims to evaluate the effects of medical gender affirmation on HIV-related outcomes among TGD primary care patients. Secondary objectives include characterizing mental health, quality of life, and unmet medical gender affirmation needs.

Methods

LEGACY is a longitudinal, multisite, clinic-based cohort of adult TGD primary care patients from two federally qualified community health centers in the United States: Fenway Health in Boston, and Callen-Lorde Community Health Center in New York. Eligible adult TGD patients contribute electronic health record data to the LEGACY research data warehouse (RDW). Patients are also offered the option to participate in patient-reported surveys for 1 year of follow-up (baseline, 6-month, and 12-month assessments) with optional HIV and sexually transmitted infection (STI) testing. Biobehavioral data from the RDW, surveys, and biospecimen collection are linked. HIV-related clinical outcomes include pre-exposure prophylaxis uptake (patients without HIV), viral suppression (patients with HIV), and anogenital STI diagnoses (all patients). Medical gender affirmation includes hormones, surgeries, and nonhormonal and nonsurgical interventions (eg, voice therapy).

Results

The contract began in April 2018. The cohort design was informed by focus groups with TGD patients (n=28) conducted between August-October 2018 and in collaboration with a community advisory board, scientific advisory board, and site-specific research support coalitions. Prospective cohort enrollment began in February 2019, with enrollment expected to continue through August 2020. As of April 2020, 7821 patients are enrolled in the LEGACY RDW and 1756 have completed a baseline survey. Participants have a median age of 29 years (IQR 11; range 18-82). More than one-third (39.7%) are racial or ethnic minorities (1070/7821, 13.68% Black; 475/7821, 6.07% multiracial; 439/7821, 5.61% Asian or Pacific Islander; 1120/7821, 14.32% other or missing) and 14.73% (1152/7821) are Hispanic or Latinx. By gender identity, participants identify as 33.79% (2643/7821) male, 37.07% (2900/7821) female, 21.74% (1700/7821) nonbinary, and 7.39% (578/7821) are unsure or have missing data. Approximately half (52.0%) of the cohort was assigned female sex at birth, and 5.4% (421/7821) are living with HIV infection.

Conclusions

LEGACY is an unprecedented opportunity to evaluate the impact of medical gender affirmation on HIV-related health. The study uses a comprehensive research methodology linking TGD patient biobehavioral longitudinal data from multiple sources. Patient-centeredness and scientific rigor are assured through the ongoing engagement of TGD communities, clinicians, scientists, and site clinical staff undergirded by epidemiological methodology. Findings will inform evidence-based clinical care for TGD patients, including optimal interventions to improve HIV-related outcomes.

International Registered Report Identifier (IRRID)

DERR1-10.2196/24198

Models of HIV Pre-Exposure Prophylaxis Care Used in Title X Family Planning Clinics in the Southern U.S

PURPOSE

HIV pre-exposure prophylaxis (PrEP) is underutilized by adolescent and young adult women, especially in the Southern U.S. Family planning (FP) clinics are potentially ideal PrEP delivery sites for adolescent and young adult women, but little is known about their PrEP services. We describe models of PrEP care in Title X FP clinics in the South and explore clinic resources that are needed to facilitate PrEP provision.

METHODS

Providers and administrators from 38 clinics participated in qualitative interviews. We assessed five steps of PrEP care: (1) HIV risk assessment; (2) PrEP education; (3) laboratory testing; (4) PrEP prescription; and (5) PrEP monitoring.

RESULTS

Among 38 clinics, 23 conducted at least one step and were classified into three models. Model 1 (n = 8) and Model 2 (n = 4) clinics provided up to Steps 1 and 2, respectively, but referred to an external PrEP provider. Model 3 clinics (n = 11) conducted all steps. Few barriers were identified for Step 1; using an HIV risk assessment tool was a key facilitator. PrEP educational materials facilitated Step 2; clinics not providing education believed they could easily do so with training and educational resources. Funding- and staff-related resource barriers were noted for Steps 3-5, including costs of laboratory tests and lack of time for longitudinal visits.

CONCLUSIONS

PrEP-providing publicly funded FP clinics in the Southern U.S. use referral services for many steps of PrEP care, which introduce patient burden. Increasing onsite PrEP services will require addressing concerns related to training, educational materials, cost, and staffing.

Estimating HIV transmissions in a large U.S. clinic-based sample: effects of time and syndemic conditions

INTRODUCTION

Little is known about onward HIV transmissions from people living with HIV (PLWH) in care. Antiretroviral therapy (ART) has increased in potency, and treatment as prevention (TasP) is an important component of ending the epidemic. Syndemic theory has informed modelling of HIV risk but has yet to inform modelling of HIV transmissions.

METHODS

Data were from 61,198 primary HIV care visits for 14,261 PLWH receiving care through the Centers for AIDS Research (CFAR) Network of Integrated Clinical Systems (CNICS) at seven United States (U.S.) sites from 2007 to 2017. Patient-reported outcomes and measures (PROs) of syndemic conditions - depressive symptoms, anxiety symptoms, drug use (opiates, amphetamines, crack/cocaine) and alcohol use - were collected approximately four to six months apart along with sexual behaviours (mean = 4.3 observations). Counts of syndemic conditions, HIV sexual risk group and time in care were modelled to predict estimated HIV transmissions resulting from sexual behaviour and viral suppression status (HIV RNA < 400/mL) using hierarchical linear modelling.

RESULTS

Patients averaged 0.38 estimated HIV transmissions/100 patients/year for all visits with syndemic conditions measured (down from 0.83, first visit). The final multivariate model showed that per 100 patients, each care visit predicted 0.05 fewer estimated transmissions annually (95% confidence interval (CI): 0.03 to 0.06; p < 0.0005). Cisgender women, cisgender heterosexual men and cisgender men of undisclosed sexual orientation had, respectively, 0.47 (95% CI: 0.35 to 0.59; p < 0.0005), 0.34 (95% CI: 0.20 to 0.49; p < 0.0005) and 0.22 (95% CI: 0.09 to 0.35; p < 0.005) fewer estimated HIV transmissions/100 patients/year than cisgender men who have sex with men (MSM). Each within-patient syndemic condition predicted 0.18 estimated transmissions/100 patients/year (95% CI: 0.12 to 0.24; p < 0.0005). Each between-syndemic condition predicted 0.23 estimated HIV transmissions/100 patients/year (95% CI: 0.17 to 0.28; p < 0.0005).

CONCLUSIONS

Estimated HIV transmissions among PLWH receiving care in well-resourced U.S. clinical settings varied by HIV sexual risk group and decreased with time in care, highlighting the importance of TasP efforts. Syndemic conditions remained a significant predictor of estimated HIV transmissions notwithstanding the effects of HIV sexual risk group and time in care.

Effect of Medicaid Expansions on HIV Diagnoses and Pre-Exposure Prophylaxis Use

INTRODUCTION

Increased insurance coverage and access to health care can increase identification of undiagnosed HIV infection and use of HIV prevention services such as pre-exposure prophylaxis. This study investigates whether the Medicaid expansions facilitated by the Affordable Care Act had these effects.

METHODS

A difference-in-differences design was used to estimate the effects of the Medicaid expansions using data on HIV diagnoses per 100,000 population, awareness of HIV status, and pre-exposure prophylaxis use. The analyses involved first calculating differences in new diagnoses and pre-exposure prophylaxis use before and after the expansions and then comparing these differences between treatment counties (i.e., all counties in states that expanded Medicaid) and control counties (i.e., all counties in states that did not expand Medicaid). Further analyses to investigate mechanisms addressed associations with HIV incidence, rates of sexually transmitted infections, and substance use. Analyses were conducted between August 2019 and July 2020.

RESULTS

Medicaid expansions were associated with an increase in HIV diagnoses of 0.508 per 100,000 population, or 13.9% (p=0.037), particularly for infections contracted via injection drug use and among low-income, rural counties with a high share of pre-Affordable Care Act uninsured rates that were most likely to be affected by the expansions. In addition, Medicaid expansions were associated with improvements in the knowledge of HIV status and pre-exposure prophylaxis use. There was no impact of the expansions on incident HIV, substance use, or sexually transmitted infection rates with the exception of gonorrhea, which decreased after the expansions. Altogether, these results suggest that the changes in new HIV diagnoses, awareness of HIV status, and pre-exposure prophylaxis were not simply because of a higher incidence or an increase in infection risk.

CONCLUSIONS

Medicaid expansions were associated with increases in the percentage of people living with HIV who are aware of their status and pre-exposure prophylaxis use. Expanding public health insurance may be an avenue for curbing the HIV epidemic.

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.

Trajectories of Viral Suppression in People Living With HIV Receiving Coordinated Care: Differences by Comorbidities

BACKGROUND

In March of 2013, the Los Angeles County (LAC) Division of HIV and STD Programs implemented a clinic-based Medical Care Coordination (MCC) Program to increase viral suppression (VS) (<200 c/mL) among people living with HIV (PLWH) at high risk for poor health outcomes.

OBJECTIVE

This study aimed to estimate trajectories of VS and to assess whether these trajectories differed by stimulant use, housing instability, and depressive symptom severity as reported by PLWH participating in MCC.

METHODS

Data represent 6408 PLWH in LAC receiving services from the MCC Program and were obtained from LAC HIV surveillance data matched to behavioral assessments obtained across 35 Ryan White Program clinics participating in MCC. Piecewise mixed-effects logistic regression with a random intercept estimated probabilities of VS from 12 months before MCC enrollment through 36 months after enrollment, accounting for time by covariate interactions for 3 comorbid conditions: housing instability, stimulant use, and depressive symptoms.

RESULTS

The overall probability of VS increased from 0.35 to 0.77 within the first 6 months in the MCC Program, and this probability was maintained up to 36 months after enrollment. Those who reported housing instability, stimulant use, or multiple comorbid conditions did not achieve the same probability of VS by 36 months as those with none of those comorbidities.

CONCLUSIONS

Findings suggest that MCC improved the probability of VS for all patient groups regardless of the presence of comorbidities. However, those with comorbid conditions will still require increased support from patient-centered programs to address disparities in VS.

An Examination of Geographic Differences in Social Determinants of Health Among Women with Diagnosed HIV in the United States and Puerto Rico, 2017

Objective:

To examine differences, at the census tract level, in the distribution of human immunodeficiency virus (HIV) diagnoses and social determinants of health (SDH) among women with diagnosed HIV in 2017 in the United States and Puerto Rico.

Background:

In the United States, HIV continues to disproportionately affect women, especially minority women and women in the South.

Methods:

Data reported in the National HIV Surveillance System (NHSS) of the Centers for Disease Control and Prevention were used to determine census tract-level HIV diagnosis rates and percentages among adult women (aged ≥18 years) in 2017. Data from the American Community Survey were combined with NHSS data to examine regional differences in federal poverty status, education level, income level, employment status, and health insurance coverage among adult women with diagnosed HIV infection in the United States and Puerto Rico.

Results:

In the United States and Puerto Rico, among 6,054 women who received an HIV diagnosis in 2017, the highest rates of HIV diagnoses generally were among those who lived in census tracts where the median household income was less than $40,000; at least 19% lived below the federal poverty level, at least 18% had less than a high school diploma, and at least 16% were without health insurance.

Conclusion:

This study is the first of its kind and gives insight into how subpopulations of women are affected differently by the likelihood of an HIV diagnosis. The findings show that rates of HIV diagnosis were highest among women who lived in census tracts having the lowest income and least health coverage.

HIV Prevalence Among Women Who Exchange Sex for Money or Drugs-4 U.S. Cities

BACKGROUND

Limited data exist in the United States on the prevalence of HIV among women who exchange sex.

SETTING

We estimate HIV prevalence of women who exchange sex from a 2016 survey in Chicago, Detroit, Houston, and Seattle and compare it with the prevalence of HIV among women of low socioeconomic status (SES), who did not exchange sex, and women in the general population.

METHODS

Women who exchange sex were recruited via respondent-driven sampling among some cities participating in National HIV Behavioral Surveillance, interviewed, and offered HIV testing. We estimate HIV prevalence and, using prevalence ratios, compare it with the prevalence among women of low SES who did not exchange sex in the 2013 National HIV Behavioral Surveillance cycle, and to women in the general population estimated using 2015 National HIV Surveillance data.

RESULTS

One thousand four hundred forty women reported exchange sex in 2016. Aggregated HIV prevalence was 4.9% [95% confidence interval (CI): 2.7 to 7.1] among women who exchanged sex, 1.6% (95% CI: 0.3 to 2.8) among women of low SES who did not exchange sex, and 0.6% (95% CI: 0.5% to 0.6%) among women in the general population. HIV prevalence among women who exchanged sex was 3.1 times (95% CI: 1.6 to 5.9) as high as among women of low SES who did not exchange sex, and 8.8 times (95% CI: 7.0 to 11.1) as high as among women in the general population.

CONCLUSION

HIV prevalence was significantly higher among women who exchanged sex compared with women in the general population and women of low SES who did not exchange sex.

Effective HIV Molecular Surveillance Requires Identification of Incident Cases of Infection

BACKGROUND

Ending the HIV epidemic requires knowledge of key drivers of spread of HIV infection.

METHODS

Between 1996 and 2018, 1119 newly and previously diagnosed, therapy-naïve persons with HIV (PWH) from San Diego were followed. A genetic distance-based network was inferred using pol sequences, and genetic clusters grew over time through linkage of sequences from newly observed infections. Cox proportional hazards models were used to identify factors associated with the rate of growth. These results were used to predict the impact of a hypothetical intervention targeting PWH with incident infection. Comparison was made to the CDC EHE molecular surveillance strategy, which prioritizes clusters recently linked to all new HIV diagnoses and does not incorporate data on incident infections.

RESULTS

Overall, 219 genetic linkages to incident infections were identified over a median follow-up of 8.8 years. Incident cluster growth was strongly associated with proportion of PWH in the cluster who themselves had incident infection. (HR 44.09; 95% CI: 17.09, 113.78). The CDC EHE molecular surveillance strategy identified 11 linkages to incident infections a genetic distance threshold of 0.5%, and 24 linkages at 1.5%.

CONCLUSIONS

Over the past two decades, incident infections drove incident HIV cluster growth in San Diego. The current CDC EHE molecular detection and response strategy would not have identified most transmission events arising from those with incident infection in San Diego. Molecular surveillance that includes detection of incident cases will provide a more effective strategy for EHE.

The acceptability and feasibility of a pilot study examining the impact of a mobile technology-based intervention informed by behavioral economics to improve HIV knowledge and testing frequency among Latinx sexual minority men and transgender women

Background

We developed a novel intervention that uses behavioral economics incentives and mobile-health text messages to increase HIV knowledge and testing frequency among Latinx sexual minority men and Latinx transgender women. Here we provide a theoretically-grounded assessment regarding the intervention’s acceptability and feasibility.

Methods

We conducted 30-min exit interviews with a stratified sample of participants (n = 26 Latinx sexual minority men, 15 Latinx transgender women), supplemented with insights from study staff (n = 6). All interviews were recorded, transcribed, and translated for a content analysis using Dedoose. Cohen’s Kappa was 89.4% across coded excerpts. We evaluated acceptability based on how participants cognitively and emotionally reacted to the intervention and whether they considered it to be appropriate. We measured feasibility based on resource, scientific and process assessments (e.g., functionality of text messaging service, feedback on study recruitment procedures and surveys).

Results

Regarding acceptability, most participants clearly understood the intervention as a program to receive information about HIV prevention methods through text messages. Participants who did not complete the intervention shared they did not fully understand what it entailed at their initial enrollment, and thought it was a one-time engagement and not an ongoing program. Though some participants with a higher level of education felt the information was simplistic, most appreciated moving beyond a narrow focus on HIV to include general information on sexually transmitted infections; drug use and impaired sexual decision-making; and differential risks associated with sexual positions and practices. Latinx transgender women in particular appreciated receiving information about Pre-Exposure Prophylaxis. While participants didn’t fully understand the exact chances of winning a prize in the quiz component, most enjoyed the quizzes and chance of winning a prize. Participants appreciated that the intervention required a minimal time investment. Participants shared that the intervention was generally culturally appropriate. Regarding feasibility, most participants reported the text message platform worked well though inactive participants consistently said technical difficulties led to their disengagement. Staff shared that clients had varying reactions to being approached while being tested for HIV, with some unwilling to enroll and others being very open and curious about the program. Both staff and participants relayed concerns regarding the length of the recruitment process and study surveys.

Conclusions

Our theoretically-grounded assessment shows the intervention is both acceptable and feasible.

Trial registration

The trial was registered on May 5, 2017 with the ClinicalTrials.gov registry [NCT03144336].

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10335-5.

Awareness and uptake of pre-exposure prophylaxis for HIV among low-income, HIV-negative heterosexuals in San Francisco

We examined pre-exposure prophylaxis (PrEP) awareness and uptake among low-income heterosexual men and women in San Francisco in 2019. Of 294 HIV-negative survey participants, 42.5% were aware of PrEP. Few women (12.5%) and men (8.9%) had discussed PrEP with a healthcare provider; 3.8% of women and 0% of men had used PrEP in the last year. White participants (adjusted odds ratio (aOR) 5.39, 95% CI 1.02, 28.56), women (aOR 2.19, 95% CI 1.30, 3.70), and age 60 years or above (aOR 4.00, 95% CI 1.12, 14.34) had greater odds of being aware of PrEP. Testing for HIV or sexually transmitted infection in the past year was marginally associated with a greater PrEP awareness. Our findings reveal gaps in PrEP implementation associated with social disparities among low-income heterosexuals. Testing services and targeted promotional and educational materials are needed lest high-risk, low-income populations are left behind in San Francisco's aggressive "Getting to Zero" efforts.

Analysis of the Driving Factors of Active and Rapid Growth Clusters Among CRF07_BC-Infected Patients in a Developed Area in Eastern China

Background

The purpose of this study was to research the molecular transmission and genetic evolutionary characteristics among CRF07_BC-infected patients in a developed area in Eastern China.

Methods

Plasma samples from newly diagnosed HIV-1-positive patients from 2015–2018 and basic demographic and epidemiological information were obtained. Pol sequences from CRF07_BC-infected patients were selected for phylogenetic, molecular transmission network, and Bayesian evolutionary analyses.

Results

Pol sequences were successfully obtained from 258 samples of CRF07_BC. Phylogenetic analysis revealed 2 distinct lineages: lineage 1 (66.3%, 171/258), primarily from men who have sex with men (MSM) and some heterosexual individuals, and lineage 2 (33.7%, 87/258), primarily from heterosexual individuals. Under an optimal genetic distance of 0.01 substitutions/site, 163 individuals (63.2%, 163/258) formed 23 groups comprising 6 clusters and 17 dyads in the networks. A distinctly large and rapidly growing cluster (C1) containing 105 individuals was identified, in which MSM with ≥4 links had quite a high transmission risk (low educational background, active sexual behavior, low sexual protection awareness, etc.). According to Bayesian analyses, most C1 clades formed from 2005 to 2009, most of which were closely geographically related to CRF07_BC epidemic strains from Anhui province.

Conclusions

Here, we elucidated the local transmission characteristics and epidemic pattern of HIV-1 CRF07_BC, revealing that MSM (especially with ≥4 links) may be a significant driver in the formation of active and rapid growth networks in regional CRF07_BC epidemics. Thus, unique region– and risk group–specific transmission network analysis based on a molecular approach can provide critical and insightful information for more effective intervention strategies to limit future HIV-1 transmission.

Advance Care Planning-Complex and Working: Longitudinal Trajectory of Congruence in End-of-Life Treatment Preferences: An RCT

CONTEXT

The effect of advance care planning (ACP) interventions on the trajectory of end-of-life treatment preference congruence between patients and surrogate decision-makers is unstudied.

OBJECTIVE

To identify unobserved distinctive patterns of congruence trajectories and examine how the typology of outcome development differed between ACP and controls.

METHODS

Multisite, assessor-blinded, intent-to-treat, randomized clinical trial enrolled participants between October 2013 to March 2017 from 5 hospital-based HIV clinics. Persons living with HIV(PLWH)/surrogate dyads were randomized to 2 weekly 60-minute sessions: ACP (1) ACP facilitated conversation, (2) advance directive completion; or Control (1) Developmental/relationship history, (2) Nutrition/Exercise. Growth Mixed Modeling was used for 18-month post-intervention analysis.

FINDINGS

223 dyads (N = 449 participants) were enrolled. PLWH were 56% male, aged 22 to 77 years, and 86% African American. Surrogates were 56% female, aged 18 to 82 years, and 84% African American. Two latent classes (High vs. Low) of congruence growth trajectory were identified. ACP influenced the trajectory of outcome growth (congruence in all 5 AIDS related situations) by latent class. ACP dyads had a significantly higher probability of being in the High Congruence latent class compared to controls (52%, 75/144 dyads versus 27%, 17/62 dyads, p = 0.001). The probabilities of perfect congruence diminished at 3-months post-intervention but was then sustained. ACP had a significant effect (β = 1.92, p = 0.006, OR = 7.10, 95%C.I.: 1.729, 26.897) on the odds of being in the High Congruence class.

CONCLUSION

ACP had a significant effect on the trajectory of congruence growth over time. ACP dyads had 7 times the odds of congruence, compared to controls. Three-months post-intervention is optimal for booster sessions.

A systematic review of early adoption of implementation science for HIV prevention or treatment in the United States

OBJECTIVE

To provide the first systematic review of the early adoption of implementation science for HIV prevention or treatment in the United States. We identified primary research studies that addressed implementation of HIV prevention or treatment in the United States and qualitatively assessed the reporting of implementation outcomes and intervention descriptions.

METHODS

We searched PubMed, PsycInfo, and CINAHL databases for evaluations of HIV prevention or treatment interventions that at least reported one implementation outcome and were published between 2014 and 2018. We used the 12-item Template for Intervention Description and Replication to assess study interventions.

RESULTS

A total of 2275 articles were identified. Thirty-nine studies met inclusion criteria. Of these, 84.6% used quantitative methods with 5% being hybrid effectiveness-implementation studies and 15% used qualitative methods. No studies cited a formal theoretical framework for implementation science. Acceptability and feasibility were the most frequently reported implementation outcomes. Eligible studies were diverse with regard to demographic categories. Most interventions focused on HIV prevention, particularly risk-reduction strategies. HIV treatment interventions targeted linkage to care and adherence to medications. Key implementation outcome findings indicated that these interventions are feasible and acceptable in the real world.

CONCLUSION

HIV implementation science could support dissemination of HIV prevention or treatment in the United States, although HIV treatment interventions are limited. Theoretical frameworks and key implementation outcomes like fidelity, penetration, and appropriateness could promote the rigor of future HIV treatment implementation research, helping the field deliver the promise of HIV prevention or treatment efforts in the United States.

Good Functional Outcomes and Low Infection Rates in Total Hip Arthroplasty in HIV-Positive Patients, Provided There Is Strict Compliance With Highly Active Antiretroviral Therapy

BACKGROUND

Patients with HIV are more likely to require a total hip arthroplasty (THA) because of an increase in life expectancy and complications with HIV. The purpose of this study is to describe the mid-term outcomes of THA in HIV-positive patients and risk factors for postoperative infections and poor outcomes.

METHODS

This is a single-center retrospective review of nonhemophiliac HIV-positive patients who underwent THA. We reviewed the short- and mid-term readmission and complication rates.

RESULTS

Eighty-seven patients underwent 102 THAs. The average age was 58 years (24-73 years). The average body mass index was 31.6 (18-55). The average CD4+ count was 569 cells per cubic millimeter (mm³) (51-1480), and the mean viral load was <40 copies/mL (undetectable-380 000). The mean follow-up time was 6.7 years (24 months- 8.3 years). Four patients had postoperative complications within 30 days. Seven patients had postoperative complications after 30 days; 5 of which had septic loosening of implants and had either not been initiated on or were noncompliant with their highly active antiretroviral therapy. The average postoperative Harris Hip Score was 81 (41-100) and Oxford Hip Score was 43.43 (34-48). There was no correlation the between CD4+ count and viral load with complications.

CONCLUSION

Low rate of complications and revision is achievable in the HIV-positive, nonhemophilic arthroplasty population contrary to published literature. An important factor ensuring good long-term outcomes in HIV-positive patients undergoing THA was the initiation of highly active antiretroviral therapy before the procedure and ensuring patient compliance with therapy after joint arthroplasty.

Benchmarks for HIV Testing: What Is Needed to Achieve Universal Testing Coverage at U.S. Ambulatory Healthcare Facilities

BACKGROUND

Black and Hispanic men have the highest rates of HIV diagnoses. To decrease the number of U.S. men who are unaware of their HIV status, they should be tested at least once. Our objective was to estimate the increases needed in HIV testing rates at ambulatory health care visits to achieve universal coverage.

METHODS

We analyzed nationally representative medical record abstraction data to estimate the number of visits per person to physician offices, emergency departments, and outpatient clinics among men aged 18-39 years during 2009-2016, and the percentage of visits with an HIV test. We calculated the increase in the percentage of visits with an HIV test needed to achieve universal testing coverage of men by age 39 years.

RESULTS

Men had a mean of 75.3 million ambulatory visits per year and 1.67 visits per person. An HIV test was performed at 0.9% of the ambulatory visits made by white men, 2.5% by black men, and 2.4% by Hispanic men. A 3-fold increase in the percentage of visits with an HIV test would result in coverage of 46.2% of white, 100% of black, and 100% of Hispanic men; an 11-fold increase would be needed to result in coverage of 100% of white men.

CONCLUSIONS

HIV testing rates of men at ambulatory health care visits were too low to provide HIV testing coverage of all men by aged 39 years. A 3-fold increase in the percentage of visits with an HIV test would result in universal testing coverage of black and Hispanic men by age 39 years.

The last Black man with HIV in San Francisco: the potential role of gentrification on HIV getting to zero achievements

San Francisco was the first city in the USA to develop a Getting to Zero HIV elimination strategy. The cause of decreased HIV incidence has been attributed to the use of biomedical prevention methods, such as pre-exposure prophylaxis (PrEP) and treatment as prevention (TasP). These strategies have benefitted White men who have sex with men (MSM), whose population has increased over the past decade. However, Black MSM in San Francisco continue to have higher HIV incidence and outmigration rates. We posit that the declining overall HIV incidence, including among White MSM, is not only explained by the use of TaSP and PrEP, but is also due to the declining Black population and rising HIV incidence among Black MSM, who have historically been more likely to acquire HIV due to structural, racial, and criminal justice-related factors than have White MSM.

The Contribution of HIV Testing Funded by the Centers for Disease Control and Prevention to HIV Diagnoses in the United States, 2010-2017

Understanding the contribution of CDC-funded testing toward diagnosing HIV informs efforts to end the HIV epidemic. Due to differences in surveillance data and CDC program data, which sometimes rely on self-reported information, the number of new diagnoses cannot be directly compared. CDC recently asked grantees to check surveillance data to inform the identification of new diagnoses from CDC-funded tests. In this analysis, we use this newly available information to estimate the percent of all HIV diagnoses from 2010 to 2017 in the United States that result from CDC-funded tests. Among tests with surveillance information, correlates of correct categorization using self-report only were assessed. Weights were calculated from that analysis and used to estimate the total number of CDC-funded new diagnoses. Estimates are presented overall and by demographics/transmission risk group. We estimate that one third of all HIV diagnoses in the United States from 2010 to 2017 resulted from a CDC-funded test. The percent of diagnoses that resulted from CDC-funded tests was higher among some high-risk groups: 41% among 20-29-year-olds and 39% among blacks/African Americans. When compared to total diagnoses in the United States from 2010 to 2017, a large proportion resulted from CDC-funded tests, particularly among young individuals and blacks/African Americans. CDC's contribution to new HIV diagnoses was previously unknown. CDC-funded testing is an important part of the national effort to diagnose all people with HIV as early as possible after infection.

Exploring influences on methamphetamine use among Black gay, bisexual and other men who have sex with men in Atlanta: A focus group study

BACKGROUND

Methamphetamine use is a contributor to HIV risk and poor health outcomes among gay, bisexual and other men who have sex with men (GBMSM). There is a paucity of research examining methamphetamine use and its social context specifically among Black GBMSM. We therefore sought to: (1) describe trends in methamphetamine use among Black GBMSM in Atlanta, Georgia, and (2) examine the risk environment (micro-, meso‑ and macro-level factors operating in the political, social, physical, economic, and healthcare environments) that might elevate risk for methamphetamine use in this population.

METHODS

We conducted a qualitative study consisting of eight focus groups with 54 key informants between December 2019 and March 2020. Participants represented community-based and healthcare organizations that work closely with Black GBMSM. Our thematic analysis included an iterative, team coding approach combining deductive and inductive elements.

RESULTS

Participants unanimously agreed that methamphetamine use was increasingly prevalent among Black GBMSM in Atlanta, with many describing a historical arc in which methamphetamine use - previously associated with predominantly white, affluent GBMSM - was now common among younger, lower socioeconomic status Black GBMSM. At the micro-level, participants described contributors to increasing methamphetamine use including use as a sex drug, and the interrelated burdens of stress and mental illness, housing instability, geographic mobility and poverty. At the meso‑level, participants described virtual and physical sex scenes including use of geosocial networking apps that facilitated the spread of methamphetamine use in the Black GBMSM community. At the macro-level, participants described how policies prioritizing other concerns (e.g., HIV, opioids) seemed to limit resources available for methamphetamine prevention and treatment programming.

CONCLUSION

Multi-level environmental influences are working together to elevate risk for methamphetamine use among Black GBMSM in Atlanta, with potential to adversely impact health and well-being and undermine HIV prevention and treatment efforts.

The continuing HIV epidemic among men who have sex with men and transgender women in the ASEAN region: implications for HIV policy and service programming

Men who have sex with men (MSM) in Western urban areas have seen substantive decreases in new diagnoses of HIV infection. This paper explores whether such declines are present among MSM and transgender women (TGW) in Southeast Asia and discusses implications for HIV policies and programming. A scoping review was conducted of scientific publications and selected documents regarding the spread of HIV infection among MSM and TGW in major urban centres of the Association of Southeast Asian Nations (ASEAN) region. Continued high HIV prevalence and incidence among MSM are found in integrated behavioural and biological surveillance (IBBS) and research studies. HIV prevalence among MSM under IBBS decreased only in Bangkok from 28.6% in 2014 to 10.3% in 2018, whereas it was increasing in Kuala Lumpur, Ho Chi Minh City, Vientiane, and Phnom Penh. HIV/AIDS case reports regarding new HIV infection diagnoses among MSM have started to decrease in Singapore since 2011 and have been plateauing in Metropolitan Manila since 2017. Where data were available, it was found that HIV prevalence among TGW was high and if IBBS was conducted, it was increasing. HIV prevalence among TGW under IBBS in Jakarta had risen to 34.0% (2015) and 14.0% (2019) in Phnom Penh. These findings suggest that most ASEAN member states have so far failed to effectively implement and scale-up scientifically proven biomedical HIV prevention measures and counter stigma and discrimination that impedes access to appropriate HIV prevention and treatment services for MSM and TGW.

Prevention of Perinatal HIV Transmission in an Area of High HIV Prevalence in the United States

OBJECTIVE

To evaluate the uptake of perinatal HIV preventive interventions by the risk of perinatal HIV transmission in mother-infant pairs in a high-HIV prevalence area in the US.

STUDY DESIGN

This was a retrospective cohort study of mother-infant pairs with perinatal HIV exposure during 2013-2017 managed at a subspecialty pediatric HIV program in Washington, DC. We collected demographic data, maternal HIV history, delivery mode, maternal and infant antiretroviral drug (ARV) use, and infant HIV test results. We compared the uptake of recommended preventive interventions in low-risk (ie, mothers on antiretroviral therapy [ART] with viral suppression) and high-risk (mothers without ART or viral suppression) mother-infant pairs using the Pearson chi-square, Fisher exact, and Wilcoxon rank-sum tests and logistic regression.

RESULTS

We analyzed 551 HIV-exposed infants (HEIs) and 542 mothers living with HIV. The majority of mothers received ARVs (95.5%), had HIV RNA ≤1000 copies/mL before delivery (81.9%), and received intrapartum zidovudine (ZDV; 65.5%). The majority of all HEIs were low risk (82.6%) and received postpartum ARVs (98.9%). Among the low-risk infants, 53.2% were delivered via cesarean delivery (CD), and 62.9% and 96.5% were administered intrapartum and postpartum ZDV, respectively. Among high-risk infants, 84.4% were delivered via CD, 78.1% received intrapartum ZDV, and 62.5% received combination ART. Nine high-risk infants acquired HIV perinatally.

CONCLUSION

In an area of high HIV prevalence in the US, a large proportion of low-risk HEIs received intrapartum ZDV and were delivered via CD. We also observed missed opportunities for the prevention of perinatal HIV transmission.

The interplay between HIV and COVID-19: summary of the data and responses to date

PURPOSE OF REVIEW

We examine the interplay between the HIV and COVID-19 epidemics, including the impact of HIV on COVID-19 susceptibility and severe disease, the effect of the COVID-19 epidemic on HIV prevention and treatment, and the influence of the HIV epidemic on responses to COVID-19.

RECENT FINDINGS

Evidence to date does not suggest that people living with HIV (PLWH) have a markedly higher susceptibility to SARS-CoV-2 infection, with disparities in the social determinants of health and comorbidities likely having a greater influence. The majority of literature has not supported a higher risk for severe disease among PLWH in Europe and the United States, although a large, population-based study in South Africa reported a higher rate of death due to COVID-19. Higher rates of comorbidities associated with COVID-19 disease severity among PLWH is an urgent concern. COVID-19 is leading to decreased access to HIV prevention services and HIV testing, and worsening HIV treatment access and virologic suppression, which could lead to worsening HIV epidemic control.

CONCLUSION

COVID-19 is threatening gains against the HIV epidemic, including the U.S. Ending the HIV Epidemic goals. The ongoing collision of these two global pandemics will continue to need both study and interventions to mitigate the effects of COVID-19 on HIV efforts worldwide.

CDC's Community-Based Organization Behavioral Outcomes Project: Perspectives for Researchers, Implementers and Funders

Behavioral interventions have been a crucial tool for the prevention of HIV transmission since early in the epidemic. The Centers for Disease Control and Prevention (CDC) has provided funding for evidence-based behavioral interventions (EBIs) at health departments and community-based organizations (CBOs) since 2004. From 2006 to 2015, CDC funded 25 CBOs to evaluate one or more of seven EBIs designed to prevent HIV through the Community-based Organization Behavioral Outcomes Project (CBOP) as implemented outside of a research setting. For each EBI, CBOP showed that most HIV risk behaviors improved after the intervention, and improvements were similar to those observed in research studies. Our findings show that behavioral interventions can be successfully implemented in real-world settings. Although the focus of HIV prevention has largely shifted toward biomedical interventions in recent years, successful implementation often depends on behavioral components. Lessons from CBOP can inform future efforts to develop and implement behavioral interventions for HIV and other areas of public health.

Assessing self-reported discrimination among men who have sex with men (MSM)

OBJECTIVES

To determine the prevalence of four forms of sexual identity discrimination among MSM in 23 US metropolitan statistical areas, examine racial/ethnic and socioeconomic disparities in each form of discrimination.

METHODS

We examined interview data collected during 2017 for National HIV Behavioral Surveillance (n = 10 029 respondents) and used generalized linear models to assess the association between the prevalence of reported discrimination during the previous 12 months and selected sociodemographic groups.

RESULTS

Overall, 34% of participants reported experiencing verbal discrimination; 16%, discrimination in a workplace, school, or a healthcare setting; and 8%, physical assault. MSM who had reported experiencing discrimination were most likely to be young, had achieved lower education, and had lower incomes. High prevalence of reported discrimination was associated with young age, lower education, lower household income, sexual identity disclosure, and lower perceived community tolerance of gay or bisexual persons.

CONCLUSION

MSM discrimination affects different groups and occurs in multiple settings. Addressing discrimination should be an integral aspect of multifaceted efforts to improve MSM health.

Effect of Truvada lawsuit advertising on preexposure prophylaxis attitudes and decisions among sexual and gender minority youth and young adults at risk for HIV

OBJECTIVE

In 2019, US advocates reported misleading language regarding the safety of TDF/FTC (Truvada) used by lawsuit advertisements against Gilead Sciences. We sought to ascertain the reach and effects of the advertisements on preexposure prophylaxis (PrEP) opinions and decisions in a cohort of youth and young adults at-risk for HIV.

DESIGN

An online survey was administered to participants enrolled in Keeping it LITE, a prospective US cohort study of ethnically diverse, sexually active, cisgender and transgender persons ages 13-37.

METHODS

Quantitative data were analyzed using descriptive and inferential analysis in SAS, and qualitative data via thematic analysis.

RESULTS

Survey response rate was 51.3% (n = 1485). Mean age at baseline was 24. Previous PrEP use was reported by 43% of respondents and 32.7% reported PrEP use in the past 6 months. Almost half (48.7%) were aware of the lawsuit. Most of these participants (81.3%) reported the advertisements did not impact their PrEP use, but 13.2% decided to not to begin a Truvada-based PrEP regimen and 5.5% decided to stop taking Truvada due to the advertisements claims. Predictors of changing PrEP behavior were lower education and no previous PrEP use. The qualitative analysis revealed the advertisements increased skepticism about safety and benefit of Truvada PrEP and led to greater distrust of the pharmaceutical industry.

CONCLUSION

The advertisements reached a large, diverse US audience. Disturbingly, 18.7% of PrEP candidates who were aware of the lawsuit attributed not initiating or cessation of a Truvada-based PrEP regimen to exposure to the Truvada lawsuit advertisements.

Rapid mixed-methods assessment of COVID-19 impact on Latinx sexual minority men and Latinx transgender women

We conducted a rapid, mixed-methods assessment to understand how COVID-19 affected Latinx sexual minority men (LSMM) and transgender women (LTGW). Using a computer-assisted telephone interviewing software, one interviewer called 52 participants (randomly sampled from a larger HIV prevention pilot study aiming to increase HIV knowledge and testing frequency; n = 36 LSMM and n = 16 LTGW) between 04/27/20-05/18/20. We quantified core domains using the Epidemic-Pandemic Impacts Inventory scale and provided important context through open-ended qualitative questions assessing: 1) COVID-19 infection history and experiences with quarantine; 2) Health and healthcare access; 3) Employment and economic impact of COVID-19. Participants reported increases in physical conflict or verbal arguments with a partner (13.5%) or other adult(s) (19.2%) due to stressors associated with the safer-at-home order. Participants also reported increased alcohol consumption (23.1%), problems with sleep (67.3%) and mental health (78.4%). Further, disruptions in access to Pre-Exposure Prophylaxis or PrEP-a daily pill to prevent HIV-occurred (33.3% of 18 participants who reported being on PrEP). Many said they received less medical attention than usual (34.6%), and LTGW reported delays in critical gender-affirming hormones/procedures. Half of the participants lost their jobs (50.0%); many undocumented participants relayed additional financial concerns because they did not qualify for financial assistance. Though no COVID-19 infections were noted, COVID-19 dramatically impacted other aspects of health and overall wellbeing of LSMM and LTGW. Public health responses should address the stressors faced by LSMM and LTGW during the COVID-19 pandemic and the impact on wellbeing.

Knowledge needs for implementing HIV pre-exposure prophylaxis among primary care providers in a safety-net health system

Safety-net health systems are a primary source of care for socioeconomically disadvantaged individuals who may be eligible for HIV pre-exposure prophylaxis (PrEP) and are priority groups under the Ending the HIV Epidemic (EHE) initiative. Nevertheless, little evidence is available about barriers to PrEP implementation in safety-net settings. We aimed to assess the association between PrEP knowledge and prescribing practices, and to ascertain unmet knowledge needs to implement PrEP. In 2019, we surveyed primary care providers (PCPs) in a safety-net health system that serves an EHE priority jurisdiction located in North Texas. Our questionnaire ascertained self-reported prescribing practices, knowledge, and training needs related to PrEP. We used penalized logistic regression to estimate odds ratio (OR) and 95% posterior limits (PL) for the association between provider self-rated knowledge of PrEP and PrEP prescribing. Our study population comprised 62 primary care providers, of whom 61% were female, 60% were non-Hispanic White, 76% were physicians (76%), 57% had ≥ 10 years of practice experience, 45% reported low self-rated PrEP knowledge, and 35% prescribed PrEP in the past year. Providers with low PrEP knowledge had 69% lower odds of prescribing PrEP within the past year (OR = 0.31, 95% PL: 0.12, 0.82). Eligibility for PrEP, side effects and adherence concerns were key unmet knowledge needs. Our findings suggest that low provider PrEP knowledge may be a barrier to PrEP prescribing among safety-net PCPs. Our results provide insight about specific educational needs of PCPs in a safety-net health system, which are amenable to educational intervention.

Annual and durable HIV retention in care and viral suppression among patients of Peter Ho Clinic, 2013-2017

Objectives

To determine rates of annual and durable retention in medical care and viral suppression among patients enrolled in the Peter Ho Clinic, from 2013–2017.

Methods

This is a retrospective review of medical record data in an urban clinic, located in Newark, New Jersey, a high prevalence area of persons living with HIV. Viral load data were electronically downloaded, in rolling 1-year intervals, in two-month increments, from January 1, 2013 to December 31, 2019. Three teams were established, and every two months, they were provided with an updated list of patients with virologic failure. Retention and viral suppression rates were first calculated for each calendar-year. After patients were determined to be retained/suppressed annually, the proportion of patients with durable retention and viral suppression were calculated in two, three, four, five and six-year periods. Descriptive statistics were used to summarize sample characteristics by retention in care, virologic failure and viral suppression with Pearson Chi-square; p-value <0.05 was statistically significant. Multiple logistic regression models identified patient characteristics associated with retention in medical care, virologic failure and suppression.

Results

As of December 31, 2017, 1000 (57%) patients were retained in medical care of whom 870 (87%) were suppressed. Between 2013 and 2016, decreases in annual (85% to 77%) and durable retention in care were noted: two-year (72% to 70%) and three-year (63% to 59%) periods. However, increases were noted for 2017, in annual (89%) and durable retention in the two-year period (79%). In the adjusted model, when compared to current patients, retention in care was less likely among patients reengaging in medical care (adjusted Odds Ratio (aOR): 0.77, 95% CI: 0.61–0.98) but more likely among those newly diagnosed from 2014–2017 (aOR: 1.57, 95% CI: 1.08–2.29), compared to those in care since 2013. A higher proportion of patients re-engaging in medical care had virologic failure than current patients (56% vs. 47%, p < 0.0001). As age decreased, virologic failure was more likely (p<0.0001). Between 2013 and 2017, increases in annual (74% to 87%) and durable viral suppression were noted: two-year (59% to 73%) and three-year (49% to 58%) periods. Viral suppression was more likely among patients retained in medical care up to 2017 versus those who were not (aOR: 5.52, 95% CI: 4.08–7.46). Those less likely to be suppressed were 20–29 vs. 60 years or older (aOR: 0.52, 95% CI: 0.28–0.97), had public vs. private insurance (aOR: 0.29, 95% CI: 0.15–0.55) and public vs. private housing (aOR: 0.59, 95% CI: 0.40–0.87).

Conclusions

Restructuring clinical services at this urban clinic was associated with improved viral suppression. However, concurrent interventions to ensure retention in medical care were not implemented. Both retention in care and viral suppression interventions should be implemented in tandem to achieve an end to the epidemic. Retention in care and viral suppression should be measured longitudinally, instead of cross-sectional yearly evaluations, to capture dynamic changes in these indicators.

Integrated Pharmacy and PrEP Navigation Services to Support PrEP Uptake: A Quality Improvement Project

Preexposure prophylaxis (PrEP) is highly effective in preventing HIV among both men and women, with the reduction in risk directly linked to medication adherence. Navigation services and other adherence interventions have demonstrated efficacy in medication uptake; however, their use may not be fully integrated into clinic operations or their roles clearly defined. This quality improvement (QI) project developed an evidenced-based PrEP Navigation (PN) tool to identify patient-reported barriers to uptake and to support process improvement at a large community health center in Washington, DC. Outcomes related to patient-reported barriers, patient demographics, and time to medication pickup from the pharmacy were measured before and after implementation. A total of 198 patients were included in this analysis. Mean days from initial prescription to medication pickup was reduced by 1.42 days (p = .030) following PN tool implementation. The evidenced-based PN tool is modifiable to the needs of the individual clinic and the patients they care for to support wide-scale PrEP uptake and continuous system process improvements.