Demographic, clinical, and virologic characteristics of African-born persons with HIV/AIDS in a Minnesota hospital

Racial Context and Health Behaviors Among Black Immigrants

Testing the Racial Context Hypothesis (Read and Emerson 2005), we examine the relationship between racial context of origin and three health behaviors (smoking, drinking, and physical activity) among Black immigrants in the USA. We conduct multinomial logistic regression analyses using data from the 2000-2018 National Health Interview Survey (N = 248,401) to determine if racial context of origin is a mechanism of health differential between Black immigrants and US-born Black Americans. Supporting the Racial Context Hypothesis, we find that Black immigrants from racially mixed (Mexico, Central America, the Caribbean, South America) and majority-Black contexts (Africa) are significantly less likely to be current or former smokers and drinkers than US-born Black Americans. Black immigrants from majority-white (Europe) contexts, on the other hand, look more similar to US-born Black Americans - again supporting the premise that racial context of origin is consequential for health. After controlling for a host of covariates, Black immigrants do not significantly differ from US-born Black Americans in exercise status. Together, these findings suggest that the impacts of racism and white supremacy have lasting effects on people of color, where Black immigrants from majority-white contexts exhibit worse health behaviors than their counterparts from majority-Black and racially mixed regions.

Impact of HIV/AIDS on African-born Women Living in the United States: a Systematic Review

BACKGROUND

There is paucity of surveillance data about African-born women (ABW) living with HIV/AIDS in the USA. Out of the 50 US states, only Washington state and Minnesota report HIV surveillance data about African-born people, and Minnesota is the only state that reports data about ABW, specifically. In Minnesota, ABW have the largest prevalence rate of HIV/AIDS among all women. In Washington state, foreign-born Black people have the highest incidence of HIV behind white people and foreign-born Hispanic people. This study aims to better understand the impact HIV/AIDS on ABW.

METHODS

This systematic review is based on articles available on three databases (PubMed, Embase, and Cochrane Library). Databases were searched for articles that included quantitative and/or qualitative findings about the impact of HIV/AIDS on ABW in the USA.

RESULTS

Several themes were identified including disproportionate impact of HIV/AIDS on ABW, barriers to care, low sexual health knowledge, HIV-related stigma, and limited HIV testing. Based on 2013 data, the incidence of HIV among ABW was 12 times higher than the incidence among women in the general US population. In 2008-2014, ABW had the smallest decline in HIV diagnosis rate when compared to US-born men and women, African-born men, and Caribbean-born men and women. Barriers that ABW face when trying to access care include, language barriers, fear of deportation and difficulty navigating the US healthcare system.

CONCLUSION

ABW living in the USA are uniquely impacted by HIV/AIDS. Lasting negative health consequences can be mitigated by improving HIV surveillance and investing in further studies about this population.

HIV treatment outcomes among newcomers living with HIV in Manitoba, Canada

BACKGROUND

Despite the overrepresentation of immigrants and refugees (newcomers) in the HIV epidemic in Canada, research on their HIV treatment outcomes is limited. This study addressed this knowledge gap by describing treatment outcomes of newcomers in comparison with Canadian-born persons living with HIV in Manitoba.

METHODS

Clinical data from 1986 to 2017 were obtained from a cohort of people living with HIV and receiving care from the Manitoba HIV Program. Retrospective cohort analysis of secondary data was completed using univariate and multivariate statistics to compare differences in socio-demographic and clinical characteristics and treatment outcomes among newcomers, Canadian-born Indigenous persons, and Canadian-born non-Indigenous persons on entry into HIV care.

RESULTS

By end of 2017, 86 newcomers, 259 Canadian-born Indigenous persons, and 356 Canadian-born non-Indigenous persons were enrolled in the cohort. Newcomers were more likely than Canadian-born Indigenous and non- Indigenous cohort participants to be younger and female and have self-reported HIV risk exposure as heterosexual contact. Average CD4 counts at entry into care did not differ significantly between groups. A higher proportion of newcomers was also diagnosed with tuberculosis within 6 months of entry into care (21%), compared with 6% and 0.6% of Canadian-born Indigenous non-Indigenous persons, respectively. Newcomers and Canadian-born non-Indigenous persons had achieved viral load suppression (< 200 copies/mL) at a similar proportion (93%), compared with 82% of Canadian-born Indigenous participants (p < 0.05).

CONCLUSIONS

The distinct demographic and clinical characteristics of newcomers living with HIV requires a focused approach to facilitate earlier diagnosis, engagement, and support in care.

HIV Testing Among Muslim Women in the United States: Results of a National Sample Study

Purpose: More than one million Americans are living with human immunodeficiency virus (HIV), and less than half of Americans have ever accepted an HIV test. There are no national HIV testing estimates for Muslim Americans, an underserved and often stigmatized population. Considering the lack of HIV testing estimates for this population, we conducted an exploratory study on HIV testing and potential associates in American Muslim women from across the United States. Methods: We applied logistic regression models to examine the Muslim Women's Health Project data, collected in 2015 (N=218). Results: Health care engagement and intimate partner violence were significantly associated with having been tested for HIV. Respondents using contraceptives received an influenza vaccination, and received an abnormal pap test had more than two times higher odds of having been tested for HIV (odds ratio [OR]=2.56, OR=2.43, OR=2.93, respectively; p<0.05 all). Having been sexually abused was associated with more than two times higher odds of having been tested for HIV (OR=2.49; p<0.05). Conclusion: Respondents reported higher rates of HIV testing as compared with the general public, signaling HIV knowledge, engagement in preventative health care, and possibly HIV risk. Scholars and practitioners should not assume that Muslim patients are at low risk for HIV and do not engage in HIV-risk behaviors. Thus, assumptions about Muslims women's willingness to accept HIV testing should be further examined to elucidate HIV risk among this population.

The Significance of Taking Antiretroviral Medications for African-Born People Living with HIV and Residing in Minnesota

Thanks to the development of antiretroviral (ART) medications, HIV is now a chronic and manageable disease. This study aimed to (1) capture the experiences of African-born persons living with HIV and taking antiretroviral treatment, and (2) explore the impact of social and cultural factors on their decisions to follow the prescribed treatment. For this study, a qualitative approach was used. The participants were recruited via fliers, then screened for inclusion and exclusion criteria. Recruitment of the participants continued until data saturation occurred. The interview guide was developed based on the extensive literature and recommendations from the clinical team. In-person narrative interviews were conducted with 14 participants-African-born persons living with HIV and residing in Minnesota. Thematic Analysis revealed three emergent themes: "To exist I have to take the medicine"; barriers and facilitators in taking ART medications; and the power of spirituality and prayers. The findings of this study paint a picture of African-born persons living with HIV, and their experiences with ART medications. This study not only presents the participants' medication experiences and their significance, but also tells their stories of how God and prayers play a significant role in helping them to get through the difficult moments of their lives.

"Stigma and HIV Are Like Brother and Sister!": The Experience of African-Born Persons Living with HIV in the US

Minnesota has seen an increase in the number of immigrants from Africa, notably in the mid-1990s, making up around 2% of Minnesota’s total population. This population also faces many impediments that cause important difficulties not only for HIV prevention but also for treatment and care options. The objectives of this study were to capture the experiences of Persons Living with HIV (PLWH) in Minnesota (US) and to elicit their stories about their diagnosis news and what management strategies they use for coping with the stigma associated with the disease. Participants were recruited via fliers in pharmacies, clinics, and HIV service centers located in Minnesota. Recruitment continued until thematic saturation was obtained. Fourteen subjects participated in audio-recorded, semi-structured interviews that were transcribed verbatim into written text. The transcriptions were analyzed using Thematic Analysis. Three themes emerged from the data. Theme 1: Cruel News: “HIV-Oooooo! I wish I was dead”, Theme 2: This is My Secret! and Theme 3: “Stigma and HIV are brother and sister”. The results demonstrate that stigma is an ever-present problem in African-born PLWH living in the US. Participants perceived the stigma associated with HIV status to affect their lives and culture at individual, familial, and societal levels.

Narrative experiences of interactions with pharmacists among African-born persons living with HIV: "It's mostly business."

BACKGROUND

African-born persons constitute 1% of the total Minnesota population, yet 24% of new HIV infections occurred in this population in 2016. Furthermore, 32% of the African born persons living with HIV [PLWH] did not check their CD4 counts or viral load in 2018. Little is known of the role of pharmacists in antiretroviral (ARV) management in the PLWH of African origin.

OBJECTIVE

This study aimed to describe the experiences of African-born PLWH in their interactions with pharmacists and perceptions of pharmacists' roles in fostering adherence to ARV therapy.

METHODS

A qualitative approach was used for this study. Recruitment via fliers for in-person interviews with African-born PLWH in Minnesota continued until saturation was achieved. Narrative Interviews with 14 participants lasting up to 2 h were conducted over five months. All interviews were audio recorded and transcribed verbatim by a professional transcription service. Conventional Content Analysis was used to analyze the data.

RESULTS

Three themes emerged from analyzed data "Interaction with the pharmacists," "Revealing the diagnosis to a pharmacist," and "Lack of disclosure of HIV status to a pharmacist."

CONCLUSIONS

The participants referred to the interaction with pharmacists as a "business" or "transactional interaction." To better understand the interaction between pharmacists and PLWH of African-born, future studies could benefit from interviewing pharmacists from different practice settings.

Undocumented African Immigrants' Experiences of HIV Testing and Linkage to Care

In the United States, undocumented African immigrants living with HIV enter care late, potentially leading to adverse individual and population health outcomes, yet little is known about the specific experiences of HIV diagnosis and linkage to care among this population. We conducted individual, semi-structured interviews with adults who were undocumented African immigrants living with HIV in New York City. Interviews explored perspectives regarding individual, social, institutional, and societal barriers and facilitators of HIV testing and linkage to care. Of 14 participants from 9 different African countries, 9 were women and the median age was 44 years (interquartile range: 42-50). Participants described fear of discovery by immigration authorities as a substantial barrier to HIV testing and linking to initial medical appointments. Actual and perceived structural barriers to both testing and care linkage included difficulty obtaining health insurance and a belief that undocumented immigrants are ineligible for any health services. Participants also expressed reluctance to be tested because of HIV-related stigma within the immigrant communities that they heavily relied on. After diagnosis, however, participants overwhelmingly described a positive role of health and social service providers in facilitating linkage to HIV care. Concerns about immigration status and HIV-related stigma are significant barriers to HIV testing and linkage to care among undocumented African immigrants. Multilevel efforts to reduce stigma and increase awareness of available services could enhance rates of HIV testing and care linkage in this population.

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

Little is known about the frequency of ongoing HIV transmission within U.S. African immigrant communities. We used HIV surveillance and partner services data to describe African-born persons newly reported with HIV infection in King County (KC), WA from 1/1/2010 to 12/31/2013. We performed phylogenetic clustering analysis of HIV-1 pol to identify putative transmission events within this population. From 2010 to 2013, 1148 KC adults were reported with HIV, including 102 (9 %) born in Africa. Forty-one African-born cases were interviewed and reported diagnosis after arrival in the U.S. Fourteen (34 %) reported ≥1 negative test prior to diagnosis, and 9 (26 %) reported ≥1 negative test after U.S. arrival. Pol genotypes were available for seven of these nine. For two of these seven, a KC case was the nearest phylogenetic neighbor; two others were infected with subtype B virus. We found substantial evidence of ongoing HIV transmission in the African community of KC.

Engaging African and Caribbean Immigrants in HIV Testing and Care in a Large US City: Lessons Learned from the African Diaspora Health Initiative

The lifting in 2010 of the HIV entry ban eliminated an access point for HIV testing of the foreign-born. The African Diaspora Health Initiative (ADHI) was developed to examine alternative pathways to testing for African and Caribbean persons. The ADHI consists of Clinics Without Walls (CWW) held in community settings. HIV testing is offered to participants along with hypertension and diabetes screening. A survey is administered to participants. Descriptive data were analyzed using SAS 9.2. Between 2011 and 2015, 4152 African and Caribbean individuals participated in 352 CWW. Participants were mostly (67.7 %) African. HIV rates were lowest in Caribbean women (0.4 %) and highest in Caribbean men (8.4 %). Efforts to engage African and Caribbean communities in HIV testing are important given the elimination of the HIV entry ban and continued immigration to the US from areas of higher prevalence. The ADHI offers a successful model of engagement.

HIV risk and barriers to care for African-born immigrant women: a sociocultural outlook

Background

Data from the Minnesota Department of Health (MDH) HIV/AIDS Surveillance Report 2015 show that African-born (AB) women continue to be disproportionately affected by HIV. In 2015, these women accounted for more than half (54%) of all new cases of HIV reported among females in Minnesota and 34% of all known female cases in the state. This study was a needs assessment for HIV pre-exposure prophylaxis (PrEP) in vulnerable subgroups within the AB population and adequacy of HIV care for AB persons. The primary objective of this study was to gain an insight into the strategies that will limit the spread of HIV infection and enhance HIV care among AB immigrants.

Methods

Community advocates, community-based organizations (CBOs), clinicians, and other HIV-related service providers were invited to participate in a focus group, structured interview or complete an assessment tool using the same questionnaire about HIV and PrEP among AB persons. A thematic analysis was then conducted on the open-ended questions addressing perceived barriers.

Results

Findings suggest the following gender-specific sociocultural factors that drive HIV transmission and constitute barriers to HIV treatment for AB women: domestic/intimate partner violence, gender-biased stigma, discriminatory cultural beliefs and normative values/expectations, unprotected sex with husbands who have sex with other men, gender discordance in health care (preference for female provider), and sexual/reproductive health illiteracy.

Recommendation

Based on recommendations, a community-based sexual and reproductive health education is being initiated with a curriculum that will be 1) broad (inclusive but not limited to HIV), 2) culturally sensitive/responsive, and 3) at appropriate literacy level for all women, including those who have little or no formal education.

HIV Stigma, Testing Attitudes and Health Care Access Among African-Born Men Living in the United States

The purpose of this study was to describe HIV-testing attitudes, HIV related stigma and health care access in African-born men taking part in the African Health Cup (AHC), a soccer tournament held annually to improve HIV awareness and testing. Venue sampling was used to collect survey and qualitative interview data related to HIV-testing attitudes, stigma and experiences associated with the AHC. The sample included 135 survey respondents and 27 interview participants. AHC participants were successfully accessing health care services. Although the AHC was viewed positively, HIV testing rates remain low due to stigma and privacy concerns. This population continues to have misconceptions about HIV transmission and to use condoms inconsistently. The AHC is a successful intervention to engage African-born men in HIV awareness and education. More work is needed to enhance these AHC aspects and address stigma and privacy concerns related to using onsite health screenings. Continuing to develop novel strategies to educate African-born immigrants about HIV is urgently needed.

Antiretroviral Therapy and Viral Suppression Among Foreign-Born HIV-Infected Persons Receiving Medical Care in the United States: A Complex Sample, Cross-Sectional Survey

Immigrants to the United States are more likely to be diagnosed with human immunodeficiency virus (HIV) infection compared with native-born persons. Navigating access to healthcare in the United States can be challenging for foreign-born persons, and HIV treatment outcomes may be suboptimal for these persons. We compared characteristics of and assessed disparities in clinical outcomes of foreign-born persons in care for HIV in the United States. The Medical Monitoring Project is a complex sample, cross-sectional survey designed to be nationally representative of HIV-infected adults receiving medical care in the United States. Using data from 2009, 2010, and 2011, we conducted descriptive analyses and multivariable logistic regression to assess associations between foreign-born status and antiretroviral therapy (ART) prescription, and between foreign-born status and viral suppression. In all, 13.4% of HIV-infected persons were self-identified as foreign-born; the most common regions of birth were Central America and Mexico (45.4%) and the Caribbean (16.0%). Nearly 90% of foreign-born persons were diagnosed with HIV after entry into the United States. Compared with US-born persons, foreign-born persons were more likely to be younger, Hispanic, less educated, and uninsured. The prevalence of ART prescription (prevalence ratio 1.00; 95% confidence interval 0.98-1.02) was not significantly different between foreign-born and US-born persons. A higher percentage of foreign-born persons achieved viral suppression compared with US-born persons (prevalence ratio 1.05; 95% confidence interval 1.00-1.09). No major disparities in ART prescription and viral suppression were found between foreign-born and US-born HIV-infected persons receiving medical care, despite higher percentages being uninsured.

Sexual Health Care, Sexual Behaviors and Functioning, and Female Genital Cutting: Perspectives From Somali Women Living in the United States

We investigated the sexual values, attitudes, and behaviors of 30 Somali female refugees living in a large metropolitan area of Minnesota by collecting exploratory sexual health information based on the components of the sexual health model-components posited to be essential aspects of healthy human sexuality. A Somali-born bilingual interviewer conducted the semistructured interviews in English or Somali; 22 participants chose to be interviewed in Somali. Interviews were translated, transcribed, and analyzed using descriptive statistics and thematic analyses. Our study findings highlighted a sexually conservative culture that values sexual intimacy, female and male sexual pleasure, and privacy in marriage; vaginal sexual intercourse as the only sanctioned sexual behavior; and the importance of Islamic religion in guiding sexual practices. Findings related to human immunodeficiency virus (HIV) revealed HIV testing at immigration, mixed attitudes toward condom use, and moderate knowledge about HIV transmission modes. Female genital cutting (FGC) was a pervasive factor affecting sexual functioning in Somali women, with attitudes about the controversial practice in transition. We recommend that health professionals take the initiative to discuss sexual health care and safer sex, sexual behaviors/functioning, and likely challenges to sexual health with Somali women--as they may be unlikely to broach these subjects without permission and considerable encouragement.

Foreign-Born Persons Diagnosed with HIV: Where are They From and Where Were They Infected?

We sought to calculate rates of HIV diagnoses by area of birth among foreign-born persons in a high-incidence US city with many immigrants, and determine probable place of HIV acquisition. Data from the New York City HIV surveillance registry and American Community Survey were used to calculate HIV diagnosis rates by area of birth and determine probable place of HIV acquisition among foreign-born diagnosed in 2006-2012. HIV diagnosis rates varied by area of birth and were highest among African-born persons; absolute numbers were highest among Caribbean-born persons. Probable place of acquisition was a foreign country for 23 % (from 9 % among Middle Easterners to 43 % among Africans), US for 61 % (from 34 % among Africans to 76 % among South Americans), and not possible to estimate for 16 %. HIV prevention and testing initiatives should take into account variability by foreign area of birth in HIV diagnosis rates and place of acquisition.

Development and validation of a computer-based algorithm to identify foreign-born patients with HIV infection from the electronic medical record

OBJECTIVE

To develop and validate an efficient and accurate method to identify foreign-born patients from a large patient data registry in order to facilitate population-based health outcomes research.

METHODS

We developed a three-stage algorithm for classifying foreign-born status in HIV-infected patients receiving care in a large US healthcare system (January 1, 2001-March 31, 2012) (n = 9,114). In stage 1, we classified those coded as non-English language speaking as foreign-born. In stage 2, we searched free text electronic medical record (EMR) notes of remaining patients for keywords associated with place of birth and language spoken. Patients without keywords were classified as US-born. In stage 3, we retrieved and reviewed a 50-character text window around the keyword (i.e. token) for the remaining patients. To validate the algorithm, we performed a chart review and asked all HIV physicians (n = 37) to classify their patients (n = 957).We calculated algorithm sensitivity and specificity.

RESULTS

We excluded 160/957 because physicians indicated the patient was not HIV-infected (n = 54), "not my patient" (n = 103), or had unknown place of birth (n = 3), leaving 797 for analysis. In stage 1, providers agreed that 71/95 foreign language speakers were foreign-born. Most disagreements (23/24) involved patients born in Puerto Rico. In stage 2, 49/50 patients without keywords were classified as US-born by chart review. In stage 3, token review correctly classified 55/60 patients (92%), with 93% (CI: 84.4, 100%) sensitivity and 90% (CI: 74.3, 100%) specificity compared with full chart review. After application of the three-stage algorithm, 2,102/9,114 (23%) patients were classified as foreign-born. When compared against physician response, estimated sensitivity of the algorithm was 94% (CI: 90.9, 97.2%) and specificity 92% (CI: 89.7, 94.1%), with 92% correctly classified.

CONCLUSION

A computer-based algorithm classified foreign-born status in a large HIV-infected cohort efficiently and accurately. This approach can be used to improve EMR-based outcomes research.

HIV/AIDS among African-born residents in the United States

The number of African-born residents living in the United States (US) increased by more than 750 % between 1980 and 2009. HIV diagnosis rates in this population are six times higher than estimated incidence in the general US population. African-immigrants with HIV are also diagnosed at later stages of infection than US-born residents, but they paradoxically have lower mortality after diagnosis. There are higher rates of HIV among women, higher rates of heterosexual transmission, and lower rates of injection-drug-use-associated transmission among African-born residents in the US relative to the general US population. Despite this distinct epidemiologic profile, surveillance reports often group African-born residents with US-born Blacks. The high rates of HIV among African-born residents in the US combined with increasing immigration and incomplete surveillance data highlight the need for more accurate epidemiologic data along with appropriate HIV service programs.

HIV/AIDS and associated conditions among HIV-infected refugees in Minnesota, 2000–2007

In 2010, the requirement for human immunodeficiency virus (HIV) testing of adult refugees prior to US resettlement was removed, thus leading to a potential for missed diagnosis. We reviewed refugee health assessment data and medical charts to evaluate the health status of HIV-infected refugees who arrived in Minnesota during 2000-2007, prior to this 2010 policy change. Among 19,292 resettled adults, 174 were HIV-infected; 169 (97%) were African (median age 26.4 (range: 17-76) years). Charts were abstracted for 157 (124 (79%) with ≥ 1 year of follow-up). At initial presentation, two of 74 (3%) women were pregnant; 27% became pregnant during follow-up. HIV clinical stage varied (59%, asymptomatic; 11%, mild symptoms; 10%, advanced symptoms; 3%, severe symptoms; 17%, unknown); coinfections were common (51 tuberculosis, 13 hepatitis B, 13 parasites, four syphilis). Prior to arrival 4% had received antiretrovirals. Opportunistic infections were diagnosed among 13%; 2% died from AIDS-related causes. Arrival screening may be needed to identify these HIV-infected refugees and prevent HIV-related morbidity and mortality.

Comparison of HIV/AIDS rates between U.S.-born Blacks and African-born Blacks in Utah, 2000 - 2009

The Utah Department of Health currently groups African-born blacks with U.S.-born blacks when reporting HIV/AIDS surveillance data. Studies suggest that categorizing HIV/AIDS cases in this manner may mask important epidemiological trends, and the distinct differences between these two populations warrant disaggregating data prior to reporting. The purpose of this study was to characterize the HIV/AIDS positive populations in U.S. and African-born blacks in Utah and evaluate the need for disaggregating the two groups. A total of 1,111 cases were identified through the statewide electronic HIV/AIDS Reporting System from 2000 - 2009. Data were analyzed for prevalence of HIV diagnosis for African-born blacks, U.S.-born blacks, and U.S.-born whites. Secondary analysis included HIV diagnosis by age, sex, African region of nativity, transmission risk factors, and differences in late diagnosis of HIV infection. U.S.-born whites accounted for 914 (82.3%) cases, and had the lowest annual prevalence (4/100,000). Conversely, African-born and U.S.- born blacks had the highest prevalence, 162/100,000 and 24/100,000 respectively. African-born blacks made up 0.25% of the total population, but accounted for 7.9% of all HIV/AIDS cases. African-born black males were more likely to report "no reported risk" for HIV transmission than U.S.-born black males. Of African-born blacks, 55.7% reported East-African nativity. These results demonstrate the importance of stratifying the black/African American racial category by African-born and U.S.-born blacks when collecting and reporting HIV/AIDS state surveillance data even in a low-incidence state,which will better inform prevention and linkage-to-care efforts in Utah.

HIV-2 encephalitis: case report and literature review

We report the case of a 59-year-old man who moved from Cape Verde to Massachusetts at the age of 29. He had multiple sexual contacts with female partners in Cape Verde and with West African women in Massachusetts, as well as multiple past indeterminate HIV-1 antibody tests. He presented to our facility with 2-3 months of inappropriate behaviors, memory impairment, weight loss, and night sweats, at which time he was found to have an abnormal enhancing lesion of the corpus collosum on brain magnetic resonance imaging (MRI). Laboratory testing revealed a CD4 count of 63 cells/mm(3), positive HIV-2 Western blot, serum HIV-2 RNA polymerase chain reaction (PCR) of 1160 copies per milliliter and cerebrospinal fluid (CSF) HIV-2 RNA PCR of 2730 copies per milliliter. Brain biopsy demonstrated syncytial giant cells centered around small blood vessels and accompanied by microglia, which correlated with prior pathologic descriptions of HIV-2 encephalitis and with well-described findings of HIV-1 encephalitis. Based on genotype resistance assay results, treatment guidelines, and prior studies validating success with lopinavir-ritonavir, he was treated with tenofovir-emtricitabine and lopinavir-ritonavir, which has led to virologic suppression along with steady neurologic and radiologic improvement, although he continues to have deficits.

Two independent epidemics of HIV in Maryland

BACKGROUND

HIV-1 subtype B virus is the predominant subtype in HIV-infected individuals in the United States. However, increasing evidence suggests that prevalence of non-B subtypes may be on the rise in the West, and this may have implications for HIV-1 disease surveillance and treatment. The state of Maryland currently has the fourth highest AIDS case report rate in the United States. The goal of this study was to evaluate the prevalence of HIV-1 non-B subtypes in Maryland. The study population included individuals diagnosed with HIV in 2007 through the voluntary counseling and testing sites at the Maryland Department of Health and Mental Hygiene and HIV-infected patients who had genotyping performed at the University of Maryland Medical Center.

RESULTS

At the Department of Health and Mental Hygiene sites, 47 unique non-B subtype strains were identified representing a non-B prevalence of 12.9%. These non-B subtypes included CRF02_AG (n = 20), C (n = 11), A (n = 7), G (n = 5), D (n = 1), and unique recombinant forms (n = 3). The non-B patients were predominantly non-Hispanic black (95.7%) with 63.8% female. Although the majority of the HIV subtype B cases (65.3%) were identified from the Baltimore metropolitan area, most (80.9%) of the non-B cases were from the Maryland suburbs of Washington, DC. Among University of Maryland Medical Center patients, there were 30 non-B subtypes, representing a non-B prevalence of 1.9%. The non-B subtypes detected were CRF02_AG (n = 14), C (n = 6), A (n = 6), G (n = 2), D (n = 1), and unique recombinant forms (n = 1). Phylogenetic analysis of the non-B subtypes revealed that viral sequences from both sources were intermixed, confirming that both sampling frames were drawing from the same overall population.

CONCLUSIONS

Multiple HIV-1 subtypes exist in the Baltimore-Washington metropolitan area with a significant non-B-infected population in the Maryland suburbs of Washington, DC, suggesting 2 independent epidemics of HIV in Maryland. Population-based surveillance inclusive of groups at higher risk of non-B strains is essential to monitor the prevalence and variations of HIV subtypes in Maryland and the United States.

Access to regular HIV care and disease progression among black African immigrants

OBJECTIVE

To describe the characteristics of human immunodeficiency virus (HIV)-infected black African immigrants living in King County, Washington, we evaluated delay in HIV diagnosis, access to HIV care, and risk of progression to AIDS or death.

METHODS

We compared differences in the risk of progression to AIDS or death between HIV-positive African-born black individuals and 2 groups of HIV-positive US-born individuals.

RESULTS

There were significant differences across the groups in residence at time of HIV diagnosis, gender, HIV transmission category, and initial CD4 count. Black Africans were more likely to present with an AIDS diagnosis (45%), compared to both US-born nonblacks (25%) and US-born blacks (35%). No significant independent associations were observed in rates of HIV disease progression when black African immigrants were compared to their US-born counterparts.

CONCLUSIONS

Once having initiated HIV care, African-born blacks accessed HIV care and progressed to AIDS at similar rates compared to US-born individuals. However, African-born blacks initiated care with more advanced HIV disease. Results underscore the need for health interventions promoting HIV testing among black African immigrants and reducing barriers to HIV testing.

African immigrant health

As the number and diversity of Africans in the U.S. increases, there is a growing need to assess their health care needs and practices. Although infectious diseases have been a traditional point of contact between health care systems and African immigrants, there is a clear and unmet need to determine the risks and prevalence for chronic diseases. This review includes what has been published concerning the health of African immigrants in the U.S. and draws on European studies to supplement this assessment. While African immigrants arrive in the U.S. with some unique health problems, namely infectious diseases, they are generally healthier than African Americans of the same age. This 'healthy immigrant effect' has been well documented, but the acquisition of risk factors for chronic diseases such as coronary artery disease, hypertension, diabetes and cancer is poorly understood among African immigrants. More information must be gathered in the broad categories of chronic disease, health attitudes and health access to better promote the health of African immigrants.

Pregnancy among HIV-infected refugees in Rhode Island

In 1999, immigration laws lifted previous barriers, allowing more HIV-infected refugees entrance to the US. Many of these refugees are women of reproductive age. At our center in Providence, RI, a significant number of HIV-infected refugees have become pregnant since resettling in the US. We describe the pregnancies seen among these predominantly West African HIV-infected refugees. A retrospective chart review was conducted on all HIV-infected female refugees who established care from 2000-2006. Descriptive statistics were used to describe the population at this site. We found that between 2000 and 2006, 28 HIV-infected female refugees established care. Liberia was the country of origin of 79% (22) of the women. There were 20 pregnancies among 14 women between 2000-2006. The median time from resettlement in the US to first pregnancy was 16 (<1-69) months. The median age at time of first pregnancy was 29 years (19-39). At time of pregnancy, the median CD4 count was 506 cells/mL and the median plasma viral load (PVL) was 3.36 log10 copies/ml. There were nine deliveries, one current pregnancy and one loss to follow-up. Other pregnancy outcomes included five terminations and three spontaneous abortions. All women received antiretroviral therapy during their pregnancy. At the time of delivery the median PVL was <1.88 log. There was one HIV transmission from mother to child. Two women became pregnant while on efavirenz, which was subsequently discontinued. One of the women delivered a normal term infant; the other relocated and transferred her care. Among this cohort of HIV-infected refugees, there is a high rate of pregnancy, highlighting the need for timely initiation of medical care, including comprehensive preconception counseling, upon resettlement in the US. It is important to gain a better understanding of this unique and growing population in order to provide the best possible care for these women.

Impact of HIV-1 viral subtype on CD4+ T-cell decline and clinical outcomes in antiretroviral naive patients receiving universal healthcare

OBJECTIVE

The influence of viral subtype on the natural history of HIV is unclear and confounded by socioeconomic and host factors that vary between groups harboring different clades. We compared Canadians (clade B), with recent immigrants from Haiti (clade B) and sub-Saharan Africa (clades non-B) to determine whether there were differences in disease progression attributable to viral subtype.

METHODS

We conducted a retrospective cohort study in a universal healthcare setting between 1996 and 2007. The rate of CD4+ T-lymphocyte decline prior to initiation of antiretroviral therapy was determined in all participants with at least two CD4+ T-lymphocyte measures using mixed linear regression models. Time to first AIDS-defining illness was compared using adjusted Cox proportional hazards models.

RESULTS

Two hundred and eighty-nine Canadians, 44 Haitians, and 123 Africans were studied for a median of 260 days (2 days-11 years). Africans and Haitians were demographically and clinically similar. However, the adjusted slope of square root CD4+ T-lymphocyte decline was significantly lower in Africans [-0.04/year; 95% confidence interval (CI) = -0.08 to -0.003] compared with Canadians (-0.07/year; 95% CI = -0.11 to -0.03; P = 0.02), and Haitians (-0.10/year; 95% CI = -0.12 to -0.07; P = 0.001). Africans were also less likely to develop AIDS.

CONCLUSION

Despite having similar demographic, socioeconomic, and nutritional status to Haitians, Africans infected with non-B clade HIV had slower rates of disease progression compared with both Haitians and Canadians, with both groups being infected by the clade B virus. Our findings suggest that viral subtype may be an important predictor of HIV natural history in a developed medical setting.

Clinical differences and viral diversity between newly HIV type 1-diagnosed African and non-African patients in Spain (2005-2007)

Abstract The diagnosis of HIV-1 is increasing in African-born persons residing in Europe. They present a high prevalence of HIV-1 non-B variant infections and of parasitic infections, both of which are infrequent in Western countries. Immigration favors their presence in nonendemic countries. In this study, all newly HIV-diagnosed individuals at an HIV/AIDS and Tropical Medicine reference center in Madrid from 2005 through 2007 were retrospectively studied. HIV-1 subtyping was performed in gag, pol, and gp41 coding regions by phylogenetic analyses. The presence of other pathogens was also evaluated. Furthermore, all HIV-1-infected Africans were screened for parasitic infections. Newly diagnosed HIV-1 subjects included 90 sub-Saharan Africans and 188 non-Africans (116 Spaniards, 13 other Europeans, and 59 Latin Americans). Significantly higher numbers of HIV-1-infected Africans than non-Africans were females, acquired HIV-1 by heterosexual contact, and presented a more advanced clinical CDC stage and criteria for starting antiretroviral therapy in the first clinical visit. They predominantly carried non-B subtype infections, mainly intersubtype recombinants. Half of HIV-1-infected Africans had parasitic infections. CD4(+) T cell counts were lower among Africans than Europeans at the time of HIV-1 diagnosis. At 12 months of follow-up after starting antiretroviral treatment, a significantly lower proportion of Africans than non-Africans achieved undetectable viremia due to their higher loss to follow-up. However, CD4(+) T cell recovery and virological failure rates were similar. Therefore, the profile of African HIV-1-infected immigrants varies widely with respect to Spanish HIV-infected individuals. More advanced immunodeficiency and the coexistence of parasitic diseases and infections with a large diversity of HIV-1 non-B and recombinant variants are expected.

HIV infection in refugees: a case-control analysis of refugees in Rhode Island

OBJECTIVES

The number of HIV-infected refugees entering the USA is increasing. There is little data describing the HIV-infected refugee population and the challenges encountered when caring for them. We performed a retrospective case-control analysis of HIV-infected refugees in order to characterize their co-morbidities, baseline HIV characteristics, and longitudinal care compared to HIV-infected non-refugees.

METHODS

A retrospective chart review was performed of HIV-infected refugees and non-refugees who were matched for gender, age, and time of establishment of initial HIV care.

RESULTS

The refugee population studied was largely from West Africa. Refugees were more likely than non-refugees to have heterosexual risk for HIV infection, latent tuberculosis infection, and active hepatitis B. Refugees were less likely than non-refugees to have a history of substance use, start antiretrovirals, and be enrolled in a clinical study. The baseline CD4 counts and HIV plasma viral loads were similar between the two groups.

CONCLUSIONS

Clinicians caring for West African HIV-infected refugees should be knowledgeable about likely co-morbidities and the impact of cultural differences on HIV care. Further studies are needed to develop culturally competent HIV treatment, education, and prevention programs for refugees who are beginning a new life in the USA.

Screening and Management of HIV-2-Infected Individuals in Northern Italy

There is a lack of updated estimates of HIV-2 infection in Italy. Moreover, lack of standardized HIV-2 viral load (VL) and drug resistance tests challenges clinical practice. Among 2941 HIV-positive patients followed in our center (Brescia, Northern Italy), 220 (7.5%) were African at the beginning of the study period. We assessed a population of 151 HIV-Ab positive patients (141 of African origin), presenting for routine blood testing from January 2006 to May 2007. Those found infected with HIV-2 started an appropriate disease management with HIV-2 VL and genotypic drug resistance testing. Sixteen of 151 (10.6%) patients were positive for HIV-2. Of those 16 patients, 14 came from Africa. Among 7 experienced patients, 1 was responding to nelfinavir and 4 to lopinavir/ritonavir-containing regimens. Two patients were failing treatment: 1 patient was switched to a saquinavir/ritonavir-containing regimen and responded. The remaining patient switched to lamivudine + atazanavir + saquinavir + ritonavir did not respond, having had previous experience to multiple ineffective drugs, resulting in a very complex HIV-2 drug-resistance pattern. Accurate screening programs and integration of virological tools must be implemented urgently, given the high prevalence of HIV-2, particularly in immigrant patients.