Becky L. White

Novel Treponema pallidum Serologic Tests: A Paradigm Shift in Syphilis Screening for the 21st Century

The mainstay of diagnosis for Treponema pallidum infections is based on nontreponemal and treponemal serologic tests. Many new diagnostic methods for syphilis have been developed, using specific treponemal antigens and novel formats, including rapid point-of-care tests, enzyme immunoassays, and chemiluminescence assays. Although most of these newer tests are not yet cleared for use in the United States by the Food and Drug Administration, their performance and ease of automation have promoted their application for syphilis screening. Both sensitive and specific, new screening tests detect antitreponemal IgM and IgG antibodies by use of wild-type or recombinant T. pallidum antigens. However, these tests cannot distinguish between recent and remote or treated versus untreated infections. In addition, the screening tests require confirmation with nontreponemal tests. This use of treponemal tests for screening and nontreponemal serologic tests as confirmatory tests is a reversal of long-held practice. Clinicians need to understand the science behind these tests to use them properly in syphilis management.

Characteristics and Behaviors Associated With HIV Infection Among Inmates in the North Carolina Prison System

OBJECTIVES We identified factors associated with testing HIV positive in a prison system performing voluntary HIV testing on inmates and estimated the number of undetected HIV cases to evaluate the efficacy of risk-factor-based HIV testing. METHODS We used logistic regression to estimate associations between HIV serostatus and HIV risk behaviors, mental health, coinfection status, and sociodemographic characteristics for prisoners entering the North Carolina Department of Correction from January 2004 through May 2006. We estimated the number of undetected HIV cases on the basis of age-, gender-, and race-specific HIV prevalences among prisoners and in the state. RESULTS Nearly 3.4% (718/21 419) of tested prisoners were HIV positive. The strongest risk factors for infection among men were having sex with men (odds ratio [OR] = 8.0), Black race (OR = 6.2), other non-White race (OR = 7.4), and being aged 35 to 44 years (OR = 4.1). The strongest risk factor among women was Black race (OR = 3.8). Among HIV-positive prisoners, 65% were coinfected with HCV. We estimated that between 24% (223) and 61% (1101) of HIV cases remained undetected. CONCLUSIONS The associations between HIV serostatus and a variety of factors highlight the potential limitations of risk-factor-based HIV testing in prisons, as do the high number of potential undetected HIV cases.

HIV-Infected Prison Inmates: Depression and Implications for Release Back to Communities

High rates of both HIV and depression are seen in prison populations; depression has been linked to disease progression in HIV, risky behaviors, and medication non-adherence. Despite this, few studies have examined HIV-infected inmates with depression. We therefore conducted an exploratory study of a sample of HIV-infected inmates in North Carolina prisons (N = 101) to determine what proportion of this sample screened positive for depression and whether depression was associated with different pre-incarceration characteristics or post-release needs. A high proportion of HIV infected inmates (44.5%) screened positive for depression. Depressed inmates were significantly more likely have low coping self-efficacy scores (180 vs. 214), to report having had resource needs (OR = 2.91) prior to incarceration and to anticipate needing income (OR = 2.81), housing (OR = 4.07), transportation (OR = 9.15), and assistance with adherence (OR = 8.67) post-release. We conclude by discussion the implications of our findings for prison based care and effective prison release planning for HIV infected inmates.

An Evaluation of HIV Testing Among Inmates in the North Carolina Prison System

OBJECTIVES We examined the use of voluntary HIV testing among state prisoners in the North Carolina prison system. METHODS We calculated system-wide and facility-specific proportions and rates of adult inmates tested for HIV and estimated associations between testing status and inmate characteristics for prisoners in North Carolina. RESULTS Of the 54 016 inmates who entered prison between January 2004 and May 2006, 20 820 (38%) were tested for HIV; of those tested, 18 574 (89%) were tested at admission. Across the 8 intake prisons, more than 80% of inmates in both female facilities but less than 15% of inmates in 4 of 6 male facilities were tested. Prisoners with a documented history of heroin use, crack or cocaine use, conventional HIV risk behavior, or tuberculosis were at least 10% more likely to be tested than were inmates without these characteristics. However, more than 60% of men reporting conventional risk behaviors were not tested. Before covariate adjustment, Black men were 30% less likely than White men to be tested; in the multivariable regression model, this difference was attenuated to 13%. CONCLUSIONS Rates of HIV testing varied widely across intake prisons, and many male inmates with documented risk of infection were never tested.

Detection of undiagnosed HIV among state prison entrants

A substantial proportion of individuals infected with the human immunodeficiency virus (HIV) in the United States enter a correctional facility annually.1,2 Therefore, incarceration presents an opportunity for HIV detection. Even though many states have adopted policies of mass HIV screening of inmates,2–4 the extent to which HIV testing on prison entry detects new infections is unclear. We examined HIV prevalence among inmates entering a state prison system and the proportion known to state public health authorities as having previously tested HIV seropositive.

Clinician Perspectives on Delaying Initiation of Antiretroviral Therapy for Clinically Eligible HIV-Infected Patients

Objectives: Guidelines for antiretroviral therapy (ART) initiation have evolved, but consistently note that adherence problems should be considered and addressed. Little is known regarding the reasons providers delay ART initiation in clinically eligible patients. Methods: In 2009, we surveyed a probability sample of HIV care providers in 582 outpatient facilities in the United States and Puerto Rico with an open-ended question about nonclinical reasons for delaying ART initiation in otherwise clinically eligible patients. Results: Very few providers (2%) reported never delaying ART. Reasons for delaying ART were concerns about patient adherence (68%), patient acceptance (60%), and structural barriers (33%). Provider and practice characteristics were associated with reasons for delaying ART. Conclusion: Reasons for delaying ART were consistent with clinical guidelines and were both patient level and structural. Providers may benefit from training and access to referrals for ancillary services to enhance their ability to monitor and address these issues with their patients.

Efficacy of an Adapted HIV and Sexually Transmitted Infection Prevention Intervention for Incarcerated Women: A Randomized Controlled Trial

OBJECTIVES We tested the efficacy of an adapted evidence-based HIV-sexually transmitted infection (STI) behavioral intervention (Providing Opportunities for Womens Empowerment, Risk-Reduction, and Relationships, or POWER) among incarcerated women. METHODS We conducted a randomized trial with 521 women aged 18 to 60 years in 2 correctional facilities in North Carolina in 2010 and 2011. Intervention participants attended 8 POWER sessions; control participants received a single standard-of-care STI prevention session. We followed up at 3 and 6 months after release. We examined intervention efficacy with mixed-effects models. RESULTS POWER participants reported fewer male sexual partners than did control participants at 3 months, although this finding did not reach statistical significance; at 6 months they reported significantly less vaginal intercourse without a condom outside of a monogamous relationship and more condom use with a main male partner. POWER participants also reported significantly fewer condom barriers, and greater HIV knowledge, health-protective communication, and tangible social support. The intervention had no significant effects on incident STIs. CONCLUSIONS POWER is a behavioral intervention with potential to reduce risk of acquiring or transmitting HIV and STIs among incarcerated women returning to their communities.

Comparing HIV case detection in prison during opt-in vs. Opt-out testing policies

Routine HIV screening in health care settings, including prisons and jails, is recommended by the US Centers for Disease Control and Prevention to enhance the detection of HIV infection.1,2 A centerpiece of this strategy is opt-out HIV screening whereby patients are informed that testing will be conducted unless they decline the test. Although incarceration is considered an opportunity to detect HIV and initiate or restart HIV care,3–6 there are few data describing the performance of an opt-out testing policy in prisons, where HIV prevalence is several-fold that found in the general population.3 In November 2008, the North Carolina Department of Public Safety (NCDPS) Division of Adult Correction changed its HIV screening policy for incoming inmates from opt-in to opt-out testing. At the time of the policy change, we were conducting a HIV seroprevalence study among incoming prisoners.7 The co-occurrence of the change in policy and our seroprevalence study provided a natural experiment to assess the impact of the testing policy on HIV case detection of both newly diagnosed and previously diagnosed cases.

Individuals motivated to participate in adherence, care and treatment (imPACT): development of a multi-component intervention to help HIV-infected recently incarcerated individuals link and adhere to HIV care

BackgroundPolicy-makers promote a seek, test, treat and retain (STTR) strategy to expand HIV testing, support linkage and engagement in care, and enhance the continuous use of antiretroviral therapy for those HIV-infected. This HIV prevention strategy is particularly appropriate in correctional settings where HIV screening and treatment are routinely available yet many HIV-infected individuals have difficulty sustaining sufficient linkage and engagement in care, disease management, and viral suppression after prison release.Methods/designOur research team developed Project imPACT (individuals motivated to Participate in Adherence, Care and Treatment), a multi-component approach for HIV-Infected recently incarcerated individuals that specifically targets their care linkage, retention, and medication adherence by addressing multiple barriers to care engagement after release. The ultimate goals of this intervention are to improve the health of HIV-infected individuals recently released from prison and reduce HIV transmission to their communities by maintaining viral suppression. This paper describes the intervention and technology development processes, based on best practices for intervention development and process evaluation. These processes included: 1) identifying the target population; 2) clarifying the theoretical basis for intervention design; 3) describing features of its foundational interventions; 4) conducting formative qualitative research; 5) integrating and adapting foundational interventions to create and refine intervention content based on target audience feedback. These stages along with the final intervention product are described in detail. The intervention is currently being evaluation and a two arm randomized, controlled trial in two US state prison systems.DiscussionBased on a literature review, qualitative research, integration of proven interventions and behavioral theory, the final imPACT intervention focused on the transition period two to three months before and three months after prison release. It emphasized pre-release readiness, pre- and post-release supportive non-judgmental counseling, linking individuals to a HIV care clinic and technological supports through videos and text messages. This article provides a useful model for how researchers can develop, test, and refine multi-component interventions to address HIV care linkage, retention and adherence.Clinical trial registrationNCT01629316, first registered 6-4-2012; last updated 6-9-2015.

Religiosity, Spirituality, and HIV Risk Behaviors among African American Women from Four Rural Counties in the Southeastern U.S.

In a cross-sectional survey of 1,013 African American women from rural Alabama and North Carolina, we examined the relationship of (1) organizational religiosity (i.e., religious service attendance), (2) non-organizational religiosity (e.g., reading religious materials), and (3) spirituality with these outcomes: women’s reports of their sexual behaviors and perceptions of their partners’ risk characteristics. Women with high non-organizational religiosity, compared with low, had fewer sex partners in the past 12 months (adjusted prevalence ratio (aPR): 0.58, 95% confidence interval (CI): 0.42, 0.80) and were less likely to have concurrent partnerships (aPR: 0.47, 95% CI: 0.30, 0.73). Similar results were observed for spirituality, and protective but weaker associations were observed for organizational religiosity. Weak associations were observed between organizational religiosity, non-organizational religiosity, and spirituality with partners’ risk characteristics. Further exploration of how religiosity and spirituality are associated with protective sexual behaviors is needed to promote safe sex for African American women.