Racial/ethnic disparities in delayed HIV diagnosis among men who have sex with men, Florida, 2000-2014

Sociodemographic correlates of late HIV diagnosis among men who have sex with men (MSM) in Ghana

Timely HIV diagnosis and medical engagement are crucial for effective viral load suppression and treatment as prevention. However, significant delays persist, particularly in Africa, including Ghana. This study focused on Ghanaian men whose route of exposure to HIV was through same-gender sexual contact (MSM), a group disproportionately impacted by HIV. Using structured surveys, we investigated the sociodemographic factors associated with late HIV diagnosis, a topic with limited existing research. Results indicate that older age groups were associated with an increased risk of late diagnosis compared to the 18-24 age group. Among the demographic variables studied, only age showed a consistent association with late HIV diagnosis. This study underscores the importance of targeted interventions to address HIV diagnosis disparities among MSM in Ghana, particularly for older age groups. The findings emphasize the need for tailored interventions addressing age-related disparities in timely diagnosis and engagement with medical services among this population. Such interventions can play a crucial role in reducing the burden of HIV within this community and fostering improved public health outcomes.

Spatial and temporal analysis of HIV clinical outcomes in Florida reveals counties with persistent racial and ethnic disparities during 2012-2019

BACKGROUND

Racial/ethnic disparities in the HIV care continuum have been well documented in the US, with especially striking inequalities in viral suppression rates between White and Black persons with HIV (PWH). The South is considered an epicenter of the HIV epidemic in the US, with the largest population of PWH living in Florida. It is unclear whether any disparities in viral suppression or immune reconstitution-a clinical outcome highly correlated with overall prognosis-have changed over time or are homogenous geographically. In this analysis, we 1) investigate longitudinal trends in viral suppression and immune reconstitution among PWH in Florida, 2) examine the impact of socio-ecological factors on the association between race/ethnicity and clinical outcomes, 3) explore spatial and temporal variations in disparities in clinical outcomes.

METHODS

Data were obtained from the Florida Department of Health for 42,369 PWH enrolled in the Ryan White program during 2008-2020. We linked the data to county-level socio-ecological variables available from County Health Rankings. GEE models were fit to assess the effect of race/ethnicity on immune reconstitution and viral suppression longitudinally. Poisson Bayesian hierarchical models were fit to analyze geographic variations in racial/ethnic disparities while adjusting for socio-ecological factors.

RESULTS

Proportions of PWH who experienced viral suppression and immune reconstitution rose by 60% and 45%, respectively, from 2008-2020. Odds of immune reconstitution and viral suppression were significantly higher among White [odds ratio =2.34, 95% credible interval=2.14-2.56; 1.95 (1.85-2.05)], and Hispanic [1.70 (1.54-1.87); 2.18(2.07-2.31)] PWH, compared with Black PWH. These findings remained unchanged after accounting for socio-ecological factors. Rural and urban counties in north-central Florida saw the largest racial/ethnic disparities.

CONCLUSIONS

There is persistent, spatially heterogeneous, racial/ethnic disparity in HIV clinical outcomes in Florida. This disparity could not be explained by socio-ecological factors, suggesting that further research on modifiable factors that can improve HIV outcomes among Black and Hispanic PWH in Florida is needed.

'Ending AIDS' between comparison and commensuration and the role of global health indicators

The use of targets and indicators in global health has become ubiquitous within global health and disease elimination programmes. The drive to 'end AIDS' has become a global flagship endeavour, including nation-states, donor organisations, NGOs, pharmaceutical companies, medical researchers, and activists. Almost synonymous with the campaign of ending AIDS is UNAIDS' 90-90-90 targets. Beyond indicators' role in neoliberal global health, an essential aspect of indicators and quantitative metrics is their ability to provide a basis for measurements and comparability across time and between different actors and entities. These processes are based on what has been called, commensuration, visual simplification, and serialisation. This article seeks to provide an account of how we can think about indicators in the drive to end AIDS as doing work that is contingent upon commensuration, simplification, and serialisation. The argument is that by attending to issues of commensuration, visual simplification, and serialisation we are better able to see how we risk erasing and foreclosing other forms of conceptualising what the end of AIDS could be. Logics of quantification risks erasing and foreclosing other qualitative aspects of the HIV epidemic as well as obscuring various epistemological tensions inherent in counting towards the end of AIDS.

Racial differences in testing for infectious diseases: An analysis of jail intake data

HIV and hepatitis C virus (HCV) testing for all people in jail is recommended by the CDC. In the community, there are barriers to HIV and HCV testing for minoritized people. We examined the relationship between race and infectious diseases (HIV, HCV, syphilis) testing in one Massachusetts jail, Middlesex House of Corrections (MHOC). This is a retrospective analysis of people incarcerated at MHOC who opted-in to infectious diseases testing between 2016-2020. Variables of interest were race/ethnicity, self-identified history of psychiatric illness, and ever having experienced restrictive housing. Twenty-three percent (1,688/8,467) of people who were incarcerated requested testing at intake. Of those, only 38% received testing. Black non-Hispanic (25%) and Hispanic people (30%) were more likely to request testing than white people (19%). Hispanic people (16%, AOR 1.69(1.24-2.29) were more likely to receive a test result compared to their white non-Hispanic (8%, AOR 1.54(1.10-2.15)) counterparts. Black non-Hispanic and Hispanic people were more likely to opt-in to and complete infectious disease testing than white people. These findings could be related to racial disparities in access to care in the community. Additionally, just over one-third of people who requested testing received it, underscoring that there is room for improvement in ensuring testing is completed. We hope our collaborative efforts with jail professionals can encourage other cross-disciplinary investigations.

Birth Country Influences the Choice of Antiretroviral Therapy in HIV-Infected Individuals: Experience From a French HIV Centre

OBJECTIVES

To assess whether antiretroviral therapy (ART) prescriptions differ between naive and virally suppressed HIV patients born in France (PBFs) and in Sub-Saharan Africa (PBSSAs).

SETTING

Observational single-center study.

METHODS

We included all PBFs and PBSSAs who entered into care at Pitié-Salpêtrière Hospital, Paris, France, from 01/01/2000 to 31/12/2018, with plasma HIV-RNA>200 copies/mL. We first compared the initial ART in naive PBFs and PBSSAs. Second, we compared the last-prescribed ART (including drug-reduced ART: daily 2-drug regimens, daily 1-drug regimens and intermittent 3-drug regimens) in virally suppressed PBFs and PBSSAs, by focusing on patients in care in 2018 with HIV-RNA <50 copies for at least 24 months. A univariable and multivariable logistic regression model was used to assess the impact of geographical origin on ART prescriptions.

RESULTS

A total of 1944 naive patients were included (915 PBSSAs and 1029 PBFs). PBSSAs were more frequently women, hepatitis B coinfected, with a lower pretherapeutic CD4 T-cell count, and most had tuberculosis at HIV diagnosis. After adjustment for confounders, PBSSAs were more likely to receive a first-line protease inhibitor-based regimen (OR 1.61, 95% CI: 1.31 to 1.98), and less likely to receive an integrase inhibitor-based regimen (OR 0.61, 95% CI: 0.42 to 0.88). Of the 968 virally suppressed patients (431 PBSSAs and 537 PBFs), PBSSAs were less likely to receive drug-reduced ART, including 2-drug regimens and intermittent three-drug regimens (OR 0.48, 95% CI: 0.36 to 0.65).

CONCLUSIONS

Differences in ART prescriptions between PBSSAs and PBFs were not only explained by different clinical and virologic situations. Personal motivations of doctors in choosing ART according to country of birth need to be explored.

Post-immigration factors affecting retention in HIV care and viral suppression in Latin American and Caribbean immigrant populations in the United States: a systematic review

OBJECTIVES

To reduce disparities in HIV care outcomes among Latin American and Caribbean (LAC) immigrants living with HIV in the U.S., it is necessary to identify factors influencing HIV care in this population. A systematic review that provides a comprehensive understanding of factors influencing retention in HIV care and viral suppression among LAC immigrants living with HIV in the U.S. is lacking. This systematic review used the Immigrant Health Services Utilization theoretical framework to provide an understanding of these factors.

DESIGN

We searched for peer-reviewed publications in MEDLINE, EMBASE, CINAHL, PsycINFO, and ASSIA, from January 1996 to June 2020.

RESULTS

A total of 17 qualitative (n = 10) and quantitative (n = 7) studies were included in the review. The most commonly reported general and immigrant-specific factors appearing in studies were undocumented immigration status, HIV stigma, homophobia, cultural norms, values and beliefs, family and social support, language barriers, structure, complexity and quality of the U.S. healthcare delivery system, and patient-provider relationship.

CONCLUSION

These findings highlight the importance of considering immigrant-specific factors along with general factors to improve the provision of HIV care services and HIV care outcomes among LAC immigrant populations.

Racial and ethnic disparities in HIV diagnoses among heterosexually active persons in the United States nationally and by state, 2018

BACKGROUND

Despite declining HIV infection rates, persistent racial and ethnic disparities remain. Appropriate calculations of diagnosis rates by HIV transmission category, race and ethnicity, and geography are needed to monitor progress towards reducing systematic disparities in health outcomes. We estimated the number of heterosexually active adults (HAAs) by sex and state to calculate appropriate HIV diagnosis rates and disparity measures within subnational regions.

METHODS

The analysis included all HIV diagnoses attributed to heterosexual transmission in 2018 in the United States, in 50 states and the District of Columbia. Logistic regression models estimated the probability of past-year heterosexual activity among adults in three national health surveys, by sex, age group, race and ethnicity, education category, and marital status. Model-based probabilities were applied to estimated counts of HAAs by state, which were synthesized through meta-analysis. HIV diagnoses were overlaid to calculate racial- and ethnic-specific rates, rate differences (RDs), and rate ratios (RRs) among HAAs by sex and state.

RESULTS

Nationally, HAA women have a two-fold higher HIV diagnosis rate than HAA men (rate per 100,000 HAAs, women: 6.57; men: 3.09). Compared to White non-Hispanic HAAs, Black HAAs have a 20-fold higher HIV diagnosis rate (RR, men: 21.28, women: 19.55; RD, men: 15.40, women: 31.78) and Hispanic HAAs have a 4-fold higher HIV diagnosis rate (RR, men: 4.68, RD, women: 4.15; RD, men: 2.79, RD, women: 5.39). Disparities were ubiquitous across regions, with >75% of states in each region having Black-to-White RR ≥10.

CONCLUSION

The racial and ethnic disparities across regions suggests a system-wide failure particularly with respect to preventing HIV among Black and Hispanic women. Pervasive disparities emphasize the role for coordinated federal responses such as the current Ending the HIV Epidemic (EHE) initiative.

Pre- and Post-immigration HIV Testing Behaviors among Young Adult Recent Latino Immigrants in Miami-Dade County, Florida

HIV testing early in the immigration process can facilitate timely linkage to HIV prevention and treatment services for immigrants. This study aims to determine the prevalence of self-report HIV testing pre- and post-immigration and the associations between pre-immigration HIV sexual risk behaviors, access to healthcare post-immigration, and HIV testing post-immigration among young adult recent Latino immigrants. Cross-sectional data from 504 recent Latino immigrants aged 18 to 34 who immigrated to Miami-Dade County, Florida during the 12 months before assessment were analyzed using robust Poisson regression models. We found that 23.8% of participants reported HIV testing post-immigration and 56.7% reported HIV testing pre-immigration. The prevalence ratio for post-immigration HIV testing was higher for participants that had health insurance (adjusted prevalence ratio [aPR]: 1.70, 95% confidence interval [CI]: 1.21-2.38) and a regular doctor or healthcare provider after immigration (aPR: 1.43, 95% CI 1.03-2.00), and post-immigration HIV testing was higher for participants that had ever been tested for HIV before immigration (aPR: 2.41, 95% CI 1.68-3.45). Also, the prevalence ratio was lower for those who engaged in condomless sex in the three months prior to immigration (aPR: 0.65, 95% 0.47-0.90). These findings suggest that addressing barriers to healthcare and prevention services for young adult recent Latino immigrants is needed to scale-up HIV testing in this population early in the immigration process.

HIV incidence in US first-time blood donors and transfusion risk with a 12-month deferral for men who have sex with men

In 2015, the US Food and Drug Administration published revised guidance that recommended a change in blood donor deferral of men who have sex with men (MSM) from an indefinite to a 12-month deferral since the donor last had sex with a man. We assessed whether HIV incidence in first-time blood donors or associated transfusion risk increased. Donations in 4 major blood collection organizations were monitored for 15 months before and 2 years after implementation of the 12-month MSM deferral policy. HIV-positive donations were classified as recently acquired or long-term using a recent infection testing algorithm and incidence in both periods estimated. Residual transfusion transmission risk was estimated by multiplying incidence by the length of the infectious window period. The latter was estimated using a model based on infectious dose and the sensitivity of nucleic acid testing. Factors associated with incident infection in each period were assessed using Poisson regression. Overall HIV incidence in first-time donors before implementation of the 12-month MSM deferral was estimated at 2.62 cases per 100 000 person-years (105 PY) (95% credible interval [CI], 1.53-3.93 cases/105 PY), and after implementation at 2.85 cases/105 PY (95% CI, 1.96-3.93 cases/105 PY), with no statistically significant change. In male first-time donors, the incidence difference was 0.93 cases/105 PY (95% CI, -1.74-3.58 cases/105 PY). The residual risk of HIV transfusion transmission through components sourced from first-time donors was estimated at 0.32 transmissions per million (106) packed red blood cell transfusions (95% CI, 0.29-0.65 transmissions/106 transfusions) before and 0.35 transmissions/106 transfusions (95% CI, 0.31-0.65 transmissions/106 transfusions) after implementation. The difference was not statistically significant. Factors associated with incident infection were the same in each period. We observed no increase in HIV incidence or HIV transfusion transmission risk after implementation of a 12-month MSM deferral policy.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Suboptimal Recent and Regular HIV Testing Among Black Men Who Have Sex With Men in the United States: Implications From a Meta-Analysis

BACKGROUND

The continuum of HIV care among black men who have sex with men (BMSM) continues to be the least favorable in the United States. BMSM are disproportionally HIV-infected-but-unaware, despite expanded HIV testing efforts among this subgroup.

METHODS

We meta-analytically analyzed various HIV testing patterns [lifetime, after 24 months, after 12 months, after 6 months, and frequent (every 3-6 months) testing] among BMSM using the PRISMA guideline. PubMed, MEDLINE, Web of Science, and PsycINFO were searched for relevant articles, reports, conference proceedings, and dissertations published between January 1, 1996, and April 25, 2018. Two independent investigators reviewed and abstracted data into a standardized form. We used the DerSimonian-Laird random-effect model to pool the HIV testing prevalence and I-square statistics to measure heterogeneity. Funnel plots and Egger tests were used to assess for publication bias. We also performed subgroup and meta-regression analyses to explore aggregate-level characteristics that explain the heterogeneity across studies.

RESULTS

Our meta-analysis includes a total of 42,074 BMSM pooled from 67 studies. Lifetime HIV testing prevalence was high, 88.2% [95% confidence interval (CI): 86.2% to 90.1%], but recent (after 6 months = 63.4%; 95% CI: 59.3% to 67.4%) and frequent (42.2%, 95% CI: 34.1% to 50.3%) HIV testing prevalence was low. Meta-regression suggests that younger age (borderline significant), lower annual income, and homelessness were correlated with lower lifetime/recent HIV testing prevalence; while ever having condomless insertive/receptive sex, alcohol consumption, and illicit drug use were associated with higher lifetime/recent HIV testing prevalence.

CONCLUSIONS

Recent and frequent HIV testing remains suboptimal among BMSM. Future testing programs should prioritize strategies to enhance self-initiated, regular HIV testing among BMSM.

Social Network Support and Decreased Risk of Seroconversion in Black MSM: Results of the BROTHERS (HPTN 061) Study

BACKGROUND AND SETTING

Black men who have sex with men (BMSM) in the United States have disproportionately high HIV infection rates. Social networks have been shown to influence HIV risk behavior; however, little is known about whether they affect the risk of HIV seroconversion. This study uses data from the BROTHERS (HPTN 061) study to test whether contextual factors related to social networks are associated with HIV seroconversion among BMSM.

METHODS

We analyzed data from the BROTHERS study (2009-2011), which examined a multicomponent intervention for BMSM in 6 US cities. We ran a series of Cox regression analyses to examine associations between time-dependent measures of network support (personal/emotional, financial, medical, and social participation) and time to HIV seroconversion. We ran unadjusted models followed by models adjusted for participant age at enrollment and study location.

RESULTS

A total of 1000 BMSM tested HIV negative at baseline and were followed at 6- and 12-month study visits. Twenty-eight men tested HIV positive. In adjusted hazard ratio models, study participants who remained HIV negative had higher proportions of social network members who provided personal/emotional {0.92 [95% confidence interval (CI): 0.85 to 0.99]}, medical [0.92 (95% CI: 0.85 to 0.99)], or social participation [0.91 (95% CI: 0.86 to 0.97)] support.

CONCLUSION

Findings suggest that the increased presence of social network support can be protective against HIV acquisition. Future research should explore the processes that link social network support with sexual and other transmission risk behaviors as a basis to inform HIV prevention efforts.

Earlier diagnoses and faster treatment of HIV in the District of Columbia: HIV surveillance analysis, 2006-2016

To address high HIV prevalence, the District of Columbia (DC) Department of Health has implemented multiple strategies to increase routine HIV testing since 2006. Examination of delayed HIV diagnosis over time can demonstrate population-level impact of public health strategies to promote HIV testing. Using HIV surveillance data, we examined delayed HIV diagnosis in DC (stage 3 within 90 days of diagnosis), CD4 count at HIV diagnosis, linkage to HIV care, and time to viral suppression among DC residents age 13 and above who were diagnosed from 2006 to 2016.  We used the Cochran-Armitage test of trend, Cuzick's test of trend, and Chi-square for univariate analyses, and we examined factors associated with delayed HIV diagnosis using a log-binomial multivariate model. 7,937 DC residents were diagnosed with HIV and had available data.  Between 2006 and 2016, delayed HIV diagnoses declined from 36.4% to 25.5%, median CD4 count increased from 190 cells/µl to 426 cells/µl, and median time from HIV diagnosis to viral suppression declined from 1,136 days to 84 days.  Women, youth ages 13-29, and men who have sex with men had lower proportions with delayed HIV diagnosis. In the multivariate models, racial/ethnic disparities in delayed HIV diagnoses were apparent during 2006-2008 but not during 2009-2016. Continued efforts around earlier HIV testing are needed in DC.

Role of Gay Neighborhood Status and Other Neighborhood Factors in Racial/Ethnic Disparities in Retention in Care and Viral Load Suppression Among Men Who Have Sex with Men, Florida, 2015

This study's objective was to examine the role of gay neighborhood residence and other neighborhood factors in racial/ethnic disparities in retention in HIV care and viral load suppression during 2015. Florida residents diagnosed 2000-2014 with HIV infection and with transmission mode of men who have sex with men (MSM) were included in multi-level logistic regression models. Of 29,156 MSM, 29.4% were not retained and 34.2% were not virally suppressed. Non-Hispanic Blacks (NHB) had a higher likelihood of not being retained (adjusted prevalence ratio [aPR] 1.31, 95% confidence interval [CI] 1.24-1.38, p value < 0.0001) and not being virally suppressed (aPR 1.82, 95% CI 1.67-1.98, p value < 0.0001) compared with non-Hispanic Whites. Among NHBs, rural residence was protective for both outcomes. Although gay neighborhood residence was not associated with either outcome, the role of other neighborhood factors suggests that individual and neighborhood barriers to HIV care and treatment should be addressed among MSM.

Sexual Risk Behaviors Among Black Men Who Have Sex With Men Who Also Report Having Sex With Transgender Partners: Analysis of HIV Prevention Trials Network (HPTN) 061 Study

HIV Prevention Trials Network (HPTN 061) study data of Black MSM were analyzed to determine characteristics associated with having transgender sexual partners (TGP) and the association of having TGP with sexual risk. Of 1,449 cisgender MSM, 343(24%) reported also having TGP. MSM with TGP were more likely to be older, have a sexual orientation other than homosexual, have a history of incarceration, or have insufficient funds for necessities, but less likely to be HIV positive or report sex with men to health care providers. MSM with TGP were 3.67 times more likely to recently have 5+ new partners and 2.02 times more likely to report 6+ condomless sexual acts. Since MSM with TGP reported not disclosing sex with men to health care providers, these men may need tailored HIV prevention and care. Future studies should examine differing sexual risks MSM take with sexual partners with different gender identities.

Optimizing the Timing of HIV Screening as Part of Routine Medical Care

US federal guidelines recommend that medical providers test all adolescents and adults for HIV infection at least once before the age of 64. The wide age range included in these guidelines may limit their utility and impact. We created an arithmetic model to estimate how HIV screening at different ages would impact the total number of years of undiagnosed HIV infection in the population and the number of persons developing clinical manifestations of HIV/AIDS. Our base case model assumed that age of infection in the screened population was the same as the estimated age of infection among all persons diagnosed with HIV in the United States in 2010. We parameterized a second model assuming age of infection was similar to the younger age distribution observed in African Americans. In the base case model, the number of years of undiagnosed HIV infection and number of persons with clinical manifestations of HIV/AIDS were both minimized by screening at age 34. If age of infection was similar to that estimated to occur among African Americans, testing at age 24 and 27 would minimize the number of years of undiagnosed infection and clinical cases, respectively. For both parameterization scenarios, testing between the ages of 21 and 38 resulted in outcomes within 10% of the model's estimated optimal age for screening. Focusing HIV screening on a narrower age range than is currently recommended may improve the impact of routine HIV screening efforts.