Gary M. Goldbaum

Prospective study of high grade anal squamous intraepithelial neoplasia in a cohort of homosexual men: influence of HIV infection, immunosuppression and human papillomavirus infection.

ObjectiveTo determine the risk of developing high grade anal squamous intraepithelial neoplasia (HG-AIN) in relation to HIV infection, and immunosuppression, after controlling for the effects of human papillomavirus (HPV) infection. DesignProspective cohort study of 158 HIV-seropositive, and 147 HIV-seronegative homosexual men presenting to a community-based clinic with initially negative anal cytologic, and colposcopic findings. MethodsSubjects completed self-administered questionnaires, underwent cytologic screening, and standardized unaided, and colposcopic examination of the proximal anal canal for presence of abnormalities suggestive of AIM. Anal specimens were screened for HPV DMA. ResultsHG-AIN developed in eight (5.4%), and 24 (15.2%) HIV-seronegative, and -seropositive men, respectively. Risk of HG-AIN among HIV-seronegative men was associated with detection of anal HPV types 16 or 18 by Southern transfer hybridization (STH), detection of HPV 16 or 18 at the lower levels by polymerase chain reaction but not by STH, and with number of positive HPV tests; HG-AIN risk among HIV-seropositive men was associated with detection of HPV 16 or 18 only by STH, detection of HPV types other than 16 or 18, CD4 count ≤ 500 × 106/l, and number of positive HPV tests. HIV-induced immunosuppression remained an independent predictor of HG-AIN after adjusting for type, and level of detection of HPV; HIV infection predicted HG-AIN risk after adjustment for number of positive HPV tests. ConclusionsThe association of HG-AIN with HIV, independent of HPV type, level of HPV detection, and number of positive HPV tests, suggests that this increased risk cannot be entirely explained by an effect of HIV on HPV detection. Future studies focusing on factors more specific to the local microenvironment in the anal canal should help clarify these issues.

Overcoming barriers to HIV testing: preferences for new strategies among clients of a needle exchange, a sexually transmitted disease clinic, and sex venues for men who have sex with men:

Objective: To determine strategies to overcome barriers to HIV testing among persons at risk. Methods: We developed a survey that elicited testing motivators, barriers, and preferences for new strategies among 460 participants at a needle exchange, three sex venues for men who have sex with men, and a sexually transmitted disease clinic. Results: Barriers to testing included factors influenced by individual concern (fear and discrimination); by programs, policies, and laws (named reporting and inability to afford treatment); and by counseling and testing strategies (dislike of counseling, anxiety waiting for results, and venipuncture). The largest proportions of participants preferred rapid testing strategies, including clinic‐based testing (27%) and home selftesting (20%); roughly equal proportions preferred oral fluid testing (18%), urine testing (17%), and standard blood testing (17%). One percent preferred home specimen collection. Participants who had never tested before were significantly more likely to prefer home self‐testing compared with other strategies. Blacks were significantly more likely to prefer urine testing. Conclusions: Strategies for improving acceptance of HIV counseling and testing include information about access to anonymous testing and early treatment. Expanding options for rapid testing, urine testing, and home self‐testing; providing alternatives to venipuncture; making pretest counseling optional; and allowing telephone results disclosure may encourage more persons to learn their HIV status.

Effect of HIV infection on the natural history of anal human papillomavirus infection.

Objective:To identify risk factors for the detection of prevalent and incident anal human papillomavirus (HPV) infection, and HPV persistence among HIV-seropositive and seronegative homosexual men. Design:Longitudinal study of 287 HIV-seronegative and 322 HIV-seropositive men attending a community-based clinic. Methods:Subjects underwent an interview and examination; specimens were collected for HIV serology and assessment of anal HPV and HIV DNA. Results:Anal HPV DNA was detected at study entry in 91.6% of HIV-infected men, and 65.9% of men not infected with HIV. HPV detection was associated with lifetime number of sexual partners and recent receptive anal intercourse (HIV-seronegative men), decreased CD4+ lymphocyte count (HIV-seropositive men), and anal warts (all men). Among men negative for HPV at study entry, subsequent detection of HPV was associated with HIV, unprotected receptive anal intercourse, and any sexual contact since the last visit. Among men positive for HPV at study entry, subsequent detection of additional HPV types was more common among HIV-seropositive men. Becoming HPV negative during follow-up was less common among men with HIV or high HPV levels at study entry. Among those with HIV, HPV persistence was associated with presence of anal HIV DNA, but not with CD4+ lymphocyte count. ConclusionRisk of anal HPV infection appears to increase with sexual exposure, epithelial trauma, HIV infection and immune deficiency. Incident infection may result from recent sexual exposure or reactivation of latent infection. Further studies are needed to elucidate the mechanism by which HIV DNA in the anal canal increases the risk of HPV persistence.

HIV Risk Associated With Gay Bathhouses and Sex Clubs: Findings From 2 Seattle Surveys of Factors Related to HIV and Sexually Transmitted Infections

OBJECTIVES We studied the HIV risk behaviors of patrons of the 3 commercial sex venues for men in Seattle, Washington. METHODS We conducted cross-sectional, observational surveys in 2004 and 2006 by use of time-venue cluster sampling with probability proportional to size. Surveys were anonymous and self-reported. We analyzed the 2004 data to identify patron characteristics and predictors of risk behaviors and compared the 2 survey populations. RESULTS Fourteen percent of respondents reported a previous HIV-positive test, 14% reported unprotected anal intercourse, and 9% reported unprotected anal intercourse with a partner of unknown or discordant HIV status during the current commercial sex venue visit. By logistic regression, recent unprotected anal intercourse outside of a commercial sex venue was independently associated with unprotected anal intercourse. Sex venue site and patron drug use were strongly associated with unprotected anal intercourse at the crude level. The 2004 and 2006 survey populations did not differ significantly in demographics or behaviors. CONCLUSIONS Patron and venue-specific characteristics factors may each influence the frequency of HIV risk behaviors in commercial sex venues. Future research should evaluate the effect of structural and individual-level interventions on HIV transmission.

Determinants of Human Immunodeficiency Virus DNA and RNA Shedding in the Anal-Rectal Canal of Homosexual Men

To define the determinants of anal-rectal shedding of human immunodeficiency virus (HIV) DNA and RNA, 374 HIV-seropositive homosexual men were tested. Factors independently associated with detection of anal-rectal HIV DNA included anal-rectal inflammation and detection of anal human papillomavirus DNA; predictors of HIV RNA included detection of anal-rectal HIV DNA, anal-rectal inflammation, and high plasma HIV RNA levels. The latter (>10,000 copies/mL) was the main determinant of anal-rectal HIV RNA shedding when HIV DNA (e.g., HIV-infected cells) was not detected in the anal-rectal sample. The local presence of HIV-infected cells and local inflammation were the principal determinants of HIV RNA among those with low (<10,000 copies/mL) plasma HIV RNA load. Among those with anal-rectal HIV DNA present, increased HIV RNA plasma load did not increase the risk of shedding of HIV RNA into the anal-rectal canal.

Designing an HIV counseling and testing program for bathhouses: the Seattle experience with strategies to improve acceptability.

Summary Bathhouses are important venues for providing HIV counseling and testing to high-risk men who have sex with men (MSM), yet relatively few bathhouses routinely provide this service, and few data are available to guide program design. We examine numerous logistic considerations that had been identified in the HIV Alternative Testing Strategies study and that influenced the initiation, effectiveness, and maintenance of HIV testing programs in bathhouses for MSM. Key programmatic considerations in the design of a bathhouse HIV counseling and testing program included building alliances with community agencies, hiring and training staff, developing techniques for offering testing, and providing options for counseling, testing, and disclosure of results. The design included ways to provide client support and follow-up for partner notification and treatment counseling and to maintain relationships with bathhouse management for support of prevention activities. Early detection of HIV infection and HIV prevention can be achieved for some high-risk MSM through an accessible and acceptable HIV counseling and testing program in bathhouses. Keys to success include establishing community prevention collaborations between bathhouse personnel and testing agencies, ensuring that testing staff are supported in their work, and offering anonymous rapid HIV testing. Use of FDA approved, new rapid tests that do not require venipuncture, centrifugation, or laboratory oversight will further decrease barriers to testing and facilitate implementation of bathhouse testing programs in other communities.

HIV transmission: Women's risk from bisexual men.

The purpose of this study was to characterize the risk of human immunodeficiency virus (HIV) infection for men who have sex with men and to identify the risk such men pose to their female sex partners. The subjects were 5480 men who were tested for HIV between January 1987 and December 1991 and who reported having had sex with a man since 1977. Men who identified themselves as bisexual or straight were more likely to use injection drugs, had a substantial HIV seroprevalence, and reported many more female partners than men who identified themselves as gay. Men who identify themselves as bisexual pose the greatest risk to their female partners.

Epidemiology of MDMA and associated club drugs in the Seattle area.

Club drug use, MDMA in particular, appeared as a growing problem in the Seattle area in the late 1990s. To understand more about the patterns of MDMA use and to evaluate the current state of MDMA use, multiple data sources were examined. The seven data sources utilized included local community-based club drug surveys collected in 2003 at raves, treatment agencies, and gay-oriented bars and sex clubs; school surveys (collected in 2002); mortality data (deaths between 2000 and 2002); data from the sexually transmitted disease clinic (October 2002 to October 2003); focus groups (2003) with men who have sex with men; emergency department drug mentions (1995 to 2002); and drug treatment admissions (1999 to 2003). Taken together, these data indicate moderate levels of MDMA use and relatively low levels of mortality and acute morbidity. However, there are several areas of concern including possible mental health effects and high levels of suspected adulteration of MDMA. Some data point to a relationship between MDMA use and risky behaviors including unprotected sex. Implications for prevention, intervention, and treatment are discussed.

Trends in evaluation for sexually transmitted infections among HIV-infected people, King County, Washington

Objective: To assess clinician sexual risk assessment and sexually transmitted infection (STI) screening rates in a large cohort of human immunodeficiency virus (HIV)-infected patients in King County, Washington. Methods: We abstracted data from medical records of HIV-infected patients seen in diverse clinical settings during 2000–2003 and used &khgr;2 and logistic regression to identify factors associated with higher rates of sexual risk assessment and STI testing. We defined patients as having had a sexual risk or STI assessment if the medical record included any information about the patients recent sexual behavior or included laboratory test results for gonorrhea, chlamydial infection, syphilis, or trichomoniasis. Results: The proportion of patients with any recorded risk assessment or STI testing increased from 16% in 2000 to 46% in 2001, and thereafter remained stable. On multivariate analysis, having a sexual risk or STI evaluation was significantly associated with later time period of evaluation, receiving care in a HIV specialty clinic, higher number of outpatient visits, being men who have sex with men, Seattle residence (vs. residence outside Seattle), female gender, higher CD4 count, white race, and having never received antiretroviral therapy. Conclusion: Although sexual risk and STI evaluation rates increased from 2000 to 2001, they now appear to be stable and many patients, particularly those seen outside of HIV specialty clinics, are not routinely evaluated for ongoing risks or STI. Clinicians and public health authorities need to develop better mechanisms to assure recommended risk assessments and STI testing among persons with HIV.

Access to Regular HIV Care and Disease Progression among Black African Immigrants

OBJECTIVE To describe the characteristics of human immunodeficiency virus (HIV)-infected black African immigrants living in King County, Washington, we evaluated delay in HIV diagnosis, access to HIV care, and risk of progression to AIDS or death. METHODS We compared differences in the risk of progression to AIDS or death between HIV-positive African-born black individuals and 2 groups of HIV-positive US-born individuals. RESULTS There were significant differences across the groups in residence at time of HIV diagnosis, gender, HIV transmission category, and initial CD4 count. Black Africans were more likely to present with an AIDS diagnosis (45%), compared to both US-born nonblacks (25%) and US-born blacks (35%). No significant independent associations were observed in rates of HIV disease progression when black African immigrants were compared to their US-born counterparts. CONCLUSIONS Once having initiated HIV care, African-born blacks accessed HIV care and progressed to AIDS at similar rates compared to US-born individuals. However, African-born blacks initiated care with more advanced HIV disease. Results underscore the need for health interventions promoting HIV testing among black African immigrants and reducing barriers to HIV testing.