Missed opportunities for HIV testing among high-risk heterosexuals

Determinants of HIV-1 Late Presentation in a Cohort of Portuguese HIV-1 Patients

Undiagnosed HIV-1 patients still account for 25% of worldwide HIV patients. Studying late presenters (LPs) for HIV care may help to identify characteristics of such patients. The present study aims to identify factors associated with late presentation and late presentation with advanced disease based on a population of patients followed in a Portuguese hospital between 1984 and 2017. Sociodemographic and clinical data from infected patients with HIV-1 aged 18 years and older, followed in Egas Moniz Hospital, in Portugal were collected. Of the 907 patients included in this study, 68.7% were males and the median age was 37 years (interquartile range 30-47). Four hundred fifty-nine patients (50.6%) were LP and, of these, 284 patients (61.9%) were LPAD. The LP population mostly originated from Portugal and sub-Saharan Africa (64.4% and 28.8%; p = .004) and the HIV exposure category, mainly heterosexuals and men have sex with men (57.0% and 24.9%; p < .001). The stage of disease and viral load at diagnosis were significantly associated with both LP and LPAD (p < .001). Factors associated with LP in the logistic regression included age at diagnosis lower than 30 years (adjusted odds ratio [aOR] 0.34; 0.17-0.68; p = .002) and origin from sub-Saharan Africa (aOR 2.24; 1.44-3.50; p < .001). Late presentation is a major obstacle to halt the HIV epidemic. In this population, the majority of newly diagnosed HIV-infected individuals were LPs. Our results characterize vulnerable populations that should be frequently tested for HIV.

Testing, Inequities and Vulnerability of Adolescents to Sexually Transmitted Infections

Sexually transmitted infections (STIs) should form part of the comprehensive healthcare agenda for adolescents and young people (A&Y) and testing plays a strategic role in STI prevention. However, little attention has been paid to the social and programmatic obstacles to this practice among A&Y. The aim of this study is to describe the prevalence of testing for syphilis and HIV reported by a group of A&Y, analyzing its relationship with variables potentially indicative of inequities related to vulnerability to STIs. This was a cross-sectional survey applied to students at public high schools in three cities in the state of São Paulo, Brazil. The responses of 369 young people who reported having started sexual life were analyzed. The analysis included description of the frequencies of demographic and socioeconomic variables and their associations with testing for syphilis and HIV through the chi-square test. The concentration index (CI) was also calculated, with construction of the respective concentration curve for the associated variables. Positive associations were found between occurrence of testing and living in homes with up to three inhabitants, living in a marital situation with a regular or committed partnership, previous use of primary care services and previous use of hospitals or emergency services. The concentration curve for testing STIs showed significant contributions from the associated variables. The findings indicated that situations of inequity need to be addressed in order to reduce A&Y's vulnerability to STIs.

Epidemiological factors associated with the absence of previous HIV testing among HIV-positive persons in Singapore, 2012-2017

OBJECTIVE

To assess the temporal trend and identify risk factors associated with the absence of previous HIV testing prior to their diagnosis among HIV-positive persons in Singapore.

STUDY DESIGN

Cross-sectional.

SETTING AND PARTICIPANTS

We analysed data of HIV-positive persons infected via sexual transmission, who were notified to the National HIV Registry in 2012-2017.

OUTCOMES

Epidemiological factors associated with the absence of HIV testing prior to diagnosis were determined separately for two groups of HIV-positive persons: early and late stages of HIV infection at diagnosis.

RESULTS

2188 HIV-positive persons with information on HIV testing history and CD4 cell count were included in the study. The median age at HIV diagnosis was 40 years (IQR 30-51). Nearly half (45.1%) had never been tested for HIV prior to their diagnosis. The most common reason cited for no previous HIV testing was 'not necessary to test' (73.7%). The proportion diagnosed at late-stage HIV infection was significantly higher among HIV-positive persons who had never been tested for HIV (63.9%) compared with those who had undergone previous HIV tests (29.0%). Common risk factors associated with no previous HIV testing in multivariable logistic regression analysis stratified by stage of HIV infection were: older age at HIV diagnosis, lower educational level, detection via medical care and HIV infection via heterosexual transmission. In the stratified analysis for persons diagnosed at early-stage of HIV infection, in addition to the four risk factors, women and those of Malay ethnicity were also less likely to have previous HIV testing prior to their diagnosis.

CONCLUSION

Targeted prevention efforts and strategies are needed to raise the level of awareness of HIV/AIDS and to encourage early and regular screening among the at-risk groups by making HIV testing more accessible.

Remaining Gap in HIV Testing Uptake Among Female Sex Workers in Iran

We estimated the prevalence of recent HIV testing (i.e., having an HIV test during the last 12 months and knew the results) among 1295 HIV-negative Iranian female sex workers (FSW) in 2015. Overall, 70.4% (95% confidence intervals: 59.6, 79.3) of the participants reported a recent HIV testing. Concerns about their HIV status (83.2%) was reported as the most common reason for HIV testing. Incarceration history, having >5 paying partners, having >1 non-paying partner, receiving harm reduction services, utilizing healthcare services, and knowing an HIV testing site were significantly associated with recent HIV testing. In contrast, outreach participants, having one non-paying sexual partner, and self-reported inconsistent condom use reduced the likelihood of recent HIV testing. HIV testing uptake showed a ~2.5 times increase among FSW since 2010. While these findings are promising and show improvement over a short period, HIV testing programs should be expanded particularly through mobile and outreach efforts.

Public Health Benefit of Peer-Referral Strategies for Detecting Undiagnosed HIV Infection Among High-Risk Heterosexuals in New York City

Identifying undiagnosed HIV infection is necessary for the elimination of HIV transmission in the United States. The present study evaluated the efficacy of 3 community-based approaches for uncovering undiagnosed HIV among heterosexuals at high-risk (HHR), who are mainly African American/Black and Hispanic. Heterosexuals comprise 24% of newly reported HIV infections in the United States, but experience complex multilevel barriers to HIV testing. We recruited African American/Black and Hispanic HHR in a discrete urban area with both elevated HIV prevalence and poverty rates. Approaches tested were (1) respondent-driven sampling (RDS) and confidential HIV testing in 2 sessions (n = 3116); (2) RDS and anonymous HIV testing in one session (n = 498); and (3) venue-based sampling (VBS) and HIV testing in a single session (n = 403). The main outcome was newly diagnosed HIV infection. RDS with anonymous testing and one session reached HHR with less HIV testing experience and more risk factors than the other approaches. Furthermore, RDS with anonymous (4.0%) and confidential (1.0%) testing yielded significantly higher rates of newly diagnosed HIV than VBS (0.3%). Thus peer-referral approaches were more efficacious than VBS for uncovering HHR with undiagnosed HIV, particularly a single-session/anonymous strategy, and have a vital role to play in efforts to eliminate HIV transmission.

A Systematic Review of Published Respondent-Driven Sampling Surveys Collecting Behavioral and Biologic Data

Reporting key details of respondent-driven sampling (RDS) survey implementation and analysis is essential for assessing the quality of RDS surveys. RDS is both a recruitment and analytic method and, as such, it is important to adequately describe both aspects in publications. We extracted data from peer-reviewed literature published through September, 2013 that reported collected biological specimens using RDS. We identified 151 eligible peer-reviewed articles describing 222 surveys conducted in seven regions throughout the world. Most published surveys reported basic implementation information such as survey city, country, year, population sampled, interview method, and final sample size. However, many surveys did not report essential methodological and analytical information for assessing RDS survey quality, including number of recruitment sites, seeds at start and end, maximum number of waves, and whether data were adjusted for network size. Understanding the quality of data collection and analysis in RDS is useful for effectively planning public health service delivery and funding priorities.

Factors Associated with Recent HIV Testing among Heterosexuals at High Risk for HIV Infection in New York City

Background

The Centers for Disease Control and Prevention recommends persons at high risk for HIV infection in the United States receive annual HIV testing to foster early HIV diagnosis and timely linkage to health care. Heterosexuals make up a significant proportion of incident HIV infections (>25%) but test for HIV less frequently than those in other risk categories. Yet factors that promote or impede annual HIV testing among heterosexuals are poorly understood. The present study examines individual/attitudinal-, social-, and structural-level factors associated with past-year HIV testing among heterosexuals at high risk for HIV.

Methods

Participants were African-American/Black and Hispanic heterosexual adults (N = 2307) residing in an urban area with both high poverty and HIV prevalence rates. Participants were recruited by respondent-driven sampling in 2012–2015 and completed a computerized structured assessment battery covering background factors, multi-level putative facilitators of HIV testing, and HIV testing history. Separate logistic regression analysis for males and females identified factors associated with past-year HIV testing.

Results

Participants were mostly male (58%), African-American/Black (75%), and 39 years old on average (SD = 12.06 years). Lifetime homelessness (54%) and incarceration (62%) were common. Half reported past-year HIV testing (50%) and 37% engaged in regular, annual HIV testing. Facilitators of HIV testing common to both genders included sexually transmitted infection (STI) testing or STI diagnosis, peer norms supporting HIV testing, and HIV testing access. Among women, access to general medical care and extreme poverty further predicted HIV testing, while recent drug use reduced the odds of past-year HIV testing. Among men, past-year HIV testing was also associated with lifetime incarceration and substance use treatment.

Conclusion

The present study identified gaps in rates of HIV testing among heterosexuals at high risk for HIV, and both common and gender-specific facilitators of HIV testing. Findings suggest a number of avenues for increasing HIV testing rates, including increasing the number and types of settings offering high-quality HIV testing; promoting STI as well as HIV testing; better integrating STI and HIV testing systems; implementing peer-driven social/behavioral intervention approaches to harness the positive influence of social networks and reduce unfavorable shared peer norms; and specialized approaches for women who use drugs.

A Randomized Study of Incentivizing HIV Testing for Parolees in Community Aftercare

HIV risk-behaviors are high in criminal justice populations and more efforts are necessary to address them among criminal justice-involved substance abusers. This study examines the role of incentives in promoting HIV testing among parolees. Participants were randomly assigned to either an incentive (n = 104) or education group (control; n = 98), where the incentive group received a voucher for testing for HIV. Bivariate comparisons showed that a larger proportion of those in the incentive group received HIV testing (59% versus 47%), but this was not statistically significant (p = .09). However, in a multivariate logistic regression model controlling for covariates likely to influence HIV-testing behavior, those in the incentive group had increased odds of HIV testing in comparison to those in the education group (OR = 1.99, p < .05, CI [1.05, 3.78]). As a first of its kind, this study provides a foundation for further research on the utility of incentives in promoting HIV testing and other healthy behaviors in criminal justice populations.

Exploring Factors Associated with Recent HIV Testing among Heterosexuals at High Risk for HIV Infection Recruited with Venue-based Sampling

Annual HIV testing is recommended for high-risk populations in the United States, to identify HIV infections early and provide timely linkage to treatment. However, heterosexuals at high risk for HIV, due to their residence in urban areas of high poverty and elevated HIV prevalence, test for HIV less frequently than other risk groups, and late diagnosis of HIV is common. Yet the factors impeding HIV testing in this group, which is predominantly African American/Black and Latino/Hispanic, are poorly understood. The present study addresses this gap. Using a systematic community-based sampling method, venue-based sampling (VBS), we estimate rates of lifetime and recent (past year) HIV testing among high-risk heterosexuals (HRH), and explore a set of putative multi-level barriers to and facilitators of recent testing, by gender. Participants were 338 HRH African American/Black and Latino/Hispanic adults recruited using VBS, who completed a computerized structured assessment battery guided by the Theory of Triadic Influence, comprised of reliable/valid measures on socio-demographic characteristics, HIV testing history, and multi-level barriers to HIV testing. Logistic regression analysis was used to identify factors associated with HIV testing within the past year. Most HRH had tested at least once (94%), and more than half had tested within the past year (58%), but only 37% tested annually. In both men and women, the odds of recent testing were similar and associated with structural factors (better access to testing) and sexually transmitted infection (STI) testing and diagnosis. Thus VBS identified serious gaps in rates of annual HIV testing among HRH. Improvements in access to high-quality HIV testing and leveraging of STI testing are needed to increase the proportion of HRH testing annually for HIV. Such improvements could increase early detection of HIV, improve the long-term health of individuals, and reduce HIV transmission by increasing rates of viral suppression.

Hybrid STTR intervention for heterosexuals using anonymous HIV testing and confidential linkage to care: a single arm exploratory trial using respondent-driven sampling

BACKGROUND

An estimated 14 % of the 1.2 million individuals living with HIV in the U.S. are unaware of their status. Yet this modest proportion of individuals with undiagnosed HIV is linked to 44-66 % of all new infections. Thus innovative intervention approaches are needed to seek out and test those with undiagnosed HIV, and link them to HIV treatment with high retention, an approach referred to as "Seek, Test, Treat, and Retain" (STTR). The present protocol describes a creative "hybrid" STTR approach that uses anonymous HIV testing followed by confidential care linkage, focused on heterosexuals at high risk (HHR) for HIV, who do not test as frequently as, and are diagnosed later, than other risk groups.

METHODS/DESIGN

This is a single-arm exploratory intervention efficacy trial. The study has two phases: one to seek out and test HHR, and another to link those found infected to HIV treatment in a timely fashion, with high retention. We will recruit African American/Black and Latino adult HHR who reside in urban locations with high poverty and HIV prevalence. Participants will be recruited with respondent-driven sampling, a peer recruitment method. The "Seek and Test" phase is comprised of a brief, convenient, single-session, anonymous HIV counseling and testing session. The "Treat and Retain" component will engage those newly diagnosed with HIV into a confidential research phase and use a set of procedures called care navigation to link them to HIV primary care. Participants will be followed for 6 months with objective assessment of outcomes (using medical records and biomarkers).

DISCUSSION

Undiagnosed HIV infection is a major public health problem. While anonymous HIV testing is an important part of the HIV testing portfolio, it does not typically include linkage to care. The present study has potential to produce an innovative, brief, cost-effective, and replicable STTR intervention, and thereby reduce racial/ethnic disparities in HIV/AIDS.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02421159 , Registered April 15, 2015.

Factors Associated with Time Since Last HIV Test Among Persons at High Risk for HIV Infection, National Survey of Family Growth, 2006-2010

The Centers for Disease Control and Prevention (CDC) recommends annual HIV screening for persons at high risk for HIV infection. We assessed the testing history and factors associated with recent testing (tested in the last 12 months) among persons at high risk for HIV infection. We analyzed 2006-2010 National Survey of Family Growth data and classified respondents aged 15-44 who reported a sexual or drug-use risk behavior in the past year as 'high-risk'. Logistic regression models estimated prevalence ratios assessing the association between demographic and health-related factors and having been recently tested for HIV compared with never been tested. Among high-risk men, 29.3% had recently tested for HIV, 30.7% tested more than 12 months ago, and 40.0% had never been tested. Among high-risk women, 38.0% had recently tested, 36.9% tested more than 12 months ago, and 26.1% had never been tested. Compared with men who were aged 15-19, white, heterosexual, and had not recently visited a doctor, men who were aged 40-44, black/African American, homosexual/gay or bisexual, and had visited a doctor in the past year were more likely to have recently tested. Compared with women who were white, had not recently visited a doctor, and had never been pregnant, women more likely to have recently tested were black/African American, had visited a doctor in the past year, and had been pregnant. Approximately two-thirds of high-risk men and women had not been recently tested for HIV. CDC recommendations for annual screening are not being implemented for the majority of persons at risk.

HIV testing practices among Latina women at risk of getting infected: a five-year follow-up of a community sample in South Florida

Latinos are more likely to delay HIV testing, present to care with an AIDS defining illness, and die within one year of learning their HIV-positive status than non-Latino blacks and whites. For this paper, we explore the role of partner-relationship characteristics and health behaviors, in predicting HIV testing among Latina adult women who engaged in risky sexual behaviors (i.e., unprotected vaginal and/or anal sex). Data from a convenience sample of 168 Latina adult women who engaged in risky sexual behavior in the year prior to assessment were analyzed for this paper. Rates and predictors of HIV testing among this sample were assessed after a five-year follow-up. Descriptive and analytical estimates include incidence rates and adjusted odds ratios (AOR) from multilevel models. At five-year follow-up, 63.7% (n = 107) women reported having been tested for HIV, of whom 12.2% (n = 13) were women who never tested before. Main reasons for not having been tested at follow-up included: low risk perception (62.1%) and trusting their partner(s)/being in a monogamous relationship/knowing their partner's HIV status (17.2%). Predictors of HIV testing included: age (AOR: 0.96; 95% CI = 0.92-0.99), provider endorsement of HIV testing (AOR: 4.59; 95% CI = 1.77-11.95), poor quality of their romantic relationships (AOR: 1.12; 95% CI = 1.03-1.26), and knowing the HIV sero-status of sexual partner (AOR: 3.61; 95% CI = 1.46-8.95). This study characterizes a group of Latina women at high risk for HIV infection and their HIV testing behaviors. Our findings underscore the need of increasing access to quality health-care services and HIV behavioral interventions, and to strengthen the adherence to HIV/sexually transmitted disease testing recommendations and guidelines among local health-care providers serving the Latino community in South Florida.

Black:White Disparities in HIV Mortality in the United States: 1990-2009

OBJECTIVES

The aim of this study was to assess whether racial disparities in human immunodeficiency virus (HIV) mortality in the USA have changed over time.

METHODS

Using vital records from the National Center for Health Statistics and census data from the US Census Bureau, we calculated the race- and gender-specific HIV mortality rates and corresponding racial rate ratios for non-Hispanic Blacks and non-Hispanic Whites in the USA for four 5-year increments from 1990-2009. Rates were age-adjusted using the 2000 USA standard population. Additionally, we calculated excess Black deaths for 2005-2009.

RESULTS

For the total, male, and female populations, we observed a statistically significant increase in the Black:White HIV mortality disparity between T1 (1990-1994) and T4 (2005-2009). The increasing disparity was due to the fact that the decrease in mortality rates from T1 to T4 was greater among Whites than Blacks. This disparity led to 5603 excess Black deaths in the USA at T4.

CONCLUSIONS

Previous research suggests that as HIV becomes more treatable, racial disparities widen, as observed in this study for both men and women. Existing disparities could be ameliorated if access to care were equal among these groups. Equal access would enable more individuals to achieve viral suppression, the final step of the HIV Care Continuum.

Unknown HIV Status in the Emergency Department: Implications for Expanded Testing Strategies

OBJECTIVES

The authors sought to determine the prevalence of unknown HIV status among emergency department (ED) patients, how it has changed over time, and whether it differs according to patient characteristics.

METHODS

The authors used electronic medical record data to identify whether HIV status was known or unknown among patients aged ≥13 seen in the ED of a large, urban medical center between 2006 and 2011. The authors used multivariate logistic regression to identify the characteristics associated with unknown HIV status.

RESULTS

The prevalence of unknown HIV status decreased each year, from 87.7% in 2006 to 74.9% in 2011 (P < .001). Characteristics associated with unknown HIV status included being nonblack, in the youngest and oldest age-groups, and nonpublically insured. Compared to men, women without prior pregnancy were equally likely to have unknown HIV status, but women with prior pregnancy were significantly less likely to have unknown HIV status.

CONCLUSION

The prevalence of unknown HIV status is decreasing, but in 2011 75% of ED patients aged ≥13 still had unknown status, and it was associated with specific patient characteristics. Understanding the trends in the prevalence of unknown HIV status and how it is associated with patient characteristics should inform the design and implementation of expanded HIV-testing strategies.

Strategies to uncover undiagnosed HIV infection among heterosexuals at high risk and link them to HIV care with high retention: a "seek, test, treat, and retain" study

Background

Over 50,000 individuals become infected with HIV annually in the U.S., and over a quarter of HIV infected individuals are heterosexuals. Undiagnosed HIV infection, as well as a lack of retention in care among those diagnosed, are both primary factors contributing to ongoing HIV incidence. Further, there are racial/ethnic disparities in undiagnosed HIV and engagement in care, with African Americans/Blacks and Latinos remaining undiagnosed longer and less engaged in care than Whites, signaling the need for culturally targeted intervention approaches to seek and test those with undiagnosed HIV infection, and link them to care with high retention.

Methods/Design

The study has two components: one to seek out and test heterosexuals at high risk for HIV infection, and another to link those found infected to HIV care with high retention. We will recruit sexually active African American/Black and Latino adults who have opposite sex partners, negative or unknown HIV status, and reside in locations with high poverty and HIV prevalence. The “Seek and Test” component will compare the efficacy and cost effectiveness of two strategies to uncover undiagnosed HIV infection: venue-based sampling and respondent-driven sampling (RDS). Among those recruited by RDS and found to have HIV infection, a “Treat and Retain” component will assess the efficacy of a peer-driven intervention compared to a control arm with respect to time to an HIV care appointment and health indicators using a cluster randomized controlled trial design to minimize contamination. RDS initial seeds will be randomly assigned to the intervention or control arm at a 1:1 ratio and all recruits will be assigned to the same arm as the recruiter. Participants will be followed for 12 months with outcomes assessed using medical records and biomarkers, such as HIV viral load.

Discussion

Heterosexuals do not test for HIV as frequently as and are diagnosed later than other risk groups. The study has the potential to contribute an efficient, innovative, and sustainable multi-level recruitment approach and intervention to the HIV prevention portfolio. Because the majority of heterosexuals at high risk are African American/Black or Latino, the study has great potential to reduce racial/ethnic disparities in HIV/AIDS.

Trial registration

ClinicalTrials.gov, NCT01607541, Registered May 23, 2012.

Opportunities for earlier HIV diagnosis in a pediatric ED

OBJECTIVES

Emergency department (ED) HIV screening is recommended but challenging to implement and of uncertain effectiveness in pediatric EDs (PEDs). We sought to determine whether there were opportunities for earlier HIV diagnosis in the PED for a cohort of young adults diagnosed with HIV.

METHODS

This retrospective cohort study reviewed PED records of a group of young adults receiving HIV care in an urban hospital setting. Pediatric ED visits were selected for review if they took place after the patient's estimated time of HIV acquisition and before their eventual diagnosis. Charts were reviewed to determine whether HIV infection was suspected and whether testing was offered.

RESULTS

Among a cohort of HIV-positive young adults, only 3 (3.6%; 95% confidence interval, 0.9-10.8) of 84 were seen in the PED during the time they were undiagnosed but likely to be infected with HIV. Among these subjects, there was no documentation that HIV testing was offered or refused nor was there documented suspicion of HIV.

CONCLUSIONS

There are opportunities for earlier diagnosis of HIV in PEDs, affirming the importance of HIV screening implementation in these settings. However, PEDs are unlikely to have the same frequency of contact with undiagnosed individuals as do adult EDs. Alternative methods of accessing at-risk adolescent populations must be identified.

Lack of awareness in both patients and physicians contributes to a high rate of late presentation in a South West German HIV patient cohort

PURPOSE

To assess rate of late presentation with HIV in Southwestern Germany and to identify patient characteristics correlated with CD4 nadir.

METHODS

Patients with primary diagnosis who presented to one of ten participating clinics rated on knowledge and behavior towards HIV testing on a self-developed questionnaire, whereas clinical data was assessed by the physician.

RESULTS

161 patients were included. Risk factors were homosexual (59.5 %) or heterosexual contacts (26.8 %), drug use (2.0 %), migration (3.9 %), or others (7.8 %). 63.5 % had a CD4 T cell count < 350/µl. 52.5, 17.4, and 31.1 % were diagnosed in CDC stadium A, B or C, respectively. 209 disease episodes were reported, from whom 83.7 % had led to the diagnosis of HIV. 75.2 and 68.3 % said to have been well-informed about ways of transmission and testing offerings, respectively, and 20.4 % admitted to have psychologically repressed the possibility of being infected. 48 patients rated their personal behavioral risk as "high" or "very high". Of these, however, only ten had performed at test in the precedent year. Performing a regression analysis, younger age and previous testing were correlated with a higher CD4 T cell nadir (p = 0.005, and 0.018, resp.).

CONCLUSION

The rate of late presentation in this region was even higher compared to national or European surveys. Most infected patients perceived to have had only a low risk. Several disease episodes did not lead to the initiation of HIV testing by the physician.

Correlates of having never been HIV tested among entrants to substance abuse treatment clinics: empiric findings from real-world New England settings

Routine testing is the cornerstone to identifying HIV, but not all substance abuse treatment patients have been tested. This study is a real-world evaluation of predictors of having never been HIV tested among patients initiating substance abuse treatment. Participants (N = 614) from six New England clinics were asked whether they had ever been HIV tested. Eighty-five patients (13.8%) reported having never been tested and were compared to those who had undergone testing. Clinic, male gender (adjusted odds ratio (AOR) = 1.91, 95% confidence interval (CI) = 1.07-3.41), and having fewer employment (AOR = 0.31; 95% CI = 0.11-0.88) and medical problems (AOR = 0.40, 95% CI = 0.17-0.99) were independently correlated with having never been HIV tested. Thus, there is still considerable room for improved testing strategies as a clinically significant minority of substance abuse patients have never undergone HIV testing when they initiate treatment.

Development of an electronic medical record-based algorithm to identify patients with unknown HIV status

Individuals with unknown HIV status are at risk for undiagnosed HIV, but practical and reliable methods for identifying these individuals have not been described. We developed an algorithm to identify patients with unknown HIV status using data from the electronic medical record (EMR) of a large health care system. We developed EMR-based criteria to classify patients as having known status (HIV-positive or HIV-negative) or unknown status and applied these criteria to all patients seen in the affiliated health care system from 2008 to 2012. Performance characteristics of the algorithm for identifying patients with unknown HIV status were calculated by comparing a random sample of the algorithm's results to a reference standard medical record review. The algorithm classifies all patients as having either known or unknown HIV status. Its sensitivity and specificity for identifying patients with unknown status are 99.4% (95% CI: 96.5-100%) and 95.2% (95% CI: 83.8-99.4%), respectively, with positive and negative predictive values of 98.7% (95% CI: 95.5-99.8%) and 97.6% (95% CI: 87.1-99.1%), respectively. Using commonly available data from an EMR, our algorithm has high sensitivity and specificity for identifying patients with unknown HIV status. This algorithm may inform expanded HIV testing strategies aiming to test the untested.

Highly visible street-based HIV rapid testing: is it an attractive option for a previously untested population? A cross-sectional study

BACKGROUND

Given the shortage of community-based HIV testing initiatives in resource-rich countries not targeting most-at-risk populations, we aimed to evaluate whether a highly visible mobile programme promoting and offering rapid HIV testing in the street can attract persons at risk for infection who have never been tested.

METHODS

Between 2008 and 2011, the programme served 7552 persons in various Spanish cities who answered a brief questionnaire while awaiting their results. The factors associated with being tested for the first time were analysed using two logistic regression models, one for men who have sex with men (MSM) and the other for only heterosexual men (MSW) and women.

RESULTS

3517 participants (47%) were first-time testers (24% of MSM, 56% of MSW and 60% of women). Among them, 22 undiagnosed HIV infections were detected with a global prevalence of 0.6% and 3.1% in MSM. Undergoing a first HIV test was independently associated with age <30, being from Spain or another developed country, lack of university education, having fewer partners, having had unprotected sex with casual partners and not having been diagnosed with a sexually transmitted infection. In heterosexuals, also with never injected drugs, and in MSM, with not being involved in the gay community. Among those tested for the first time, 22% had never thought of being tested and 62% decided to be tested when they passed by and noticed the programme, regardless of their previous intentions.

CONCLUSIONS

This community programme attracted a substantial number of persons previously untested and particularly hard to reach, such as those with low education and MSM who were least involved in the gay community. Programme visibility was a decisive factor for almost two of every three persons who had never been tested.

The status of HIV prevention efforts for women in correctional facilities

In the United States, women are a significant proportion of the correctional population. Women also account for an increasing proportion of newly diagnosed human immunodeficiency virus (HIV) cases. When compared with white women, black women have higher incarceration rates and represent more of the newly diagnosed HIV cases. Correctional facilities offer an opportunity to provide women with HIV testing and prevention services so that they will know their status and receive HIV/sexually transmitted disease (STD) risk-reduction counseling and other preventive services. In this report, we describe incarcerated population statistics and HIV surveillance epidemiology for women. We also describe HIV prevention activities undertaken by the Centers for Disease Control and Prevention's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Additional research, program development, and implementation are needed to improve HIV prevention efforts for high-risk women.

Sexual HIV/HSV-2 risk among drug users in New York City: an HIV testing and counseling intervention

Undiagnosed and untreated sexually transmitted infections are highly prevalent among users of heroin, crack, cocaine, and amphetamines. Between 2008 and 2009, 58 heroin, cocaine, and crack users in New York City who reported unprotected vaginal and anal sex with more than one partner in the past 30 days were enrolled in an HIV testing and counseling intervention. Four weeks post intervention, increases were found for condom use and STI knowledge. Reductions were noted for safe-sex risk fatigue, number of same-and opposite-sex partners, and days when drugs were injected. Brief but intense counseling interventions can reduce HIV risk among high-risk populations.

Reframing the context of preventive health care services and prevention of HIV and other sexually transmitted infections for young men: new opportunities to reduce racial/ethnic sexual health disparities

Young Black males, aged 13 to 29 years, have the highest annual rates of HIV infections in the United States. Young Black men who have sex with men (MSM) are the only subgroup with significant increases in HIV incident infections in recent years. Black men, particularly MSM, are also disproportionately affected by other sexually transmitted infections (STIs). Therefore, we must strengthen HIV and STI prevention opportunities during routine, preventive health care visits and at other, nontraditional venues accessed by young men of color, with inclusive, nonjudgmental approaches. The Affordable Care Act and National HIV/AIDS Strategy present new opportunities to reframe and strengthen sexual health promotion and HIV and STI prevention efforts with young men of color.

HIV risk behavior and access to services: what predicts HIV testing among heterosexually active homeless men?

HIV is a serious epidemic among homeless persons, where rates of infection are estimated to be three times higher than in the general population. HIV testing is an effective tool for reducing HIV transmission and for combating poor HIV/AIDS health outcomes that disproportionately affect homeless persons, however, little is known about the HIV testing behavior of homeless men. This study examined the association between individual (HIV risk) and structural (service access) factors and past year HIV testing. Participants were a representative sample of 305 heterosexually active homeless men interviewed from meal programs in the Skid Row region of Los Angeles. Logistic regression examined the association between past year HIV testing and demographic characteristics, HIV risk behavior, and access to other services in the Skid Row area in the past 30 days. Despite high rates of past year HIV testing, study participants also reported high rates of HIV risk behavior, suggesting there is still significant unmet need for HIV prevention among homeless men. Having recently used medical/dental services in the Skid Row area (OR: 1.91; CI: 1.09, 3.35), and being a military veteran (OR: 2.10; CI: 1.01-4.37) were significantly associated with HIV testing service utilization. HIV testing was not associated with HIV risk behavior, but rather with access to services and veteran status, the latter of which prior research has linked to increased service access. We suggest that programs encouraging general medical service access may be important for disseminating HIV testing services to this high-risk, vulnerable population.

Delayed entry into HIV medical care after HIV diagnosis: risk factors and research methods

Timely linkage to HIV medical care has the potential to improve individual health outcomes and prevent secondary HIV transmission. Recent research found that estimates of delayed care entry varied by study design, with higher estimates among studies using only HIV case surveillance data. In this analysis, we compared the prevalence and risk factors for care delay using data from two studies with different designs conducted in New York City. The Medical Monitoring Project (MMP) used a retrospective design to estimate historical delay among persons currently receiving care, while the Never in Care (NIC) study used a prospective design to estimate current delay status among persons who were care-naive at baseline. Of 513 MMP subjects in 2007-2008, 23% had delayed care entry greater than three months after diagnosis. Independent risk factors for care delay were earlier year of diagnosis and testing positive in a nonmedical environment. Of 28 NIC subjects in 2008-2010, over half had tested positive in a nonmedical environment. The primary-stated reasons for delay were the same in both studies: denial of HIV status and lack of perceived need for medical care. The strengths and weaknesses of surveillance only, prospective, and retrospective study designs with respect to investigating this issue are explored. Future studies and interventions should be mindful of the common selection biases and measurement limitations with each design. A triangulation of estimates from varying designs is suggested for accurately measuring care linkage efforts over time.

Barriers to HIV testing among HIV/AIDS concurrently diagnosed persons in New York City

OBJECTIVES

To assess barriers to human immunodeficiency virus (HIV) testing, health care contacts history, and HIV testing history among patients diagnosed concurrently with HIV and acquired immunodeficiency syndrome (AIDS).

METHODS

We surveyed patients concurrently diagnosed with HIV/AIDS who had participated in the partner notification program of the New York City Department of Health and Mental Hygiene, between January 2008 and December 2008.

RESULTS

The most common reason interviewees volunteered for delaying testing (64%) was that they did not believe they were at risk for HIV. When read a list of potential barriers, 69% of interviewees replied affirmatively that they did not test for HIV because they did not believe they were at risk, and 52% replied affirmatively that they did not test because they thought their behaviors kept them safe from getting HIV. Half of all interviewees reported having insurance during part or all of the year before they were diagnosed with HIV/AIDS, and 70% had at least 1 health care visit in the year before they were diagnosed with HIV/AIDS.

CONCLUSIONS

A lack of perception of risk was the most common reason for not testing for HIV sooner among these concurrently diagnosed patients. The majority of these patients were accessing medical care, indicating that this population could have benefited from routine HIV testing.

HIV testing behaviors among undocumented Central American immigrant women in Houston, Texas

This paper describes HIV testing behaviors among undocumented Central American immigrant women living in Houston, Texas, USA. Respondent driven sampling was used to recruit participants for an HIV behavioral survey. HIV testing items included lifetime history of testing, date and location of the most recent test, and reason for testing. Multivariate logistic regression was used to assess the demographic, behavioral, and structural characteristics associated with testing. The lifetime prevalence of HIV testing was 67%. Half of those who tested did so within the past 2 years and almost 80% received their most recent test in a healthcare setting. The primary reason for testing was pregnancy. Lifetime testing was associated with being from Honduras, having over a sixth grade education, having a regular healthcare provider, and having knowledge of available healthcare resources. Our results suggest that expanding access to healthcare services may increase the prevalence of HIV testing in this population.

Comparison of missed opportunities for earlier HIV diagnosis in 3 geographically proximate emergency departments

OBJECTIVE

Differences in the prevalence of undiagnosed HIV between different types of emergency departments (EDs) are not well understood. We seek to define missed opportunities for HIV diagnosis within 3 geographically proximate EDs serving different patient populations in a single metropolitan area.

METHODS

For an urban academic, an urban community, and a suburban community ED located within 10 miles of one another, we reviewed visit records for a cohort of patients who received a new diagnosis of HIV between July 1999 and June 2003. Missed opportunities for earlier HIV diagnosis were defined as ED visits in the year before diagnosis, during which there was no documented ED HIV testing offer or test. Outcomes were the number of missed opportunity visits and the number of patients with a missed opportunity for each ED. We secondarily reviewed medical records for missed opportunity encounters, using an extensive list of indications that might conceivably trigger testing.

RESULTS

Among 276 patients with a new HIV diagnosis, 123 (44.5%) visited an ED in the year before diagnosis or received a diagnosis in the ED. The urban academic ED HIV testing program diagnosed 23 (8.3%) cases and offered testing to 24 (8.7%) patients who declined. Missed opportunities occurred during 187 visits made by 76 (27.5%) patients. These included 70 patients with 157 visits at the urban academic ED, 9 patients with 24 visits at the urban community ED, and 4 patients with 6 visits at the suburban community ED. Medical records were available for 172 of the 187 missed opportunity visits. Visits were characterized by the following potential testing indicators: HIV risk factors (58; 34%), related diagnosis indicating risk (7; 4%), AIDS-defining illness (8; 5%), physician suspicion of HIV (29; 17%), and nonspecific signs or symptoms of illness potentially consistent with HIV (126; 73%).

CONCLUSION

Geographically proximate EDs differ in their opportunities for earlier HIV diagnosis, but all 3 sites had missed opportunities. Many ED patients with undiagnosed HIV have potential indications for testing documented even in the absence of a dedicated risk assessment, although most of these are nonspecific signs or symptoms of illness that may not be clinically useful selection criteria.

HIV seropositivity and correlates of infection among heterosexually active adults in high-risk areas in South Florida

The U.S. HIV/AIDS epidemic disproportionately impacts lower-income populations. We conducted a cross-sectional study of heterosexually active adults (N = 1076) in areas with high poverty and HIV/AIDS rates in South Florida in 2007. Using venue-based sampling, anonymous interviews and HIV tests were conducted at randomly selected venues (primarily retail businesses not associated with risk behaviors). The sample's HIV infection rate was 7.1%. Half (52.2%) of the infections were previously undiagnosed. Our findings underscore the impact of social and environmental factors on HIV risk, as well as the need to increase and optimize HIV testing and other prevention services.

Patterns of exchange sex and HIV infection in high-risk heterosexual men and women

Heterosexual partnerships involving the trade of money or goods for sex are a well-described HIV risk factor in Africa and Southeast Asia, but less research has been conducted on exchange partnerships and their impact on HIV infection in the United States. In our study, men and women were recruited from high-risk risk neighborhoods in New York City through respondent-driven sampling in 2006-2007. We examined the factors associated with having an exchange partner in the past year, the relationship between exchange partnerships and HIV infection, and the risk characteristics of those with exchange partners by the directionality of payment. Overall, 28% of men and 41% of women had a past-year exchange partner. For men, factors independently associated with exchange partnerships were older age, more total sexual partners, male partners, and frequent non-injection drug use. For women, factors were homelessness, more total sexual partners, more unprotected sex partners, and frequent non-injection drug use. Exchange partnerships were associated with HIV infection for both men and women, although the relationships were substantially confounded by other behavioral risks. Those who both bought and sold sex exhibited the highest levels of risk with their exchange and non-exchange partners. Exchange partnerships may be an HIV risk both directly and indirectly, given the overlap of this phenomenon with other risk factors that occur with both exchange and non-exchange partners.

Estimated HIV incidence among high-risk heterosexuals in New York City, 2007

Estimates of HIV incidence rates among high-risk heterosexuals (HRH) in the United States have been limited to heterosexual subgroups like prison inmates and commercial sex workers. In this analysis, we estimate incidence with detuned assay testing among a group of HRH defined through a multidimensional sampling strategy and recruited through respondent-driven sampling. Incidence was 3.31% per year (95% confidence interval = 1.43 to 6.47) overall and 2.59% per year (95% confidence interval = 0.84 to 6.06) among participants with no lifetime history of drug injection or male-to-male sex. This study design is suggested as an efficient method for recruiting HRH for cohort studies and behavioral interventions.

Unprotected anal intercourse and sexually transmitted diseases in high-risk heterosexual women

OBJECTIVES

We examined the association between unprotected anal intercourse and sexually transmitted diseases (STDs) among heterosexual women.

METHODS

In 2006 through 2007, women were recruited from high-risk areas in New York City through respondent-driven sampling as part of the National HIV Behavioral Surveillance study. We used multiple logistic regression to determine the relationship between unprotected anal intercourse and HIV infection and past-year STD diagnosis.

RESULTS

Of the 436 women studied, 38% had unprotected anal intercourse in the past year. Unprotected anal intercourse was more likely among those who were aged 30 to 39 years, were homeless, were frequent drug or binge alcohol users, had an incarcerated sexual partner, had sexual partners with whom they exchanged sex for money or drugs, or had more than 5 sexual partners in the past year. In the logistic regression, women who had unprotected anal intercourse were 2.6 times as likely as women who had only unprotected vaginal intercourse and 4.2 times as likely as women who had neither unprotected anal nor unprotected vaginal intercourse to report an STD diagnosis. We found no significant association between unprotected anal intercourse and HIV infection.

CONCLUSIONS

Increased screening for history of unprotected anal intercourse and, for those who report recent unprotected anal intercourse, counseling and testing for HIV and STDs would likely reduce STD infections.

Heterosexual HIV and sexual partnerships between injection drug users and noninjection drug users

Sex partnerships with injection drug users (IDU) are an understudied network-level risk factor for heterosexual HIV infection. Heterosexuals with no history of injection were recruited from high-risk areas in New York City through respondent-driven sampling. We examined the prevalence of IDU sex partnerships among these non-IDU, the factors associated with having a past year IDU partner, and the independent association of HIV infection and IDU sex partnerships in multiple logistic regression. Of the 601 non-IDU in this analysis, 13.8% had a sex partner in the past year with a history of injection. IDU partnerships were significantly more common among women and those with higher levels of unprotected sex and drug and alcohol use. Overall, 7.0% tested positive for HIV. HIV prevalence was higher (p = 0.07) for participants with IDU partners (9.6%) compared to those with no IDU partners (4.6%). In multiple logistic regression, participants with IDU partners were over twice as likely to be HIV-infected (p = 0.08). Sex partnerships with IDU were common and may play an important role in heterosexual HIV transmission in areas with large IDU populations. Prevention interventions to encourage the disclosure of injection history and risk reduction specifically for those with IDU partners are indicated.