Evidence of Local HIV Transmission in the African Community of King County, Washington

Post-migration HIV acquisition among african immigrants in the U.S

BACKGROUND

African immigrants in the U.S. are more likely to have a late HIV diagnosis than U.S.-born people, potentially leading to onward transmission. We sought to determine the proportion of African-born people living with HIV (APLWH) who (1) had tested HIV negative prior to diagnosis, and (2) likely acquired HIV in the U.S.

METHODS

We interviewed APLWH from 2014 to 2017 and estimated the proportion with post-migration HIV acquisition based on clinical data, HIV testing history, immigration date, and behavioral data.

RESULTS

Of 179 participants, 113 (63%) were women. Less than half (44%) reported a negative HIV test prior to diagnosis. Among 142 (79%) participants with sufficient data to evaluate post-migration HIV acquisition, we estimate that 29% acquired HIV post-migration. Most APLWH acquire HIV prior to immigration.

DISCUSSION

Approximately one-quarter of APLWH acquire HIV post-migration and HIV testing is infrequent, highlighting the need for prevention efforts for African immigrants in the U.S.

Barriers to HIV Pre-Exposure Prophylaxis Uptake and Ways to Mitigate Them: Perspectives of Ghanaian Immigrants in the United States

African immigrants in the United States experience disparities in HIV incidence. Pre-exposure prophylaxis (PrEP) effectively prevents HIV infection, yet uptake is low among racial and ethnic minorities. To better understand PrEP adoption among African immigrants, in March 2020, we conducted interviews with Ghanaian immigrants (N = 40) to explore the barriers and ways to overcome these barriers to PrEP adoption. Participants described several barriers (e.g., low HIV knowledge and risk perception, fear of social judgment, cultural values, and norms), which may impede PrEP adoption. We categorized these barriers according to the levels of the socioecological model (individual, interpersonal, community, and organizational/structural factors). Participants also identified strategies to overcome the barriers, such as providing comprehensive education on HIV and PrEP. Our research provides foundational knowledge that can inform future PrEP research with Ghanaian and other African immigrants and offers important insights into factors that may impact PrEP adoption in this population.

Evaluation of Undiagnosed HIV Estimates Computed from the CD4 Depletion Model in a Rural, Medium-low HIV Prevalence State

The CD4 depletion model estimates diagnosis delays by approximating infection date from CD4 T-cell count at diagnosis, and back-calculation can compute the proportion of undiagnosed PLWHA. The model assumes the immigration of PLWHA to the U.S. is negligible and counts as a transmission event, which may be impractical outside high prevalence states. Duration of U.S. residency among foreign-born PLWHA and diagnosis delays were compared. The impact on estimates of undiagnosed PLWHA was tested through simulation with different proportions of foreign-born people assumed to have acquired HIV abroad. In 67% of foreign-born people, the mean (SD) years of delay (9.9 (6.3)) exceeded the duration of U.S. residency (2.0 (1.9)). Additionally, inaccuracies in the estimates for proportions of undiagnosed PLWHA were pronounced when foreign-born people who acquired HIV abroad comprised 30% of diagnoses. The CD4 model inadvertently misclassified some diagnoses as in-state transmission events. Consequently, simulated results demonstrated inaccuracies and unstable calculations.

A Review of Cultural Influences on Risk for HIV and Culturally-Responsive Risk Mitigation Strategies Among African Immigrants in the US

There is a paucity of research on HIV risk factors and risk reduction among African immigrants living in the US. This is despite the fact that the literature on HIV prevention and treatment continues to grow. We conducted a focused review to identify cultural factors contributing to the high incidence of HIV among African immigrants and best practices to increase engagement in HIV prevention services in this population. We conducted a search for empirical research published between 2009 and 2019, yielding 17 relevant studies with 16 unique samples. Inadequate knowledge about HIV transmission, low HIV risk perception, and stigma may be barriers to engaging in HIV prevention. Targeted interventions included bundled HIV testing, flexible scheduling, and involvement of community leaders in intervention planning and implementation. Implications for practice and directions for future research among this population are discussed.

Sexual Health, HIV Care and Pre-exposure Prophylaxis in the African Immigrant Population: A Needs Assessment

The objective was to gain insight, from the perspective of healthcare professionals, non-medical service providers and community-based organizations working with a large majority of African immigrant patients or clients, regarding sexual health and the potential for the use of HIV PrEP in this priority population. Thirty key informants participated in a needs assessment. A questionnaire was used to obtain information through focus groups, structured interviews and by self-administration. There are cultural and linguistic barriers to engaging Africans in discussing sexual health issues. Key challenges to uptake of PrEP are multi-dimensional: socioeconomic [immigration status, housing]; cultural [talking about sex 'taboo', HIV related stigma, no concept of preventive care]; provider-related (cultural competency, inadequate PrEP education, language barrier); and individual (lack of awareness, perception of HIV risk). Meeting basic needs like housing, assuring access to care (including PrEP), community-based education, relevant training of providers, and tailored messaging are strongly recommended. Effectively addressing HIV incidence in the African-born immigrant population redonequires a multi-pronged approach.

Natural selection favoring more transmissible HIV detected in United States molecular transmission network

HIV molecular epidemiology can identify clusters of individuals with elevated rates of HIV transmission. These variable transmission rates are primarily driven by host risk behavior; however, the effect of viral traits on variable transmission rates is poorly understood. Viral load, the concentration of HIV in blood, is a heritable viral trait that influences HIV infectiousness and disease progression. Here, we reconstruct HIV genetic transmission clusters using data from the United States National HIV Surveillance System and report that viruses in clusters, inferred to be frequently transmitted, have higher viral loads at diagnosis. Further, viral load is higher in people in larger clusters and with increased network connectivity, suggesting that HIV in the United States is experiencing natural selection to be more infectious and virulent. We also observe a concurrent increase in viral load at diagnosis over the last decade. This evolutionary trajectory may be slowed by prevention strategies prioritized toward rapidly growing transmission clusters.

Challenges in Recruiting African-Born, US-Based Participants for HIV and Tuberculosis Research

Research is critical for developing HIV and tuberculosis (TB) programming for U.S. African-born communities, and depends on successful recruitment of African-born people. From January 2014 to June 2016, we recruited African-born people for HIV and TB research in King County, Washington. We compared the characteristics of study participants and the underlying populations of interest, and assessed recruitment strategies. Target enrollment for the HIV study was 167 participants; 51 participants (31%) were enrolled. Target enrollment for the TB study was 218 participants; 38 (17%) were successfully recruited. Of 249 prior TB patients we attempted to contact by phone, we reached 72 (33%). Multiple recruitment strategies were employed with variable impact. Study participants differed from the underlying populations in terms of gender, country of origin and language. Inequities in research participation and in meaningful opportunities for such participation may exacerbate existing health disparities.

HIV outcomes among migrants from low-income and middle-income countries living in high-income countries: a review of recent evidence

PURPOSE OF REVIEW

Migrants living in high-income countries are disproportionately affected by HIV infection and frequently have characteristics associated with poor HIV clinical outcomes. HIV epidemiology among migrants is influenced by changes in migration patterns and variations in transmission risk behaviors. Here we review the recently published literature on known HIV outcomes among migrants from low-income and middle-income countries living in high-income countries.

RECENT FINDINGS

High proportions of migrants acquire HIV after migration, and this group frequently presents to care late. Once established in care, migrants are often more likely to experience worse HIV treatment outcomes compared with native populations. Multiple individual and structural factors influence HIV diagnosis and treatment outcomes among migrants, including disruption of social networks, increased sexual risk behaviors, communication barriers, limited access to care, and stigma. Few studies have examined interventions targeted at improving HIV outcomes among migrants.

SUMMARY

Stigma and limited access to care appear to be primary drivers of poor HIV outcomes among migrants in high-income countries. Addressing these disparities is limited by difficulties in identifying and monitoring this population as well as a lack of evidence regarding appropriate interventions for migrants living with HIV. Improving outcomes for this group requires interventions that are specifically targeted at this marginalized and growing population.

Harambee!: A pilot mixed methods study of integrated residential HIV testing among African-born individuals in the Seattle area

Background

African-born individuals in the U.S. are disproportionately affected by HIV yet have low HIV testing rates. We conducted a mixed methods study to assess the uptake and feasibility of a novel strategy for integrating HIV testing into residential health fairs among African-born individuals in Seattle, WA.

Methods

From April to May 2018, we held six health fairs at three apartment complexes with high numbers of African-born residents. Fairs included free point-of-care screening for glucose, cholesterol, body mass index, blood pressure, and HIV, as well as social services and health education. The health fairs were hosted in apartment complex common areas with HIV testing conducted in private rooms. Health fair participants completed a series of questionnaires to evaluate demographics, access to health services, and HIV testing history. We conducted 18 key informant interviews (KIIs) with health fair participants and community leaders to identify barriers to HIV testing among African-born individuals.

Results

Of the 111 adults who accessed at least one service at a health fair, 92 completed questionnaires. Fifty-five (61%) were female, 48 (52%) were born in Africa, and 55 (63%) had health insurance. Half of African-born participants accepted HIV testing; all tested negative. The most common reasons for declining testing were lack of perceived risk for HIV and knowledge of HIV status. We identified a high prevalence of non-communicable diseases (NCDs) among health fair participants; among those tested, 77% (55/71) were overweight/obese, 39% (31/79) had blood pressure > 140/90 mmHg, and 30% (22/73) had total cholesterol > 200 mg/dL. KIIs identified community stigma and misinformation as major barriers to HIV testing among African-born individuals.

Conclusions

Residential health fairs are a feasible method to increase HIV testing among African-born individuals in Seattle. The high prevalence of NCDs highlights the importance of integrating general preventive services within HIV testing programs in this population.

Foreign-Born Individuals with HIV in King County, WA: A Glimpse of the Future of HIV?

To better understand country of birth-related shifts in the demography of people newly diagnosed with HIV infection, we compared demographic and clinical characteristics of foreign-born and U.S.-born residents of King County, WA diagnosed with HIV from 2006 to 2015. The proportion of cases that were foreign-born increased from 23 to 34% during this time. Most foreign-born cases were born in Africa (34%), Latin America (32%), Asia (22%), or Europe (7%). Latin Americans and Asians were similar to U.S.-born individuals by HIV risk factor and gender, while Africans were more likely to be female and less often men who have sex with men. In 2015, approximately 15% of cases presumptively newly diagnosed in King County were foreign-born individuals who self-reported a pre-immigration HIV diagnosis. Increases in foreign-born individuals previously diagnosed out of country may lead to inaccuracy in the count of new diagnoses, including an over-estimate of community-acquired HIV in King County.