HIV among women in the District of Columbia: an evolving epidemic?

Ending the HIV epidemic using National HIV Behavioral Surveillance (NHBS): Recommendations based on DC model

INTRODUCTION

Social network strategies have been used by health departments to identify undiagnosed cases of HIV. Heterosexual cycle (HET4) of National HIV Behavioral Surveillance (NHBS) is a social network strategy implemented in jurisdictions. The main objectives of this research are to 1) evaluate the utility of the NHBS HET cycle data for network analysis; 2) to apply statistical analysis in support of previous HIV research, as well as to develop new research results focused on demographic variables and prevention/intervention with respect to heterosexual HIV risk; and 3) to employ NHBS data to inform policy with respect to the EHE plan.

METHOD

We used data from the 2016 NHBS HET4 (DC). A total of 747 surveys were collected. We used the free social-network analysis package, GEPHI, for all network visualization using adjacency matrix representation. We additionally conducted logistic regression analysis to examine the association of selected variables with HIV status in three models representing 1) demographic and economic effects, 2) behavioral effects, and 3) prevention-intervention effects.

RESULTS

The results showed 3% were tested positive. Seed 1 initiated the largest networks with 426 nodes (15 positives); seed 4 with 273 nodes (6 positives). Seed 3 had 35 nodes (2 positives). All 23 HIV diagnoses were recruited from 4 zip-codes across DC. The risk of testing positive was higher among people high-school dropouts (Relative Risk (RR) (25.645); 95 CI% 5.699, 115.987), unemployed ((4.267); 1.295, 14.064), returning citizens ((14.319); 4.593, 44.645). We also found in the final model higher association of pre-exposure prophylaxis (PrEP) awareness among those tested negative ((4.783); 1.042, 21.944) and HIV intervention in the past 12 months with those tested positive ((17.887); 2.350,136.135).

CONCLUSION

The network visualization was used to address the primary aim of the analysis-evaluate the success of the implementation of the NHBS as a social network strategy to find new diagnoses. NHBS remains one of the strongest behavioral supplements for DC's HIV planning activities. As part of the evaluation process our analysis helps to understand the impact of demographic, behavioral, and prevention efforts on peoples' HIV status. We strongly recommend other jurisdictions use network visualizations to evaluate the efficacy in reaching hidden populations.

HIV Sexual Risk and Syndemics among Women in Three Urban Areas in the United States: Analysis from HVTN 906

Limited data are available on the longitudinal occurrence of syndemic factors among women at risk for HIV infection in the USA and how these factors relate to sexual risk over time. HVTN 906 was a longitudinal study enrolling 799 HIV-uninfected women in three cities. Assessments were done at baseline, 6, 12, and 18 months to assess syndemic factors (low education, low income, unemployment, lack of health insurance, housing instability, substance use, heavy alcohol use, partner violence, incarceration) and sexual risk outcomes. For each sexual risk outcome, a GEE model was fit with syndemic factors or syndemic score (defined as sum of binary syndemics, ranging from 0 to 9), visit, study site, age and race/ethnicity as predictors to examine the multivariable association between syndemic factors and outcomes over time. Odds of unprotected sex while drunk or high were significantly higher when women reported lack of health insurance, substance and heavy alcohol use and partner violence. Housing instability, substance and heavy alcohol use, partner violence and recent incarceration were associated with higher odds of having multiple sexual partners. Odds of sex exchange were significantly higher in the presence of unemployment, housing instability, low education, lack of health insurance, substance and heavy alcohol use, partner violence and incarceration. Housing instability, substance and heavy alcohol use, and partner violence were significantly associated with higher odds of unprotected anal sex. Odds of having a recent STI were significantly higher when women reported housing instability and partner violence. There were significantly higher odds of the reporting of any risk outcomes during follow-up with higher syndemic score. This study highlights a group of women experiencing multiple poor social and health outcomes who need to be the focus of comprehensive interventions.

Using the National HIV Behavioral Surveillance System to inform HIV prevention efforts in the United States

The National HIV Behavioral Surveillance system (NHBS) was designed to monitor HIV prevalence and risk factors for infection among higher-risk individuals, i.e., sexually active men who have sex with men who attend venues, injection drug users who injected in the past 12 months, and heterosexuals living in low socioeconomic urban areas. These groups were selected as priorities for behavioral surveillance since they represent the major HIV transmission routes and the populations with the highest HIV burden. NHBS contributes to the nation's program of HIV surveillance by being the only multi-site population-based system that provides estimates on key HIV prevention measures among high-risk HIV-negative individuals, HIV-positive individuals unaware of their infection, and HIV-positive individuals aware of their infection who are in and out of care. Accurate and precise data on the behaviors in these populations are critical for tracking the epidemic, planning effective responses, and monitoring and evaluating those responses. Reports in this supplement illustrate the uses of NHBS data at the national and local level and reflect ongoing efforts to improve the system and remains essential for characterizing and monitoring the burden of HIV infection and sexual and behavioral risks.