James W. Dilley

Impact of Highly Active Antiretroviral Treatment on HIV Seroincidence Among Men Who Have Sex With Men: San Francisco

OBJECTIVES This study assessed the countervailing effects on HIV incidence of highly active antiretroviral treatment (HAART) among San Francisco men who have sex with men (MSM). METHODS Behavioral risk was determined on the basis of responses to cross-sectional community interviews. HIV incidence was assessed through application of an enzyme-linked immunoassay testing strategy. RESULTS Use of HAART among MSM living with AIDS increased from 4% in 1995 to 54% in 1999. The percentage of MSM who reported both unprotected anal intercourse and multiple sexual partners increased from 24% in 1994 to 45% in 1999. The annual HIV incidence rate increased from 2.1% in 1996 to 4.2% in 1999 among MSM who sought anonymous HIV testing, and the rate was high (5.3%) but stable in a blinded survey of MSM seeking sexually transmitted disease services. CONCLUSIONS Any decrease in per contact risk of HIV transmission due to HAART use appears to have been counterbalanced or overwhelmed by increases in the number of unsafe sexual episodes.

Increases in sexually transmitted infections and sexual risk behaviour without a concurrent increase in HIV incidence among men who have sex with men in San Francisco: a suggestion of HIV serosorting?

Background: Sexually transmitted infections (STI) and unprotected anal intercourse (UAI) have been increasing among men who have sex with men (MSM) in San Francisco. However, HIV incidence has stabilised. Objectives: To describe recent trends in sexual risk behaviour, STI, and HIV incidence among MSM in San Francisco and to assess whether increases in HIV serosorting (that is, selective unprotected sex with partners of the same HIV status) may contribute to preventing further expansion of the epidemic. Methods: The study applies an ecological approach and follows the principles of second generation HIV surveillance. Temporal trends in biological and behavioural measures among MSM were assessed using multiple pre-existing data sources: STI case reporting, prevention outreach programmatic data, and voluntary HIV counselling and testing data. Results: Reported STI cases among MSM rose from 1998 through 2004, although the rate of increase slowed between 2002 and 2004. Rectal gonorrhoea cases increased from 157 to 389 while early syphilis increased from nine to 492. UAI increased overall from 1998 to 2004 (p<0.001) in community based surveys; however, UAI with partners of unknown HIV serostatus decreased overall (p<0.001) among HIV negative MSM, and among HIV positive MSM it declined from 30.7% in 2001 to a low of 21.0% in 2004 (p<0.001). Any UAI, receptive UAI, and insertive UAI with a known HIV positive partner decreased overall from 1998 to 2004 (p<0.001) among MSM seeking anonymous HIV testing and at the STI clinic testing programme. HIV incidence using the serological testing algorithm for recent HIV seroconversion (STARHS) peaked in 1999 at 4.1% at the anonymous testing sites and 4.8% at the STI clinic voluntary testing programme, with rates levelling off through 2004. Conclusions: HIV incidence among MSM appears to have stabilised at a plateau following several years of resurgence. Increases in the selection of sexual partners of concordant HIV serostatus may be contributing to the stabilisation of the epidemic. However, current incidence rates of STI and HIV remain high. Moreover, a strategy of risk reduction by HIV serosorting can be severely limited by imperfect knowledge of one’s own and one’s partners’ serostatus.

Amphetamine use is associated with increased HIV incidence among men who have sex with men in San Francisco

We examined the association between amphetamine use and HIV incidence for 2991 men who have sex with men (MSM) who tested anonymously for HIV in San Francisco. HIV incidence among 290 amphetamine users was 6.3% per year (95% CI 1.9–10.6%), compared with 2.1% per year (95% CI 1.3–2.9%) among 2701 non-users (RR 3.0, 95% CI 1.4–6.5). HIV prevention programmes in San Francisco should include efforts to reduce amphetamine use and associated high-risk sexual behaviors.

Late diagnosis of HIV infection : Trends, prevalence, and characteristics of persons whose HIV diagnosis occurred within 12 months of developing AIDS

Background:Persons diagnosed late in the course of HIV infection may be unknowingly transmitting infection and once diagnosed may have worse outcomes and greater medical expenses. Methods:Persons diagnosed with AIDS in San Francisco between 2001 and 2005 were included. Late testers were persons diagnosed with HIV 12 months or less before their AIDS diagnosis. Prevalence trends, demographic and risk correlates, and predictors of late testing were measured. Results:Among 2139 persons included, 830 (38.8%) were late testers. The prevalence of late testing was stable between 2001 and 2005. Late testing was more likely among persons <30 years old (Odds ratio [OR]: 1.99, 95% confidence interval [CI]: 1.4, 2.8), heterosexuals (OR: 1.88, 95% CI: 1.1, 3.1), persons without a reported risk (OR: 2.88, 95% CI: 1.7, 5.0), persons with private insurance (OR: 1.82, 95% CI: 1.4, 2.4), no insurance (OR: 1.83, 95% CI: 1.4, 2.4), born outside of the United States (OR: 1.64, 95% CI: 1.2, 2.2), and whose initial AIDS diagnosis was an opportunistic infection (OR: 2.24, 95% CI: 1.8, 2.8). Conclusions:A large proportion of persons with AIDS have tested late in the course of HIV infection and this proportion has not declined in recent years. Routine testing in medical settings, and use of rapid oral-fluid testing in traditional and nontraditional settings may increase early HIV diagnosis.

Incidence of human immunodeficiency virus among male-to-female transgendered persons in San Francisco.

Objective: To estimate HIV incidence among male‐to‐female transgendered persons (MtF transgendered persons) who repeatedly tested for HIV antibodies at public San Francisco counseling and testing sites between July 1997 and June 2000. Methods: HIV seroconversions were identified and person‐time of observation were estimated using the date and result of the current test and the self‐reported date and result of the previous test. Factors independently associated with HIV seroconversion were determined using multivariable proportional hazard analysis. Results: HIV incidence was 7.8 per 100 person‐years (95% confidence intervals [CI], 4.6‐12.3) based on 13 seroconversions among 155 repeat testers with 167.7 person‐years of observation. African‐American race/ethnicity (adjusted relative hazard ratio [HR], 5.0; 95% CI, 1.5‐16.2) and unprotected receptive anal intercourse (HR, 3.9; 95% CI, 1.2‐13.1) were independent predictors of HIV seroconversion. Conclusions: HIV is currently spreading at an extremely high rate among MtF transgendered persons in San Francisco, especially those who are African Americans.

Identifying barriers to HIV testing: personal and contextual factors associated with late HIV testing

Abstract Late diagnosis of HIV is associated with increased morbidity, mortality, and health care costs. Despite the availability of HIV testing, persons continue to test late in the course of HIV infection. We used the HIV/AIDS case registry of San Francisco Department of Public Health to identify and recruit 41 persons who developed AIDS within 12 months of their HIV diagnosis to participate in a qualitative and quantitative interview regarding late diagnosis of HIV. Thirty-one of the participants were diagnosed with HIV because of symptomatic disease and 50% of the participants were diagnosed with HIV and AIDS concurrently. Half of the subjects had not been tested for HIV prior to diagnosis. Fear was the most frequently cited barrier to testing. Other barriers included being unaware of improved HIV treatment, free/low cost care, and risk for HIV. Recommendations for health care providers to increase early diagnosis of HIV include routine ascertainment of HIV risk behaviors and testing histories, stronger recommendations for patients to be tested, and incorporating testing into routine medical care. Public health messages to increase testing include publicizing that (1) effective, tolerable, and low cost/free care for HIV is readily available, (2) early diagnosis of HIV improves health outcomes, (3) HIV can be transmitted to persons who engage in unprotected oral and insertive anal sex and unprotected receptive anal intercourse without ejaculation and from HIV-infected persons whose infection is well-controlled with antiretroviral therapy, (4) persons who may be infected based upon these behaviors should be tested following exposure, (5) HIV testing information will be kept private, and (6) encouraging friends and family to get HIV tested is beneficial.

Risk of HIV infection attributable to oral sex among men who have sex with men and in the population of men who have sex with men

We examined HIV infection and estimated the population-attributable risk percentage (PAR%) for HIV associated fellatio among men who have sex with other men (MSM). Among 239 MSM who practised exclusively fellatio in the past 6 months, 50% had three partners, 98% unprotected; and 28% had an HIV-positive partner; no HIV was detected. PAR%, based on the number of fellatio partners, ranges from 0.10% for one partner to 0.31% for three partners. The risk of HIV attributable to fellatio is extremely low.

Changing sexual behavior among gay male repeat testers for HIV: a randomized, controlled trial of a single-session intervention.

CONTEXT High-risk sexual behavior is increasingly prevalent among men who have sex with men (MSM) and among men with a history of repeat testing for HIV. OBJECTIVES The study assessed whether one counseling intervention session focusing on self-justifications (thoughts, attitudes, or beliefs that allow the participant to engage in high-risk sexual behaviors) at most recent unprotected anal intercourse (UAI) is effective in reducing future high-risk behaviors among HIV-negative men. DESIGN, SETTING, AND PARTICIPANTS A randomized, controlled, counseling intervention trial was conducted at an anonymous testing site in San Francisco, California, between May 1997 and January 2000. Participants were 248 MSM with a history of at least one previous negative HIV test result and self-reported UAI (receptive or insertive) in the previous 12 months with partners of unknown or discordant HIV status. Two intervention groups received standard HIV test counseling plus a cognitive-behavioral intervention, and two control groups received only standard HIV test counseling. Follow-up evaluation was at 6 and 12 months. MAIN OUTCOME MEASURE Number of episodes of UAI with nonprimary partners (of unknown or discordant HIV status) in the 90 days preceding the interview was measured via self-report during face-to-face interview. RESULTS A novel counseling intervention focusing on self-justifications significantly decreased the proportion of participants reporting UAI with nonprimary partners of unknown or discordant HIV status at 6 and 12 months (from 66% to 21% at 6 months and to 26% at 12 months, p =.002; p <.001) as compared with a control group when added to standard client-centered HIV counseling and testing. CONCLUSIONS A specific, single-session counseling intervention focusing on a reevaluation of a persons self-justifications operant during a recent occasion of high-risk behavior may prove useful in decreasing individual risk behavior and thus limiting community-level HIV transmission.

Detection of early HIV infection and estimation of incidence using a sensitive/less-sensitive enzyme immunoassay testing strategy at anonymous counseling and testing sites in San Francisco.

Timely estimates of HIV incidence are needed to monitor the epidemic and target primary prevention but have been difficult to obtain. We applied a sensitive/ less-sensitive (S/LS) enzyme immunoassay (EIA) testing strategy to stored HIV-positive sera (N = 452) to identify early infections, estimate incidence, and characterize correlates of recent seroconversion among persons seeking anonymous HIV testing in San Francisco from 1996 to 1998 (N = 21,292). Sera positive on a sensitive EIA but negative on a less-sensitive EIA were classified as early HIV infections; sera positive on both EIA were classified as long standing. Seventy-nine sera were from people with early HIV infection. Estimated HIV incidence was 1.1% per year (95% confidence interval [CI], 0.68%-1.6%) overall and 1.9% per year (95% CI, 1.2%-3.0%) among men who have sex with men (MSM). Early HIV infection among MSM was associated with injection drug use, unprotected receptive anal sex, and multiple sex partners in the previous year. No temporal trend in HIV incidence was noted over the study period. The S/LS strategy provides a practical public health tool to identify early HIV infection and estimate HIV incidence in a variety of study designs and settings.

Brief cognitive counseling with HIV testing to reduce sexual risk among men who have sex with men: results from a randomized controlled trial using paraprofessional counselors.

Objectives:To test the efficacy and acceptability of a single-session personalized cognitive counseling (PCC) intervention delivered by paraprofessionals during HIV voluntary counseling and testing. Methods:HIV-negative men who have sex with men (MSM; n = 336) were randomly allocated to PCC or usual counseling (UC) between October 2002 and September 2004. The primary outcome was the number of episodes of unprotected anal intercourse (UAI) with any nonprimary partner of nonconcordant HIV serostatus in the preceding 90 days, measured at baseline, 6 months, and 12 months. Impact was assessed as “intent to treat” by random-intercept Poisson regression analysis. Acceptability was assessed by a standardized client satisfaction survey. Results:Men receiving PCC and UC reported comparable levels of HIV nonconcordant UAI at baseline (mean episodes: 4.2 vs. 4.8, respectively; P = 0.151). UAI decreased by more than 60% to 1.9 episodes at 6 months in the PCC arm (P < 0.001 vs. baseline) but was unchanged at 4.3 episodes for the UC arm (P = 0.069 vs. baseline). At 6 months, men receiving PCC reported significantly less risk than those receiving UC (P = 0.029 for difference to PCC). Risk reduction in the PCC arm was sustained from 6 to 12 months at 1.9 (P = 0.181), whereas risk significantly decreased in the UC arm to 2.2 during this interval (P < 0.001 vs. 6 months; P = 0.756 vs. PCC at 12 months). Significantly more PCC participants were “very satisfied” with the counseling experience (78.2%) versus UC participants (59.2%) (P = 0.002). Conclusions:Both interventions were effective in reducing high-risk sexual behavior among MSM repeat testers. PCC participants demonstrated significant behavioral change more swiftly and reported a more satisfying counseling experience than UC participants.