Spatial clustering of HIV prevalence in Atlanta, Georgia and population characteristics associated with case concentrations

Spatiotemporal Cluster Detection for COVID-19 Outbreak Surveillance: Descriptive Analysis Study

BACKGROUND

During the peak of the winter 2020-2021 surge, the number of weekly reported COVID-19 outbreaks in Washington State was 231; the majority occurred in high-priority settings such as workplaces, community settings, and schools. The Washington State Department of Health used automated address matching to identify clusters at health care facilities. No other systematic, statewide outbreak detection methods were in place. This was a gap given the high volume of cases, which delayed investigations and decreased data completeness, potentially leading to undetected outbreaks. We initiated statewide cluster detection using SaTScan, implementing a space-time permutation model to identify COVID-19 clusters for investigation.

OBJECTIVE

To improve outbreak detection, the Washington State Department of Health initiated a systematic cluster detection model to identify timely and actionable COVID-19 clusters for local health jurisdiction (LHJ) investigation and resource prioritization. This report details the model's implementation and the assessment of the tool's effectiveness.

METHODS

In total, 6 LHJs participated in a pilot to test model parameters including analysis type, geographic aggregation, cluster radius, and data lag. Parameters were determined through heuristic criteria to detect clusters early when they are smaller, making interventions more feasible. This study reviews all clusters detected after statewide implementation from July 17 to December 17, 2021. The clusters were analyzed by LHJ population and disease incidence. Clusters were compared with reported outbreaks.

RESULTS

A weekly, LHJ-specific retrospective space-time permutation model identified 2874 new clusters during this period. While the weekly analysis included case data from the prior 3 weeks, 58.25% (n=1674) of all clusters identified were timely-having occurred within 1 week of the analysis and early enough for intervention to prevent further transmission. There were 2874 reported outbreaks during this same period. Of those, 363 (12.63%) matched to at least one SaTScan cluster. The most frequent settings among reported and matched outbreaks were schools and youth programs (n=825, 28.71% and n=108, 29.8%), workplaces (n=617, 21.46% and n=56, 15%), and long-term care facilities (n=541, 18.82% and n=99, 27.3%). Settings with the highest percentage of clusters that matched outbreaks were community settings (16/72, 22%) and congregate housing (44/212, 20.8%). The model identified approximately one-third (119/363, 32.8%) of matched outbreaks before cases were associated with the outbreak event in our surveillance system.

CONCLUSIONS

Our goal was to routinely and systematically identify timely and actionable COVID-19 clusters statewide. Regardless of population or incidence, the model identified reasonably sized, timely clusters statewide, meeting the objective. Among some high-priority settings subject to public health interventions throughout the pandemic, such as schools and community settings, the model identified clusters that were matched to reported outbreaks. In workplaces, another high-priority setting, results suggest the model might be able to identify outbreaks sooner than existing outbreak detection methods.

Use of routinely collected blood donation data for expanded HIV and Syphilis surveillance in Blantyre district, Malawi

The World Health Organization recommends that all blood donations be screened for transfusion transmissible infections; these data are currently not incorporated into national disease surveillance efforts. We set out to use routinely collected data from blood donors in Blantyre district, Malawi to explore HIV and syphilis prevalence and identify sero-conversions among repeat donors. We conducted a retrospective cohort analysis of blood donation data collected by the Malawi Blood Transfusion Service from 2015 to 2021. All blood donations were routinely screened for HIV and syphilis. We characterized donor demographics as well as screening outcomes, including identifying sero-conversions among repeat donors who previously tested negative on their last donation. A total of 23,280 donations from 5,051 donors were recorded, with a median frequency of donations of 3 (IQR:2-6). Most donors were male (4,294; 85%) and students (3,262; 64.6%). Prevalence of HIV at first donation was 1.0% (52/5,051) and prevalence of syphilis was 1.6% (80/5,051); 52 HIV sero-conversions and 126 syphilis sero-conversions were identified, indicating an incidence rate per 1,000 person-years of 5.9 (95% CI: 4.7, 7.4) and 13.3 (95% CI:11.4, 15.4) respectively. Students had a lower prevalence of HIV and syphilis but higher risk of syphilis seroconversion. While blood donors are generally considered a low-risk population for HIV and syphilis, we were able to identify relatively high rates of undiagnosed HIV and syphilis infections among donors. Routinely collected data from national blood donation services may be used to better understand local HIV and syphilis epidemiology, with the potential to enhance disease surveillance systems. These findings may be used to identify priority prevention areas and populations in Blantyre district that can inform targeted interventions for improved disease prevention, testing and treatment.

Ending the HIV Epidemic in Metropolitan Atlanta: a mixed-methods study to support the local HIV/AIDS response

INTRODUCTION

Four counties within the Atlanta, Georgia 20-county eligible metropolitan area (EMA) are currently prioritized by the US "Ending the HIV Epidemic" (EHE) initiative which aims for a 90% reduction in HIV incidence by 2030. Disparities driving Atlanta's HIV epidemic warrant an examination of local service availability, unmet needs and organizational capacity to reach EHE targets. We conducted a mixed-methods evaluation of the Atlanta EMA to examine geographic HIV epidemiology and distribution of services, service needs and organization infrastructure for each pillar of the EHE initiative.

METHODS

We collected 2021 county-level data (during June 2022), from multiple sources including: AIDSVu (HIV prevalence and new diagnoses), the Centers for Disease Control and Prevention web-based tools (HIV testing and pre-exposure prophylaxis [PrEP] locations) and the Georgia Department of Public Health (HIV testing, PrEP screenings, viral suppression and partner service interviews). We additionally distributed an online survey to key local stakeholders working at major HIV care agencies across the EMA to assess the availability of services, unmet needs and organization infrastructure (June-December 2022). The Organizational Readiness for Implementing Change questionnaire assessed the organization climate for services in need of scale-up or implementation.

RESULTS

We found racial/ethnic and geographic disparities in HIV disease burden and service availability across the EMA-particularly for HIV testing and PrEP in the EMA's southern counties. Five counties not currently prioritized by EHE (Clayton, Douglas, Henry, Newton and Rockdale) accounted for 16% of the EMA's new diagnoses, but <9% of its 177 testing sites and <7% of its 130 PrEP sites. Survey respondents (N = 48; 42% health agency managers/directors) reported high unmet need for HIV self-testing kits, mobile clinic testing, HIV case management, peer outreach and navigation, integrated care, housing support and transportation services. Respondents highlighted insufficient existing staffing and infrastructure to facilitate the necessary expansion of services, and the need to reduce inequities and address intersectional stigma.

CONCLUSIONS

Service delivery across all EHE pillars must substantially expand to reach national goals and address HIV disparities in metro Atlanta. High-resolution geographic data on HIV epidemiology and service delivery with community input can provide targeted guidance to support local EHE efforts.

Area-based comparison of risk factors and testing rates to improve sexual health care access: cross-sectional population-based study in a Dutch multicultural area

OBJECTIVES

Areas with high sexually transmitted infection (STI) testing rates may not require additional strategies to improve testing. However, it may be necessary to intervene in areas with elevated STI risk, but with low STI testing rates. We aimed to compare STI-related risk profiles and STI testing rates by geographical area to determine areas for improvement of sexual healthcare access.

DESIGN

Cross-sectional population-based study.

SETTING

Greater Rotterdam area, the Netherlands (2015-2019).

PARTICIPANTS

All residents aged 15-45 years. Individual population-based register data were matched with laboratory-based STI testing data of general practitioners (GPs) and the only sexual health centre (SHC).

OUTCOME MEASURES

Postal code (PC) area-specific STI risk scores (based on age, migratory background, education level and urbanisation), STI testing rates and STI positivity.

RESULTS

The study area consists of approximately 500 000 residents aged 15-45 years. Strong spatial variation in STI testing, STI positivity and STI risk was observed. PC area testing rate ranged from 5.2 to 114.9 tests per 1000 residents. Three PC clusters were identified based on STI risk and testing rate: (1) high-high; (2) high-low; (3) low, independently of testing rate. Clusters 1 and 2 had comparable STI-related risk and STI positivity, but the testing rate differed greatly (75.8 vs 33.2 per 1000 residents). Multivariable logistic regression analysis with generalised estimating equation was used to compare residents in cluster 1 and cluster 2. Compared with cluster 1, residents in cluster 2 more often did not have a migratory background, lived in less urbanised areas with higher median household income, and more distant from both GP and SHC.

CONCLUSION

The determinants associated with individuals living in areas with high STI-related risk scores and low testing rates provide leads for improvement of sexual healthcare access. Opportunities for further exploration include GP education, community-based testing and service (re)allocation.

HIV geospatially clusters with firearm trauma in 35 Atlanta zip codes

The purpose of this study was to assess if rates of firearm trauma within Atlanta geospatially clustered with HIV prevalence and new HIV diagnosis rates. We retrospectively reviewed our Atlanta trauma center's registry for patients sustaining a ballistic firearm trauma from 2014 through 2018. Using the patient's zip code of home residence, we determined the rate of firearm trauma for that zip code. We obtained publicly available rates for HIV that corresponded with these select zip codes to perform a geospatial cluster analysis. The cohort was comprised of 1495 patients and represented 35 zip codes in Atlanta. The mean rate of firearm trauma for the 35 zip codes was 171.1 (±296.4) per 100,000 people. Compared to all Atlanta, the 35 zip codes' mean HIV prevalence (1863.9 vs 924.1, p < .0001) and new HIV diagnosis rate (396.9 vs 199.7, p < .0001) were significantly higher. Rates of firearm trauma and HIV prevalence demonstrated significant geospatial clustering (β 0.38, 95% CI 0.22-0.53, p < .0001) as did rates of firearm trauma and new HIV diagnoses (β 0.36, 95% CI 0.18-0.54, p = 0.0002). Our findings provide granular geographic data that could guide targeted HIV screening efforts in communities where our firearm-injured patients live.

Predictive Value of Time-Space Clusters for HIV Transmission in Washington State, 2017-2019

BACKGROUND

Pillar 4 of the United States' End the HIV Epidemic plan is to respond quickly to HIV outbreaks, but the utility of CDC's tool for identifying HIV outbreaks through time-space cluster detection has not been evaluated. The objective of this evaluation is to quantify the ability of the CDC time-space cluster criterion to predict future HIV diagnoses and to compare it to a space-time permutation statistic implemented in SaTScan software.

SETTING

Washington State from 2017 to 2019.

METHODS

We applied both cluster criteria to incident HIV cases in Washington State to identify clusters. Using a repeated-measures Poisson model, we calculated a rate ratio comparing the 6 months after cluster detection with a baseline rate from 24 to 12 months before the cluster was detected. We also compared the demographics of cases within clusters with all other incident cases.

RESULTS

The CDC criteria identified 17 clusters containing 192 cases in the 6 months after cluster detection, corresponding to a rate ratio of 1.25 (95% confidence interval: 0.95 to 1.65) relative to baseline. The time-space permutation statistic identified 5 clusters containing 25 cases with a rate ratio of 2.27 (95% confidence interval: 1.28 to 4.03). Individuals in clusters identified by the new criteria were more likely to be of Hispanic origin (61% vs 20%) and in rural areas (51% vs 12%).

CONCLUSIONS

The space-time permutation cluster analysis is a promising tool for identification of clusters with the largest growth potential for whom interruption may prove most beneficial.

Spatial analysis of HIV infection and the associated correlates among transgender persons in the United States

Identifying the geographic hotspots of HIV infection among high-risk populations such as transgender people is critical to ending the HIV epidemic in the United States (U.S.). This study examined the spatial pattern of HIV positivity rate and the associated correlates among transgender persons in the 48 contiguous states and the District of Columbia in the U.S. The data source was the 2015 U.S. Transgender Survey (n = 27,715). We conducted spatial analyses, with state as the unit of analysis. We fitted a spatial lag regression model to assess demographic, social, and behavioral risk variables associated with HIV. The HIV positivity rate ranged by state from 0.5% to 17.1%, with a mean of 2.9%. There was a significant positive global spatial autocorrelation (global Moran's I = 0.42, p = 0.001). The identified spatial clusters of high values (hot spots i.e., states with high HIV positivity rates surrounded by states with similarly high rates) included five neighboring states (Arkansas, Louisiana, Mississippi, Alabama, and Tennessee) in the Southern region. HIV positivity rate was positively associated with the percentage of transgender persons who were non-Hispanic Black, had no high school education, living in poverty, and engaged in sex work. Structural interventions are needed to address education, poverty, racial discrimination, and sex work that predispose transgender persons to HIV.

County-level predictors of retention in care status among people living with HIV in South Carolina from 2010 to 2016: a data-driven approach

OBJECTIVE

The aim of this study was to examine the geospatial variation of retention in care (RIC) across the counties in South Carolina (SC) from 2010 to 2016 and identify the relevant county-level predictors.

DESIGN

Aggregated data on county-level RIC among HIV patients from 2010 to 2016 were retrieved from an electronic HIV/AIDS reporting system in SC Department of Health and Environmental Control. Sociological framework of health was used to select potential county-level predictors from multiple public datasets.

METHODS

Geospatial mapping was used to display the spatial heterogeneity of county-level RIC rate in SC. Generalized linear mixed effect regression with least absolute shrinkage and selection operator (LASSO) was employed to identify county-level predictors related to the change of RIC status over time. Confusion matrix and area under the curve statistics were used to evaluate model performance.

RESULTS

More than half of the counties had their RIC rates lower than the national average. The change of county-level RIC rate from 2010 to 2016 was not significant, and spatial heterogeneity in RIC rate was identified. A total of 22 of the 31 county-level predictors were selected by LASSO for predicting county-level RIC status. Counties with lower collective efficacy, larger proportions of men and/or persons with high education were more likely to have their RIC rates lower than the national average. In contrast, numbers of accessible mental health centres were positively related to county-level RIC status.

CONCLUSION

Spatial variation in RIC could be identified, and county-level factors associated with accessible healthcare facilities and social capital significantly contributed to these variations. Structural and individual interventions targeting these factors are needed to improve the county-level RIC and reduce the spatial variation in HIV care.

HIV Related Knowledge, HIV Testing Decision-Making, and Perceptions of Alcohol Use as a Risk Factor for HIV among Black and African American Women

The HIV/AIDS epidemic disproportionately affects Black and African American women in the United States. This study examined the extent of HIV related knowledge, HIV testing decision-making, and perceptions of alcohol use as a risk factor for HIV among Black and African American women in urban and suburban communities. Seven focus groups were conducted with 37 women aged 18 to 49 residing in the Commonwealth of Massachusetts. Women participating in focus groups had a wide breadth of HIV related knowledge. Findings suggest the influence of interpersonal relationships and provider-patient interactions on HIV testing, the need for building community capacity and leveraging community resources towards HIV prevention, and the influence of alcohol outlet density on HIV vulnerability and exposure in communities of color. Comprehensive multifaceted evidence informed interventions that are culturally relevant and gender responsive are needed to reduce HIV/AIDS disparities.

From Silos to Solidarity: Case Study of a Patient-Centered, Integrative Approach to Opioid Tapering and Chronic Pain Mitigation in a Multidisciplinary AIDS Clinic

Background:

People with HIV (PWH) are at a disproportionate risk for experiencing both chronic pain and opioid use disorder (OUD). Prescription opioid tapering is typically addressed within the “silo model” of medical care, whereby attention is focused solely on opioid addiction rather than also addressing chronic pain management, and limited communication occurs between patient and providers.

Objective:

This descriptive case study examined an integrative, collaborative care model consisting of Provider, Physical Therapist (PT), and Patient aimed at decreasing chronic pain and opioid use within a multidisciplinary HIV/AIDS clinic.

Method:

A physical-therapy based model of chronic pain mitigation and physician-driven opioid tapering was implemented. The Provider, PT, and Patient worked collaboratively to address physiological pain, pain coping skills and opioid tapering. A patient case example was used to illustrate the implementation of the model for a future, larger study in the same patient population.

Results:

This model was feasible in this case example in terms of clinic workflow and acceptability to both the Patient and Providers in this clinic. After the intervention, the Patient’s pain was fully eliminated, and he had ceased all opioid use.

Conclusion:

Results of this case study suggest that utilizing an integrative, patient-centered approach to both chronic pain management and opioid tapering may be feasible within the context of a multidisciplinary HIV/AIDS clinic. Generalizability is limited by case study model; however, this gives insight into the value of a collaborative alternative compared to a “silo” model of opioid tapering and chronic pain management in preparation for a larger study.

Spatiotemporal Analysis of AIDS Incidence and Its Influencing Factors on the Chinese Mainland, 2005-2017

Acquired Immune Deficiency Syndrome (AIDS) has become one of the most severe public health issues and nowadays around 38 million people are living with the human immunodeficiency virus (HIV). Ensuring healthy lives and promoting well-being is one of 17 United Nations Sustainable Development Goals. Here, we used the Markov chain matrix and geospatial clustering to comprehensively quantify the trends of the AIDS epidemic at the provincial administrate level in the mainland of China from 2005 to 2017. The Geographically Weighted Regression (GWR) model was further adopted to explore four groups of potential influencing factors (i.e., economy, traffic and transportation, medical care, and education) of the AIDS incidence rate in 2017 and their spatially distributed patterns. Results showed that the AIDS prevalence in southeastern China had been dominant and become prevalent in the past decade. The AIDS intensity level had been increasing between 2008 and 2011 but been gradually decreasing afterward. The analysis of the Markov chain matrix indicated that the AIDS epidemic has been generally in control on the Chinese mainland. The economic development was closely related to the rate of AIDS incidence on the Chinese mainland. The GWR result further suggested that medical care and the education effects on AIDS incidence rate can vary with different regions, but significant conclusions cannot be directly demonstrated. Our findings contribute an analytical framework of understanding AIDS epidemic trends and spatial variability of potential underlying factors throughout a complex extent to customize scientific prevention.

Measuring the impact of spatial perturbations on the relationship between data privacy and validity of descriptive statistics

BACKGROUND

Like many scientific fields, epidemiology is addressing issues of research reproducibility. Spatial epidemiology, which often uses the inherently identifiable variable of participant address, must balance reproducibility with participant privacy. In this study, we assess the impact of several different data perturbation methods on key spatial statistics and patient privacy.

METHODS

We analyzed the impact of perturbation on spatial patterns in the full set of address-level mortality data from Lawrence, MA during the period from 1911 to 1913. The original death locations were perturbed using seven different published approaches to stochastic and deterministic spatial data anonymization. Key spatial descriptive statistics were calculated for each perturbation, including changes in spatial pattern center, Global Moran's I, Local Moran's I, distance to the k-th nearest neighbors, and the L-function (a normalized form of Ripley's K). A spatially adapted form of k-anonymity was used to measure the privacy protection conferred by each method, and its compliance with HIPAA and GDPR privacy standards.

RESULTS

Random perturbation at 50 m, donut masking between 5 and 50 m, and Voronoi masking maintain the validity of descriptive spatial statistics better than other perturbations. Grid center masking with both 100 × 100 and 250 × 250 m cells led to large changes in descriptive spatial statistics. None of the perturbation methods adhered to the HIPAA standard that all points have a k-anonymity > 10. All other perturbation methods employed had at least 265 points, or over 6%, not adhering to the HIPAA standard.

CONCLUSIONS

Using the set of published perturbation methods applied in this analysis, HIPAA and GDPR compliant de-identification was not compatible with maintaining key spatial patterns as measured by our chosen summary statistics. Further research should investigate alternate methods to balancing tradeoffs between spatial data privacy and preservation of key patterns in public health data that are of scientific and medical importance.

An Innovative Physical Therapy Intervention for Chronic Pain Management and Opioid Reduction Among People Living with HIV

Chronic pain management has become a treatment priority for people living with HIV (PLH), and PLH may be at increased risk for opioid addiction. Physical therapy (PT) has been shown to be effective as a nonpharmacological method of chronic pain management; however, there is a gap in research examining the role of PT for chronic pain, especially as it relates to opioid reduction, in this patient population. This retrospective study evaluated pain level and opioid use before and after PT intervention among HIV-positive adults with chronic pain on chronic opioid therapy (n = 22). The study was conducted at a multidisciplinary AIDS clinic in Atlanta, GA. Outcome measures were self-reported pain on the numerical rating scale (0–10) and morphine milligram equivalents (MMEs), which measure opioid use. A majority of patients (77%) demonstrated a decrease in pain by the conclusion of the study period; however, only 18.2% of patients reported decreased pain as well as a decrease in MMEs. The most common PT treatments used among the patients with a decrease in pain and/or opioid use included home exercise programs, manual therapy, and self-pain management education. Eighty percent of the participants who did not decrease opioid use reported a decrease or elimination of pain by the end of the PT intervention. This reflects the need for careful consideration of the complexity of opioid use and addiction, and the importance of a multidisciplinary team to best serve the needs of PLH aiming to decrease chronic pain and opioid use.

AIDS in men in the city of São Paulo, 1980-2012: spatial and space-time analysis

OBJECTIVES

To identify spatial and space-time clusters with high incidence rates of AIDS in men living in the city of São Paulo since the first case of the disease in 1980.

METHODS

HIV/AIDS notifications were obtained from the Notifiable Diseases Information System (57,440 men) between January 1980 and June 2012. The cases were geocoded by residence address; then analyses of purely spatial, space-time and spatial variation in temporal trends were performed for three sets of data: total cases of AIDS in men aged 13 years or older, men aged 50 years or older, and deaths from AIDS.

RESULTS

It was possible to geocode a significant proportion of AIDS cases (93.7%). In the purely spatial scanning analysis, considering the entire period evaluated, the AIDS epidemic in men presented an important spatial concentration in the Center and in contiguous areas of the North, Southeast and West regions of the municipality, regardless of age group and evolution to death (relative risks between 1.22 and 5.90). Considering space and time simultaneously, several clusters were found, spread throughout all regions of the municipality (relative risks between 1.44 and 8.61). In the analysis of spatial variation in temporal trends, the clusters in the most peripheral regions presented a higher annual percentage increase in disease rates (up to 7.58%), denoting the tendency of "peripherization" of the epidemic in men in the city of São Paulo.

CONCLUSIONS

This study allowed the detection of geographic clusters of high risk for AIDS in men, pointing to priority areas in the municipality, both for programmatic actions and to guide other studies.

Spatial characteristics of men who have sex with men and transgender women attending HIV voluntary counselling and testing in Bangkok, Thailand, 2005-2015

Spatiotemporal analyses can support Human Immuno-deficiency Virus (HIV) prevention programmes by identifying locations of at-risk populations in space and time, and their proximity to HIV testing and prevention services. We assessed residential proximity to HIV testing venues for Men who have Sex with Men (MSM) and Transgender Women (TGW) attending Voluntary Counselling and Testing (VCT) at a large urban MSM clinic in Bangkok, Thailand in the period 2005-2015. We mapped clientprovided spatial data and HIV testing venues, calculating distance from residence to venues for VCT clients between i) September 2005-December 2009; ii) January 2010-September 2013; and iii) October 2013-May 2015. We assessed spatial characteristics across times, evaluating autocorrelation of HIV prevalence and visit density using Moran's I. Among 8,758 first-time VCT clients reporting geographic information from 2005-2015 (by period: 2737, 3917, 2104), 1329 (15.2%) lived in postal codes ≤5 km from the clinic. Over time, the proportion living in areas covered by Bangkok postal codes ≤2 km from any MSM HIV testing venue increased from 12.6% to 41.0% (p<0.01). The proportion living ≤5 km from the clinic decreased from 16.6% to 13.0% (p<0.01). HIV prevalence and clinic visit density demonstrated statistically significant non-random spatial patterning. Significant non-random patterning of prevalent infection and client visits highlighted Bangkok's urban HIV epidemic, clinic proximity to clients, and geographic reach. Clients lived closer to testing venues, yet farther from the urban MSM clinic, over time. Spatiotemporal characteristics of VCT clients can help assess service accessibility and guide targeted prevention planning.

A systematic review of the geospatial barriers to antiretroviral initiation, adherence and viral suppression among people living with HIV

Background With the emergence of antiretroviral therapy (ART), Treatment as Prevention (TasP) has become the cornerstone of both HIV clinical care and HIV prevention. However, despite the efficacy of treatment-based programs and policies, structural barriers to ART initiation, adherence and viral suppression have the potential to reduce TasP effectiveness. These barriers have been studied using Geographic Information Systems (GIS). While previous reviews have examined the use of GIS for HIV testing - an essential antecedent to clinical care - to date, no reviews have summarised the research with respect to other ART-related outcomes.

METHODS

Therefore, the present review leveraged the PubMed database to identify studies that leveraged GIS to examine the barriers to ART initiation, adherence and viral suppression, with the overall goal of understanding how GIS has been used (and might continue to be used) to better study TasP outcomes. Joanna Briggs Institute criteria were used for the critical appraisal of included studies.

RESULTS

In total, 33 relevant studies were identified, excluding those not utilising explicit GIS methodology or not examining TasP-related outcomes.

CONCLUSIONS

Findings highlight geospatial variation in ART success and inequitable distribution of HIV care in racially segregated, economically disadvantaged, and, by some accounts, increasingly rural areas - particularly in the United States. Furthermore, this review highlights the utility and current limitations of using GIS to monitor health outcomes related to ART and the need for careful planning of resources with respect to the geospatial movement and location of people living with HIV (PLWH).

Factors Associated with HIV Seroconversion Among Women Attending an Urban Health Clinic in the South: A Matched Case-Control Study

Compared to knowledge about HIV risk factors among men in the south, less is known about risk factors for women. We conducted an individually matched case-control study to identify factors associated with HIV seroconversion among women. Cases had a clinician-assisted visit (CAV) between 2011 and 2016 at an Atlanta-based public health clinic before HIV diagnosis. Controls were women who visited the clinic but remained HIV negative. Controls were matched to cases in a 2:1 ratio on race, age at first CAV, and date of first CAV. Conditional logistic regression was used to develop a best-fitting model for characterizing HIV risk. Of 18,281 women who were HIV negative at their first visit, 110 (0.6%) seroconverted before 2019. Of these, 80 (73%) had a CAV before HIV diagnosis. Having multiple gonorrhea episodes, a syphilis episode, a greater number of sex partners in the past 2 months, anal sex, history of drug use, history of exchanging drugs or money for sex, and heterosexual sex with >1 sex partner in the last month were individually associated with HIV seroconversion. In multivariate analyses, having a syphilis episode [odds ratio (OR) = 4.7, 95% confidence interval (CI): 1.3-16.3], anal sex (OR = 2.8, 95% CI: 1.0-8.1), and injection drug or crack cocaine use (OR = 33.5, 95% CI: 3.6-313.3) remained associated with HIV. Women having all three risk factors were six times more likely to seroconvert compared to women without these factors. Our results offer insights into which women in a southern HIV "hotspot" may be at greatest risk for HIV.

Demographic characteristics and spatial clusters of recent HIV-1 infections among newly diagnosed HIV-1 cases in Yunnan, China, 2015

BACKGROUND

The characteristics of recent HIV infections can provide the information about the dynamics of HIV transmission. Yunnan is one of the provinces hardest-hit by HIV-1 in China. To further understand the characteristics of the HIV-1 epidemic in Yunnan, we analyzed the prevalence of recent HIV-1 infections among newly diagnosed cases, identified the associated factors and explored the spatial distribution of recent HIV-1 infections.

METHODS

Residual plasma samples from HIV-1 diagnostic tests were preserved. The associated information was collected from China HIV/AIDS case reporting system. Recent HIV-1 infections were estimated by combining the information about disease progression and BED- capture enzyme immunoassay (CEIA). The proportions of recent HIV-1 infections among newly diagnosed cases stratified by demographic characteristics were analyzed. The spatial clusters of recent HIV-1 infections were investigated by spatial scan statistics.

RESULTS

Among 6119 HIV/AIDS cases were newly reported between January 2015 and June 2015 in Yunnan Province, 9.3% (570/6119) were estimated as recent infections. Female, aged below 25 years and homosexual contact were more associated with the higher proportion of recent HIV-1 infections. Among the different demographic sub-groups, men who have sex with men (MSM) aged < 25 years and ≥ 50 years had a higher chance of being diagnosed as recent infections, heterosexually infected men aged ≥25 years had a lower chance of being diagnosed as recent infections. In the sub-groups with different screening approaches, the highest proportion of recent infections (16.1%) was found among women diagnosed by testing during pregnancy and childbirth. In the sub-groups with different contact histories, the higher proportion of recent infections was found among the female cases having commercial heterosexual contacts (16.4%) and MSM (19.7%). The statistically significant spatial clusters of recent infections attributed to heterosexual contact, homosexual contact and intravenous drug injection were identified, respectively.

CONCLUSIONS

The investigation of recent HIV infections among newly diagnosed cases supplements the routine HIV surveillance, and reveals the characteristics of ongoing HIV transmission. Our finding identified the potential sub-populations and geographic areas in need of services or improved interventions.

Opioid-related diagnoses and HIV, HCV and mental disorders: using Pennsylvania hospitalisation data to assess community-level relationships over space and time

BACKGROUND

We assessed the community-level spatiotemporal connexions between hospitalisations for common opioid comorbidities (HIV, hepatitis C (HCV) and mental disorders) and opioid-related hospitalisations in the current and previous year.

METHODS

We used Bayesian hierarchical spatiotemporal Poisson regression with conditionally autoregressive spatial effects to assess counts of HCV-related, HIV-related and mental disorder-related hospitalisations at the ZIP code level from 2004 to 2014 in Pennsylvania. Models included rates of current-year and previous-year opioid-related hospitalisations as well as covariates measuring demographic and environmental characteristics.

RESULTS

After adjusting for measures of demographic and environmental characteristics, current-year and previous-year opioid-related hospitalisations were associated with higher risk of HCV, HIV and mental disorders. The relative risks and 95% credible intervals for previous-year opioid-related hospitalisations were 1.092 (1.078 to 1.106) for HCV, 1.098 (1.068 to 1.126) for HIV and 1.020 (1.013 to 1.027) for mental disorders.

CONCLUSION

Previous-year opioid-related hospitalisations are connected to common comorbid conditions such as HCV, HIV and mental disorders, illustrating some of the broader health-related impacts of the opioid epidemic. Public health interventions focused on the opioid epidemic must consider individual community needs and comorbid diagnoses.

Spatial clusters of HIV-1 genotypes in a recently infected population in Yunnan, China

Background

As a gateway for HIV-1 in China, Yunnan has experienced dramatic changes in HIV-1 epidemics, during which HIV-1 genotypes have become complex. To track dynamic changes in HIV-1 genotypes, an HIV-1 molecular epidemiological study was implemented in the recently infected population in Yunnan.

Methods

From 6,357 HIV-1-positive samples diagnosed during the first half of 2015 in Yunnan, 586 samples were identified as recent infections with BED-capture enzyme immunoassay (CEIA) and were subjected to phylogenetic analyses. Spatial scanning analyses for the main HIV-1 genotypes were also performed.

Results

Among the 439 specimens successfully genotyped, more than ten genotypes were detected, including CRF08_BC (45.3%), CRF07_BC (19.4%), unique recombinant forms (URFs) (18.2%), CRF01_AE (11.4%), subtype C (2.1%), CRF85_BC (1.1%), CRF55_01B (0.9%), subtype B (0.5%), CRF64_BC (0.5%), CRF59_01B (0.2%), CRF83_cpx (0.2%) and CRF87_cpx (0.2%). Females, Chinese, heterosexual contact and intravenous drug injection were significantly associated with CRF08_BC infection; homosexual contact was significantly associated with CRF01_AE and CRF07_BC infection; males and non-Chinese had a higher risk of URF infection than females. Among all HIV-1 genotypes, the geographic coverage of CRF08_BC was the largest. For CRF08_BC, CRF07_BC, URFs and CRF01_AE, spatial clusters were detected. The two CRF08_BC clusters and one URF cluster were associated with heterosexual transmission, and two of CRF01_AE clusters were associated with homosexual transmission. Transmitted drug resistance (TDR)-associated mutations were detected in 2.4% of individuals.

Conclusions

The diversity of HIV-1 genotypes increased in recent infections because of a long-term HIV-1 epidemic in Yunnan. The predominant HIV-1 strains showed distinct demographic characteristics and formed spatial clusters. These findings improved our understanding of the evolution of HIV-1 in Yunnan and provided information for further HIV-1 control and prevention.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-4276-9) contains supplementary material, which is available to authorized users.

Associations of Statewide Legislative and Administrative Interventions With Vaccination Status Among Kindergartners in California

IMPORTANCE

California implemented 3 interventions to increase uptake of vaccines. In 2014, Assembly bill 2109 tightened requirements for obtaining a personal belief exemption. A 2015 campaign provided educational materials to school staff on the proper application of conditional admission for kindergartners who were not up to date on required vaccinations. In 2016, Senate bill 277 eliminated personal belief exemptions. Prior research has not evaluated these 3 interventions together with regard to the vaccination status of students.

OBJECTIVE

To assess the changes in the yearly rates of kindergartners who were not up to date on required vaccinations who were entering school during the period of the interventions, by focusing on geographic clustering and the potential contacts of these kindergartners.

DESIGN, SETTING, AND PARTICIPANTS

Observational study that used cross-sectional school-entry data from 2000-2017 to calculate the rates of kindergartners attending California schools who were not up to date on required vaccinations.

EXPOSURES

Assembly bill 2109, a conditional admission education program, and Senate bill 277.

MAIN OUTCOMES AND MEASURES

The primary outcome was the yearly rate of kindergartners without up-to-date vaccination status. The secondary outcomes were (1) the modified aggregation index, which was used to assess the potential within-school contacts among kindergartners without up-to-date vaccination status, (2) the number of geographic clusters of schools with rates for kindergartners without up-to-date vaccination status that were higher than the rates for schools located outside the cluster, and (3) the number of schools located inside the geographic clusters.

RESULTS

In California between 2000 and 2017, 9 323 315 children started attending kindergarten and 721 593 were not up to date on required vaccinations. Prior to the interventions, the statewide rate of kindergartners without up-to-date status for required vaccinations increased from 7.80% during 2000 to 9.84% during 2013 and then decreased after the interventions to 4.87% during 2017. The percentage chance for within-school contact among kindergartners without up-to-date vaccination status decreased from 26.02% during 2014 to 4.56% (95% CI, 4.21%-4.99%) during 2017. During 2012-2013, there were 124 clusters that contained 3026 schools with high rates of kindergartners without up-to-date vaccination status. During 2014-2015, there were 93 clusters that contained 2290 schools with high rates of kindergartners without up-to-date vaccination status. During 2016-2017, there were 110 clusters that contained 1613 (95% CI, 1565-1691) schools.

CONCLUSIONS AND RELEVANCE

In California, statewide legislative and educational interventions were associated with a decrease in the yearly rates of kindergartners without up-to-date vaccination status. These interventions also were associated with reductions in the number of schools inside the clusters with high rates of kindergartners without up-to-date vaccination status and the potential for contact among these kindergartners.

Evaluating the Availability and Quality of HIV/AIDS Services and Supports for Individuals with Intellectual and Developmental Disabilities

We used a community-based participatory research (CBPR) framework to conduct a needs assessment of the availability and quality of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) services for persons with intellectual and developmental disabilities (PWIDD) in the Atlanta metropolitan area. We present the findings of a three-phase research project. Findings from the research informs organizations and policymakers on how to provide persons with disabilities better access to HIV/AIDS care.

Finding Hidden HIV Clusters to Support Geographic-Oriented HIV Interventions in Kenya

Background:

In a spatially well known and dispersed HIV epidemic, identifying geographic clusters with significantly higher HIV prevalence is important for focusing interventions for people living with HIV (PLHIV).

Methods:

We used Kulldorff spatial-scan Poisson model to identify clusters with high numbers of HIV-infected persons 15–64 years old. We classified PLHIV as belonging to either higher prevalence or lower prevalence (HP/LP) clusters, then assessed distributions of sociodemographic and biobehavioral HIV risk factors and associations with clustering.

Results:

About half of survey locations, 112/238 (47%) had high rates of HIV (HP clusters), with 1.1–4.6 times greater PLHIV adults observed than expected. Richer persons compared with respondents in lowest wealth index had higher odds of belonging to a HP cluster, adjusted odds ratio (aOR) 1.61 [95% confidence interval (CI): 1.13 to 2.3], aOR 1.66 (95% CI: 1.09 to 2.53), aOR 3.2 (95% CI: 1.82 to 5.65), and aOR 2.28 (95% CI: 1.09 to 4.78) in second, middle, fourth, and highest quintiles, respectively. Respondents who perceived themselves to have greater HIV risk or were already HIV-infected had higher odds of belonging to a HP cluster, aOR 1.96 (95% CI: 1.13 to 3.4) and aOR 5.51 (95% CI: 2.42 to 12.55), respectively; compared with perceived low risk. Men who had ever been clients of female sex worker had higher odds of belonging to a HP cluster than those who had never been, aOR 1.47 (95% CI: 1.04 to 2.08); and uncircumcised men vs circumcised, aOR 3.2 (95% CI: 1.74 to 5.8).

Conclusions:

HIV infection in Kenya exhibits localized geographic clustering associated with sociodemographic and behavioral factors, suggesting disproportionate exposure to higher HIV risk. Identification of these clusters reveals the right places for targeting priority-tailored HIV interventions.

Chronic Pain Mitigation and Opioid Weaning at a Multidisciplinary AIDS Clinic: A Case Report

Background and Purpose

Chronic pain has emerged as a treatment priority among people living with HIV (PLHIV). Recent studies indicate the use of physical therapy (PT) for chronic pain mitigation among PLHIV, however there is a paucity of literature regarding PT as part of multidisciplinary collaboration to address the intersection of HIV, chronic pain and opioid use.

Case Description

This case report examined the effect of a 24-session PT intervention aimed at decreasing chronic pain and opioid weaning for a 64 year-old patient at a multidisciplinary AIDS clinic in Atlanta, Georgia. The PT intervention focused on pain mitigation, utilizing using pain-relief techniques such as a home TENS unit, home stretching regimen, diaphragmatic breathing techniques. In addition, the physical therapist communicated regularly with the patient's primary HIV provider regarding patient progress.

Outcomes

After the intervention, outcomes included: decreased pain from 10/10 to 0/10, independent pain management, and increased independence in functional activities. In addition, the patient decreased opioid usage from 15 to 2.5 mg Hydrocodone, an 83.3% decrease.

Discussion

In a complex chronic pain case with a patient on chronic opioid therapy, multidisciplinary communication is key in successful management. To truly address opiate weaning in the context of pain management, physical therapists' expertise in pain management should ideally be complemented by close communication with the patient's primary medical provider. This allows for open dialogue, and acknowledges the importance of various specialty areas committed to a joint effort of not simply opioid weaning, but of patient-centered, multidisciplinary chronic pain control.

Detecting spatial clusters of HIV and hepatitis coinfections

BACKGROUND

People with HIV infection in the United States are often affected by chronic viral hepatitis. These coinfected people with either HBV or HCV are at increased risk for serious, life-threatening complications. Coinfections with viral hepatitis may also complicate the delivery of anti-retroviral therapy (ART) by escalating the risk of drug-related hepatoxicity. According to the Centers for Disease Control and Prevention (CDC), approximately 10 percent of people with HIV in the United States also have HBV, and 25 percent also have HCV coinfection. With the advent of highly active antiretroviral therapy (HAART) and the increased life-expectancy of HIV patients, clinicians are more likely to be confronted with issues related to co-infection and the management challenges that they present, especially in resource-limited settings. The purpose of this analysis was to identify geographical clusters of HIV- (HBV/HCV) co-infection and compared to the geographical clusters of not co-infected using DC, Department of Health surveillance data. The results of the analysis will be used to target resources to areas at risk.

METHODS

HIV and Hepatitis surveillance data were matched among cases diagnosed between 1980 and 2016. HIV-hepatitis co-infected and the not co-infected spatial clusters were detected using discrete Poisson model. Kulldorff's spatial scan statistic method was implemented in the free software tool called SaTScan which has been widely adopted for detecting disease cluster. The analysis was conducted by tracts, but for visualization, ease of interpretation and assist in policy making the tract map was overlaid with the ward map using ArcGIS 10.5.1.

RESULTS

Between 1980 and 2016, there were 12,965 diagnosed cases of HIV, of which 2,316 HIV/Hepatitis matches were identified. Of the 2316 co-infected people living in DC, 25 percent (N = 590) of people had HBV, and 75 percent (N = 1,726) had HCV. Out of 12,965 diagnosed cases, remaining 10,649 did not have any co-infections (not co-infected). IDU (27.16 percent) and MSM (32.86 percent) were the highest mode of transmission for co-infected population. African-American were reported 83.64 percent (N = 1,937) among co-infection population. Three clusters were identified for both co-infected population in DC. The largest cluster radius for co-infected analysis covers wards 6, 7 and 8 as well as large parts of 2 and 5 (p < 0.001). Multiple clusters were identified for not co-infected population (p < 0.001). IDU (n = 450) was the highest mode of transmission for the co-infected clusters. For all clusters combined of not co-infected population highest mode of transmission were MSM (n = 2,534). This analysis also showed racial disparity, economic deprivation and lack of education were prominent in the co-infected clusters.

CONCLUSION

We identified locations of high risk clusters where enhanced hepatitis and HIV prevention, treatment, and care can help combat the epidemic. The clusters radius expands into the neighboring state of Maryland as well. The findings from this analysis will be used to target area based public health policy and healthcare interventions for HIV-hepatitis. It is recommended based on the analysis that needle exchange programs can successfully control new HIV infections as well as hepatitis co-infections.

Associations Between Neighborhood Characteristics, Social Cohesion, and Perceived Sex Partner Risk and Non-Monogamy Among HIV-Seropositive and HIV-Seronegative Women in the Southern U.S

Neighborhood social and physical factors shape sexual network characteristics in HIV-seronegative adults in the U.S. This multilevel analysis evaluated whether these relationships also exist in a predominantly HIV-seropositive cohort of women. This cross-sectional multilevel analysis included data from 734 women enrolled in the Women's Interagency HIV Study's sites in the U.S. South. Census tract-level contextual data captured socioeconomic disadvantage (e.g., tract poverty), number of alcohol outlets, and number of non-profits in the census tracts where women lived; participant-level data, including perceived neighborhood cohesion, were gathered via survey. We used hierarchical generalized linear models to evaluate relationships between tract characteristics and two outcomes: perceived main sex partner risk level (e.g., partner substance use) and perceived main sex partner non-monogamy. We tested whether these relationships varied by women's HIV status. Greater tract-level socioeconomic disadvantage was associated with greater sex partner risk (OR 1.29, 95% CI 1.06-1.58) among HIV-seropositive women and less partner non-monogamy among HIV-seronegative women (OR 0.69, 95% CI 0.51-0.92). Perceived neighborhood trust and cohesion was associated with lower partner risk (OR 0.83, 95% CI 0.69-1.00) for HIV-seropositive and HIV-seronegative women. The tract-level number of alcohol outlets and non-profits were not associated with partner risk characteristics. Neighborhood characteristics are associated with perceived sex partner risk and non-monogamy among women in the South; these relationships vary by HIV status. Future studies should examine causal relationships and explore the pathways through which neighborhoods influence partner selection and risk characteristics.

Spatial extreme learning machines: An application on prediction of disease counts

Extreme learning machines have gained a lot of attention by the machine learning community because of its interesting properties and computational advantages. With the increase in collection of information nowadays, many sources of data have missing information making statistical analysis harder or unfeasible. In this paper, we present a new model, coined spatial extreme learning machine, that combine spatial modeling with extreme learning machines keeping the nice properties of both methodologies and making it very flexible and robust. As explained throughout the text, the spatial extreme learning machines have many advantages in comparison with the traditional extreme learning machines. By a simulation study and a real data analysis we present how the spatial extreme learning machine can be used to improve imputation of missing data and uncertainty prediction estimation.

Spatial Analysis of the Human Immunodeficiency Virus Epidemic among Men Who Have Sex with Men in China, 2006-2015

Background

Studies have shown a recent upsurge in human immunodeficiency virus (HIV) burden among men who have sex with men (MSM) in China, especially in urban areas. For intervention planning and resource allocation, spatial analyses of HIV/AIDS case-clusters were required to identify epidemic foci and trends among MSM in China.

Methods

Information regarding MSM recorded as HIV/AIDS cases during 2006-2015 were extracted from the National Case Reporting System. Demographic trends were determined through Cochran-Armitage trend tests. Distribution of case-clusters was examined using spatial autocorrelation. Spatial-temporal scan was used to detect disease clustering. Spatial correlations between cases and socioenvironmental factors were determined by spatial regression.

Results

Between 2006 and 2015, in China, 120 371 HIV/AIDS cases were identified among MSM. Newly identified HIV/AIDS cases among self-reported MSM increased from 487 cases in 2006 to >30 000 cases in 2015. Among those HIV/AIDS cases recorded during 2006-2015, 47.0% were 20-29 years old and 24.9% were aged 30-39 years. Based on clusters of HIV/AIDS cases identified through spatial analysis, the epidemic was concentrated among MSM in large cities. Spatial-temporal clusters contained municipalities, provincial capitals, and main cities such as Beijing, Shanghai, Chongqing, Chengdu, and Guangzhou. Spatial regression analysis showed that sociodemographic indicators such as population density, per capita gross domestic product, and number of county-level medical institutions had statistically significant positive correlations with HIV/AIDS among MSM.

Conclusions

Assorted spatial analyses revealed an increasingly concentrated HIV epidemic among young MSM in Chinese cities, calling for targeted health education and intensive interventions at an early age.

The Human Immunodeficiency Virus Endemic: Maintaining Disease Transmission in At-Risk Urban Areas

OBJECTIVES

A study of network relationships, geographic contiguity, and risk behavior was designed to test the hypothesis that all 3 are required to maintain endemicity of human immunodeficiency virus (HIV) in at-risk urban communities. Specifically, a highly interactive network, close geographic proximity, and compound risk (multiple high-risk activities with multiple partners) would be required.

METHODS

We enrolled 927 participants from two contiguous geographic areas in Atlanta, GA: a higher-risk area and lower-risk area, as measured by history of HIV reporting. We began by enrolling 30 "seeds" (15 in each area) who were comparable in their demographic and behavioral characteristics, and constructed 30 networks using a chain-link design. We assessed each individual's geographic range; measured the network characteristics of those in the higher and lower-risk areas; and measured compound risk as the presence of two or more (of 6) major risks for HIV.

RESULTS

Among participants in the higher-risk area, the frequency of compound risk was 15%, compared with 5% in the lower-risk area. Geographic cohesion in the higher-risk group was substantially higher than that in the lower-risk group, based on comparison of geographic distance and social distance, and on the extent of overlap of personal geographic range. The networks in the 2 areas were similar: both areas show highly interactive networks with similar degree distributions, and most measures of network attributes were virtually the same.

CONCLUSIONS

Our original hypothesis was supported in part. The higher and lower-risk groups differed appreciably with regard to risk and geographic cohesion, but were substantially the same with regard to network properties. These results suggest that a "minimum" network configuration may be required for maintenance of endemic transmission, but a particular prevalence level may be determined by factors related to risk, geography, and possibly other factors.

Community-based participatory research in a heavily researched inner city neighbourhood: Perspectives of people who use drugs on their experiences as peer researchers

Community-based participatory research (CBPR) has become an increasingly common approach to research involving people who use(d) drugs (PWUD), who are often employed as peer researchers on these projects. This paper seeks to understand the impact of CBPR on PWUD, particularly those living in heavily researched and stigmatized neighbourhoods where CBPR projects are often located. This study draws on 14 in-depth interviews with PWUD who had previous experience as both peer researchers and research participants in CBPR projects conducted between July 2010 and February 2011. The study employed a CBPR approach in its study design, recruitment, interviewing, and analysis. Our analysis indicates that participants were supportive of CBPR in principle and described the ways in which it helped contest stigmatizing assumptions and researcher bias. Participants also reported positive personal gains from participation in CBPR projects. However, many participants had negative experiences with CBPR projects, especially when CBPR principles were implemented in a superficial or incomplete manner. Participants emphasized the importance of inclusiveness and active deconstruction of hierarchy between researchers and community members to successful CBPR among drug using populations. CBPR has been widely adopted as a research approach within marginalized communities but has often been implemented inconsistently. Still, CBPR can empower communities to contest forms of social stigma that are often reproduced through academic research on marginalized communities. Our findings describe how the benefits of CBPR are maximized when CBPR principles are consistently applied and when community-based researchers are supported in ways that reduce power hierarchies. This suggests a need for capacity building within affected communities to develop independent support, training, and grievance processes for peer researchers.

Disparities in Retention in HIV Care Among HIV-Infected Young Men Who Have Sex with Men in the District of Columbia, 2013

PURPOSE

Among young men who have sex with men (YMSM), aged 13-24 years, Blacks/African Americans and Hispanics/Latinos are disproportionately affected by HIV, accounting for 58% and 21%, respectively, of diagnoses of HIV infection in the United States. In the District of Columbia (DC), YMSM of color are also disproportionately affected by HIV. National goals are that 80% of HIV-infected persons be retained in HIV care. We analyzed DC surveillance data to examine retention among YMSM living with HIV infection in DC.

METHODS

We characterized correlates of retention in HIV care (≥2 clinical visits, ≥3 months apart, within 12 months of diagnosis) among YMSM in DC to inform and strengthen local HIV care efforts. We analyzed data from DC HIV surveillance system for YMSM aged 13-29 years diagnosed between 2005 and 2012 and alive in 2013. We also combined demographic and clinical variables with sociodemographic data from the U.S. American Community Survey (ACS) by census tracts.

RESULTS

From 2005 to 2012, 1034 YMSM were diagnosed and living with HIV infection in DC; 83% were Black or Latino. Of the 1034 YMSM, 910 (88%) had census tract data available and were included in analyses (72% Black, 10% Latino, and 17% White); among the 854 (94%) linked to care, 376 (44%) were retained in care. In multivariate analyses, retention in care was less likely among 19-24 year YMSM compared with 13-18-year-old YMSM (adjusted prevalence ratios [aPR] = 0.89, 95% confidence intervals [CI] 0.80-0.99).

CONCLUSION

Retention in HIV care was suboptimal for YMSM. Increased retention efforts are warranted to improve outcomes and reduce age and racial/ethnic disparities.

Socioecological factors influencing women's HIV risk in the United States: qualitative findings from the women's HIV SeroIncidence study (HPTN 064)

Background

We sought to understand the multilevel syndemic factors that are concurrently contributing to the HIV epidemic among women living in the US. We specifically examined community, network, dyadic, and individual factors to explain HIV vulnerability within a socioecological framework.

Methods

We gathered qualitative data (120 interviews and 31 focus groups) from a subset of women ages 18–44 years (N = 2,099) enrolled in the HPTN 064 HIV seroincidence estimation study across 10 US communities. We analyzed data from 4 diverse locations: Atlanta, New York City (the Bronx), Raleigh, and Washington, DC. Data were thematically coded using grounded theory methodology. Intercoder reliability was assessed to evaluate consistency of team-based coding practices.

Results

The following themes were identified at 4 levels including 1) exosystem (community): poverty prevalence, discrimination, gender imbalances, community violence, and housing challenges; 2) mesosystem (network): organizational social support and sexual concurrency; 3) microsystem (dyadic): sex exchange, interpersonal social support, intimate partner violence; and 4) individual: HIV/STI awareness, risk taking, and substance use. A strong theme emerged with over 80 % of responses linked to the fundamental role of financial insecurity underlying risk-taking behavioral pathways.

Conclusions

Multilevel syndemic factors contribute to women’s vulnerability to HIV in the US. Financial insecurity is a predominant theme, suggesting the need for tailored programming for women to reduce HIV risk.

Trial registration

Clinicaltrials.gov, NCT00995176

Development of a comprehensive measure of spatial access to HIV provider services, with application to Atlanta, Georgia

BACKGROUND

No existing measures of HIV care access consider both spatial proximity to services and provider-related characteristics in a single measure. We developed and applied a tool to: (1) quantify spatial access to HIV care services (supply) and (2) identify underserved areas with respect to HIV cases (demand), by travel mode, in Atlanta.

METHODS

Building on a study of HIV care engagement, data from an HIV care provider database, and HIV case counts by zip code tabulation area (ZCTA) from AIDSVu.org, we fit a discrete choice model to estimate practice characteristics most salient in defining patient care access. Modified spatial gravity modeling quantified supply access based on discrete choice model results separately for travel by car and by public transportation. Relative access scores were calculated by ZCTA, and underserved areas (defined as having low supply access and high HIV case count) were identified for each travel mode.

RESULTS

Characteristics retained in the final model included: travel distance, available provider-hours, availability of ancillary services, and whether Ryan White patients were accepted. HIV provider supply was higher in urban versus suburban/rural areas for both travel modes, with lower supply access if traveling by public transportation. Underserved areas were concentrated in south and east Atlanta if traveling by public transportation, overlapping with many areas of high poverty. Approximately 7.7 %, if traveling by car, and 64.3 %, if traveling by public transportation, of Atlanta-based persons with diagnosed HIV infection resided in underserved areas.

CONCLUSION

These findings highlight underserved areas in south and east Atlanta if traveling by public transit. Conceptualizing access to medical services spatially and by travel mode may help bridge gaps between patient needs and service availability and improve HIV outcomes.

Characterization of Heterogeneity in Childhood Immunization Coverage in Central Florida Using Immunization Registry Data

Despite high vaccine coverage in the United States in general, and in the State of Florida specifically, some children miss scheduled vaccines due to health system failures or vaccine refusal by their parents. Recent experiences with outbreaks in the United States suggest that geographic clustering of un(der)vaccinated populations represent a threat to the elimination status of some vaccine-preventable diseases. Immunization registries continue to expand and play an important role in efforts to track vaccine coverage and use. Using nearly 700,000 de-identified immunization records from the Florida Department of Health immunization information system (Florida SHOTS™) for children born during 2003-2014, we explored heterogeneity and potential clustering of un(der)vaccinated children in six counties in central Florida-Brevard, Lake, Orange, Oseola, Polk, and Seminole-that represent a high-risk area for importation due to family tourist attractions in the area. By zip code, we mapped the population density, the percent of children with religious exemptions, the percent of children on track or overdue for each vaccine series without and with exemptions, and the numbers of children with no recorded dose of each vaccine. Overall, we found some heterogeneity in coverage among the counties and zip codes, but relatively consistent and high coverage. We found that some children with an exemption in the system received the vaccines we analyzed, but exemption represents a clear risk factor for un(der)immunization. We identified many challenges associated with using immunization registry data for spatial analysis and potential opportunities to improve registries to better support future analyses.

Completeness and Reliability of Location Data Collected on the Web: Assessing the Quality of Self-Reported Locations in an Internet Sample of Men Who Have Sex With Men

BACKGROUND

Place is critical to our understanding of human immunodeficiency virus (HIV) infections among men who have sex with men (MSM) in the United States. However, within the scientific literature, place is almost always represented by residential location, suggesting a fundamental assumption of equivalency between neighborhood of residence, place of risk, and place of prevention. However, the locations of behaviors among MSM show significant spatial variation, and theory has posited the importance of nonresidential contextual exposures. This focus on residential locations has been at least partially necessitated by the difficulties in collecting detailed geolocated data required to explore nonresidential locations.

OBJECTIVE

Using a Web-based map tool to collect locations, which may be relevant to the daily lives and health behaviors of MSM, this study examines the completeness and reliability of the collected data.

METHODS

MSM were recruited on the Web and completed a Web-based survey. Within this survey, men used a map tool embedded within a question to indicate their homes and multiple nonresidential locations, including those representing work, sex, socialization, physician, and others. We assessed data quality by examining data completeness and reliability. We used logistic regression to identify demographic, contextual, and location-specific predictors of answering all eligible map questions and answering specific map questions. We assessed data reliability by comparing selected locations with other participant-reported data.

RESULTS

Of 247 men completing the survey, 167 (67.6%) answered the entire set of eligible map questions. Most participants (>80%) answered specific map questions, with sex locations being the least reported (80.6%). Participants with no college education were less likely than those with a college education to answer all map questions (prevalence ratio, 0.4; 95% CI, 0.2-0.8). Participants who reported sex at their partner's home were less likely to indicate the location of that sex (prevalence ratio, 0.8; 95% CI, 0.7-1.0). Overall, 83% of participants placed their home's location within the boundaries of their reported residential ZIP code. Of locations having a specific text description, the median distance between the participant-selected location and the location determined using the specific text description was 0.29 miles (25th and 75th percentiles, 0.06-0.88).

CONCLUSIONS

Using this Web-based map tool, this Web-based sample of MSM was generally willing and able to provide accurate data regarding both home and nonresidential locations. This tool provides a mechanism to collect data that can be used in more nuanced studies of place and sexual risk and preventive behaviors of MSM.

Exploring spatial patterns in the associations between local AIDS incidence and socioeconomic and demographic variables in the state of Rio de Janeiro, Brazil

Access to antiretroviral therapy (ART), universally provided in Brazil since 1996, resulted in a reduction in overall morbidity and mortality due to AIDS or AIDS-related complications, but in some municipalities of Rio de Janeiro, AIDS incidence remains high. Public health surveillance remains an invaluable tool for understanding current AIDS epidemiologic patterns and local socioeconomic and demographic factors associated with increased incidence. Geographically Weighted Poisson Regression (GWPR) explores spatial varying impacts of these factors across the study area focusing attention on local variations in ecological associations. The set of sociodemographic variables under consideration revealed significant associations with local AIDS incidence and these associations varied geographically across the study area. We find the effects of predictors on AIDS incidence are not constant across the state, contrary to assumptions in the global models. We observe and quantify different local factors driving AIDS incidence in different parts of the state.

Prediction of HIV Sexual Risk Behaviors Among Disadvantaged African American Adults Using a Syndemic Conceptual Framework

The focus of this paper is on HIV sexual risk taking among a community-based sample of disadvantaged African American adults. The objective is to examine multiple factors associated with sexual HIV risk behaviors within a syndemic conceptual framework. Face-to-face, computer-assisted, structured interviews were conducted with 1535 individuals in Atlanta, Georgia. Bivariate analyses indicated a high level of relationships among the HIV sexual risks and other factors. Results from multivariate models indicated that gender, sexual orientation, relationship status, self-esteem, condom use self-efficacy, sex while the respondent was high, and sex while the partner was high were significant predictors of condomless sex. Additionally, a multivariate additive model of risk behaviors indicated that the number of health risks significantly increased the risk of condomless sex. This intersection of HIV sexual risk behaviors and their associations with various other behavioral, socio-demographic, and psychological functioning factors help explain HIV risk-taking among this sample of African American adults and highlights the need for research and practice that accounts for multiple health behaviors and problems.

Geographic Variations in Retention in Care among HIV-Infected Adults in the United States

Objective

To understand geographic variations in clinical retention, a central component of the HIV care continuum and key to improving individual- and population-level HIV outcomes.

Design

We evaluated retention by US region in a retrospective observational study.

Methods

Adults receiving care from 2000–2010 in 12 clinical cohorts of the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) contributed data. Individuals were assigned to Centers for Disease Control and Prevention (CDC)-defined regions by residential data (10 cohorts) and clinic location as proxy (2 cohorts). Retention was ≥2 primary HIV outpatient visits within a calendar year, >90 days apart. Trends and regional differences were analyzed using modified Poisson regression with clustering, adjusting for time in care, age, sex, race/ethnicity, and HIV risk, and stratified by baseline CD4+ count.

Results

Among 78,993 adults with 444,212 person-years of follow-up, median time in care was 7 years (Interquartile Range: 4–9). Retention increased from 2000 to 2010: from 73% (5,000/6,875) to 85% (7,189/8,462) in the Northeast, 75% (1,778/2,356) to 87% (1,630/1,880) in the Midwest, 68% (8,451/12,417) to 80% (9,892/12,304) in the South, and 68% (5,147/7,520) to 72% (6,401/8,895) in the West. In adjusted analyses, retention improved over time in all regions (p<0.01, trend), although the average percent retained lagged in the West and South vs. the Northeast (p<0.01).

Conclusions

In our population, retention improved, though regional differences persisted even after adjusting for demographic and HIV risk factors. These data demonstrate regional differences in the US which may affect patient care, despite national care recommendations.

An Integrated Service Delivery Model to Identify Persons Living with HIV and to Provide Linkage to HIV Treatment and Care in Prioritized Neighborhoods: A Geotargeted, Program Outcome Study

BACKGROUND

Recent studies have demonstrated that high human immunodeficiency virus (HIV) prevalence (2.1%) rates exist in "high-risk areas" of US cities that are comparable to rates in developing nations. Community-based interventions (CBIs) have demonstrated potential for improving HIV testing in these areas, thereby facilitating early entry and engagement in the HIV continuum of care. By encouraging neighborhood-based community participation through an organized community coalition, Project LINK sought to demonstrate the potential of the CBI concept to improve widespread HIV testing and referral in an area characterized by high poverty and HIV prevalence with few existing HIV-related services.

OBJECTIVE

This study examines the influence of Project LINK to improve linkage-to-care and HIV engagement among residents of its target neighborhoods.

METHODS

Using a venue-based sampling strategy, survey participants were selected from among all adult participants aged 18 years or more at Project LINK community events (n=547). We explored multilevel factors influencing continuum-of-care outcomes (linkage to HIV testing and CBI network referral) through combined geospatial-survey analyses utilizing hierarchical linear model methodologies and random-intercept models that adjusted for baseline effect differences among zip codes. The study specifically examined participant CBI utilization and engagement in relation to individual and psychosocial factors, as well as neighborhood characteristics including the availability of HIV testing services, and the extent of local prevention, education, and clinical support services.

RESULTS

Study participants indicated strong mean intention to test for HIV using CBI agencies (mean 8.66 on 10-point scale [SD 2.51]) and to facilitate referrals to the program (mean 8.81 on 10-point scale [SD 1.86]). Individual-level effects were consistent across simple multiple regression and random-effects models, as well as multilevel models. Participants with lower income expressed greater intentions to obtain HIV tests through LINK (P<.01 across models). HIV testing and CBI referral intention were associated with neighborhood-level factors, including reduced availability of support services (testing P<.001), greater proportion of black/African Americans (testing and referral P<.001), and reduced socioeconomic capital (testing P=.017 and referral P<.001). Across models, participants expressing positive attitudes toward the CBI exhibited greater likelihood of engaging in routine HIV testing (P<.01) and referring others to HIV care (P<.01). Transgender individuals indicated greater intent to refer others to the CBI (P<.05). These outcomes were broadly influenced by distal community-level factors including availability of neighborhood HIV support organizations, population composition socioeconomic status, and high HIV prevalence.

CONCLUSIONS

Project LINK demonstrated its potential as a geotargeted CBI by evidencing greater individual intention to engage in HIV testing, care, and personal referrals to its coalition partner organizations. This study highlights important socioecological effects of US-based CBIs to improve HIV testing and initiate acceptable mechanisms for prompt referral to care among a vulnerable population.

Spatial Analysis Methods for Health Promotion and Education

This article provides a review of spatial analysis methods for use in health promotion and education research and practice. Spatial analysis seeks to describe or make inference about variables with respect to the places they occur. This includes geographic differences, proximity issues, and access to resources. This is important for understanding how health outcomes differ from place to place; and in terms of understanding some of the environmental underpinnings of health outcomes data by placing it in context of geographic location. This article seeks to promote spatial analysis as a viable tool for health promotion and education research and practice. Four more commonly used spatial analysis techniques are described in-text. An illustrative example of motor vehicle collisions in a large metropolitan city is presented using these techniques. The techniques discussed are as follows: descriptive mapping, global spatial autocorrelation, cluster detection, and identification and spatial regression analysis. This article provides useful information for health promotion and education researchers and practitioners seeking to examine research questions from a spatial perspective.

The Effect of Commuting Patterns on HIV Care Attendance Among Men Who Have Sex With Men (MSM) in Atlanta, Georgia

Background

Travel-related barriers to human immunodeficiency virus (HIV) care, such as commute time and mode of transportation, have been reported in the United States.

Objective

The objective of the study was to investigate the association between public transportation use and HIV care attendance among a convenience sample of Atlanta-based, HIV-positive men who have sex with men (MSM), evaluate differences across regions of residence, and estimate the relationship between travel distance and time by mode of transportation taken to attend appointments.

Methods

We used Poisson regression to estimate the association between use of public transportation to attend HIV-related medical visits and frequency of care attendance over the previous 12 months. The relationship between travel distance and commute time was estimated using linear regression. Kriging was used to interpolate commute time to visually examine geographic differences in commuting patterns in relation to access to public transportation and population-based estimates of household vehicle ownership.

Results

Using public transportation was associated with lower rates of HIV care attendance compared to using private transportation, but only in south Atlanta (south: aRR: 0.75, 95% CI 0.56, 1.0, north: aRR: 0.90, 95% CI 0.71, 1.1). Participants living in south Atlanta were more likely to have longer commute times associated with attending HIV visits, have greater access to public transportation, and may live in areas with low vehicle ownership. A majority of attended HIV providers were located in north and central Atlanta, despite there being participants living all across the city. Estimated commute times per mile traveled were three times as high among public transit users compared to private transportation users.

Conclusions

Improving local public transit and implementing use of mobile clinics could help address travel-related barriers to HIV care.

Spatial analysis of infection by the human immunodeficiency virus among pregnant women

OBJECTIVES:

to analyze the spatial distribution of reported cases of pregnant women infected by the human immunodeficiency virus and to identify the urban areas with greater social vulnerability to the infection among pregnant women.

METHOD:

ecological study, developed by means of spatial analysis techniques of area data. Secondary data were used from the Brazilian National Disease Notification System for the city of Recife, Pernambuco. Birth data were obtained from the Brazilian Information System on Live Births and socioeconomic data from the 2010 Demographic Census.

RESULTS:

the presence of spatial self-correlation was verified. Moran's Index was significant for the distribution. Clusters were identified, considered as high-risk areas, located in grouped neighborhoods, with equally high infection rates among pregnant women. A neighborhood located in the Northwest of the city was distinguished, considered in an epidemiological transition phase.

CONCLUSION:

precarious living conditions, as evidenced by the indicators illiteracy, absence of prenatal care and poverty, were relevant for the risk of vertical HIV transmission, converging to the grouping of cases among disadvantaged regions.

Environmental Influences on HIV Medication Adherence: The Role of Neighborhood Disorder

OBJECTIVES

We hypothesized that highly disordered neighborhoods would expose residents to environmental pressures, leading to reduced antiretroviral (ARV) medication adherence.

METHODS

Using targeted sampling, we enrolled 503 socioeconomically disadvantaged HIV-positive substance users in urban South Florida between 2010 and 2012. Participants completed a 1-time standardized interview that took approximately 1 hour. We tested a multiple mediation model to examine the direct and indirect effects of neighborhood disorder on diversion-related nonadherence to ARVs; risky social networks and housing instability were examined as mediators of the disordered neighborhood environment.

RESULTS

The total indirect effect in the model was statistically significant (P = .001), and the proportion of the total effect mediated was 53%. The model indicated substantial influence of neighborhood disorder on nonadherence to ARVs, operating through recent homelessness and diverter network size.

CONCLUSIONS

Long-term improvements in diversion-related ARV adherence will require initiatives to reduce demand for illicit ARV medications, as well as measures to reduce patient vulnerability to diversion, including increased resources for accessible housing, intensive treatment, and support services.

Neighborhood Condition and Geographic Locale in Assessing HIV/STI Risk Among African American Adolescents

Although region and neighborhood condition's effect on HIV/sexually transmitted infection (STI) risk has been studied separately, there is little research examining their interplay. African American adolescents (n = 1,602) from four matched cities in the Northeastern and Southeastern US completed Audio Computer Assisted Self-Interviews and submitted biospecimen samples to detect Sexually Transmitted Infections (chlamydia, gonorrhea, and trichomonas). Logistic and negative binomial regressions determined HIV/STI risk differences by region, neighborhood stress, and stress-region dyads. Northeastern participants demonstrated lower HIV/STI risk while participants from higher stress neighborhoods exhibited greater risk. Relationships between neighborhood condition and ever having anal sex (p < 0.01), anal condom use (p < 0.05), and number of anal partners (p < 0.05) were significant in the Northeast only. Participants in unstressed Northeastern neighborhoods were less likely to have vaginal sex than those in comparable Southeastern neighborhoods (p < 0.05). Participants in unfavorable Northeastern neighborhoods had fewer anal partners than participants in comparable Southeastern neighborhoods (p < 0.01). In concert, neighborhood and region differentially affect HIV/STI risk.

Mapping U.S. long-haul truck drivers' multiplex networks and risk topography in inner-city neighborhoods

This article illustrates how urban inner-city trucking milieux may influence STI/BBI/HIV acquisition and transmission risks for U.S. long-haul truckers, as well as their social and risk relationships. Using mixed methods, we collected ethnoepidemiological and biological data from long-haul truck drivers and their risk contacts in inner-city trucking milieux in Atlanta, Georgia, United States. Key findings indicate that within the risk-endemic environment of distressed inner-city areas, diverse trucking risk milieux can amplify STI/BBI/HIV risk for multiplex networks of truckers. Inner-city neighborhood location, short geographic distance among risk contacts, and trucker concurrency can potentially exacerbate transmission via bridging higher-risk individuals with lower-risk populations at disparate geographic and epidemiological locations.

Assessing the geographic coverage and spatial clustering of illicit drug users recruited through respondent-driven sampling in New York City

We assess the geographic coverage and spatial clustering of drug users recruited through respondent-driven sampling (RDS) and discuss the potential for biased RDS prevalence estimates. Illicit drug users aged 18-40 were recruited through RDS (N = 401) and targeted street outreach (TSO) (N = 210) in New York City. Using the Google Maps API™, we calculated travel distances and times using public transportation between each participant's recruitment location and the study office and between RDS recruiter-recruit pairs. We used K function analysis to evaluate and compare spatial clustering of (1) RDS vs. TSO respondents and (2) RDS seeds vs. RDS peer recruits. All participant recruitment locations clustered around the study office; however, RDS participants were significantly more likely to be recruited within walking distance of the study office than TSO participants. The TSO sample was also less spatially clustered than the RDS sample, which likely reflects (1) the van's ability to increase the sample's geographic heterogeneity and (2) that more TSO than RDS participants were enrolled on the van. Among RDS participants, individuals recruited spatially proximal peers, geographic coverage did not increase as recruitment waves progressed, and peer recruits were not less spatially clustered than seeds. Using a mobile van to recruit participants had a greater impact on the geographic coverage and spatial dependence of the TSO than the RDS sample. Future studies should consider and evaluate the impact of the recruitment approach on the geographic/spatial representativeness of the sample and how spatial biases, including the preferential recruitment of proximal peers, could impact the precision and accuracy of estimates.

Comparison of geographic methods to assess travel patterns of persons diagnosed with HIV in Philadelphia: how close is close enough?

Travel distance to medical care has been assessed using a variety of geographic methods. Network analyses are less common, but may generate more accurate estimates of travel costs. We compared straight-line distances and driving distance, as well as average drive time and travel time on a public transit network for 1789 persons diagnosed with HIV between 2010 and 2012 to identify differences overall, and by distinct geographic areas of Philadelphia. Paired t-tests were used to assess differences across methods, and analysis of variance was used to assess between-group differences. Driving distances were significantly longer than straight-line distances (p<0.001) and transit times were significantly longer than driving times (p<0.001). Persons living in the northeast section of the city traveled greater distances, and at greater cost of time and effort, than persons in all other areas of the city (p<0.001). Persons living in the northwest section of the city traveled farther and longer than all other areas except the northeast (p<0.0001). Network analyses that include public transit will likely produce a more realistic estimate of the travel costs, and may improve models to predict medical care outcomes.