Jacqueline P. Tulsky

HIV Seroprevalence Among Homeless and Marginally Housed Adults in San Francisco

OBJECTIVES We report HIV seroprevalence and risk factors for urban indigent adults. METHODS A total of 2508 adults from shelters, meal programs, and low-cost hotels received interviews, blood tests, and tuberculosis screening. RESULTS Seroprevalence was 10.5% overall, 29.6% for men reporting sex with men (MSM), 7.7% for non-MSM injection drug users (IDUs), and 5.0% for residual non-MSM/non-IDUs. Risk factors were identified for MSM (sex trade among Whites, non-White race, recent receptive anal sex, syphilis), non-MSM IDUs (syphilis, lower education, prison, syringe sharing, transfusion), and residual subjects (> or = 5 recent sexual partners, female crack users who gave sex for drugs). CONCLUSIONS HIV seroprevalence was 5 times greater for indigent adults than in San Francisco generally. Sexual behavior predicted HIV infection better than drug use, even among IDUs.

Rapid point-of-care HIV testing in pregnant women: a systematic review and meta-analysis

Rapid, point‐of‐care human immunodeficiency virus (HIV) testing has the potential to enhance strategies to prevent mother‐to‐child transmission (MTCT) of HIV infection. Rapid tests need minimal laboratory infrastructure and can be performed by health workers with minimal training. In our systematic review and meta‐analysis, we aimed to summarize the overall diagnostic accuracy of rapid HIV tests in pregnancy, and outcomes such as acceptability, patient preference, feasibility and impact of rapid testing. We searched four major databases, identified and screened 1377 citations, and included 17 studies that met our eligibility criteria. Analyses of these studies suggested that the overall sensitivity and specificity of blood‐based rapid tests was high compared with oral rapid tests. A two‐step testing strategy, particularly parallel testing, was found to be superior to single‐test strategy in labour and delivery settings. Acceptability of rapid tests and patient preference was variable across studies. Overall, rapid HIV testing was highly accurate compared with conventional tests and offer a clear advantage of enabling the implementation of timely interventions to reduce MTCT of HIV. To improve diagnostic accuracy and to reduce false‐positive results, it may be necessary to use two rapid tests during labour and delivery.

Screening for tuberculosis in Jail and clinic follow-up after release

OBJECTIVES The purpose of this study was to describe tuberculosis (TB) screening and preventive therapy in the San Francisco County Jail and to measure the follow-up rate at the public health department TB clinic. METHODS The records of male inmates screened for 6 months in 1994 were reviewed. Those prescribed isoniazid and released before therapy ended were matched with TB clinic records. Inmates were considered to have followed up if they came to the TB clinic within 1 month of release. RESULTS Of 3352 inmates screened, 553 (16.5%) reported a prior positive skin test, and 330 (26.9%) of 1229 tests placed and read were positive. Of those with positive tests, 151 (45.8%) began isoniazid. Most of the inmates were foreign-born Hispanics (80.8%). Ninety-three (61.6%) inmates were released before completion, after an average of 68.5 days. Three (3.2%) went to the TB clinic within a month. CONCLUSIONS Jail represents an important screening site for TB, but care is not continued after release. Strategies are needed to enhance the continuity of isoniazid preventive care.

Impact of round-the-clock, rapid oral fluid HIV testing of women in labor in rural India.

Background Testing pregnant women for HIV at the time of labor and delivery is the last opportunity for prevention of mother-to-child HIV transmission (PMTCT) measures, particularly in settings where women do not receive adequate antenatal care. However, HIV testing and counseling of pregnant women in labor is a challenge, especially in resource-constrained settings. In India, many rural women present for delivery without any prior antenatal care. Those who do get antenatal care are not always tested for HIV, because of deficiencies in the provision of HIV testing and counseling services. In this context, we investigated the impact of introducing round-the-clock, rapid, point-of-care HIV testing and counseling in a busy labor ward at a tertiary care hospital in rural India. Methods and Findings After they provided written informed consent, women admitted to the labor ward of a rural teaching hospital in India were offered two rapid tests on oral fluid and finger-stick specimens (OraQuick Rapid HIV-1/HIV-2 tests, OraSure Technologies). Simultaneously, venous blood was drawn for conventional HIV ELISA testing. Western blot tests were performed for confirmatory testing if women were positive by both rapid tests and dual ELISA, or where test results were discordant. Round-the-clock (24 h, 7 d/wk) abbreviated prepartum and extended postpartum counseling sessions were offered as part of the testing strategy. HIV-positive women were administered PMTCT interventions. Of 1,252 eligible women (age range 18 y to 38 y) approached for consent over a 9 mo period in 2006, 1,222 (98%) accepted HIV testing in the labor ward. Of these, 1,003 (82%) women presented with either no reports or incomplete reports of prior HIV testing results at the time of admission to the labor ward. Of 1,222 women, 15 were diagnosed as HIV-positive (on the basis of two rapid tests, dual ELISA and Western blot), yielding a seroprevalence of 1.23% (95% confidence interval [CI] 0.61%–1.8%). Of the 15 HIV test–positive women, four (27%) had presented with reported HIV status, and 11 (73%) new cases of HIV infection were detected due to rapid testing in the labor room. Thus, 11 HIV-positive women received PMTCT interventions on account of round-the-clock rapid HIV testing and counseling in the labor room. While both OraQuick tests (oral and finger-stick) were 100% specific, one false-negative result was documented (with both oral fluid and finger-stick specimens). Of the 15 HIV-infected women who delivered, 13 infants were HIV seronegative at birth and at 1 and 4 mo after delivery; two HIV-positive infants died within a month of delivery. Conclusions In a busy rural labor ward setting in India, we demonstrated that it is feasible to introduce a program of round-the-clock rapid HIV testing, including prepartum and extended postpartum counseling sessions. Our data suggest that the availability of round-the-clock rapid HIV testing resulted in successful documentation of HIV serostatus in a large proportion (82%) of rural women who were unaware of their HIV status when admitted to the labor room. In addition, 11 (73%) of a total of 15 HIV-positive women received PMTCT interventions because of round-the-clock rapid testing in the labor ward. These findings are relevant for PMTCT programs in developing countries.

Tracking and Follow-Up of Marginalized Populations: A Review

Maintaining study cohorts is a key element of longitudinal research. Participant attrition introduces the possibility of bias and limits the generalizability of a studys findings, but with appropriate planning it is possible to sustain contact with even the most transient participants. This paper reviews the essential elements of tracking and follow-up of marginalized populations, which are (1) collection of contact information, (2) thorough organization of tracking efforts, (3) attention to staff training and support, (4) use of phone and mail follow-up, (5) use of incentives, (6) establishing rapport with participants, (7) assurance of confidentiality, (8) use of agency tracking, (9) use of field tracking, and (10) attention to safety concerns. Diligent application of these tracking strategies allows researchers to achieve follow-up rates of 75 percent to 97 percent with vulnerable populations such as homeless, mentally ill adults, injection drug users, and runaway youth.

Evaluation of Diagnostic Accuracy, Feasibility and Client Preference for Rapid Oral Fluid-Based Diagnosis of HIV Infection in Rural India

Background Oral fluid-based rapid tests are promising for improving HIV diagnosis and screening. However, recent reports from the United States of false-positive results with the oral OraQuick® ADVANCE HIV1/2 test have raised concerns about their performance in routine practice. We report a field evaluation of the diagnostic accuracy, client preference, and feasibility for the oral fluid-based OraQuick® Rapid HIV1/2 test in a rural hospital in India. Methodology/Principal Findings A cross-sectional, hospital-based study was conducted in 450 consenting participants with suspected HIV infection in rural India. The objectives were to evaluate performance, client preference and feasibility of the OraQuick® Rapid HIV-1/2 tests. Two Oraquick® Rapid HIV1/2 tests (oral fluid and finger stick) were administered in parallel with confirmatory ELISA/Western Blot (reference standard). Pre- and post-test counseling and face to face interviews were conducted to determine client preference. Of the 450 participants, 146 were deemed to be HIV sero-positive using the reference standard (seropositivity rate of 32% (95% confidence interval [CI] 28%, 37%)). The OraQuick test on oral fluid specimens had better performance with a sensitivity of 100% (95% CI 98, 100) and a specificity of 100% (95% CI 99, 100), as compared to the OraQuick test on finger stick specimens with a sensitivity of 100% (95% CI 98, 100), and a specificity of 99.7% (95% CI 98.4, 99.9). The OraQuick oral fluid-based test was preferred by 87% of the participants for first time testing and 60% of the participants for repeat testing. Conclusion/Significance In a rural Indian hospital setting, the OraQuick® Rapid- HIV1/2 test was found to be highly accurate. The oral fluid-based test performed marginally better than the finger stick test. The oral OraQuick test was highly preferred by participants. In the context of global efforts to scale-up HIV testing, our data suggest that oral fluid-based rapid HIV testing may work well in rural, resource-limited settings.

Discharge Planning and Continuity of Health Care: Findings From the San Francisco County Jail

Continuity of health care among the formerly incarcerated is an emerging public health challenge. We used data from the San Francisco County Jail to determine whether discharge planning improves access to care on release. Inmates who were HIV positive and received discharge planning were 6 times more likely to have a regular source of care in the community compared with inmates with other chronic medical conditions, and they were as likely to have a regular source of care compared with the general San Francisco population.

Basic Subsistence Needs and Overall Health Among Human Immunodeficiency Virus-infected Homeless and Unstably Housed Women

Some gender differences in the progression of human immunodeficiency virus (HIV) infection have been attributed to delayed treatment among women and the social context of poverty. Recent economic difficulties have led to multiple service cuts, highlighting the need to identify factors with the most influence on health in order to prioritize scarce resources. The aim of this study was to empirically rank factors that longitudinally impact the health status of HIV-infected homeless and unstably housed women. Study participants were recruited between 2002 and 2008 from community-based venues in San Francisco, California, and followed over time; marginal structural models and targeted variable importance were used to rank factors by their influence. In adjusted analysis, the factor with the strongest effect on overall mental health was unmet subsistence needs (i.e., food, hygiene, and shelter needs), followed by poor adherence to antiretroviral therapy, not having a close friend, and the use of crack cocaine. Factors with the strongest effects on physical health and gynecologic symptoms followed similar patterns. Within this population, an inability to meet basic subsistence needs has at least as much of an effect on overall health as adherence to antiretroviral therapy, suggesting that advances in HIV medicine will not fully benefit indigent women until their subsistence needs are met.

Expanding directly observed therapy: tuberculosis to human immunodeficiency virus

The resurgence of tuberculosis and the association between poor treatment adherence and drugresistant tuberculosis in the 1990s emphasized the importance of identifying ways to improve medication adherence. In particular, directly observed therapy improved adherence to tuberculosis therapy for several groups of patients, including those with frequent drug use, mental illness, and unstable housing, thereby contributing to the control of drug-resistant tuberculosis in New York City (1,2). This success was later extended to the delivery of isoniazid preventive therapy to similar patients (3). Still, nonadherence remains the Achilles’ heel of medical treatment for many diseases, including tuberculosis. In this issue of The American Journal of Medicine, Chaisson and colleagues (4) report on a three-arm, random assignment trial of isoniazid adherence. Injection drug users were randomly assigned to directly observed therapy, self-administered therapy with peer counseling and education, or self-administered therapy alone. All participants received either immediate or delayed cash incentives to promote adherence. The study adds two new contributions to the body of adherence research. First, directly observed therapy improved adherence among injection drug users. Second, injection drug users were successfully maintained in monthly care for more than 6 months, perhaps as a result of the cash incentives. This study raises several important questions for adherence strategists. First, why does directly observed therapy yield better results than psychoeducational interventions? Second, what is the role of incentives, especially cash, in improving adherence? Finally, should incentivebased directly observed therapy be used for patients with chronic diseases for which lifetime adherence is required, such as antiretroviral therapy for patients with human immunodeficiency virus (HIV) infection? DIRECTLY OBSERVED THERAPY VERSUS PSYCHOEDUCATIONAL APPROACHES

Confined to Ignorance: The Absence of Prisoner Information from Nationally Representative Health Data Sets

AbtractBACKGROUNDIncarceration is associated with poor health and high costs. Given the dramatic growth in the criminal justice system’s population and associated expenses, inclusion of questions related to incarceration in national health data sets could provide essential data to researchers, clinicians and policy-makers.OBJECTIVETo evaluate a representative sample of publically available national health data sets for their ability to be used to study the health of currently or formerly incarcerated persons and to identify opportunities to improve criminal justice questions in health data sets.DESIGN & APPROACHWe reviewed the 36 data sets from the Society of General Internal Medicine Dataset Compendium related to individual health. Through content analysis using incarceration-related keywords, we identified data sets that could be used to study currently or formerly incarcerated persons, and we identified opportunities to improve the availability of relevant data.KEY RESULTSWhile 12 (33%) data sets returned keyword matches, none could be used to study incarcerated persons. Three (8%) could be used to study the health of formerly incarcerated individuals, but only one data set included multiple questions such as length of incarceration and age at incarceration. Missed opportunities included: (1) data sets that included current prisoners but did not record their status (10, 28%); (2) data sets that asked questions related to incarceration but did not specifically record a subject’s status as formerly incarcerated (8, 22%); and (3) longitudinal studies that dropped and/or failed to record persons who became incarcerated during the study (8, 22%).CONCLUSIONSFew health data sets can be used to evaluate the association between incarceration and health. Three types of changes to existing national health data sets could substantially expand the available data, including: recording incarceration status for study participants who are incarcerated; recording subjects’ history of incarceration when this data is already being collected; and expanding incarceration-related questions in studies that already record incarceration history.