Medical encounter characteristics of HIV seroconverters in the US Army and Air Force, 2000–2004

"That's kind of like the big struggle right now is can we get PrEP?": Facilitators and Barriers to PrEP Uptake Among Active Duty Gay and Bisexual Men

Introduction

The US Military is experiencing a rise in HIV infections among gay and bisexual men (GBM) serving on active duty, yet little is known about this population's uptake of pre-exposure prophylaxis (PrEP), an evidence-based intervention for HIV prevention. This mixed methods study examines the facilitators and barriers to PrEP access and uptake among active duty GBM.

Methods

Active duty GBM were recruited using respondent-driven sampling (2017 and 2018). Participants (n = 93) answered quantitative survey questions on PrEP interest and accessibility. Another set of participants (n = 10) discussed their PrEP experiences in qualitative interviews. We conducted descriptive and bivariate analyses of quantitative data, while qualitative data were analyzed using structural and descriptive coding techniques.

Results

Approximately 71% of active duty GBM indicated interest in accessing PrEP. A greater proportion of those who disclosed (vs. did not disclose) their sexual orientation to their military doctor discussed (p < 0.001) or accessed (p = 0.017) PrEP. The following qualitative themes emerged: (1) providers' negative views and knowledge gaps related to PrEP; (2) lack of a systems approach to PrEP access; (3) confidentiality concerns; and (4) reliance on peer networks for PrEP guidance and support.

Conclusions

Study results indicate that active duty GBM are interested in and want to discuss PrEP with their military doctors, but gaps in providers' PrEP-related knowledge and skills, as well as mistrust in the military health care system, remain.

Policy Implications

A system-wide approach that addresses confidentiality concerns and removes procedural barriers to PrEP access is recommended to improve PrEP uptake in this population.

Sexually Transmitted Infections in Soldiers - A Cross-Sectional Assessment in German Paratroopers and Navy Soldiers and a Literature Review

Introduction

The study was performed to estimate the prevalence and determinants of occurrence of sexually transmitted infections (STIs) in paratroopers and navy soldiers by anonymously analyzing medical records from the medical departments of two large German barracks in order to assess the need for medical STI prevention.

Methods

Medical records from 80 paratroopers and 80 navy soldiers were screened for records of STI. Results were anonymously collected next to information on risk factors, as well as diagnostic and therapeutic management, and comparatively assessed.

Results

Proportions of suspected STIs were 17.5% and 20%, and proportions of diagnosed STIs were 13.9% and 11.3% for paratroopers and navy soldiers, respectively. Chlamydia trachomatis, human papillomavirus, and genital scabies were observed in paratroopers and navy soldiers, while Gardnerella vaginalis, herpes simplex virus, Molluscum contagiosum virus, Neisseria gonorrhoeae, and Trichomonas vaginalis were additionally identified in navy soldiers.

Conclusions

Although clinical hints for STIs were frequently observed, clinical management was usually restricted to syndrome-based antibiotic treatment without detailed diagnostic workup, leaving room for procedural improvement. Ongoing need for medical STI prevention in the military could be confirmed.

Missed Opportunities for HIV Prevention: Individuals Who HIV Seroconverted Despite Accessing Healthcare

Individuals with a negative HIV test before a positive one (seroconverters) may represent missed opportunities for prevention. To inform HIV prevention strategies, we aimed to characterize patients who seroconverted despite accessing care. We identified patients at a large, urban healthcare system who seroconverted between 2009 and 2014. Demographics, visits, and HIV-related variables were extracted from the medical records. We performed descriptive statistics, assessed for trends, and tested for associations according to sex. 220 seroconverters were identified: 45% were female, 87% were non-Hispanic Black or Hispanic, and median number of negative tests prior to diagnosis was 2 (IQR 1-3). Overall, 49% reported heterosexual contact as their risk factor and the proportion with heterosexual risk increased over time (24% in 2009 vs. 56% in 2014, p = 0.03). Compared to men, women were older at the time of diagnosis (35 vs. 26 years old, p < 0.01), had more visits between their latest negative and positive HIV test (4 vs. 2, p < 0.01), and were more likely to be diagnosed in the context of screening (64% vs. 56%, p = 0.05). We identified a population that became HIV-infected despite multiple healthcare encounters and undergoing HIV testing multiple times. Patients were mostly heterosexual and almost half were female. To avoid missed opportunities for those already accessing care, HIV prevention efforts should include strategies tailored to individuals with less frequently recognized risk profiles.

Nationally representative prevalence estimates of gay, bisexual, and other men who have sex with men who have served in the U.S. military

Objectives

To estimate the number of men in the U.S. military who are gay, bisexual, or other men who have sex with men (MSM) to inform the development of military and other federal policies.

Study design

We analyzed data from the National Surveys of Family Growth to estimate the number of U.S. men who were gay, bisexual, or MSM, and who had served in the military, compared to those who did not serve. We stratified using hierarchical categories of gay, bisexual, and other MSM to compare proportions in the military and general population.

Results

We found that 4.23% of men self-reported as gay, bisexual, or other MSM among men who served in the military, compared to 4.14% among men who had not served (p = 0.93). When stratified, we found that 0.78% self-reported as gay among men who served in the military, compared to 2.12% among men who had not served (p<0.001).

Conclusions

The proportion of men who identified as a gay was lower in the military than in the general population. This finding might have been influenced by historical military policies related to sexual orientation.

Clinical indicators associated with HIV acquisition in the United States Air Force

Mandatory HIV screening of United States Air Force (USAF) personnel every two years effectively identifies incident cases, however testing frequency limits the ability to detect early HIV infection. Identifying clinical indicators of HIV in the USAF population is necessary to develop a supplemental provider-based targeted testing strategy. We conducted a matched case-control study of male active duty USAF personnel with a new HIV diagnosis (n = 452) between 1996 and 2011 matched to five randomly selected controls (n = 2176). The relationship between clinical diagnoses, determined by ICD-9 codes, and HIV infection was assessed using conditional logistic regression. In unadjusted analyses of ICD-9 codes ever and within the last two years before HIV diagnosis, the conditional odds of HIV infection were greater in those with clinical signs and symptoms of HIV (cOR 5.05, 95% CI 4.00-6.39), mental health diagnoses (cOR 2.61, 95% CI 1.86-3.67), and STI diagnoses (cOR 2.33, 95% CI 1.50-3.60). Compared to those with ≤10 medical encounters in the two years prior to HIV diagnosis, individuals with 11-35 medical encounters (cOR 2.19, 95% CI 1.73-2.79) and >35 medical encounters (cOR 4.15, 95% CI 2.69-6.39) had a higher odds of HIV acquisition. In multivariate analyses, clinical signs and symptoms of HIV within the last two years of HIV diagnosis (cOR 4.10, 95% CI 3.22-5.22) and ever having a mental health diagnosis (cOR 1.97, 95% CI 1.44-2.70) remained significant (p < .01). Clinical encounters, particularly those featuring clinical signs and symptoms of HIV or a history of mental health complaints, provide an opportunity for targeted testing as a supplement to mandated testing at two-year intervals. Provider education to increase HIV testing in persons at risk would enhance early HIV diagnosis and potentially reduce forward transmission in the USAF population.

HIV testing patterns for United States Air Force personnel, 2008-2012

OBJECTIVE

This study evaluated 3rd generation human immunodeficiency virus (HIV) test patterns and HIV infection rates in the United States Air Force (USAF).

STUDY DESIGN

Retrospective database study.

METHODS

HIV enzyme-linked immunoassay (ELISA) and Western blot tests were analysed for all USAF personnel from 2008 to 2012. For new HIV cases, unadjusted and adjusted annual rates were calculated per 100,000 persons.

RESULTS

In total, 1,608,665 tests were performed in 626,298 individuals, with a reactive ELISA observed in 809 (0.001%) persons. Western blot (n = 1949) results included 378 (19.4%) positive, 1283 (65.8%) negative, and 288 (15.0%) indeterminate (WBi). Unadjusted annual HIV rates were between 16.7 and 20.6 per 100,000 persons during the study period. The overall age-adjusted rate was 14.8 cases per 100,000 persons tested. Blacks/African Americans had the highest risk of HIV (risk ratio 7.9 [95% confidence interval 5.78, 9.95] compared to Whites).

CONCLUSIONS

WBi results, which can cause delays in determining HIV status, were relatively common with the 3rd generation assay. However, this will be mitigated by a planned transition to a 4th generation assay. Although the overall rate of HIV in the USAF is lower than US civilian adults, HIV prevention efforts targeting young Blacks/African Americans may help to reduce HIV incidence in the USAF.

Molecular epidemiology of early and acute HIV type 1 infections in the United States Navy and Marine Corps, 2005-2010

The U.S. military represents a unique population within the human immunodeficiency virus 1 (HIV-1) pandemic. The last comprehensive study of HIV-1 in members of the U.S. Navy and Marine Corps (Sea Services) was completed in 2000, before large-scale combat operations were taking place. Here, we present molecular characterization of HIV-1 from 40 Sea Services personnel who were identified during their seroconversion window and initially classified as HIV-1 negative during screening. Protease/reverse transcriptase (pro/rt) and envelope (env) sequences were obtained from each member of the cohort. Phylogenetic analyses were carried out on these regions to determine relatedness within the cohort and calculate the most recent common ancestor for the related sequences. We identified 39 individuals infected with subtype B and one infected with CRF01_AE. Comparison of the pairwise genetic distance of Sea Service sequences and reference sequences in the env and pro/rt regions showed that five samples were part of molecular clusters, a group of two and a group of three, confirmed by single genome amplification. Real-time molecular monitoring of new HIV-1 acquisitions in the Sea Services may have a role in facilitating public health interventions at sites where related HIV-1 infections are identified.

Epidemiology of Sexually Transmitted Infections among Human Immunodeficiency Virus Positive United States Military Personnel

Background. Minimal data exist that describe the epidemiology of sexually transmitted infections (STI) in human immunodeficiency virus (HIV) positive populations across the pre- and post-diagnosis periods for HIV. Purpose. The purpose of this study was to identify and describe the epidemiology of gonorrhea, chlamydia, syphilis, herpes simplex virus, and human papillomavirus in an HIV-positive population. Methods. All 1,961 HIV seropositive United States active duty military personnel from 2000–2010 were identified. STI diagnoses relative to HIV diagnosis from 1995, which was the earliest electronic medical record available, to 2010 were examined. Results. The incidence diagnosis rates of STI generally increased during the period leading up to eventual HIV diagnosis. The rates of STI during the post-HIV diagnosis period fluctuated, but remained elevated compared to pre-HIV diagnosis period. Approximately 45%–69% with an STI in the HIV seropositive military population were diagnosed with their first STI greater than one year after their HIV diagnosis. Of those who were diagnosed with an STI in the post-HIV diagnosis period, 70.6% had one STI diagnosis, 23.5% had two STI diagnoses, and 5.8% had three or more STI diagnoses. Conclusions. Despite aggressive counseling, high-risk sexual behavior continues to occur in the HIV-positive military population.