Jamie P. Morano

The Burgeoning HIV/HCV Syndemic in the Urban Northeast: HCV, HIV, and HIV/HCV Coinfection in an Urban Setting

Introduction Despite recommendations for generation-based HCV and once lifetime HIV screening, thousands of individuals in the U.S. still remain untested and undiagnosed. This cross-sectional study examines the correlates of HCV and HIV monoinfection and HIV/HCV coinfection in an urban Northeast setting. Methods Utilizing an electronic database from a mobile medical clinic in New Haven, CT from January 2003 to July 2011, 8,311 individuals underwent structured health assessment and screening for HIV and HCV. Results HIV [N = 601 (8.0%)] and HCV [N = 753 (10.1%)] infection were identified, and 197 (26.1%) of the 753 with HCV were coinfected with HIV. Both monoinfection and coinfection status were independently correlated with crack cocaine use and increasing age. HIV/HCV coinfection was correlated with men having sex with men (MSM) (AOR = 38.53, p<0.0080), shooting gallery use (AOR = 3.06, p<0.0070), and not completing high school (AOR = 2.51, p<0.0370). HCV monoinfection correlated with health insurance (AOR = 2.16, p<0.0020), domestic violence (AOR = 1.99, p<0.0070), and being Hispanic (AOR = 2.63, p<0.0001), while HIV monoinfection correlated with having had syphilis (AOR = 2.66, p<0.0001) and being Black (AOR = 1.73, p = 0.0010). Conclusions Though HIV and HCV share common transmission risk behaviors, independent correlates with viral infection status in an urban Northeast setting are distinct and have important implications for surveillance, healthcare delivery, disease prevention, and clinical care.

Bridging the epidemic: a comprehensive analysis of prevalence and correlates of HIV hepatitis C and syphilis and infection among female sex workers in Guangxi Province China.

Introduction Female sex workers (FSWs) are at highest risk for contracting HIV and facilitating the current heterosexual HIV epidemic in Guangxi, China, yet little is known of the impact of recent harm reduction campaigns in the province. We analyzed sentinel surveillance data collected between 2010 and 2012 in Guangxi to explore correlations between the prevalence of HIV, hepatitis C (HCV), and syphilis and risk behaviors of different categories of FSWs in Guangxi. Methods The sentinel surveillance data for 5,1790 FSWs in all 14 prefectures and 64 city/county regions of Guangxi, China from 2010 to 2012 were collected. Differences between three categories of FSWs (grouped by venue) and disease trends (HIV, HCV, and syphilis) by year were analyzed using bivariate and multivariate logistic regression analyses as to evaluate risk factors correlated with HIV, HCV, or syphilis infection. Results HIV and HCV prevalence remained constant across the three FSW categories; however, syphilis prevalence showed a significant increase from 5.7% to 7.3% for low-tier FSWs. Most cases with HIV, HCV, syphilis and intravenous drug use were seen in low-tier FSWs. Testing positive for HIV and syphilis were most correlated with being HCV positive (AOR 4.12 and AOR 4.36), only completing elementary school (AOR 3.71 and AOR 2.35), low tier venues (AOR 2.02 and AOR 2.00), and prior STI (AOR 1.40 and AOR 3.56), respectively. HCV infection was correlated with ever injecting drugs (AOR 60.65) and testing positive for syphilis (AOR 4.16) or HIV (AOR 3.74). Conclusions This study highlights that low tier FSWs with lower formal education levels are the most vulnerable population at risk for acquiring and transmitting HIV, HCV, and syphilis in Guangxi, China. Condom distribution with evolution to safer sex practices are the reasons to explain the non-increasing prevalence of HIV, HCV in Guangxi for 2010–2012.

Latent tuberculosis infection screening in foreign-born populations: a successful mobile clinic outreach model.

OBJECTIVES We evaluated the efficacy of a mobile medical clinic (MMC) screening program for detecting latent tuberculosis infection (LTBI) and active tuberculosis. METHODS A LTBI screening program in a MMC in New Haven, Connecticut, used medical surveys to examine risk factors and tuberculin skin test (TST) screening eligibility. We assessed clinically relevant correlates of total (prevalent; n = 4650) and newly diagnosed (incident; n = 4159) LTBI from 2003 to 2011. RESULTS Among 8322 individuals, 4159 (55.6%) met TST screening eligibility criteria, of which 1325 (31.9%) had TST assessed. Similar to LTBI prevalence (16.8%; 779 of 4650), newly diagnosed LTBI (25.6%; 339 of 1325) was independently correlated with being foreign-born (adjusted odds ratio [AOR] = 8.49; 95% confidence interval [CI] = 5.54, 13.02), Hispanic (AOR = 3.12; 95% CI = 1.88, 5.20), Black (AOR = 2.16; 95% CI = 1.31, 3.55), employed (AOR = 1.61; 95% CI = 1.14, 2.28), and of increased age (AOR = 1.04; 95% CI = 1.02, 1.05). Unstable housing (AOR = 4.95; 95% CI = 3.43, 7.14) and marijuana use (AOR = 1.57; 95% CI = 1.05, 2.37) were significantly correlated with incident LTBI, and being male, heroin use, interpersonal violence, employment, not having health insurance, and not completing high school were significantly correlated with prevalent LTBI. CONCLUSIONS Screening for TST in MMCs successfully identifies high-risk foreign-born, Hispanic, working, and uninsured populations and innovatively identifies LTBI in urban settings.

Exploring HIV-related stigma among HIV-infected men who have sex with men in Beijing, China: a correlation study.

ABSTRACT Human immunodeficiency virus (HIV)-related stigma among HIV-infected men who have sex with men (MSM) has been associated with adverse health outcomes, including poor adherence to antiretroviral therapy and care, and increased participation in behaviors linked to higher rates of HIV transmission. In China, the incidence of HIV is growing more rapidly among MSM than among other subgroups. This study characterizes and quantifies HIV stigma among HIV-infected MSM in Beijing, China, which arguably may be driving this epidemic. A cross-sectional survey study was performed among 266 HIV-positive MSM in Beijing, China, in 2014. The Berger HIV Stigma Scale was used to measure levels of HIV-related stigma. Participants additionally answered questions regarding socio-demographic characteristics and HIV-associated risk factors; previously validated Mandarin-language scales assessed depression, coping style, and social support networks. Multivariable linear regression models were used to identify variables significantly associated with HIV stigma. The mean overall HIV stigma score among the study population was 112.78 ± 18.11 (score range: 40–160). Higher HIV stigma scores were positively associated with depression (β = 7.99, 95% CI:3.69, 12.29, p < .001) and negative coping skills (β = 0.64, 95% CI:0.21,1.08, p < .01), and was negatively associated with disclosed HIV status (β = −6.45, 95%CI:−11.80, −1.11, p < .05), and availability of social support networks (β = −0.12, 95%CI:−0.22, −0.02, p < .05). Other variables such as poor self-rated health status and presence of opportunistic infections were positively associated with individual dimensions of HIV-related stigma. The results of this study can inform the development of culturally sensitive interventions to reduce HIV-related stigma among MSM with HIV in China, with the overarching goal of reducing HIV transmission in this vulnerable population.

Accessibility and utilization patterns of a mobile medical clinic among vulnerable populations

We mapped mobile medical clinic (MMC) clients for spatial distribution of their self-reported locations and travel behaviors to better understand health-seeking and utilization patterns of medically vulnerable populations in Connecticut. Contrary to distance decay literature, we found that a small but significant proportion of clients was traveling substantial distances to receive repeat care at the MMC. Of 8404 total clients, 90.2% lived within 5 miles of a MMC site, yet mean utilization was highest (5.3 visits per client) among those living 11-20 miles of MMCs, primarily for those with substance use disorders. Of clients making >20 visits, 15.0% traveled >10 miles, suggesting that a significant minority of clients traveled to MMC sites because of their need-specific healthcare services, which are not only free but available at an acceptable and accommodating environment. The findings of this study contribute to the important research on healthcare utilization among vulnerable population by focusing on broader dimensions of accessibility in a setting where both mobile and fixed healthcare services coexist.

The Relationship Between Individual Characteristics and Interest in Using a Mobile Phone App for HIV Self-Management: Observational Cohort Study of People Living With HIV

Background The human immunodeficiency virus (HIV) continues to be a major health issue in the United States, and an estimated 1.2 million people in the United States are living with HIV. As part of Healthy People 2020, the Office of Disease Prevention and Health Promotion has targeted the persistent demographic and geographic disparities in HIV prevalence and management. Preliminary evidence suggests that mobile health technology (smartphone apps) may be a promising way to support HIV self-management among vulnerable populations of people living with HIV (PLWH) who lack access to appropriate health care services. Objective This study examines the association between individual characteristics of PLWH and level of interest in using a free mobile phone app for HIV self-management. Methods This study was conducted using cross-sectional survey data collected in the Florida Cohort Study between 2014 and 2016 (N=766). Associations between individual characteristics of PLWH and level of interest in using a free mobile phone app for HIV self-management were examined using bivariate analysis and logistic regression. Results Overall, 85.5% (655/766) of respondents were interested in using a free mobile phone app that supports HIV self-management. Participants expressed the highest interest in app functions that facilitate communication with health care providers (568/740, 76.8%) or help to identify relevant health care services (556/745 74.6%). Age (OR 0.959, 95% CI 0.936-0.982), education (OR 1.281, 95% CI 1.027-1.598) and disability or inability to work (OR 0.296, 95% CI 0.145-0.606) were all significantly associated with being interested in using a free mobile phone app for HIV self-management. Conclusions This study indicates that a majority of PLWH are interested in using a free mobile phone app to self-manage their condition. The findings can inform the development of mobile phone apps that support effective HIV self-management.

Human Immunodeficiency Virus Infection-Associated Mortality during Pulmonary Tuberculosis Treatment in Six Provinces of China

OBJECTIVE To investigate the risk factors attributable to tuberculosis-related deaths in areas with human immunodeficiency virus (HIV) infection epidemics. METHODS A prospective cohort study of newly registered patients in tuberculosis (TB) dispensaries in six representative Chinese provinces was conducted from September 1, 2009 to August 31, 2011. Risk factors for TB-associated death were identified through logistic regression analysis. RESULTS Of 19,103 newly registered pulmonary TB patients, 925 (4.8%) were found to be HIV-positive. Miliary TB and acid-fast bacillus smear-negative TB were more common among these patients. Out of a total of 322 (1.7%) deaths that occurred during TB treatment, 85 (26%) of the patients were co-infected with HIV. Multivariate analysis revealed that HIV infection was the strongest predictor of death [adjusted odds ratio (aOR) 7.86]. Other significant mortality risk factors included presentation with miliary TB (aOR 4.10; 95% confidence interval: 2.14-7.88), ⋝35 years of age (aOR 3.04), non-Han ethnicity (aOR 1.67), and farming as an occupation (aOR 1.59). For patients with TB/HIV co-infection, miliary TB was the strongest risk factor for death (aOR 5.48). A low CD4 count (⋜200 cells/µL) (aOR 3.27) at the time of TB treatment initiation and a lack of antiretroviral therapy (ART) administration (aOR 3.78) were also correlated with an increased risk of death. CONCLUSION Infection with HIV was independently associated with increased mortality during TB treatment. Offering HIV testing at the time of diagnosis with TB, early TB diagnosis among HIV/acquired immunodeficiency syndrome patients, and the timely provision of ART were identified as the key approaches that could reduce the number of HIV-associated TB deaths.

Causes of Death among AIDS Patients after Introduction of Free Combination Antiretroviral Therapy (cART) in Three Chinese Provinces, 2010–2011

Introduction Although AIDS-related deaths have had significant economic and social impact following an increased disease burden internationally, few studies have evaluated the cause of AIDS-related deaths among patients with AIDS on combination anti-retroviral therapy (cART) in China. This study examines the causes of death among AIDS-patients in China and uses a methodology to increase data accuracy compared to the previous studies on AIDS-related mortality in China, that have taken the reported cause of death in the National HIV Registry at face-value. Methods Death certificates/medical records were examined and a cross-sectional survey was conducted in three provinces to verify the causes of death among AIDS patients who died between January 1, 2010 and June 30, 2011. Chi-square analysis was conducted to examine the categorical variables by causes of death and by ART status. Univariate and multivariate logistic regression were used to evaluate factors associated with AIDS-related death versus non-AIDS related death. Results This study used a sample of 1,109 subjects. The average age at death was 44.5 years. AIDS-related deaths were significantly higher than non-AIDS and injury-related deaths. In the sample, 41.9% (465/1109) were deceased within a year of HIV diagnosis and 52.7% (584/1109) of the deceased AIDS patients were not on cART. For AIDS-related deaths (n = 798), statistically significant factors included CD4 count <200 cells/mm3 at the time of cART initiation (AOR 1.94, 95%CI 1.24–3.05), ART naïve (AOR 1.69, 95%CI 1.09–2.61; p = 0.019) and age <39 years (AOR 2.96, 95%CI 1.77–4.96). Conclusion For the AIDS patients that were deceased, only those who initiated cART while at a CD4 count ≥200 cells/mm3 were less likely to die from AIDS-related causes compared to those who didn’t initiate ART at all.

Interest in using mobile technology to help self-manage alcohol use among persons living with the human immunodeficiency virus: A Florida Cohort cross-sectional study

BACKGROUND Alcohol consumption at hazardous levels is more prevalent and associated with poor health outcomes among persons living with the human immunodeficiency virus (HIV; PLWH). Although PLWH are receptive to using technology to manage health issues, it is unknown whether a cell phone app to self-manage alcohol use would be acceptable among PLWH who drink. The objectives of this study were to determine factors associated with interest in an app to self-manage drinking and to identify differences in baseline mobile technology use among PLWH by drinking level. METHODS The study population included 757 PLWH recruited from 2014 to 2016 into the Florida Cohort, an ongoing cohort study investigating the utilization of health services and HIV care outcomes among PLWH. Participants completed a questionnaire examining demographics, substance use, mobile technology use, and other health behaviors. Multivariable logistic regression was used to identify factors significantly associated with interest in an app to self-manage drinking. We also determined whether mobile technology use varied by drinking level. RESULTS Of the sample, 40% of persons who drink at hazardous levels, 34% of persons who drink at nonhazardous levels, and 19% of persons who do not drink were interested in a self-management app for alcohol use. Multivariable logistic regression analysis indicated that nonhazardous drinking (adjusted odds ratio [AOR] = 1.78; confidence interval [CI 95%]: 1.10-2.88) and hazardous drinking (AOR = 2.58; CI: 1.60-4.16) were associated with interest, controlling for age, gender, education, and drug use. Regarding mobile technology use, most of the sample reported smartphone ownership (56%), text messaging (89%), and at least one cell phone app (69%). CONCLUSIONS Regardless of drinking level, overall mobile technology use among PLWH was moderate, whereas PLWH who consumed alcohol expressed greater interest in a cell phone app to self-manage alcohol use. This indicates that many PLWH who drink would be interested in and prepared for a mobile technology-based intervention to reduce alcohol consumption.

HIV-related stigma among people living with HIV/AIDS in rural Central China

BackgroundHIV-related stigma among people living with HIV/AIDS (PLWHA) has been associated with many negative consequences, including poor adherence to therapy and undue psychological stress. However, the relative influence of specific demographic and situational factors contributing to HIV-related stigma among rural PLWHA in central China remains unknown. The aim of this study was to explore the level of HIV-related stigma among rural PLWHA across specific demographic and situational factors in central China.MethodsA cross-sectional study was conducted among PLWHA receiving care through the Chinese Centers for Disease Control of Zhenping county in Henan Province, China. Participants completed a 55-item questionnaire which included demographic and disease-related factors, HIV-related stigma was measured utilizing the validated Berger HIV Stigma Scale which has good psychometric characteristics in Chinese PLWHA.ResultsA total of 239 PLWHA completed the survey. The mean total HIV-related stigma score was 105.92 (SD = 12.35, 95% CI: 104.34, 107.49). Multivariable linear regression analysis revealed a higher level of HIV-related stigma in younger PLWHA (β = − 0.57, 95% CI = − 0.78,-0.35, p<0.001) and those who self-reported opportunistic infections (β = 6.26, 95% CI = 1.26, 11.26, p < 0.05).ConclusionsThe findings in the current study suggest that rural PLWHA in central China suffer from the burden of HIV-related stigma at a moderate to high level. Younger PLWHA and PLWHA that have opportunistic infections tend to perceive a higher level of HIV stigma.