David W. Forrest

HIV Infection and Testing among Latino Men Who Have Sex with Men in the United States: The Role of Location of Birth and Other Social Determinants

Background In the United States, Latino men who have sex with men (MSM) are disproportionately affected by HIV. Latino MSM are a diverse group who differ culturally based on their countries or regions of birth and their time in the United States. We assessed differences in HIV prevalence and testing among Latino MSM by location of birth, time since arrival, and other social determinants of health. Methods For the 2008 National HIV Behavioral Surveillance System, a cross-sectional survey conducted in large US cities, MSM were interviewed and tested for HIV infection. We used generalized estimating equations to test associations between various factors and 1) prevalent HIV infection and 2) being tested for HIV infection in the past 12 months. Results Among 1734 Latino MSM, HIV prevalence was 19%. In multivariable analysis, increasing age, low income, and gay identity were associated with HIV infection. Moreover, men who were U.S.-born or who arrived ≥5 years ago had significantly higher HIV prevalence than recent immigrants. Among men not reporting a previous positive HIV test, 63% had been tested for HIV infection in the past 12 months; recent testing was most strongly associated with having seen a health care provider and disclosing male-male attraction/sexual behavior to a health care provider. Conclusions We identified several social determinants of health associated with HIV infection and testing among Latino MSM. Lower HIV prevalence among recent immigrants contrasts with higher prevalence among established immigrants and suggests a critical window of opportunity for HIV prevention, which should prioritize those with low income, who are at particular risk for HIV infection. Expanding health care utilization and encouraging communication with health care providers about sexual orientation may increase testing.

Early Linkage to HIV Care and Antiretroviral Treatment among Men Who Have Sex with Men — 20 Cities, United States, 2008 and 2011

Early linkage to care and antiretroviral (ARV) treatment are associated with reduced HIV transmission. Male-to-male sexual contact represents the largest HIV transmission category in the United States; men who have sex with men (MSM) are an important focus of care and treatment efforts. With the release of the National HIV/AIDS Strategy and expanded HIV treatment guidelines, increases in early linkage to care and ARV treatment are expected. We examined differences in prevalence of early linkage to care and ARV treatment among HIV-positive MSM between 2008 and 2011. Data are from the National HIV Behavioral Surveillance System, which monitors behaviors among populations at high risk of HIV infection in 20 U.S. cities with high AIDS burden. MSM were recruited through venue-based, time-space sampling. Prevalence ratios comparing 2011 to 2008 were estimated using linear mixed models. Early linkage was defined as an HIV clinic visit within 3 months of diagnosis. ARV treatment was defined as use at interview. Prevalence of early linkage to care was 79% (187/236) in 2008 and 83% (241/291) in 2011. In multivariable analysis, prevalence of early linkage did not differ significantly between years overall (P = 0.44). Prevalence of ARV treatment was 69% (790/1,142) in 2008 and 79% (1,049/1,336) in 2001. In multivariable analysis, ARV treatment increased overall (P = 0.0003) and among most sub-groups. Black MSM were less likely than white MSM to report ARV treatment (P = 0.01). While early linkage to care did not increase significantly between 2008 and 2011, ARV treatment increased among most sub-groups. Progress is being made in getting MSM on HIV treatment, but more efforts are needed to decrease disparities in ARV coverage.

Unexamined Challenges to Applying the Treatment as Prevention Model Among Men Who Have Sex with Men in the United States: A Community Public Health Perspective

Last year’s HIV Prevention Trials Network 052 study documented substantial reductions in HIV transmission to partners by persons living with HIV who had initiated early antiretroviral treatment [1]. The study’s initial findings revealed that just one new HIV infection traceable to a treated partner occurred in the early treatment arm, whereas 27 such new infections occurred in the delayed treatment arm. This difference represents a 96 % reduction in new infections amongst partners of those who took antiretroviral treatment throughout the entire course of the study. Seeking to meet the National HIV/AIDS Strategy goal of reducing new infections 25 % by 2015, the Centers for Disease Control’s new High Impact Prevention approach for the United States now prioritizes expanded HIV testing and antiretroviral treatment [2]. Even before the release of HPTN 052 results, expanded HIV screening and treatment in the U.S. had been modeled to be cost effective, though only moderately successful in reducing new infection rates [3]. Recently, HPTN 052’s principal investigator noted ‘‘The HPTN 052 trial demonstrated nearly complete prevention of HIV transmission by early treatment of infection, but the generalizability of the results to other risk groupsincluding injection drug users and men who have sex with men (MSM)-has not been determined’’ [4]. Nearly all participants in the HPTN 052 study were heterosexuals (98 %) enrolled from lowand middle-income nations (97 %). As one entry criterion for HPTN 052, HIVnegative persons were required to have been involved in a stable relationship with their HIV-positive partner for at least 3 months. Of the participants ultimately enrolled, 94 % were married, and less than 5 % had a sexually transmitted infection at enrollment [1]. Nearly all HIV-negative partners enrolled in the study were monogamous (96 and 97 %, in the early and delayed therapy arms respectively) throughout the study’s mean 1.7 year duration. These HIV-negative participants reported sexual relations with only one partner, whose HIV treatment was monitored [1]. By contrast, Reynolds et al. [5] previously found no significant decline in numbers of outside sexual partners reported by persons in a relationship in which a partner living with HIV had initiated Highly Active Antiretroviral Therapy. Recognizing the importance that relationship status plays in antiretroviral treatment as prevention (TasP), El-Sadr et al. [6] predicted greater success in decreasing HIV incidence when populations had a higher proportion of stable partnerships. However, the CDC’s High Impact Prevention approach focuses on diagnosis and linkage to care, and does not yet incorporate assessment of monogamy versus sexual concurrency (having overlapping sexual partnerships) in at-risk MSM populations. We maintain that sexual monogamy and awareness of partner’s status likely contributed substantially to the 052 study’s success with TasP, and that this entry criterion may have biased the study outcomes towards more promising results. Prevailing relationship practices among MSM will likely undermine the potential preventive effect when attempting to utilize TasP to significantly curb the U.S. epidemic.

HIV Among MSM and Heterosexual Women in the United States: An Ecologic Analysis

Background: Phylogenetic studies show links between heterosexual women and men who have sex with men (MSM) that are more numerous than from heterosexual men to women suggesting that HIV infections among heterosexual women may stem from MSM. Poor communities have been associated with high rates of HIV among heterosexual women. Our analysis investigates potential transmission of HIV between MSM and female heterosexuals. Methods: National HIV Behavioral Surveillance data describe transmission risk behaviors of MSM, and HIV case reporting data describe the percentages of cases that are attributed to transmission risk categories. We examined correlations between the percentages of men who were MSM who also have sex with women and female heterosexual cases. We also examined census data to characterize each city in terms of poverty level and race/ethnicity makeup. Results: There was a high correlation (0.93) between the percentage of reported living HIV cases attributed to male heterosexual contact and female heterosexual contact and a moderate nonsignificant correlation (0.49) between the percentage of MSM who were men who have sex with men and women (MSMW) in National HIV Behavioral Surveillance and the percentage of reported cases that were attributed to female heterosexual contact suggesting some potential overlap. Cities with high levels of poverty and African American/Black residents had higher levels of MSMW and higher levels of heterosexual female cases. Conclusions: Addressing HIV in cities with high levels of MSMW may have the dual effect of improving the health of MSM populations that have a high burden of HIV and to improve the health of their larger communities.

Incident Infection and Resistance Mutation Analysis of Dried Blood Spots Collected in a Field Study of HIV Risk Groups, 2007-2010

Objective To assess the utility of cost-effective dried blood spot (DBS) field sampling for incidence and drug resistance surveillance of persons at high risk for HIV infection. Methods We evaluated DBS collected in 2007–2010 in non-clinical settings by finger-stick from HIV-positive heterosexuals at increased risk of HIV infection (n = 124), men who have sex with men (MSM, n = 110), and persons who inject drugs (PWID, n = 58). Relative proportions of recent-infection findings among risk groups were assessed at avidity index (AI) cutoffs of ≤25%, ≤30%, and ≤35%, corresponding to an infection mean duration of recency (MDR) of 220.6, 250.4, and 278.3 days, respectively. Drug resistance mutation prevalence was compared among the risk groups and avidity indices. Results HIV antibody avidity testing of all self-reported ARV-naïve persons (n = 186) resulted in 9.7%, 11.3% and 14.0% with findings within the 221, 250, and 278-day MDRs, respectively. The proportion of ARV-naïve MSM, heterosexuals, and PWID reporting only one risk category who had findings below the suggested 30% AI was 23.1%, 6.9% and 3.6% (p<0.001), respectively. MSM had the highest prevalence of drug resistance and the only cases of transmitted multi-class resistance. Among the ARV-experienced, MSM had disproportionately more recent-infection results than did heterosexuals and PWID. Conclusions The disproportionately higher recent-infection findings for MSM as compared to PWID and heterosexuals increased as the MDR window increased. Unreported ARV use might explain greater recent-infection findings and drug resistance in this MSM population. DBS demonstrated utility in expanded HIV testing; however, optimal field handling is key to accurate recent-infection estimates.