Increases in HIV diagnoses at the U.S.-Mexico border, 2003-2006

Sexually transmitted infections on the border between Suriname and French Guiana: A scoping review

Purpose

The Maroni basin –delineating the border between Suriname and French Guiana— presents sociocultural, geographical and economic circumstances that have been conducive to the circulation of sexually transmitted infections and to delays in diagnosis and care. Given the scarcity of published data, we aimed to describe different sexually transmitted infections along the Maroni and to gain a broader understanding of the epidemiologic situation.

Methods

We conducted a scoping review of the efforts to approach the problem of sexually transmitted infections in this complex border area. Temporal trends were plotted and crude numbers were divided by local population numbers.

Results

For HIV, despite increasing testing efforts, most patients still present at the advanced HIV stage (median CD4 count at diagnosis is < 20 per mm³), and 25% of patients in Saint Laurent du Maroni were lost to follow-up within 6 years. However, progress on both sides has led to a decline in AIDS cases and mortality. Despite a rapid increase in the 1990’s along the Maroni, the current HIV prevalence seemed lower (0.52%) in the rural villages than in coastal urban centers (> 1%). High risk HPV infection prevalence among women reaches 23.3%. The incidence of gonorrhea was 4.2 per 1,000 population aged 15-59. For chlamydiasis it was 3.4 per 1,000 population aged 15-59. For syphilis, the incidence was 2.5 per 1,000 population aged 15-59. Gonorrhea, chlamydiasis, hepatitis B detection increased over time with greater testing efforts and new diagnostic tests. Since the COVID-19 epidemic, congenital syphilis has dramatically increased in Saint Laurent du Maroni reaching 808 per 100,000 live births.

Conclusion

Sexually transmitted infections seemed more prevalent in Saint Laurent du Maroni –the sole urban center—than in the remote villages along the Maroni. The syndromic approach and the heterogeneity of diagnostic platforms presumably overlook most infections in the region. Therefore, a concerted approach and a shared diagnostic upgrade with molecular diagnosis and rapid diagnostic tests seem necessary to reduce the burden of sexually transmitted infections on both sides of the Maroni. Congenital syphilis resulting from COVID-19 disruption of health services requires urgent attention.

HIV Testing in Clinical and Community Settings for an International Sample of Latino Immigrants and Nonimmigrants

Latino/as in the U.S. and Spain make up a disproportionate percentage of cases of HIV infection, and often are diagnosed later than their non-Latino/a counterparts. Understanding the factors that affect HIV testing in different contexts is critical to best promote HIV testing, which is considered essential to both prevention and early treatment. This study explored differences in HIV testing rates among Latino/a participants in an international study designed to examine behavioral health screening for Latino/a populations. We collected data on testing rates and results from 407 Latino/as - both first generation immigrants and those of Latino/a descent - in the U.S. (Boston) and Spain (Madrid and Barcelona), through interviews conducted in community clinics and agencies. Using multivariate logit models, we evaluated predictors of screening and positive testing, adjusting for sex, age, and clinic type. HIV testing rates were highest in Boston, followed by Barcelona and Madrid (82%, 69%, and 59%, respectively, p < .0001). In multivariate regression models, Barcelona and Madrid patients were significantly less likely to have received testing than Boston patients. Significant positive predictors of HIV testing were: education level higher than high school, HIV concerns, infrequent condom use, other risk behaviors, reports of discrimination, and higher benzodiazepine consumption. Significant differences in HIV testing found in this study help to illuminate best practices for engaging patients in testing across sites.

Enhanced immigration enforcement in the USA and the transnational continuity of HIV care for Latin American immigrants in deportation proceedings

In our work as clinicians, researchers, and immigrant rights advocates, we have noted increased anxiety about the possibility of deportation and disruptions in care among immigrants with HIV. Before the 2016 US elections, patients rarely asked about HIV treatment in their home countries. However, since the increase in anti-immigrant rhetoric and arrests by US Immigration and Customs Enforcement, patients have voiced concerns about the availability of HIV treatment in their home countries much more frequently. Although antiretroviral therapy is available throughout Latin America, access depends on economic, social, and political circumstances. Maintaining uninterrupted continuity of care among immigrants held in detention or deported to their home countries is challenging. In this Viewpoint, we identify periods of particular vulnerability for immigrants during deportation proceedings, from initial detention to deposition in their country of origin. We discuss the effect of enhanced immigration enforcement on the health and wellbeing of HIV-infected immigrants, and on public health. Finally, we also discuss recommendations for clinicians, immigration authorities, and public health institutions in the USA and in receiving countries.

Factors Associated with Sexual Risk of HIV Transmission Among HIV-Positive Latino Men Who have Sex with Men on the U.S.-México Border

We present results from a cross-sectional, clinic-based survey of border-region Latino men who have sex with men (MSM) and who also are living with HIV in the El Paso-Ciudad Juárez area. Among the 66 participants who reported serodiscordant anal or vaginal intercourse, we examined levels of psychological distress and substance use and the association of these variables with condomless sex. Bivariate analyses indicated that MSM who reported condomless sex with a serodiscordant partner were more likely to report higher scores on measures of anxiety, depression, and trauma. These men were also more likely to report more days of alcohol use to the point of intoxication. In multivariate logistic regression, no variables were independently associated with sexual risk behavior, but symptoms of anxiety trended toward statistical significance. Our study is one of few reports aimed at understanding the HIV epidemic among Latino MSM living with HIV in the El Paso-Ciudad Juárez border region. Although we found no evidence of a relation between our measures of psychological distress and substance use and sexual risk behavior in multivariate analyses, psychological distress and problematic alcohol use were common in the sample and are important targets for intervention in their own right.

Population movements and the HIV cascade in recently diagnosed patients at the French Guiana -Suriname border

Border areas are particular "hot spots" generating high levels of HIV vulnerability and facing great challenges to control epidemics. The objective of this study is to describe the sociodemographic, clinical and biological profiles of newly HIV diagnosed people at the French Guiana - Suriname border, to construct an HIV care cascade and compare it with the Surinamese one. HIV-patients aged over 15 years newly diagnosed in western French Guiana in 2011 and 2012 were included in a retrospective cohort study. Patients were identified using different sources (n = 121). The male-to-female ratio was 0.8, 85% of the patients were of foreign origin, 72% were undocumented migrants, 21% were living in Suriname and 48% had baseline CD4 cell counts <200 cells/mm³. After one year, 34% were lost to follow-up, 54% received treatment, 34% had controlled viremia and 6% died. We observed a disappointing HIV cascade, like that of Suriname, requiring to develop a coordinated healthcare offer on both sides of the border. Targeted efforts through a bi-national collaboration are needed to address the specific issues of cross-border patients to reach the 90*3 UNAIDS's diagnosis, link to care and treatment targets and better control the local epidemic.

Engagement in the HIV Care Continuum among Key Populations in Tijuana, Mexico

In Tijuana, Mexico, HIV is concentrated in sub-epidemics of key populations: persons who inject drugs (PWID), sex workers (SW), and men who have sex with men (MSM). To date, data on engagement in the HIV care continuum among these key populations, particularly in resource-constrained settings, are sparse. We pooled available epidemiological data from six studies (N = 3368) to examine HIV testing and treatment uptake in these key populations; finding an overall HIV prevalence of 5.7 %. Of the 191 identified HIV-positive persons, only 11.5 % knew their HIV-positive status and 3.7 % were on ART. Observed differences between these HIV-positive key populations suggest PWID (vs. non-PWID) were least likely to have previously tested or initiate HIV care. MSM (vs. non-MSM) were more likely to have previously tested but not more likely to know their HIV-positive status. Of persons aware of their HIV-positive status, SW (vs. non-SW) were more likely to initiate HIV care. Findings suggest engagement of key populations in HIV treatment is far below estimates observed for similarly resource-constrained generalized epidemics in sub-Saharan Africa. These data provide one of the first empirical-snapshots highlighting the extent of HIV treatment disparities in key populations.

Health outcomes among HIV-positive Latinos initiating antiretroviral therapy in North America versus Central and South America

Introduction

Latinos living with HIV in the Americas share a common ethnic and cultural heritage. In North America, Latinos have a relatively high rate of new HIV infections but lower rates of engagement at all stages of the care continuum, whereas in Latin America antiretroviral therapy (ART) services continue to expand to meet treatment needs. In this analysis, we compare HIV treatment outcomes between Latinos receiving ART in North America versus Latin America.

Methods

HIV-positive adults initiating ART at Caribbean, Central and South America Network for HIV (CCASAnet) sites were compared to Latino patients (based on country of origin or ethnic identity) starting treatment at North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) sites in the United States and Canada between 2000 and 2011. Cox proportional hazards models compared mortality, treatment interruption, antiretroviral regimen change, virologic failure and loss to follow-up between cohorts.

Results

The study included 8400 CCASAnet and 2786 NA-ACCORD patients initiating ART. CCASAnet patients were younger (median 35 vs. 37 years), more likely to be female (27% vs. 20%) and had lower nadir CD4 count (median 148 vs. 195 cells/µL, p<0.001 for all). In multivariable analyses, CCASAnet patients had a higher risk of mortality after ART initiation (adjusted hazard ratio (AHR) 1.61; 95% confidence interval (CI): 1.32 to 1.96), particularly during the first year, but a lower hazard of treatment interruption (AHR: 0.46; 95% CI: 0.42 to 0.50), change to second-line ART (AHR: 0.56; 95% CI: 0.51 to 0.62) and virologic failure (AHR: 0.52; 95% CI: 0.48 to 0.57).

Conclusions

HIV-positive Latinos initiating ART in Latin America have greater continuity of treatment but are at higher risk of death than Latinos in North America. Factors underlying these differences, such as HIV testing, linkage and access to care, warrant further investigation.

Analysis of HIV Correlated Factors in Chinese and Vietnamese Female Sex Workers in Hekou, Yunnan Province, a Chinese Border Region

Objectives

To assess the prevalence and correlated factors of HIV-1 among Chinese and Vietnamese female sex workers (FSW) in the border county of Hekou, Yunnan province, China.

Methods

A cross-sectional survey was conducted collecting information on demographics, sexual behavior, medical history, and drug use. Blood samples were obtained to test for HIV/STIs. Multivariate logistic regression model was used to examine associations between factors and HIV-1 infection.

Results

Of 345 FSWs who participated in this study, 112 (32.5%) were Chinese and 233 (67.5) were Vietnamese. Vietnamese FSWs were significantly more likely to be HIV-1 positive (7.7%) compared with Chinese FSWs (0.9%) (p = 0.009). In multivariate analysis, sexual debut at age≤16 (OR 3.8: 95% CI: 1.4, 10.6), last client’s payment <150 RMB ($22 USD) (OR: 5.2, 95% CI; 1.7, 16.6), and HSV-2 (OR: 12.3; 95% CI: 1.6, 94.8) were significant for HIV-1 infection.

Conclusions

Differences in HIV prevalence in Vietnamese and Chinese FSWs may be indicative of differential risk. It is important to characterize the nature of trans-border transmission in order to gain a better understanding of the potential impact on the international HIV epidemic. Understanding the correlated factors for HIV in Vietnamese and Chinese FSWs is important for designing interventions for this vulnerable population.

Tuberculosis and HIV co-infection, California, USA, 1993–2008

To understand the epidemiology of tuberculosis (TB) and HIV co-infection in California, we cross-matched incident TB cases reported to state surveillance systems during 1993–2008 with cases in the state HIV/AIDS registry. Of 57,527 TB case-patients, 3,904 (7%) had known HIV infection. TB rates for persons with HIV declined from 437 to 126 cases/100,000 persons during 1993–2008; rates were highest for Hispanics (225/100,000) and Blacks (148/100,000). Patients co-infected with TB–HIV during 2001–2008 were significantly more likely than those infected before highly active antiretroviral therapy became available to be foreign born, Hispanic, or Asian/Pacific Islander and to have pyrazinamide-monoresistant TB. Death rates decreased after highly active antiretroviral therapy became available but remained twice that for TB patients without HIV infection and higher for women. In California, HIV-associated TB has concentrated among persons from low and middle income countries who often acquire HIV infection in the peri-immigration period.

Stigma and racial/ethnic HIV disparities: moving toward resilience

Prior research suggests that stigma plays a role in racial/ethnic health disparities. However, there is limited understanding about the mechanisms by which stigma contributes to HIV-related disparities in risk, incidence and screening, treatment, and survival and what can be done to reduce the impact of stigma on these disparities. We introduce the Stigma and HIV Disparities Model to describe how societal stigma related to race and ethnicity is associated with racial/ethnic HIV disparities via its manifestations at the structural level (e.g., residential segregation) as well as the individual level among perceivers (e.g., discrimination) and targets (e.g., internalized stigma). We then review evidence of these associations. Because racial/ethnic minorities at risk of and living with HIV often possess multiple stigmas (e.g., HIV-positive, substance use), we adopt an intersectionality framework and conceptualize interdependence among co-occurring stigmas. We further propose a resilience agenda and suggest that intervening on modifiable strength-based moderators of the association between societal stigma and disparities can reduce disparities. Strengthening economic and community empowerment and trust at the structural level, creating common ingroup identities and promoting contact with people living with HIV among perceivers at the individual level, and enhancing social support and adaptive coping among targets at the individual level can improve resilience to societal stigma and ultimately reduce racial/ethnic HIV disparities.

HIV risk behaviors and sociodemographic features of HIV-infected Latinos residing in a new Latino settlement area in the Southeastern United States

The Southeastern United States (US) has a rapidly growing Latino population, yet little is known about HIV-infected Latinos in the region. To help inform future prevention studies, we compared sociodemographic, clinical, and behavioral characteristics between immigrant and US-born HIV-infected Latinos using face-to-face interviews conducted at three clinics in North Carolina. Questions encompassed HIV testing, acculturation, sexual- and substance-related behaviors, and migration history. Behavioral data were compared with 451 black and white clinic patients. Differences were tested using Pearson's and Kruskal-Wallis tests. Participants (n = 127) were primarily male (74%) and immigrants (82%). Most immigrants were Mexican (67%), had low acculturation scores (92%), and were diagnosed a median of 8 years (IQR 0-12) following immigration. Compared with US-born Latinos, immigrants had lower CD4 counts at clinic entry (median 187 vs. 371 cells/mm(3)) and were less likely to have graduated high school (49% vs. 78%) or have insurance (9% vs. 52%; all P <0.05). Most immigrants identified as heterosexual (60%) and reported fewer lifetime partners than US-born Latinos (median 6 vs. 20; P = 0.001). Immigrant men were less likely to report sex with men than US-born men (43% vs. 81%; P = 0.005). Immigrant men also had similar risk behaviors to black men, and US-born Latino men exhibited behaviors that were more similar to white men in our clinic. At the time of survey, >90% of participants were receiving antiretroviral therapy (ART) and most had achieved HIV RNA <50 copies/mL (62% immigrants vs. 76% US-born; P = 0.32). In conclusion, Latino immigrants were more likely to present with advanced disease, identify as heterosexual, and report different risk behaviors than US-born Latinos, yet receipt and response to ART were similar between the two groups. Prevention strategies should prioritize finding innovative methods to reach Latino immigrants for routine early testing regardless of risk stratification and include programs targeted toward the different needs of immigrant and US-born Latinos.

HIV testing behaviors among Latinos in Baltimore City

In the US, HIV disproportionately affects Latinos who often present late in the disease. Baltimore has seen a recent rapid growth in its Latino population paralleled by an increasing impact of HIV/AIDS among Latinos. From 2009 to 2010, we performed a cross-sectional survey of Latinos accessing the Baltimore City Health Department (BCHD) Latino Outreach services to assess self-report of previous HIV testing, with particular attention to migration history and risk behaviors. Of 247 Latinos (46% male) accessing BCHD outreach services, 96% were foreign-born. Self-perceived HIV risk was not associated with actual risk behaviors or HIV testing. In multivariate models, previous HIV testing was correlated with knowledge of HIV transmission modes and knowing that a person with HIV can appear healthy. Consistent with CDC recommendations, HIV screening among Latino immigrants should not be limited to individuals with self-perceived risk for HIV. Promoting key pieces of HIV knowledge may improve HIV testing behaviors.

A systematic review of HIV/AIDS survival and delayed diagnosis among Hispanics in the United States

HIV/AIDS disproportionately affects Hispanics. Our objective was to determine the risk of late diagnosis and rate of survival after HIV/AIDS diagnosis among Hispanics compared to other racial/ethnic groups. We performed a systematic review of the PubMed database for peer-reviewed articles published between January 2000 and September 2010. Primary outcomes included survival after HIV/AIDS diagnosis and delayed diagnoses. The definition of delayed diagnosis varied by study, ranging from concurrent HIV/AIDS diagnosis to diagnosis of AIDS within 3 years of HIV diagnosis. We found that Hispanics are at significantly greater risk for delayed diagnosis than non-Hispanic whites. Hispanic males and foreign-born Hispanics had the highest risk of late diagnosis. Available data on survival were heterogeneous, with better outcomes in some Hispanic subgroups than in others. Survival after antiretroviral initiation was similar between Hispanics and Whites. These findings emphasize the need for culturally-sensitive strategies to promote timely diagnosis of HIV infection among Hispanics and to examine the health outcomes and needs of high risk Hispanic subgroups.

Late entry to HIV care among Latinos compared with non-Latinos in a southeastern US cohort

BACKGROUND

Late diagnosis of human immunodeficiency virus (HIV) infection remains common despite advances in therapy and prognosis. The southeastern United States is a rapidly growing Latino settlement area where ethnic disparities may contribute to late presentation to care.

METHODS

We assessed demographic and clinical factors between racial/ethnic groups at the time of HIV care initiation in the University of North Carolina Center for AIDS Research Clinical Cohort. We identified independent predictors of late presentation, defined as a CD4(+) T lymphocyte (CD4) count <350 cells/mm(3) or an AIDS-defining event (ADE), using log-linear binomial regression.

RESULTS

During the period 1999-2009, 853 patients initiated HIV care, of whom 11% were Latino, 28% were white, and 61% were black. Median initial CD4 counts were lower for Latino patients (186 cells/mm(3)) than white patients (292 cells/mm(3); P = .006) and black patients (302 cells/mm(3); P = .02). Latino persons were more likely to be late presenters than white or black persons (76% vs 58%; P < .001) and accounted for 86%, 75%, and 50% of all presenting cases of active tuberculosis, histoplasmosis, and toxoplasmosis, respectively. Latino ethnicity, older age, male sex, and earlier entry year were independently associated with late presentation (P < .05 for all). In multivariable analyses, Latino persons were 1.29 times more likely to present to care late than white or black persons (95% confidence interval, 1.15-1.45).

CONCLUSIONS

Latinos are more likely to initiate HIV care later in the course of illness than are black and white persons and account for a majority of several ADEs. Strategies to improve earlier HIV testing among Latinos in new settlement areas are needed.

Disparities in access to HIV prevention among men of Mexican descent living in the Midwestern United States

Men of Mexican descent (MMD) in the U.S. are disproportionately affected by HIV. Understanding MMD's access to HIV prevention is necessary to reduce their transmission rates. We explored disparities in access to HIV prevention among MMD of different assimilation status, healthcare access, and sexual risk behavior. 322 Midwestern MMD completed a survey assessing their access to passive interventions (e.g., lectures), interactive interventions (e.g., counseling), HIV testing, media information, and information from the Internet. 64% MMD had received passive interventions, 36% interactive interventions, 42% HIV testing, 41% information from media, and 12% from the Internet. MMD who were less assimilated to the U.S., had lower healthcare access, and were at risk for HIV, were less likely to have accessed prevention interventions but more likely to have received media information. Access to HIV prevention among Midwestern MMD is tied to their assimilation and healthcare access. Findings have implications for developing strategies of intervention delivery.

Prevalence and correlates of sexual risk among male and female sex workers in Tijuana, Mexico

We investigated prevalence and correlates of sexual risk behaviours among male and female sex workers in Tijuana, Mexico, the busiest border crossing area on the US - Mexico border, analysing survey data from a purposive, cross-sectional sample of male and female sex workers who worked in a range of indoor and outdoor settings. Logistic regression was used to determine factors that were associated with sexual risk-taking, defined as failing to use a condom with last client. In bivariate regression models, gender, work setting (e.g., indoor vs. outdoor), poverty, engaging in survival sex, marital status and perceived drug addiction were correlated with sexual risk. When controlling for work location, housing insecurity, poverty, survival sex, marital status and perceived drug addiction, male sex workers were still 10 times more likely than female sex workers (FSW) to engage in sex without a condom during their last encounter with a client. And, although FSW were significantly more likely than males to have used a condom with a client, they were significantly less likely than males to have used a condom with their regular partner. Future research should further examine how gender shapes sexual risk activities in both commercial and non-commercial relationships.