Colin Flynn

Prevalence of HIV, syphilis, hepatitis B, and hepatitis C among entrants to Maryland correctional facilities

Although high prevalence of hepatitis C virus (HCV) in correctional institutions has been established, data are sparse regarding the comorbidities of hepatitis B virus (HBV), HCV, and human immunodeficiency virus (HIV), all of which may complicate the management of HCV. This study sought to estimate the prevalence and correlates associated with HCV prevalence among entrants into the Maryland Division of Correction and the Baltimore City Detention Center. Participants included all newly incarcerated entrants between January 28 and March 28, 2002. Excess sera with identifiers removed from samples drawn for routine syphilis testing were assayed for antibodies to HIV and HCV and for HBV surface antigen and surface and total core antibodies. Separately, all HIV-positive specimens were tested using the serological testing algorithm for recent HIV seroconversion. Of the 1,081 immates and 2,833 detainees, reactive syphilis serology was noted in 0.6% of the combined population; HIV seroprevalence was 6.6%; HCV prevalence was 29.7%; and 25.2% of detainees and prisoners had antigen or core or surface antibodies to HBV. A multivariate analysis of predictors of HCV positivity indicated that detainees, women, whites, older age groups, those who were HIV seropositive, and individuals with past or present infection with HBV were significantly more likely to be positive for HCV. These data indicate that hepatitis C remains an important public health concern among entrants to jail and prison and is complicated with coinfections that need to be addressed for effective treatment.

Health services use by urban women with or at risk for HIV-1 infection: the HIV Epidemiology Research Study (HERS).

OBJECTIVE To characterize health services use by urban women with or at risk for HIV-1 infection enrolled in a prospective multicenter study. METHODS 1310 women 16 to 55 years of age who were at risk for HIV-1 infection were recruited between April 1993 and January 1995 at four urban centers (Baltimore, Maryland; The Bronx, New York; Detroit, Michigan; and Providence, Rhode Island). HIV-1-seropositive women without AIDS-defining illness were oversampled in a ratio of 2:1 in comparison with HIV-1-seronegative women. At a baseline study visit, the women received physical and laboratory examinations, including CD4+ counts, and were interviewed regarding HIV risk behavior, health services use, and clinical data. RESULTS 863 women were HIV-1-seropositive and 430 were HIV-1-seronegative. Fifty-two percent of the women reported injection drug use (IDU) since 1985, and 48% acquired HIV through sexual contact. Seventy-seven percent were African American, 23% were white, and 16% were Hispanic. The median age was 35 years. HIV-seronegative women were significantly less likely to have health insurance (19%) than were HIV-seropositive women (30%; p < .001). Among the HIV-seropositive women, 68% had CD4+ cell counts of <500/microl, and 64% were asymptomatic. Sixty-four percent of the HIV-seronegative women had had an outpatient hospital visit in the past 6 months, as had 86% of HIV-seropositive women (p < 0.001). Hospitalization in the past 6 months was also higher in HIV-seropositive women (22% vs. 12%; p < .001). Despite heavy use of health services, only 49% of women with CD4+ counts of <200/microl reported current use of antiretroviral therapy, and only 58% reported current use of Pneumocystis carinii pneumonia (PCP) prophylaxis. Among HIV-seropositive women, and after adjusting for CD4+ count, HIV symptoms, race, and study site, IDUs were significantly less likely to have a regular doctor and a recent outpatient visit and more likely to be hospitalized and use the emergency department (ED) than were non-IDUs. In multivariate analyses of HIV-seropositive persons, African American women had similar access to care and use of antiretroviral therapy and PCP prophylaxis than did white women but were less likely to have an outpatient department visit in the previous 6 months and to be taking PCP and opportunistic infection (OI) prophylaxis. Health services access and use of HIV-related therapies did not significantly differ between Hispanic and white women with HIV infection. CONCLUSION Although both HIV-seropositive and HIV-seronegative women had high levels of use of medical services, current use of antiretrovirals and OI prophylaxis was low throughout, and IDUs used HIV-related primary health services less and were more likely to receive emergency or episodic care. IDU and African American race were independently associated with decreased use of medical services.

Violence Among Women with or at Risk for HIV Infection

To estimate the prevalence and to identify correlates of physical and sexual assaults or abuse among women with or at risk for HIV infection, a cross-sectional survey was conducted within a longitudinal cohort study. A total of 765 HIV-seropositive and 367 HIV-seronegative women with a history of injection drug use (51%) or high-risk sex (49%) completed the interview. Both physical abuse and sexual abuse as a child were common for both HIV-seropositive (41.3%, 41.0%) and uninfected women (43.3%, 45.8%), respectively. Both physical abuse and sexual abuse as adults were even more common in both HIV-seropositive (66.4%, 45.7%) and HIV-seronegative women (69.2%, 48.8%), respectively. In the 6 months prior to interview, the most important predictors for being the victim of violence was age <30 years old, use of crack, use of marijuana, having multiple sex partners, and not having a steady sex partner. However, even after accounting for these other factors, HIV-infected women with low CD4 cell counts (<350/μl) were less likely than the other women to experience recent violence. While the lower rate of recent violence among those with low CD4 cell count probably represents effects of HIV-related disability, women at high risk for HIV remain at high risk for violence. Both HIV prevention and treatment services need to recognize the background level of violence and incorporate appropriate counseling services.

Racial disparities in HIV incidence among young men who have sex with men : The baltimore young Men's survey

Recent reports have demonstrated racial disparities in the prevalence of HIV infection among men who have sex with men (MSM). The objectives of this study are to investigate whether racial disparities exist in HIV incidence among young MSM in Baltimore, MD and to examine potential explanations for differences. Data were collected by the Baltimore Young Mens Survey, a cross-sectional venue-based survey (1996 to 2000) enrolling MSM aged 15 to 29 years. HIV incidence was ascertained using the serologic testing algorithm for recent HIV seroconversion. HIV incidence was 4.2% per year (95% confidence interval [CI]: 1.2 to 10.5) among 843 participants. There were substantial racial differences in HIV incidence, ranging from 0 among Hispanics to 11.0% per year (95% CI: 5.5 to 19.7) among non-Hispanic blacks. In multivariate analysis, among MSM at risk for HIV acquisition, race was not associated with unprotected anal intercourse. Independent risks included having more than 4 recent male sexual partners (adjusted odds ratio [AOR] = 1.6, 95% CI: 1.0 to 2.4) and being under the influence of drugs while having sex (AOR = 1.6, 95% CI: 1.1 to 2.3). Non-Hispanic blacks were no more likely than non-Hispanic whites to report these risk behaviors. Possible alternative explanations for the observed racial disparities in HIV incidence and implications for prevention are explored.

Dietary intake of community-based HIV-1 seropositive and seronegative injecting drug users

Dietary intake was assessed in a subsample of a cohort of inner-city injecting drug users (IDUs). In this population of predominantly African-American IDUs, including both HIV -1-infected and noninfected men and women, a food frequency questionnaire (FFQ) and a 24-h recall were administered. One hundred seven volunteers participated. Although total caloric intake was consistently higher with the food frequency method, percent of total calories from fat, protein, and carbohydrates were similar between the FFQ and 24-h recall. Spearmans correlations for agreement between the 24-h recall and the FFQ ranged from 0.22 for vitamin E to 0.52 for carbohydrates. HIV-1 seropositives reported higher protein (p = 0.05) and fat (p = 0.02) consumption than seronegatives according to the 24-h recall. The difference in total fat consumption was due to higher intakes of saturated and monounsaturated fats (p = 0.01). Median intakes of vitamins B2 and B12, pantothenic acid (p < or = 0.05), phosphorous (p < or = 0.01), and selenium (p < or = 0.005) were also greater in HIV-1 seropositives. Reported intake of vitamins A and E, calcium, and zinc were below the recommended daily allowances for both HIV-1 seropositives and seronegatives. Although intakes of most nutrients appeared adequate for the group as a whole, extreme ranges were observed and may be the result of imbalanced food selections and day to day variation. Food group analysis indicated low intakes of fruits, vegetables, milk, and milk products. More research is needed to fully understand the implication of dietary habits and nutritional status in the free-living HIV-1-infected and noninfected IDUs.

Persistently high prevalence and unrecognized HIV infection among men who have sex with men in Baltimore: the BESURE study.

Background:Given high rates of HIV among Baltimore men who have sex with men (MSM), we examined characteristics associated with HIV prevalence and unrecognized HIV infection among Baltimore MSM at two time points. Methods:Cross-sectional behavioral surveys and HIV testing in 2004-2005 and 2008 using venue-based sampling among adult Baltimore men at MSM-identified locations. MSM was defined as sex with a male partner in the past year. Bivariate and backward stepwise regression identified characteristics associated with HIV and unrecognized infection. Results:HIV prevalence was 37.7% overall in 2004-2005 (n = 645) and 37.5% in 2008 (n = 448), 51.4% and 44.7% among black MSM and 12.9% and 18.3% among non-Hispanic white MSM. Compared with non-Hispanic white MSM, black MSM were 4.0 times (95% confidence interval, 2.3-7.0) more likely to be HIV-positive in 2004-2005 and 2.5 times (95% confidence interval, 1.5-4.0) more likely in 2008. Prevalence of unrecognized HIV infection was 58.4% overall in 2004-2005 and 74.4% in 2008, 63.8% and 76.9% among black MSM and 15.4% and 47.4% among non-Hispanic white MSM. In adjusted models, unrecognized infection was significantly associated with minority race/ethnicity, younger age, and no prior year doctor visits in 2004-2005 and with younger age and no prior year doctor visits in 2008. Conclusion:High rates of HIV infection and substantial rates of unrecognized HIV infection among Baltimore MSM, particularly men of color and young men, require urgent public and private sector attention and increased prevention response.

Willingness to Take, Use of, and Indications for Pre-exposure Prophylaxis Among Men Who Have Sex With Men-20 US Cities, 2014.

BACKGROUND Pre-exposure prophylaxis (PrEP) is an effective prevention tool for people at substantial risk of acquiring human immunodeficiency virus (HIV). To monitor the current state of PrEP use among men who have sex with men (MSM), we report on willingness to use PrEP and PrEP utilization. To assess whether the MSM subpopulations at highest risk for infection have indications for PrEP according to the 2014 clinical guidelines, we estimated indications for PrEP for MSM by demographics. METHODS We analyzed data from the 2014 cycle of the National HIV Behavioral Surveillance (NHBS) system among MSM who tested HIV negative in NHBS and were currently sexually active. Adjusted prevalence ratios and 95% confidence intervals were estimated from log-linked Poisson regression with generalized estimating equations to explore differences in willingness to take PrEP, PrEP use, and indications for PrEP. RESULTS Whereas over half of MSM said they were willing to take PrEP, only about 4% reported using PrEP. There was no difference in willingness to take PrEP between black and white MSM. PrEP use was higher among white compared with black MSM and among those with greater education and income levels. Young, black MSM were less likely to have indications for PrEP compared with young MSM of other races/ethnicities. CONCLUSIONS Young, black MSM, despite being at high risk of HIV acquisition, may not have indications for PrEP under the current guidelines. Clinicians may need to consider other factors besides risk behaviors such as HIV incidence and prevalence in subgroups of their communities when considering prescribing PrEP.

New evidence to reconcile in vitro and epidemiologic data on the possible role of heroin on CD4+ decline among HIV-infected injecting drug users

Long-term effects of drug type and other drug use related risk factors on CD4+ cell decline were assessed in 224 HIV-infected injecting drug users (IDUs) from Baltimore (ALIVE), USA, and 63 IDUs from Amsterdam, The Netherlands. Higher frequencies of borrowing used injection equipment since 1980 resulted in a higher CD4+ count already present before seroconversion (P = 0.049). Use of mainly heroin in the seroconversion interval resulted in a sharper CD4+ decline until the first 6 months after seroconversion (P = 0.004), but CD4+ values converged later on. This finding might reconcile earlier discordant epidemiological and laboratory study results regarding the possible effects of heroin.

The geography of heterosexual partnerships in Baltimore city adults.

Background: Human immunodeficiency virus/sexually transmitted disease (HIV/STD) risk is determined in part by sexual network characteristics, which include spatial parameters. Geography and proximity of partner selection are important factors, which may explain neighborhood-level differences in HIV/STD morbidity. To study the effects of neighborhood factors on HIV/STD transmission in high-density urban areas, the geography of partner selection must be understood. Methods: The Baltimore site of the National HIV Behavioral Surveillance system surveyed adults reporting one or more heterosexual partnerships. Spatial assortativity was defined as both partners residing in the same or adjacent census tracts and based on participant report. HIV core areas were defined as the census tracts in the top quartile for standardized HIV/AIDS case rates. Results: Participants (n = 307) provided data on 776 recent sexual partnerships, and geographic information were obtained for 510 partnerships (66%). Almost half (47%) reported choosing spatially assortative partners. Participants who lived in high HIV-prevalence areas were more likely to choose spatially assortative partners than residents of lower prevalence areas after adjusting for partnership type, gender, and number of partners. Although this population exhibited assortative mixing in all types of partnerships, racial and age assortativities were not associated with choosing spatially assortative partners. Conclusions: Over 15 years ago, STD clinic patients in Baltimore were found to seek partners within close proximity. We confirm these results in a non-STD clinic population, indicating a continuing need for neighborhood approaches to intervention programs in urban areas.

Feasibility of one-time use of sterile syringes : A study of active injection drug users in seven United States metropolitan areas

OBJECTIVES To assess the feasibility of advice to injection drug users (IDUs) to use a sterile syringe for each injection, we examined sources of syringes, syringe use and reuse, and barriers to and facilitators of compliance with the one-time use of syringes by active IDUs in seven U.S. metropolitan areas. METHODS Brief, interviewer-administered surveys were completed by 593 active IDUs, defined as injection reported within the past 90 days, in seven U.S. metropolitan areas characterized by various restrictions on syringe acquisition and possession. RESULTS Most of the IDUs interviewed were male (69%) and African American (74%). Overall, only 23% obtained the most recently used syringe from a reliable source of sterile syringes (i.e., pharmacy or syringe exchange program [SEP]). The median number of injections per most recently used syringe was 3 (mean=5.2); 21% used the syringe only once. IDUs were more likely to have used a reliable source for obtaining their most recent syringe in cities with a SEP (odds ratio [OR]=5.3; 95% confidence interval [CI] 3.3-8.5) or without restrictive paraphernalia laws (OR=0.1; 95% CI 0.1-0.3). To facilitate one-time use of sterile syringes, IDUs recommended the provision of free syringes (50.3%), access to a SEP (38.1%), and access to pharmacy purchase of syringes (24.0%). CONCLUSIONS Restrictions on syringe availability and the beliefs and practices of IDUs are barriers to the public health recommendation of one-time use of sterile syringes for IDUs who cannot stop injecting. Increased access to legal, inexpensive sterile syringes and education about the merits of one-time use are needed.