Applying public health principles to the HIV epidemic

The impact of delay in HIV diagnosis on patient survival: analysis of HIV infection trends from 2007 to 2023

BACKGROUND AND PURPOSE

HIV disease is one of the major public health challenges and its early diagnosis and timely management play a vital role in reducing mortality. This study examines factors affecting the mortality of HIV patients and the effect of delay in diagnosis on survival.

METHODS

In this retrospective cohort study, data from the ART Center of Koppal District Hospital, India, from April 2007 to August 2023 were used. Of the 11,799 patients, 8,092 with complete data were included in the final analysis. Demographic and clinical variables including age, gender, HIV status, treatment, laboratory parameters, TB infection and survival were investigated. Delayed diagnosis was defined as CD4 ≤ 350. Statistical analyzes were performed with Cox regression and survival curves (Kaplan-Meier).

RESULTS

Out of 8092 patients, 5897 (72.8%) had delayed diagnosis. The average survival time for patients with delay was 61.55 months and without delay was 84.09 months. Delay in diagnosis increases the risk of death with HR 3.01 (95% CI: 2.67-3.40) in univariate analysis and HR 1.70 (95% CI: 1.48-1.96) in multivariate analysis. TS/TG patients had a higher risk of death than women with a HR of 1.64 (95% CI: 1.52-1.78) and patients over 45 with a HR of 2.17 (95% CI: 1.94-2.43) compared to those under 30. AIDS stage patients had a higher risk of death with HR 2.54 (95% CI: 2.34-2.75) and TB patients with HR 1.43 (95% CI: 1.31-1.56).

CONCLUSION

delay in diagnosis, age, disease stage and the presence of TB are important factors of mortality in patients with HIV. Early diagnosis and timely management of the disease can reduce the risk of death and increase the life expectancy of patients. Programs to increase awareness and access to diagnostic and treatment services should be strengthened.

Using molecular network analysis to understand current HIV-1 transmission characteristics in an inland area of Yunnan, China

HIV-1 molecular surveillance provides a new approach to explore transmission risks and targeted interventions. From January to June 2021, 663 newly reported HIV-1 cases were recruited in Zhaotong City, Yunnan Province, China. The distribution characteristics of HIV-1 subtypes and HIV-1 molecular network were analysed. Of 542 successfully subtyped samples, 12 HIV-1 strains were identified. The main strains were CRF08_BC (47.0%, 255/542), CRF01_AE (17.0%, 92/542), CRF07_BC (17.0%, 92/542), URFs (8.7%, 47/542), and CRF85_BC (6.5%, 35/542). CRF08_BC was commonly detected among Zhaotong natives, illiterates, and non-farmers and was mostly detected in Zhaoyang County. CRF01_AE was frequently detected among married and homosexual individuals and mostly detected in Weixin and Zhenxiong counties. Among the 516 pol sequences, 187 (36.2%) were clustered. Zhaotong natives, individuals aged ≥60 years, and illiterate individuals were more likely to be found in the network. Assortativity analysis showed that individuals were more likely to be genetically associated when stratified by age, education level, occupation, and reporting area. The genetic diversity of HIV-1 reflects the complexity of local HIV epidemics. Molecular network analyses revealed the subpopulations to focus on and the characteristics of the risk networks. The results will help optimise local prevention and control strategies.

Highlighting and addressing barriers to widespread adaptation of HIV self-testing in the United States

INTRODUCTION

HIV self-testing (HIVST), whereby an individual performs and interprets their own rapid screening test at home, is another tool to increase the proportion of at-risk individuals who know their status. Globally, HIVST has rapidly been adopted through global partnerships to ensure equitable access to tests in low- and middle-income countries (LMIC).

AREA COVERED

This review discusses the regulatory burdens of HIV self-testing within the United States while examining the use of HIV self-tests on a global scale. While the United States only has one approved HIV self-test, numerous tests have been prequalified by the WHO.

EXPERT OPINION

Despite the US Food and Drug Administration (FDA) clearance of the first and only self-test in 2012, there have been no other tests that have undergone FDA consideration due to regulatory barriers. This, in turn, has stifled market competition. Despite existing evidence that such programs are an innovative approach to testing hesitant or hard-to-reach populations, high individual test cost and bulky packaging make large-scale, mail-out, and HIV self-testing programs expensive. COVID-19 pandemic has accelerated the public demand for self-testing - HIV self-test programs should capitalize on this to increase the proportion of at-risk people who know their status and are linked to care to contribute to ending the HIV epidemic.

Retinal Microvasculature And Immune Restoration Among South Eastern Asian HIV/AIDS Patients Over A 9-Month Antiretroviral Therapy

BACKGROUND

Longitudinal evidence on retinal microvasculature and subsequent systemic inflammatory alteration is lacking. We investigated the association between retinal microvasculature and immune response among HIV/AIDS patients over a 9-month antiretroviral therapy (ART).

METHODS

We conducted a prospective cohort on HIV/AIDS patients at Singapore Communicable Disease Centre (CDC) since June 2011. We recruited all eligible patients and then reviewed them every three months over a 9-month follow-up, including performing blood tests (CD4+/CD8+ T-cell counts, HIV viral load), blood pressure, anthropometry measurements, and retinal photography at each visit. We assessed retinal vascular indexes via a semi-automated computer-based program. Lastly, we applied a linear mixed model to analyze associations between baseline retinal vascular indexes and 9-month changes of CD4+/CD8+ T-cell cell counts and HIV viral load throughout study observation, after adjusting for major confounders.

RESULTS

We found that narrower arteriolar caliber (per 10 μm decrease), wider venular caliber (per 10 μm increase), and larger arteriolar branching angle (per 10 degrees increase) in the retina assessed at baseline were significantly associated with 9-month reductions in CD4+ T-cell count by 52.97 cells/µl (p=0.006), 33.55 cells/µl (p=0.01), and 39.09 cells/ µl (p=0.008), accordingly.

CONCLUSION

HIV/AIDS Patients with a suboptimal retinal microvascular morphology tended to fail immune restoration undertaking a 9-month ART.

Research Synthesis, HIV Prevention Response, and Public Health: CDC's HIV/AIDS Prevention Research Synthesis Project

OBJECTIVE

Research synthesis, through qualitative or quantitative systematic reviews, allows for integrating results of primary research to improve public health. We examined more than 2 decades of work in HIV prevention by the Centers for Disease Control and Prevention's (CDC's) HIV/AIDS Prevention Research Synthesis (PRS) Project. We describe the context and contributions of research synthesis, including systematic reviews and meta-analyses, through the experience of the PRS Project.

METHODS

We reviewed PRS Project publications and products and summarized PRS contributions from 1996 to July 2020 in 4 areas: synthesis of interventions and epidemiologic studies, synthesis methods, prevention programs, and prevention policy.

RESULTS

PRS Project publications summarized risk behaviors and effects of prevention interventions (eg, changing one's perception of risk, teaching condom negotiation skills) across populations at risk for HIV infection and intervention approaches (eg, one-on-one or group meetings) as the HIV/AIDS epidemic and science evolved. We used the PRS Project cumulative database and intervention efficacy reviews to contribute to prevention programs and policies through identification of evidence-based interventions and development of program guidance. Subject matter experts and scientific evidence informed PRS Project products and contributions, which were implemented through strategic programmatic partnerships.

CONCLUSIONS

The contributions of the PRS Project to HIV prevention and public health efforts in the United States can be credited to CDC's long-standing support of the project and its context within a federal prevention agency, where HIV programs and policies were developed and implemented. The effect of the PRS Project was likely facilitated by opportunities to directly influence program and policy because of connections with other research translation activities and program and policy decision making within CDC.

The First 40 Years of AIDS: Promising Programs, Limited Success

HIV-prevention program planning, implementation, and evaluation began in the United States shortly after reports of a mysterious, apparently acquired, immune deficiency syndrome appeared in summer 1981. In San Francisco, New York City, and elsewhere, members of LGBT communities responded by providing accurate information, giving support, and raising money. During the first decade of the AIDS pandemic (1981-1990), social and behavioral scientists contributed by designing theory-based and practical interventions, combining interventions into programs, and measuring impact on behavior change and HIV incidence. In the second decade (1991-2000), federal, state, and local agencies and organizations played a more prominent role in establishing policies and procedures, funding research and programs, and determining the direction of intervention efforts. In the third decade (2001-2010), biomedical interventions were prioritized over behavioral interventions and have dominated attempts in the fourth decade (2011-2020) to integrate biomedical, behavioral, and structural interventions into coherent, efficient, and cost-effective programs to end AIDS.

Determinants of HIV testing among Filipino women: Results from the 2013 Philippine National Demographic and Health Survey

BACKGROUND

The prevalence of having ever tested for HIV in the Philippines is very low and is far from the 90% target of the Philippine Department of Health (DOH) and UNAIDS, thus the need to identify the factors associated with ever testing for HIV among Filipino women.

METHODS

We analysed the 2013 Philippine National Demographic and Health Survey (NDHS). The NDHS is a nationally representative survey which utilized a two-stage stratified design to sample Filipino women aged 15-49. We considered the following exposures in our study: socio-demographic characteristics of respondent and her partner (i.e., age of respondent, age of partner, wealth index, etc.), sexual practices and contraception (i.e., age at first intercourse, condom use, etc.), media access, tobacco use, HIV knowledge, tolerance to domestic violence, and women's empowerment. The outcome variable is HIV testing. We used logistic regression for survey data to study the said associations.

RESULTS

Out of 16,155 respondents, only 372 (2.4%) have ever tested for HIV. After adjusting for confounders, having tertiary education (adjusted odds ratio (aOR) = 2.15; 95% Confidence Interval (CI): 1.15-4.04), living with partner (aOR = 1.72; 95% CI: 1.19-2.48), tobacco use (aOR = 1.87; 95% CI: 1.13-3.11); belonging to the middle class (aOR = 2.72; 95% CI: 1.30-5.67), richer (aOR = 3.00; 95% CI: 1.37-5.68), and richest (aOR = 4.14; 95% CI: 1.80-5.91) populations, having weekly television access (aOR = 1.75; 95% CI: 1.04-2.94) or internet access (aOR = 2.01; 95% CI: 1.35-3.00), living in a rural area (aOR = 1.87; 95% CI: 1.34-2.61); and being a Muslim (aOR = 2.30; 95% CI: 1.15-4.57) were associated with ever testing for HIV.

CONCLUSIONS

The low percentage of respondents who test for HIV is a call to further strengthen efforts to promote HIV testing among Filipino women. Information on its determinants can be used to guide the crafting and implementation of interventions to promote HIV testing to meet DOH and UNAIDS targets.

Risk network approaches to locating undiagnosed HIV cases in Odessa, Ukraine

INTRODUCTION

Providing HIV healthcare and Treatment as Prevention both depend on diagnosing HIV cases, preferably soon after initial infection. We hypothesized that tracing risk networks recruits higher proportions of undiagnosed positives than outreach-based testing or respondent-driven sampling (RDS) in Odessa, Ukraine.

METHODS

The Transmission Reduction Intervention Project (TRIP) used risk network tracing to recruit sexual and injection networks of recently-infected and longer-term infected (LTs) seeds (2013 to 2016). Integrated Biobehavioural Surveillance (IBBS) (2013) used RDS to recruit people who inject drugs (PWID). Outreach Testing tested PWID for HIV at community outreach sites (2013 to 2016). Proportions of undiagnosed positives among those tested were compared TRIP versus IBBS; TRIP versus Outreach Testing and between TRIP arms. Costs were compared across the projects.

RESULTS

TRIP tested 1252 people (21% women) in seeds' risk networks; IBBS tested 400 (18% women); Outreach Testing 13,936 (31% women). TRIP networks included a higher proportion of undiagnosed positives (14.6%) than IBBS (5.0%) or Outreach Testing (2.4%); odds ratio (OR) 3.25 (95% CI 2.07, 5.12) versus IBBS and 7.03 (CI 5.95, 8.31) versus Outreach Testing respectively. Findings remained significant in analyses stratified by sex and when PWID in TRIP networks were compared with Outreach Testing and IBBS. Within TRIP, recently-infected participants' networks contained higher proportions of undiagnosed positives (16.3%) than LTs' networks (12.2%); OR 1.41 (CI 1.01, 1.95). TRIP located undiagnosed positives less expensively than did RDS or Outreach Testing.

CONCLUSIONS

TRIP's recruiting techniques, including prioritizing networks of the recently infected, find undiagnosed HIV-positive people efficiently. They should be integrated with standard practice to improve case-finding. Research should test these techniques in other socio-epidemiologic contexts.

CLINICAL TRIAL REGISTRY

Registered ClinicalTrials.gov: NCT01827228.

Housing: A Case for The Medicalization of Poverty

"Medicalization" has been a contentious notion since its introduction centuries ago. While some scholars lamented a medical overreach into social domains, others hailed its promise for social justice advocacy. Against the backdrop of a growing commitment to health equity across the nation, this article reviews historical interpretations of medicalization, offers an application of the term to non-biologic risk factors for disease, and presents the case of housing the demonstrate the great potential of medicalizing poverty.

The Health and Sociocultural Correlates of AIDS Genocidal Beliefs and Medical Mistrust Among African American MSM

This study examined social and health-related correlates of AIDS conspiracy theories among 464 African American men who have sex with men (MSM). Exploratory factor analysis revealed two subscales within the AIDS conspiracy beliefs scale: medical mistrust and AIDS genocidal beliefs. Multiple regression analyses revealed medical mistrust and AIDS genocidal beliefs were both associated negative condom use attitudes and higher levels of internalized homonegativity. Medical mistrust was also associated with lower knowledge of HIV risk reduction strategies. Finally, we conducted bivariate regressions to examine the subsample of participants who reported being HIV-positive and currently taking HIV antiretroviral therapy (ART) to test associations between sexual behavior and HIV treatment and AIDS conspiracy theories. Among this subsample, medical mistrust was associated with having a detectable viral load and not disclosing HIV-status to all partners in the previous 3 months. Collectively, these findings have implications for HIV prevention and treatment for African American MSM.

Using HIV Surveillance Data to Link People to HIV Medical Care, 5 US States, 2012-2015

INTRODUCTION

From 2012 through 2015, the Centers for Disease Control and Prevention (CDC) provided funding to 5 health departments for demonstration projects using HIV surveillance data to link people with newly diagnosed HIV to care. We assessed how well these health departments established linkage to care, how the demonstration projects helped them with this work, and if they sustained these activities after CDC funding ended.

MATERIALS AND METHODS

We obtained quantitative and qualitative data on linkage-to-care activities from health department communications and progress reports submitted to CDC. We calculated and combined linkage-to-care results for the 5 health departments, and we compared these results with the combined linkage-to-care results for 61 health departments that received CDC funding for routine HIV prevention activities (eg, HIV testing, linkage to and reengagement in HIV care, HIV partner services) and for the same 5 health departments when they used only routine HIV prevention activities for linkage to care.

RESULTS

Of 1269 people with a new HIV diagnosis at the 5 health departments, 1124 (89%) were linked to care, a result that exceeded the 2010-2015 National HIV/AIDS Strategy goal (85%), the CDC Funding Opportunity Announcement performance standard (80%), and combined results for the 61 health departments (63%) and the same 5 health departments (66%) using routine HIV prevention activities. Benefits of the projects were improved collaboration and coordination and more accurate, up-to-date surveillance data. All health departments continued linkage-to-care activities after funding ended.

PRACTICE IMPLICATIONS

Using HIV surveillance data to link people with HIV to care resulted in substantial clinical and public health benefits. Our observations underscore the importance of collaboration among medical providers, public health staff members, community-based organizations, and people with HIV to ensure the best possible clinical and public health outcomes.

Care continuum entry interventions: seek and test strategies to engage persons most impacted by HIV within the United States

: The current review re-conceptualizes seek and test strategies, particularly given the changing importance of HIV testing as care continuum entry for persons irrespective of their HIV status. Care continuum entry advances previous seek and test strategies for client engagement with two next-generation functions: use of testing to engage (or re-engage) HIV negative clients in preexposure prophylaxis (PrEP) care; and testing individuals who may already be known positives for care continuum re-entry. We review existing seek and test strategies for most impacted community members with a goal of optimizing care continuum entry as we move towards HIV transmission elimination. These strategies are context, sub-group, community and epidemic-specific. This review is timely, given the initiation of routine PrEP care, which shifts and broadens our conceptualization of care continuum entry triggered by the HIV testing event. In addition, as the epidemic becomes more concentrated, focusing on re-engagement of HIV-infected persons becomes increasingly important given that transmission events involve both those acutely and newly infected as well as the large numbers who may not be virally suppressed. We start with examination of routine testing in healthcare settings, emphasizing its potential role in re-engagement for persons out of care. Subsequently, we describe risk-based testing to identify key populations. We then review network-based approaches and their impact on the epidemic. We close with future directions for individual and combination care continuum entry strategies most relevant to elimination of HIV transmission in the United States.

The End of Written Informed Consent for HIV Testing: Not With a Bang but a Whimper

In 2014, only two states in the United States still mandated specific written informed consent for HIV testing and, after years of controversy, New York ended this requirement, leaving only Nebraska. New York's shift to opt-out testing meant that a singular feature of what had characterized the exceptionalism surrounding HIV testing was eliminated. We trace the history of debates on written informed consent nationally and in New York State. Over the years of dispute from when HIV testing was initiated in 1985 to 2014, the evidence about the benefits and burdens of written informed consent changed. Just as important was the transformation of the political configuration of HIV advocacy and funding, both nationwide and in New York State. What had for years been the subject of furious debate over what a rational and ethical screening policy required came to an end without the slightest public protest. (Am J Public Health. 2017;107:1259-1265. doi:10.2105/AJPH.2017.303819).

Randomized Controlled Trial of an Intervention to Maintain Suppression of HIV Viremia After Prison Release: The imPACT Trial

BACKGROUND

HIV-infected individuals transitioning from incarceration to the community are at risk for loss of viral suppression. We compared the effects of imPACT, a multidimensional intervention to promote care engagement after release, to standard care on sustaining viral suppression after community re-entry.

METHODS

This trial randomized 405 HIV-infected inmates being released from prisons in Texas and North Carolina with HIV-1 RNA levels <400 copies/mL to imPACT versus standard care. The imPACT arm received motivational interviewing prerelease and postrelease, referral to care within 5 days of release, and a cellphone for medication text reminders. The standard care arm received routine discharge planning and a cellphone for study staff contact. The primary outcome was the difference between arms in week 24 postrelease viral suppression (HIV-1 RNA <50 copies/mL) using intention-to-treat analysis with multiple imputation of missing data.

RESULTS

The proportion with 24-week HIV-1 RNA <50 copies/mL was 60% and 61% in the imPACT and standard care arms, respectively [odds ratio for suppression 0.95 (95% confidence interval: 0.59 to 1.53)]. By week 6 postrelease, 86% in the imPACT arm versus 75% in the standard care arm attended at least 1 nonemergency clinic visit (P = 0.02). At week 24, 62% in both arms reported not missing any antiretroviral doses in the past 30 days (P > 0.99).

CONCLUSIONS

Higher rates of HIV suppression and medical care engagement than expected based on previous literature were observed among HIV-infected patients with suppressed viremia released from prison. Randomization to a comprehensive intervention to motivate and facilitate HIV care access after prison release did not prevent loss of viral suppression. A better understanding of the factors influencing prison releasees' linkage to community care, medication adherence, and maintenance of viral suppression is needed to inform policy and other strategic approaches to HIV prevention and treatment.

The Politics of Prevention: Lessons from the Neglected History of US HIV/AIDS Policy

The history of government action on HIV/AIDS has much to teach us about the dynamics and possibilities of US public health policy, but it has been insufficiently studied by social scientists of the epidemic. This article draws on a large set of original interviews with policy makers, thousands of news articles, and extensive documentation to reconstruct the history of three areas of debate and decision making about HIV prevention since 1990: needle exchange, HIV testing, and sex education for at-risk groups. These histories illuminate three key lessons. First, scientific evidence has less power to drive public health policy in the United States than in the United Kingdom, which is used as a comparison case to contextualize US choices within a broader range of options. Second, moral concerns weigh so heavily in the United States that a publicly articulated moral argument can countermand the dictates of solid scientific evidence, the voices of experts, and practical considerations to push public health policy in entirely oppositional directions. Third, having the ear of the presidential administration is usually a necessary-although not always sufficient-condition for the success of advocates trying to move US policy in the public health-indicated direction.

HIV Testing Among Men at Risk for Acquiring HIV Infection Before and After the 2006 CDC Recommendations

OBJECTIVES

Testing for human immunodeficiency virus (HIV) is the key first step in HIV treatment and prevention. In 2006, the Centers for Disease Control and Prevention (CDC) recommended annual HIV testing for people at high risk for HIV infection. We evaluated HIV testing among men with high-risk heterosexual (HRH) contact and sexually active men who have sex with men (MSM) before and after the CDC recommendations.

METHODS

We used data from the National Survey of Family Growth, 2002 and 2006-2010, to assess proportions of HRH respondents and MSM reporting HIV testing in the prior 12 months, compare rates of testing before and after release of the 2006 CDC HIV testing guidelines, and examine demographic variables and receipt of health-care services as correlates of HIV testing.

RESULTS

Among MSM, the proportion tested was 37.2% (95% confidence interval [CI] 28.2, 47.2) in 2002, 38.2% (95% CI 25.9, 52.2) in 2006-2008, and 41.7% (95% CI 29.2, 55.3) in 2008-2010; among HRH respondents, the proportion was 23.7% (95% CI 20.5, 27.3) in 2002, 24.5% (95% CI 20.9, 28.7) in 2006-2008, and 23.9% (95% CI 20.2, 28.1) in 2008-2010. HIV testing was more likely among MSM and HRH respondents who received testing or treatment for sexually transmitted disease in the prior 12 months, received a physical examination in the prior 12 months (MSM only), or were incarcerated in the prior 12 months.

CONCLUSIONS

The rate of annual HIV testing was low for men with sexual risk for HIV infection, and little improvement took place from 2002 to 2006-2010. Interventions aimed at men at risk, especially MSM, in both nonmedical and health-care settings, likely could increase HIV testing.

Citizenship in a time of HIV: Understanding medical adult male circumcision in South Africa

Medical adult male circumcision has been shown to offer men significant protection against HIV infection during peno-vaginal sex. This has resulted in calls for a national roll-out of medical adult male circumcision in South Africa, a rights-based constitutional democracy. This article explores the ways that the potential tensions between this call to circumcise as a practice of good health citizenship and the guaranteed right to bodily integrity are negotiated in interviews with 30 urban-based men in Johannesburg. The results suggest that despite its demonstrable biological efficacy, these tensions may paralyse decision- and policy-makers in grappling with the potential scaling up of medical adult male circumcision for HIV prevention in South Africa.

HIV provider and patient perspectives on the Development of a Health Department "Data to Care" Program: a qualitative study

Background

U.S. health departments have not historically used HIV surveillance data for disease control interventions with individuals, but advances in HIV treatment and surveillance are changing public health practice. Many U.S. health departments are in the early stages of implementing “Data to Care” programs to assists persons living with HIV (PLWH) with engaging in care, based on information collected for HIV surveillance. Stakeholder engagement is a critical first step for development of these programs. In Seattle-King County, Washington, the health department conducted interviews with HIV medical care providers and PLWH to inform its Data to Care program. This paper describes the key themes of these interviews and traces the evolution of the resulting program.

Methods

Disease intervention specialists conducted individual, semi-structured qualitative interviews with 20 PLWH randomly selected from HIV surveillance who had HIV RNA levels >10,000 copies/mL in 2009–2010. A physician investigator conducted key informant interviews with 15 HIV medical care providers. Investigators analyzed de-identified interview transcripts, developed a codebook of themes, independently coded the interviews, and identified codes used most frequently as well as illustrative quotes for these key themes. We also trace the evolution of the program from 2010 to 2015.

Results

PLWH generally accepted the idea of the health department helping PLWH engage in care, and described how hearing about the treatment experiences of HIV seropositive peers would assist them with engagement in care. Although many physicians were supportive of the Data to Care concept, others expressed concern about potential health department intrusion on patient privacy and the patient-physician relationship. Providers emphasized the need for the health department to coordinate with existing efforts to improve patient engagement. As a result of the interviews, the Data to Care program in Seattle-King County was designed to incorporate an HIV-positive peer component and to ensure coordination with HIV care providers in the process of relinking patients to care.

Conclusions

Health departments can build support for Data to Care efforts by gathering input of key stakeholders, such as HIV medical and social service providers, and coordinating with clinic-based efforts to re-engage patients in care.

"Seek, Test, Treat" Lessons From Australia: A Study of HIV Testing Patterns From a Cohort of Men Who Have Sex With Men

OBJECTIVE

HIV diagnoses are increasing in Australia, mostly among men who have sex with men (MSM). Similar to many countries, Australia's HIV prevention strategies emphasize a "seek, test, treat" approach including enhancing HIV testing frequency. We describe HIV testing among MSM and correlates of returning for testing within 12 months in the context of new HIV prevention paradigms.

METHODS

Testing and behavioral data (2007-2013) contributed by MSM aged ≥ 16 years were included. Total HIV tests by calendar year and repeat tests within 12 months were described, alongside negative binomial regression for trend. A 2-level mixed-effects logistic regression model examined correlates of testing within 12 months. Median (days) between HIV tests was compared between MSM diagnosed with HIV and persistently HIV-negative MSM.

RESULTS

The study included 46,060 tests from 17,904 MSM. There was an increase in annual tests (P < 0.01), repeat tests within 12 months (P < 0.01), and the proportion of tests within 12 months of an index test (P < 0.01), although only to 53.3% in 2013. Return rates were higher in MSM aged 16-29 years (adjusted odds ratio 1.30, 95% confidence interval: 1.1 to 1.5) and those reporting higher numbers of partners (adjusted odds ratio 3.5, 95% confidence interval: 3.0 to 4.0). Median time between tests among MSM diagnosed with HIV (233 days) was greater than for HIV-negative MSM (189 days) (P = 0.03).

CONCLUSIONS

Although testing has increased, testing frequency among many MSM remains suboptimal. To optimize "seek, test, treat"-based HIV prevention strategies, new approaches to increase testing uptake and early HIV detection among MSM are needed.

The increased effectiveness of HIV preventive intervention among men who have sex with men and of follow-up care for people living with HIV after 'task-shifting' to community-based organizations: a 'cash on service delivery' model in China

Background

A large number of men who have sex with men (MSM) and people living with HIV/AIDS (PLHA) are underserved despite increased service availability from government facilities while many community based organizations (CBOs) are not involved. We aimed to assess the feasibility and effectiveness of the task shifting from government facilities to CBOs in China.

Methods

HIV preventive intervention for MSM and follow-up care for PLHA were shifted from government facilities to CBOs. Based on ‘cash on service delivery’ model, 10 USD per MSM tested for HIV with results notified, 82 USD per newly HIV cases diagnosed, and 50 USD per PLHA received a defined package of follow-up care services, were paid to the CBOs. Cash payments were made biannually based on the verified results in the national web-based HIV/AIDS information system.

Findings

After task shifting, CBOs gradually assumed preventive intervention for MSM and follow-up care for PLHA from 2008 to 2012. HIV testing coverage among MSM increased from 4.1% in 2008 to 22.7% in 2012. The baseline median CD4 counts of newly diagnosed HIV positive MSM increased from 309 to 397 cells/µL. HIV tests among MSM by CBOs accounted for less than 1% of the total HIV tests in Nanjing but the share of HIV cases detected by CBOs was 12.4% in 2008 and 43.6% in 2012. Unit cost per HIV case detected by CBOs was 47 times lower than that by government facilities. The coverage of CD4 tests and antiretroviral therapy increased from 71.1% and 78.6% in 2008 to 86.0% and 90.1% in 2012, respectively.

Conclusion

It is feasible to shift essential HIV services from government facilities to CBOs, and to verify independently service results to adopt ‘cash on service delivery’ model. Services provided by CBOs are cost-effective, as compared with that by government facilities.

Recent trends in early stage response to combination antiretroviral therapy in Australia

BACKGROUND

There have been improvements in combination antiretroviral therapy (cART) over the past 15 years. The aim of this analysis was to assess whether improvements in ART have resulted in improvements in surrogates of HIV outcome.

METHODS

Patients in the Australian HIV Observational Database who initiated treatment using mono/duo therapy prior to 1996, or using cART from 1996 onwards, were included in the analysis. Patients were stratified by era of ART initiation. Median changes in CD4(+) T-cell count and the proportion of patients with detectable HIV viral load (>400 copies/ml) were calculated over the first 4 years of treatment. Probabilities of treatment switch were estimated using the Kaplan-Meier method.

RESULTS

A total of 2,753 patients were included in the analysis: 28% initiated treatment <1996 using mono/duo therapy and 72% initiated treatment ≥1996 using cART (30% 1996-1999, 12% 2000-2003, 11% 2004-2007 and 19% ≥2008). Overall CD4(+) T-cell count response improved by later era of initiation (P<0.001), although 2000-2003 CD4(+) T-cell count response was less than that for 1996-1999 (P=0.007). The average proportion with detectable viral load from 2 to 4 years post-treatment commencement by era was: <1996 mono/duo 0.69 (0.67-0.71), 1996-1999 cART 0.29 (0.28-0.30), 2000-2003 cART 0.22 (0.20-0.24), 2004-2007 cART 0.09 (0.07-0.10) and ≥2008 cART 0.04 (0.03-0.05). Probability of treatment switch at 4 years after initiation decreased from 53% in 1996-1999 to 29% after 2008 (P<0.001).

CONCLUSIONS

Across the five time-periods examined, there have been incremental improvements for patients initiated on cART, as measured by overall response (viral load and CD4(+) T-cell count) and also increased durability of first-line ART regimens.

Lost or just not following up: public health effort to re-engage HIV-infected persons lost to follow-up into HIV medical care

OBJECTIVE

Locate persons living with HIV (PLWH) presumed lost to follow-up (LTFU), and assist them with partner services and linkage to HIV-related care.

DESIGN

Locate and facilitate re-engagement in care for PLWH-LTFU in New York City (NYC), with longitudinal follow-up using HIV surveillance registry.

SETTINGS

HIV care facilities and communities in NYC.

PATIENTS

PLWH, reported in the NYC HIV surveillance registry, who had a NYC care provider and residential address at last report in the registry. Presumed-LTFU was defined as having no CD4+ or viral load during the most recent 9 months during the study period July 2008-December 2010.

INTERVENTION

Case-workers conducted public health investigation to locate PLWH presumed-LTFU and offered them assistance with partner and linkage-to-care services.

MAIN OUTCOME MEASURES

Results of partner and linkage-to-care services, and reasons for LTFU.

RESULTS

From July 2008 to December 2010, 797 PLWH presumed-LTFU were prioritized for investigation; 14% were never located. Of the 689 located, 33% were current to care, 5% had moved or were incarcerated, 2% had died, and 59% (409) were verified to be LTFU. Once located, 77% (315/409) accepted clinic appointments, and 57% (232/409) returned to care. Among the 161 who provided reasons for LTFU, the most commonly reported was 'felt well' (41%).

CONCLUSIONS

Health department case-workers helped more than half PLWH-LTFU re-engage in HIV medical care. HIV prevention strategies must include efforts to re-engage PLWH-LTFU in care, for treatment consideration under current treatment guidelines to improve their clinical status and decrease transmission risk.

Expanding HIV testing: back to the future

The value of HIV testing has grown in parallel with the development of increasingly effective HIV treatment. Evidence for the substantial reductions in transmission when persons receive antiretroviral therapy creates a new impetus to increase testing and early diagnosis. Models of treatment as prevention--dubbed "test and treat"--give reason for optimism that control and elimination of HIV may now be within reach. This will be possible only with widespread testing, prompt and accurate diagnosis, and universal access to immediate antiviral therapy. Many successful approaches for scaling up testing were pioneered in resource-limited countries before they were adopted by countries in the developed world. The future of HIV testing is changing. Lessons learned from other case-finding initiatives can help chart the course for comparable HIV testing endeavors.

Shifting the paradigm: using HIV surveillance data as a foundation for improving HIV care and preventing HIV infection

CONTEXT

Reducing HIV incidence in the United States and improving health outcomes for people living with HIV hinge on improving access to highly effective treatment and overcoming barriers to continuous treatment. Using laboratory tests routinely reported for HIV surveillance to monitor individuals' receipt of HIV care and contacting them to facilitate optimal care could help achieve these objectives. Historically, surveillance-based public health intervention with individuals for HIV control has been controversial because of concerns that risks to privacy and autonomy could outweigh benefits. But with the availability of lifesaving, transmission-interrupting treatment for HIV infection, some health departments have begun surveillance-based outreach to facilitate HIV medical care.

METHODS

Guided by ethics frameworks, we explored the ethical arguments for changing the uses of HIV surveillance data. To identify ethical, procedural, and strategic considerations, we reviewed the activities of health departments that are using HIV surveillance data to contact persons identified as needing assistance with initiating or returning to care.

FINDINGS

Although privacy concerns surrounding the uses of HIV surveillance data still exist, there are ethical concerns associated with not using HIV surveillance to maximize the benefits from HIV medical care and treatment. Early efforts to use surveillance data to facilitate optimal HIV medical care illustrate how the ethical burdens may vary depending on the local context and the specifics of implementation. Health departments laid the foundation for these activities by engaging stakeholders to gain their trust in sharing sensitive information; establishing or strengthening legal, policy and governance infrastructure; and developing communication and follow-up protocols that protect privacy.

CONCLUSIONS

We describe a shift toward using HIV surveillance to facilitate optimal HIV care. Health departments should review the considerations outlined before implementing new uses of HIV surveillance data, and they should commit to an ongoing review of activities with the objective of balancing beneficence, respect for persons, and justice.

Assessing willingness to test for HIV among men who have sex with men using conjoint analysis, evidence for uptake of the FDA-approved at-home HIV test

Men who have sex with men (MSM) in the USA, represent a vulnerable population with lower rates of HIV testing. There are various specific attributes of HIV testing that may impact willingness to test (WTT) for HIV. Identifying specific attributes influencing patients' decisions around WTT for HIV is critical to ensure improved HIV testing uptake. This study examined WTT for HIV by using conjoint analysis, an innovative method for systematically estimating consumer preferences across discrete attributes. WTT for HIV was assessed across eight hypothetical HIV testing scenarios varying across seven dichotomous attributes: location (home vs. clinic), price (free vs. $50), sample collection (finger prick vs. blood), timeliness of results (immediate vs. 1-2 weeks), privacy (anonymous vs. confidential), results given (by phone vs. in-person), and type of counseling (brochure vs. in-person). Seventy-five MSM were recruited from a community-based organization providing HIV testing services in Los Angeles to participate in conjoint analysis. WTT for HIV score was based on a 100-point scale. Scores ranged from 32.2 to 80.3 for eight hypothetical HIV testing scenarios. Price of HIV testing (free vs. $50) had the highest impact on WTT (impact score = 31.4, SD = 29.2, p<0.0001), followed by timeliness of results (immediate vs. 1-2 weeks) (impact score = 13.9, SD = 19.9, p≤0.0001) and testing location (home vs. clinic) (impact score = 10.3, SD = 22.8, p=0.0002). Impacts of other HIV testing attributes were not significant. Conjoint analysis method enabled direct assessment of HIV testing preferences and identified specific attributes that significantly impact WTT for HIV among MSM. This method provided empirical evidence to support the potential uptake of the newly FDA-approved over-the-counter HIV home test kit with immediate results, with cautionary note on the cost of the kit.

Community viral load as a measure for assessment of HIV treatment as prevention

Community viral load, defined as an aggregation of individual viral loads of people infected with HIV in a specific community, has been proposed as a useful measure to monitor HIV treatment uptake and quantify its effect on transmission. The first reports of community viral load were published in 2009, and the measure was subsequently incorporated into the US National HIV/AIDS Strategy. Although intuitively an appealing strategy, measurement of community viral load has several theoretical limitations and biases that need further assessment, which can be grouped into four categories: issues of selection and measurement, the importance of HIV prevalence in determining the potential for ongoing HIV transmission, interpretation of community viral load and its effect on ongoing HIV transmission in a community, and the ecological fallacy (ie, ecological bias). These issues need careful assessment as community viral load is being considered as a public health measurement to assess the effect of HIV care on prevention.

Changes in sexual behaviors among HIV-infected individuals after their HIV diagnosis in a rural prefecture of Eastern China

OBJECTIVE

To describe changes in sexual behaviors among HIV-infected individuals after their HIV diagnosis.

METHODS

All HIV-infected individuals diagnosed by the end of 2009 in Taizhou Prefecture were invited to participate in this 12-month prospective study. Assessments including the total number and types of sexual contacts, and condom use details for up to their most familiar eight sexual contacts were collected both at enrollment and 12-month follow-up.

RESULTS

262 HIV-infected individuals were eligible for analysis. The total number of sexual contacts reported by participants was 4,017, 1,496 and 356 during the 12- month period prior to HIV diagnosis (T1), the 12-month period prior to the baseline survey (T2), and the 12-month follow-up period (T3), respectively. The difference in the number of sexual contacts between T2 and T1 was -5 in median (IQR -1, -14), and the difference between T3 and T2 was 0 in median (IQR: 0, -6). A larger proportion of spousal or long-term heterosexual contact was reported from T1(27.7%) to T2(42.5%) to T3(76.1%), whereas a smaller proportion of commercial heterosexual contacts was reported from T1 (48.6%) to T2 (33.2%) to T3 (7.0%) as well as a smaller proportion of non-commercial casual homosexual contacts was reported from T2 (8.4%) to T3 (3.8%).The proportion of consistent condom use increased significantly from T1 (9.3%) to T2 (35.3%) to T3 (91.5%).

CONCLUSION

Sexual behaviors did not change in a uniform manner for the participants in our study. Sexual behaviors and sexual networks vis-à-vis HIV diagnosis and follow-up were associated with the participant's characteristics and HIV infection and treatment status. The overall lesson is that individuals who are unaware of their HIV infection are the main drivers of secondary transmission. Early identification of HIV infection and access to antiretroviral therapy (ART) are both key strategies to the control and prevention.

Has testing been normalized? An analysis of changes in barriers to HIV testing among men who have sex with men between 2000 and 2010 in Scotland, UK

OBJECTIVES

This paper examines changes in barriers to HIV testing amongst gay men. We compared data collected in 2000 and 2010 to assess changes in HIV testing behaviours, in community-level perceptions of barriers to HIV testing, and in the relative contributions of barrier measures.

METHODS

Cross-sectional surveys were conducted within the commercial gay scene in Glasgow with good response rates (78% and 62%) using a form of time and location sampling.

RESULTS

Major changes in HIV testing behaviours were observed between 2000 and 2010 (30.6% increase in testing within previous year). At the community level, the perceived benefits of testing [t (1284) = -8.46; P < 0.001] and the norm for HIV testing [t (1236) = -11.62; P < 0.001] increased; however, other perceived barriers did not change (fear of a positive result, clinic-related barriers and attitudes to sex with HIV-positive men). Multinomial logistic regression showed that fear of a positive test result remained a key barrier to HIV testing; however, a significant fear × year of survey interaction indicated that fear played a lesser role in differentiating those who had never been tested from those who had been tested in 2010 than it had in 2000.

CONCLUSIONS

These findings suggest the partial normalization of HIV testing. While some barriers have reduced, other key barriers remain important. Interventions should be designed and evaluated that attend to both the biomedical and the psychosocial aspects of HIV testing (e.g. the meaning of positive test results, the sexual exclusion of positive men, and HIV-related stigma).

Impact of a behaviour change intervention model for promotion of condoms amongst young adult males in an occupational setting

BACKGROUND

Studies have justified that social and cultural factors influence young people not to use condoms. Sexually active people associate condoms with lack of trust, while others believe carrying them could imply sexual inexperience. The aim of this study was to provide an intervention model based on this social perception and assess the impact of the intervention in improving condom use.

METHODS

2083 personnel in the intervention group were subjected to behaviour change intervention based on perception and use of condoms. Using a cluster design, we randomly assigned 40 departments to department-based intervention (20) or assessment (20) groups. Around 100 persons in the same age group of 18-45 years were again randomly assigned to each group. Chi Square test was used to assess the effectiveness of the intervention.

RESULTS

Over 6% individuals in the control group (Table 2) had non-regular partners and out of them 23.5% had used a condom. Again, in the same group (Fig. 1), 45.36% individuals thought it is acceptable for single men to use condoms with their partners and 8.15% agreed that it is alright for married women to use condoms with their husbands. The perception significantly increased in the intervention group (p < 0.001).

CONCLUSION

This study thus highlights the importance of continued behavioural intervention in filling certain gaps in the social and structural perception to improve condom use for effective HIV prevention in the community.

Quarantine, isolation, and cohorting: from cholera to Klebsiella

BACKGROUND

Isolation is defined as the separation of persons with communicable diseases from those who are healthy. This public health practice, along with quarantine, is used to limit the transmission of infectious diseases and provides the foundation of current-day cohorting.

METHODS

Review of the pertinent English-language literature.

RESULTS

Mass isolation developed during the medieval Black Death outbreaks in order to protect ports from the transmission of epidemics. In the mid-1800s, infectious disease hospitals were opened. It now is clear that isolation and cohorting of patients and staff interrupts the transmission of disease. Over the next century, with the discovery of penicillin and vaccines against many infectious agents, the contagious disease hospitals began to close. Today, we find smaller outbreaks of microorganisms that have acquired substantial resistance to antimicrobial agents. In the resource-limited hospital, a dedicated area or region of a unit may suffice to separate affected from unaffected patients.

CONCLUSION

Quarantine, or cohorting when patients are infected with the same pathogen, interrupts the spread of infections, just as the contagious disease hospitals did during the epidemics of the 18th and 19th centuries.

Changes in sexual behaviour among HIV-infected women in west and east Africa in the first 24 months after delivery

OBJECTIVE

Describe changes in sexual behaviour and determinants of unsafe sex among HIV-infected women in the 24 months after delivery.

DESIGN

Cohort analysis nested within a prevention of mother-to-child transmission trial in Burkina Faso (n = 339) and Kenya (n = 432).

METHODS

Women were followed during pregnancy and until 12-24 months after delivery. At each visit, structured questionnaires were administered about sexual activity and condom use, and risk-reduction counselling and condoms were provided.

RESULTS

At study entry, a median 2 months after HIV testing (interquartile range =1-4), 411/770 (53.4%) of women reported partner disclosure, increasing to 284/392 (71.9%) at the final visit. Although most partners were supportive following disclosure, between 5 and 10% of disclosed women experienced hostile or unsupportive partner responses during follow-up visits. At each visit, about a third of sexually active women reported unsafe sex (unprotected sex with HIV-uninfected or unknown status partner). In multivariable logistic regression, unsafe sex was 1.70-fold more likely in Kenyan than in Burkinabe women [95% confidence interval (95% CI) = 1.14-2.54], and in those with less advanced HIV disease or aged 16-24 years. Compared with women who disclosed their status to partners and others, unsafe sex was over six-fold higher in nondisclosers (95% CI = 3.31-12.11), the effect size reducing with increasing disclosure.

CONCLUSION

HIV-infected women who recently delivered have a high potential for further HIV transmission, especially as HIV discordance is common in Africa. Longitudinal care for women, including positive-prevention interventions, is needed within new services providing antiretroviral prophylaxis during breastfeeding - this repeated interface with services could focus on reducing unsafe sex. Much remains unknown about how to facilitate beneficial disclosure.

Essentiality of HIV testing and education for effective HIV control in the national pilot harm reduction program: the Taiwan experience

In 2005, a national pilot harm reduction program (PHRP), which mainly included a methadone maintenance treatment program (MMTP) and a needle/syringe exchange program (NSP), was implemented in Taiwan. We conducted this study to evaluate the effectiveness of harm reduction measures on HIV control among injecting drug users (IDUs) between PHRP and nonPHRP. The data on HIV, collected from incumbent Taiwanese authorities, were analyzed for their associations, risk and protective factors with PHRP measures. While the monthly HIV incidences did not show significant differences before and after PHRP in the four areas with PHRP (Taipei City, Taipei County, Taoyuan County and Tainan County), a significant increase in the HIV incidence was found in the 21 areas without PHRP. Hence, the implementation of the PHRP did result in a significant difference in the monthly HIV incidence between areas with and without the PHRP. Mandatory HIV testing was significantly associated with the HIV incidence according to the generalized estimation equations (GEE) model. With adjustments of time period and area with PHRP, and urban area, protective factors associated with HIV incidence were: educational materials, condoms, dilution water, and alcohol sponges/swabs. MMTP contributed to a higher HIV incidence, probably due to the concurrent HIV testing upon admission. Since HIV testing was not required in the NSP, the HIV testing-dependent MMTP may explain the association of the PHRP intervention and an increased HIV incidence. In summary, HIV testing and education were essential for effective HIV control upon implementing the PHRP.

Disparities among US states in HIV-related mortality in persons with HIV infection, 2001-2007

OBJECTIVE

To examine interstate variation in US HIV case-fatality rates, and compare them with corresponding conventional HIV death rates.

DESIGN

Cross-sectional analysis using data on deaths due to HIV infection from the National Vital Statistics System and data on persons 15 years or older living with HIV infection in 2001-2007 in 37 US states from the national HIV/AIDS Reporting System.

METHODS

State rankings by age-adjusted HIV case-fatality rates (with HIV-infected population denominators) were compared with rankings by conventional death rates (with general population denominators). Negative binomial regression determined case-fatality rate ratios among states, adjusted for age, sex, race/ethnicity, year, and state-level markers of late HIV diagnosis.

RESULTS

On the basis of 3,096,729 HIV-infected person-years, the overall HIV case-fatality rate was 20.6 per 1000 person-years [95% confidence interval (CI) 20.3-20.9]. Age-adjusted rates by state ranged from 9.6 (95% CI 6.8-12.4) in Idaho to 32.9 (95% CI 29.8-36.0) in Mississippi, demonstrating significant differences across states, even after adjusting for race/ethnicity (P < 0.0001). Many states with low conventional death rates had high case-fatality rates. Nine of the 10 states with the highest case-fatality rates were located in the southern United States.

CONCLUSION

Case-fatality rates complement and are not entirely concordant with conventional death rates. Interstate differences in these rates may reflect differences in secondary and tertiary prevention of HIV-related mortality among infected persons. These data suggest that state-specific contextual barriers to care may impede improvements in quality and disparities of healthcare without targeted interventions.

Public health and clinical impact of increasing emergency department-based HIV testing: perspectives from the 2007 conference of the National Emergency Department HIV Testing Consortium

OBJECTIVE

Understanding perceived benefits and disadvantages of HIV testing in emergency departments (EDs) is imperative to overcoming barriers to implementation. We codify those domains of public health and clinical care most affected by implementing HIV testing in EDs, as determined by expert opinion.

METHODS

Opinions were systematically collected from attendees of the 2007 National ED HIV Testing Consortium meeting. Structured evaluation of strengths, weaknesses, opportunities, and threats analysis was conducted to assess the impact of ED-based HIV testing on public health. A modified Delphi method was used to assess the impact of ED-based HIV testing on clinical care from both individual patient and individual provider perspectives.

RESULTS

Opinions were provided by 98 experts representing 42 academic and nonacademic institutions. Factors most frequently perceived to affect public health were (strengths) high volume of ED visits and high prevalence of HIV, (weaknesses) undue burden on EDs, (opportunities) reduction of HIV stigma, and (threats) lack of resources in EDs. Diagnostic testing and screening for HIV were considered to have a favorable impact on ED clinical care from both individual patient and individual provider perspectives; however, negative test results were not perceived to have any benefit from the provider's perspective. The need for HIV counseling in the ED was considered to have a negative impact on clinical care from the provider's perspective.

CONCLUSION

Experts in ED-based HIV testing perceived expanded ED HIV testing to have beneficial impacts for both the public health and individual clinical care; however, limited resources were frequently cited as a possible impediment. Many issues must be resolved through further study, education, and policy changes if the full potential of HIV testing in EDs is to be realized.

HIV testing in Europe: mapping policies

OBJECTIVES

In the absence of treatment and in the context of discrimination, HIV testing was embedded within exceptional procedures. With increasing treatment effectiveness, early HIV diagnosis became important, calling for the normalization of testing. National HIV testing policies were mapped to explore the characteristics and variations across European countries.

METHODS

Key informants within the health authorities of all EU/EEA countries were questioned on HIV testing policies, which were assessed within a conceptual framework and the level of exceptionalism and normalization was scored based on defined attributes.

RESULTS

Twenty-four out of 31 countries participated in the survey. Policies tended to support confidential voluntary testing, informed consent, and counselling. In the majority of countries, specific groups were targeted for provider-initiated testing. Taking together all attributes of HIV testing, 14 countries obtained a high score for exceptionalism, while only 3 achieved a high score on normalization. Italy, Lithuania and Romania had primarily exceptional procedures; Norway leant more towards normalization; Netherlands, the United Kingdom, and Denmark scored high in both.

CONCLUSIONS

In most EU/EEA countries, policies are integrating HIV testing in health care settings, through voluntary and targeted testing strategies. Current HIV testing policies exhibited a high level of exceptionalism with varying degrees of normalization. Further research should compare HIV testing policies with practices.

Dilemma of concepts and strategies for the prevention of spread of HIV in relation to human behavior, law and human rights

The new prevalence data regarding the estimated global number of human immunodeficiency virus positive (HIV+) cases, i.e., including people who are either aware or unaware of their HIV infection in 2010, lead many to wonder why the increase in incidence has reached today's unprecedented level and escalated within such a short time. This, in spite of prevention campaigns in countries affected by HIV/acquired immune deficiency syndrome (AIDS) with their urgent messages aimed at preventing HIV transmission by promoting changes in individual's behavior. This article analyzes the background of the prevention strategies, in particular their political, social and legal concepts in terms of human rights, and reveals traits of human behavior not considered thus far. A radical reappraisal is necessary, at social and legislative levels, as well as options additional to current concepts. When ethical issues come up, they become blamed for outmoded moralistic positions. However, ignoring the reality has led to dire consequences from prioritizing individual human rights over society's collective need to prevent the spread of HIV.

[Baseline survey on physician practice and attitude in recommending partner HIV testing]

OBJECTIVES

We studied physician partner testing (PT) practice and obstacles against PT in the clinical settings in Japan.

METHODS

Subjects were 513 physicians identified at HIV/AIDS sentinel hospitals. The questionnaire included demographics, current practices, factors for facilitating PT, experience in finding new HIV cases through PT, and information channels for PT.

RESULTS

Of physicians interviewed, 66% did PT for all HIV cases, with 37% finding 185 new HIV cases through PT. Physicians reported too little time for PT, together with a lack of legal authorization and standardized educational material. Of those interviewed, 78% did PT orally.

CONCLUSIONS

Detecting new HIV cases showed the effectiveness of PT in identifying and diagnosing HIV cases as early as possible in Japan. To expand PT legal authorization, standardized practices, and educational material all require development.

An ethical evaluation of the 2006 Centers for Disease Control and Prevention Recommendations for HIV testing in health care settings

When in 2006 the Centers for Disease Control and Prevention issued revised recommendations for HIV testing in health care settings, vocal opponents charged that use of an "opt-out" approach to presenting HIV testing to patients; the implementation of nontargeted, widespread HIV screening; the elimination of a separate signed consent; and the decoupling of required HIV prevention counseling from HIV testing are unethical. Here we undertake the first systematic ethical examination of the arguments both for and against the recommendations. Our examination reveals that the ethical concerns raised by the critics predominantly pertain not to ethically suspect elements of the recommendations themselves, but to suspicions that they will be implemented improperly. It has not been shown that the recommendations cannot be implemented properly. Here we show that in the United States the recommendations are morally justifiable and that safeguards or regulatory oversight may serve to ensure that the recommendations are properly implemented.

Impact of accelerated progression to AIDS on public health monitoring of late HIV diagnosis

Some patients develop AIDS within a year of HIV infection ("accelerated progression"). Classifying such cases as late HIV diagnosis may lead to inaccurate evaluation of HIV testing efforts. We sought to determine this group's contribution to overall late diagnosis rates. To identify cases of accelerated progression (development of AIDS within 12 months of a negative HIV test), we reviewed published HIV seroconverter cohort studies and used New York City's (NYC) HIV/AIDS surveillance registry. From the literature review, three seroconverter cohort studies revealed that 1.0-3.6% of participants had accelerated progression to AIDS. Applying this frequency estimate to the number of new infections in NYC (4762) for 2006 calculated by the Centers for Diseases Control and Prevention's incidence formula, we estimated that 3.6-13.0% of 1317 NYC HIV cases who are diagnosed with AIDS within 12 months of HIV diagnosis are accelerated progressors, not persons HIV infected for many years who did not test and present with AIDS (i.e., delayed diagnosis). In addition, our analysis of the 2006 NYC surveillance registry confirmed the occurrence of accelerated progression in a population-based setting; 67 accelerated progressors were reported and 9 (13%) could be confirmed through follow-up medical record review. With increased HIV testing initiatives, the irreducible proportion of AIDS cases with accelerated progression must be considered when interpreting late diagnosis data.

High HIV-TB co-infection rates in marginalized populations: evidence from Alberta in support of screening TB patients for HIV

Heretofore we have not seen strong evidence of synergy between HIV and tuberculosis (TB) in Canada. This may simply reflect a lack of concurrent surveillance for the two diseases. To date, the goal of universal HIV testing of TB patients (> 80% tested) in Canada has not been achieved, despite the existence of two national advisories recommending universal HIV testing of TB patients. In response to these advisories, we recently undertook to demonstrate the feasibility of using an 'opt-out' approach to achieve universal HIV testing of TB patients in Alberta--see the Canadian Journal of Public Health 2009;100(2):116-20. In the present commentary, we add two more years of data (2007-2008) to our earlier report and demonstrate for the first time that HIV co-infection is significantly greater in middle-aged (35-64 years) compared to young adult (15-34 years) TB patients and in Aboriginal and sub-Saharan African, compared to Canadian-born non-Aboriginal and foreign-born 'other' TB patients. Our findings underscore the need for universal concurrent testing as well as greater interaction between TB and HIV programs.

Decreases in community viral load are accompanied by reductions in new HIV infections in San Francisco

Background

At the individual level, higher HIV viral load predicts sexual transmission risk. We evaluated San Francisco's community viral load (CVL) as a population level marker of HIV transmission risk. We hypothesized that the decrease in CVL in San Francisco from 2004–2008, corresponding with increased rates of HIV testing, antiretroviral therapy (ART) coverage and effectiveness, and population-level virologic suppression, would be associated with a reduction in new HIV infections.

Methodology/Principal Findings

We used San Francisco's HIV/AIDS surveillance system to examine the trends in CVL. Mean CVL was calculated as the mean of the most recent viral load of all reported HIV-positive individuals in a particular community. Total CVL was defined as the sum of the most recent viral loads of all HIV-positive individuals in a particular community. We used Poisson models with robust standard errors to assess the relationships between the mean and total CVL and the primary outcome: annual numbers of newly diagnosed HIV cases. Both mean and total CVL decreased from 2004–2008 and were accompanied by decreases in new HIV diagnoses from 798 (2004) to 434 (2008). The mean (p = 0.003) and total CVL (p = 0.002) were significantly associated with new HIV cases from 2004–2008.

Conclusions/Significance

Reductions in CVL are associated with decreased HIV infections. Results suggest that wide-scale ART could reduce HIV transmission at the population level. Because CVL is temporally upstream of new HIV infections, jurisdictions should consider adding CVL to routine HIV surveillance to track the epidemic, allocate resources, and to evaluate the effectiveness of HIV prevention and treatment efforts.