Epidemiology of HIV among US Air Force Military Personnel, 1996-2011

U=U: "Undetectable Equals Untransmittable" Perceptions Among Men Who Have Sex With Men Active Duty Service Members: A Cross-Sectional Study

ABSTRACT

Undetectable = Untransmittable (U=U) is a key message emphasizing that antiretroviral therapy suppresses HIV and prevents its sexual transmission. However, dissemination of U=U varies among health care providers, potentially leading to knowledge gaps among patients. Little research exists on the understanding of U=U among active duty men who have sex with men (MSM) in the U.S. military. Our cross-sectional, online study examines 222 active duty MSM to determine prevalence of accurate knowledge of U=U and demographic predictors of misinformation. Participants received a pre-exposure prophylaxis (PrEP) overview and were asked to indicate if the statement "Undetectable equals Untransmittable" was true or false. Although the majority accurately understood U=U (70%; n = 156), approximately 30% did not (n = 66); a binary logistic regression revealed lower U=U understanding among White, bisexual, unmarried, and Marines/Navy participants. Standardized education on U=U is crucial for resolving knowledge gaps and combating stigmas surrounding HIV treatment.

Follow-up of Military Blood Donors Who Test Positive for Syphilis

BACKGROUND

Several large studies have demonstrated that syphilis carries a risk of future sexually transmitted infections (STI), such as human immunodeficiency virus. There are limited data on outcomes of syphilis infections that occur in populations that undergo universal syphilis screening, such as blood donors. Military trainees who donate blood can be followed through their military career to determine the future risk of STIs.

METHODS

Blood donor data were gathered from the Armed Services Blood Bank Center-San Antonio for those with positive Treponema pallidum antibodies between 2014 and 2021. The medical chart of each case was compared with 6 sex- and military accession date-matched controls with negative T. pallidum antibodies to determine the risk of STI in the 3 years after donation.

RESULTS

A total of 63,375 individuals donated blood during the study period. A total of 23 military trainees (0.36 per 1000 donors) had positive T. pallidum antibodies. A minority (n = 7; 30%) of cases were treated for early syphilis. Only 6 cases (26%) received a follow-up nontreponemal test within 1 year. Donors who tested positive had a significantly higher risk of developing an STI within 3 years after blood donation compared with blood donors who tested negative (relative risk, 3.8; 95% confidence interval, 1.3-10.5; P = 0.01) including gonorrhea (9% vs. 0%, P = 0.02) and syphilis (9% vs. 0%, P = 0.02).

CONCLUSIONS

This study shows the presence of T. pallidum antibodies in blood donors was associated with an increased risk of future STIs. These cases support the need for close follow-up and broad STI testing in blood donors with positive T. pallidum antibodies.

HIV therapy adherence and outcomes in Peruvian military personnel over a 30-year period

<b>Objectives: </b>We aimed to describe the sociodemographic, clinical, and therapeutic characteristics of Peruvian military personnel diagnosed with HIV. Furthermore, we determined the frequency of highly active antiretroviral therapy (HAART) adherence, the complications and mortality.<br /> <b>Methods:</b> We retrospectively reviewed the medical records of patients diagnosed with HIV, confirmed by Western blot at a single institution from 1989-2020. Descriptive analyses were performed for all the variables using mean and standard deviation (SD) in the case of quantitative variables, and frequency and percentage for qualitative variables.<br /> <b>Results: </b>Of the 161 patients included, 95.7% were males and the mean age was 39.59 years (SD= 16.45 years). Most had college or higher education (67.7%) and were on active duty at diagnosis (77%). 35.4% had AIDS at diagnosis; 28.6% opportunistic infections; and 8.1% tuberculosis. The median follow-up was five years. 94.4% of the patients received HAART as the principal treatment; of these, 88.8% was adherent to treatment, and death was reported in 6.8%. There were no factors associated with adherence.<br /> <b>Conclusions: </b>Although the sociodemographic characteristics of Peruvian military personnel are similar to those of other countries, our findings suggest that Peruvian military personnel present higher adherence to HAART compared to previous studies in other military populations from South American countries. Further studies are recommended to assess specific factors attributed to these successful outcomes in the military personnel that can be applied in other hospitals.

Preferences for Long-Acting and Alternative Modalities for PrEP among Military Men Who Have Sex with Men: Segmentation Results of an Adaptive Choice-Based Conjoint Analysis Study

The use of pre-exposure prophylaxis (PrEP) for HIV prevention within the U.S. military is low. Implementing preference-based alternative modalities of PrEP delivery, however, can be an innovative strategy to address the specific barriers to PrEP uptake among military MSM. We sought to identify population-based, segment-specific preferences for longer-acting and alternative PrEP delivery modalities to guide patient-centered strategies to optimize uptake within military-serving healthcare systems. HIV-negative military men who have sex with men (MSM) completed an anonymous, adaptive choice-based conjoint (ACBC) analysis survey consisting of five key attributes of interest (dosing method, provider type, visit location, lab work evaluation location, and dispensing venue). Relative importance and part-worth utility scores were generated using Hierarchical Bayes (HB) estimation, and cluster ensemble analysis grouped participants into "phenotype" segments by preference similarity. The randomized first-choice model was then used to examine changes in program interest rates among segments through market simulation. The 429 participants were segmented into five preference groups. The dosing method attribute was found to be the most important to nearly all segments. Simulations revealed that PrEP program interest among two segments with low interest levels increased when smartphone, civilian-based, and long-acting injectable PrEP options were involved. Findings also suggested a need for clinics to be responsive and sensitive to sexual practices, risk perception, and functional PrEP knowledge. Responsiveness to segment-specific preferences in the design of military PrEP programs and acting on the importance of clinical relationships within the context of PrEP engagement within a military setting may contribute to increasing PrEP uptake.

Machine Learning-Based HIV Risk Estimation Using Incidence Rate Ratios

HIV/AIDS is an ongoing global pandemic, with an estimated 39 million infected worldwide. Early detection is anticipated to help improve outcomes and prevent further infections. Point-of-care diagnostics make HIV/AIDS diagnoses available both earlier and to a broader population. Wide-spread and automated HIV risk estimation can offer objective guidance. This supports providers in making an informed decision when considering patients with high HIV risk for HIV testing or pre-exposure prophylaxis (PrEP). We propose a novel machine learning method that allows providers to use the data from a patient's previous stays at the clinic to estimate their HIV risk. All features available in the clinical data are considered, making the set of features objective and independent of expert opinions. The proposed method builds on association rules that are derived from the data. The incidence rate ratio (IRR) is determined for each rule. Given a new patient, the mean IRR of all applicable rules is used to estimate their HIV risk. The method was tested and validated on the publicly available clinical database MIMIC-IV, which consists of around 525,000 hospital stays that included a stay at the intensive care unit or emergency department. We evaluated the method using the area under the receiver operating characteristic curve (AUC). The best performance with an AUC of 0.88 was achieved with a model consisting of 53 rules. A threshold value of 0.66 leads to a sensitivity of 98% and a specificity of 53%. The rules were grouped into drug abuse, psychological illnesses (e.g., PTSD), previously known associations (e.g., pulmonary diseases), and new associations (e.g., certain diagnostic procedures). In conclusion, we propose a novel HIV risk estimation method that builds on existing clinical data. It incorporates a wide range of features, leading to a model that is independent of expert opinions. It supports providers in making informed decisions in the point-of-care diagnostics process by estimating a patient's HIV risk.

Preferences for pre-exposure prophylaxis among U.S. military men who have sex with men: results of an adaptive choice based conjoint analysis study

BACKGROUND

Pre-exposure prophylaxis (PrEP) prevents human immunodeficiency virus (HIV) infection, but its use remains low among U.S. military men who have sex with men (MSM), likely due to mis-matching with personal preferences. We conducted a study to characterize preferences to PrEP measures within this population.

METHODS

HIV-negative military MSM were recruited through a closed, Lesbian, Gay, Bisexual, and Transgendered (LGBT) military social media group. The survey was anonymous, and consisted of five experimentally varied attributes in service delivery: dosing method, provider type, visit location, lab work evaluation location, and dispensing venue. Relative importance and part-worth utility scores were generated using hierarchical bayes (HB) estimation, and the randomized first choice model was used to examine participation interest across eight possible PrEP program scenarios.

RESULTS

A total of 429 participants completed the survey. Among the eight scenarios with varying attributes, the most preferred scenario featured a daily tablet, PrEP injection or implant, along with a military provider, smartphone/telehealth visit, and on-base locations for lab evaluation and medication pick-up. The results also emphasized the importance for providers to be familiar with PrEP prescription knowledge, and to provide interactions sensitive to sexual identity and mental health.

CONCLUSION

A PrEP program consisting of daily tablet is preferred in military healthcare settings is preferred. Long-acting implants and injections are also desired.

Psychopathology and HIV diagnosis among older adults in the United States: disparities by age, sex, and race/ethnicity

In 2016, 17% of new HIV infections in the US were among adults aged 50 and older. Differences by age, sex, and race/ethnicity exist among older people living with HIV. Co-morbid mental health and substance use disorders (SUD) are also major challenges for this population. This study examined the association between generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), SUD, depression, and HIV diagnosis among adults aged 50 and older, and the disparities by age, sex, and race/ethnicity. Data were obtained from Cerner Corporation's Health Facts® database. Multivariable logistic regression models were used to determine the associations between GAD, PTSD, SUD, and depression, and HIV diagnosis. Results were also stratified by age group, sex, and race/ethnicity. Overall, there were positive associations between SUD, depression, GAD, PTSD and HIV; and differences by age, sex and race/ethnicity existed in these associations. For example, after adjusting for age, race/ethnicity and marital status, men who were diagnosed with GAD were 10 times more likely (adjusted OR: 10.3; 95% CI: 8.75 - 12.1) to have an HIV diagnosis compared to men who were not diagnosed with GAD. Women who were diagnosed with GAD were five times more likely (adjusted OR: 5.01; 95% CI: 3.81 - 6.58) to have an HIV diagnosis compared to women who were not diagnosed with GAD. HIV prevention and intervention programs for older adults should address GAD, PTSD, SUD and depression and consider the age, sex and racial/ethnic disparities in the association between psychopathology and HIV.

HIV PrEP in the Military: Experience at a Tertiary Care Military Medical Center

Objectives

We evaluated human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) administration at the Walter Reed National Military Medical Center (WRNMMC), which serves a geographic area at high risk of HIV infection.

Methods

Medical records were reviewed for all patients initiating PrEP at WRNMMC from November 1, 2013, to March 30, 2016. Demographic, laboratory, clinical, and risk exposure characteristics and outcomes were described.

Results

One hundred fifty-nine patients received PrEP; 133 (84%) patients were active duty, 95 (60%) patients were over 28 yr old. The majority were non-Hispanic Whites (n = 87, 55%). The median men who have sex with men (MSM) risk index score was 18.0 (IQR 12.0-22.0); 20 patients scored less than 10. One hundred and thirty-one (82%) patients remained on PrEP through the evaluation period. Patients mainly discontinued PrEP for service-related or toxicity reasons. Incident STIs occurred in 31 (19%) patients. No cases of HIV seroconversion were observed.

Conclusions

In this first description of PrEP utilization in a U.S. military health care system, a significant number of patients were non-Hispanic Whites, well-educated, were older, or were otherwise at low risk for HIV acquisition. Further effort is needed to enhance PrEP use among the higher risk young African-American MSM population, and further studies are needed to determine the cost-effectiveness of PrEP in individuals who are not categorized as high risk.

Epidemiological analyses of regional and age differences of HIV/AIDS prevalence in China, 2004-2016

OBJECTIVES

To describe the prevalence of HIV/AIDS in China from 2004 to 2016 and to assess whether regional and age differences exist with HIV/AIDS infection.

METHODS

We searched the Chinese Public Health Science Data Center by the keywords of "HIV" or "AIDS", and collected the data referred to HIV/AIDS morbidity, mortality, and new HIV infection rate, 2004 to 2016.

RESULTS

The HIV/AIDS morbidity, mortality, and new HIV infection rate continually increased per year in China from 2004 to 2016 (0.235, 0.057 and 1.020 in 2004; 3.990, 1.034 and 6.442 in 2016 respectively) (all p<0.001). The middle-aged HIV/AIDS populations showed the highest infection and regional difference significantly existed in the geographical distribution of HIV/AIDS prevalence.

CONCLUSIONS

Our analyses of HIV/AIDS prevalence during more than a decade indicate that HIV/AIDS prevalence is getting more and more serious and the rapid spread of HIV exists with the characteristics of regional and age differences.

Are you PEPped and PrEPped for travel? Risk mitigation of HIV infection for travelers

The HIV pandemic persists globally and travelers are at risk for infection by the Human Immunodeficiency Virus (HIV). While HIV-focused guidelines delineate risk stratification and mitigation strategies for people in their home communities, travel issues are not addressed. In this review, direct and indirect evidence on HIV risk among travelers is explored. The burgeoning practice of employing pre-exposure prophylaxis (PrEP) with anti-retroviral therapy in the non-travel setting is introduced, as well as the more established use of post-exposure prophylaxis (PEP). Challenges in applying these lessons to travelers are discussed, and a new guidelines process is scoped and recommended.

Knowledge, attitudes, and beliefs about HIV pre-exposure prophylaxis among US Air Force Health Care Providers

Providers are central to effective implementation of HIV pre-exposure prophylaxis (PrEP). Primary care providers (PCP) and infectious disease physicians (ID) in the US Air Force (USAF) participated in a cross-sectional survey regarding knowledge, attitudes, and beliefs toward HIV PrEP. Characteristics associated with PrEP knowledge were assessed in univariate and multivariate analyses.Among 403 (40% of 1015 providers) participants, 9% (PCP 383, ID 20) ever prescribed PrEP. In univariate analysis, years in practice, number of HIV-infected patients treated in the past 12 months, past prescription of antiretrovirals for HIV prevention, frequency of prescribing PrEP in the past 12 months, and ever being questioned by a patient about PrEP were associated with PrEP knowledge (P < 0.05). In multivariate analysis, providers who had ever prescribed antiretrovirals to prevent HIV (AOR: 2.37, 95% CI: 1.27-4.42) had greater odds of high PrEP knowledge. Despite concerns about medication side effects (overall 67%: PCP 68%, ID 85%) and prescribing PrEP without clear evidence (overall 60%: PCP 65%, ID 62%), 64% (PCP 65%, ID 85%) of participants indicated PrEP should be offered in the Military Health System and 68% (PCP 70%, ID 100%) disagreed with the statement that their patient population was not at risk for HIV infection.Successful PrEP implementation in the USAF will require continued education and training of primary care providers to improve knowledge and mitigate concerns about PrEP.