Kyle T. Bernstein

Why don't physicians test for Hiv? A review of the Us literature

Objective:In its 2006 HIV testing guidelines, the Centers for Disease Control and Prevention (CDC) recommended routine testing in all US medical settings. Given that many physicians do not routinely test for HIV, the objective of this study was to summarize our current understanding of why US physicians do not offer HIV testing. Design:A comprehensive review of the published and unpublished literature on HIV testing barriers was conducted. Methods:A literature search was conducted in Pubmed using defined search terms. Other sources included Google, recent conference abstracts, and experts in the field. Studies were divided into three categories: prenatal; emergency department; and other medical settings. These categories were chosen because of differences in physician training, practice environment, and patient populations. Barriers identified in these sources were summarized separately for the three practice settings and compared. Results:Forty-one barriers were identified from 17 reports. Twenty-four barriers were named in the prenatal setting, 20 in the emergency department setting, and 23 in other medical settings. Eight barriers were identified in all three categories: insufficient time; burdensome consent process; lack of knowledge/training; lack of patient acceptance; pretest counselling requirements; competing priorities; and inadequate reimbursement. Conclusion:US physicians experience many policy-based, logistical, and educational barriers to HIV testing. Although some barriers are exclusive to the practice setting studied, substantial overlap was found across practice settings. Some or all of these barriers must be addressed before the CDC recommendation for routine HIV testing can be realized in all US medical settings.

Rectal gonorrhea and chlamydia reinfection is associated with increased risk of HIV seroconversion.

Introduction:HIV infection continues to disproportionately affect men who have sex with men (MSM). Identification of modifiable risk factors for HIV infection among MSM is critical for effective prevention. Methods:We examined the relationship between number of prior rectal Neisseria gonorrhoeae (GC) or Chlamydia trachomatis (CT) infections and HIV seroconversion in a retrospective cohort of HIV-uninfected MSM diagnosed with a rectal infection. Number of rectal CT or GC infections in the prior 2 years was the primary exposure. Univariate and multivariate Cox proportional hazards models were used to estimate the association between prior rectal infections and HIV seroconversion. Results:A total of 541 MSM were observed for a total of 1197.96 person-years. Overall, 27 (4.99%) of the MSM became infected with HIV, for an estimated annual incidence of 2.25% [95% confidence interval (CI): 1.49 to 3.26]. In multivariate analysis, an early syphilis diagnosis in the past 2 years (hazard ratio = 4.04, 95% CI: 1.19 to 13.79) and 2 prior CT or GC rectal infections in the past 2 years (hazard ratio = 8.85, 95% CI: 2.57 to 30.40) were associated with incident HIV. Conclusions:Among MSM infected with rectal GC or CT, a history of 2 additional prior rectal infections was associated with an 8-fold increased risk of HIV infection. HIV-uninfected MSM with multiple rectal infections represent a population in need of innovative HIV-prevention interventions.

Ebola RNA Persistence in Semen of Ebola Virus Disease Survivors — Final Report

BACKGROUND Ebola virus has been detected in the semen of men after their recovery from Ebola virus disease (EVD). We report the presence of Ebola virus RNA in semen in a cohort of survivors of EVD in Sierra Leone. METHODS We enrolled a convenience sample of 220 adult male survivors of EVD in Sierra Leone, at various times after discharge from an Ebola treatment unit (ETU), in two phases (100 participants were in phase 1, and 120 in phase 2). Semen specimens obtained at baseline were tested by means of a quantitative reverse‐transcriptase–polymerase‐chain‐reaction (RT‐PCR) assay with the use of the target sequences of NP and VP40 (in phase 1) or NP and GP (in phase 2). This study did not evaluate directly the risk of sexual transmission of EVD. RESULTS Of 210 participants who provided an initial semen specimen for analysis, 57 (27%) had positive results on quantitative RT‐PCR. Ebola virus RNA was detected in the semen of all 7 men with a specimen obtained within 3 months after ETU discharge, in 26 of 42 (62%) with a specimen obtained at 4 to 6 months, in 15 of 60 (25%) with a specimen obtained at 7 to 9 months, in 4 of 26 (15%) with a specimen obtained at 10 to 12 months, in 4 of 38 (11%) with a specimen obtained at 13 to 15 months, in 1 of 25 (4%) with a specimen obtained at 16 to 18 months, and in no men with a specimen obtained at 19 months or later. Among the 46 participants with a positive result in phase 1, the median baseline cycle‐threshold values (higher values indicate lower RNA values) for the NP and VP40 targets were lower within 3 months after ETU discharge (32.4 and 31.3, respectively; in 7 men) than at 4 to 6 months (34.3 and 33.1; in 25), at 7 to 9 months (37.4 and 36.6; in 13), and at 10 to 12 months (37.7 and 36.9; in 1). In phase 2, a total of 11 participants had positive results for NP and GP targets (samples obtained at 4.1 to 15.7 months after ETU discharge); cycle‐threshold values ranged from 32.7 to 38.0 for NP and from 31.1 to 37.7 for GP. CONCLUSIONS These data showed the long‐term presence of Ebola virus RNA in semen and declining persistence with increasing time after ETU discharge. (Funded by the World Health Organization and others.)

Chlamydia trachomatis and Neisseria gonorrhoeae Transmission from the Oropharynx to the Urethra among Men who have Sex with Men

BACKGROUND Limited data exist on the risk of Chlamydia trachomatis and Neisseria gonorrhoeae transmission from oropharynx to urethra. We examined urethral C. trachomatis and N. gonorrhoeae positivity among men who have sex with men (MSM) seen at San Francisco City Clinic (San Francisco, CA) during 2007. METHODS All patients who sought care at the San Francisco City Clinic (the only municipal sexually transmitted disease clinic in San Francisco) received a standardized interview conducted by clinicians. We estimated urethral C. trachomatis and N. gonorrhoeae positivity for 2 groups of visits by MSM who visited during 2007: (1) men who reported their only urethral exposure was receiving fellatio in the previous 3 months and (2) men who reported unprotected insertive anal sex in the previous 3 months. Additionally, urethral C. trachomatis and N. gonorrhoeae positivity was estimated, stratified by human immunodeficiency virus infection status, urogenital symptom history, and whether the patient had been a contact to a sex partner with either chlamydia or gonorrhea. RESULTS Among MSM who reported only receiving fellatio, urethral C. trachomatis and N. gonorrhoeae positivity were 4.8% and 4.1%, respectively. These positivity estimates were similar to positivity found among MSM who reported unprotected insertive anal sex. CONCLUSIONS A more complete understanding of the risks of transmission of C. trachomatis and N. gonorrhoeae from oropharynx to urethra will help inform prevention and screening programs.

Trichomonas vaginalis Antimicrobial Drug Resistance in 6 US Cities, STD Surveillance Network, 2009–2010

Such isolates should undergo drug susceptibility testing periodically to detect emerging resistance.

HIV testing frequency among men who have sex with men attending sexually transmitted disease clinics: implications for HIV prevention and surveillance.

Objectives:To describe trends in the occurrence and frequency of HIV testing among men who have sex with men (MSM) receiving care in 4 US sexually transmitted disease (STD) clinics and to define factors associated with HIV testing frequency and positivity. Study Design:Routine clinical encounters during 57,131 visits by MSM to STD clinics in 4 cities (Seattle-King County, San Francisco, Denver, and District of columbia), 2002-2006, were examined. Results:From 2002 to 2006, a city-specific median of 69.1% of presumptive HIV-uninfected MSM were tested for HIV, of which, a median of 86.7% had previously tested (4.5% unknown) and a median of 3.9% were newly diagnosed with HIV. Between 2002 and 2006, the median percentage of tested MSM who reported no previous HIV testing decreased from 9.4% to 5.4% (P = 0.01) and the city-specific median intertest interval decreased from 302 to 243 days (P = 0.03). Among MSM with newly diagnosed HIV, the median intertest interval decreased from 531 days in 2002 to 287 days in 2006 (P = 0.001). Predictors of newly diagnosed HIV infection included the following: younger age, longer intertest interval, black or Hispanic race/ethnicity, clinic in San Francisco, and concurrent diagnosis with a bacterial STD. Conclusions:In MSM seen at 4 STD clinics, the percentage of never previously HIV tested is decreasing and MSM are testing more frequently.

Extragenital Gonorrhea and Chlamydia Testing and Infection Among Men Who Have Sex With Men—STD Surveillance Network, United States, 2010–2012

BACKGROUND Gonorrhea (GC) and chlamydia (CT) are the most commonly reported notifiable diseases in the United States. The Centers for Disease Control and Prevention recommends that men who have sex with men (MSM) be screened for urogenital GC/CT, rectal GC/CT, and pharyngeal GC. We describe extragenital GC/CT testing and infections among MSM attending sexually transmitted disease (STD) clinics. METHODS The STD Surveillance Network collects patient data from 42 STD clinics. We assessed the proportion of MSM attending these clinics during July 2011-June 2012 who were tested and positive for extragenital GC/CT at their most recent visit or in the preceding 12 months and the number of extragenital infections that would have remained undetected with urethral screening alone. RESULTS Of 21 994 MSM, 83.9% were tested for urogenital GC, 65.9% for pharyngeal GC, 50.4% for rectal GC, 81.4% for urogenital CT, 31.7% for pharyngeal CT, and 45.9% for rectal CT. Of MSM tested, 11.1% tested positive for urogenital GC, 7.9% for pharyngeal GC, 10.2% for rectal GC, 8.4% for urogenital CT, 2.9% for pharyngeal CT, and 14.1% for rectal CT. More than 70% of extragenital GC infections and 85% of extragenital CT infections were associated with negative urethral tests at the same visit and would not have been detected with urethral screening alone. CONCLUSIONS Extragenital GC/CT was common among MSM attending STD clinics, but many MSM were not tested. Most extragenital infections would not have been identified, and likely would have remained untreated, with urethral screening alone. Efforts are needed to facilitate implementation of extragenital GC/CT screening recommendations for MSM.

Implementation of HIV Testing at 2 New York City Bathhouses: From Pilot to Clinical Service

BACKGROUND Commercial sex venues (e.g., bathhouses) that cater to men who have sex with men (MSM) continue to function in most urban areas. These venues present a challenge to developing strategies to prevent the spread of the human immunodeficiency virus (HIV), but they also provide opportunities for interventions to reduce the risk and rate of disease transmission. Several cities in the United States have developed programs that offer HIV testing in these venues. Similar programs have not existed before in New York City. METHODS A pilot HIV testing program was implemented at 2 New York City bathhouses. Testing included rapid HIV testing, the use of the serologic testing algorithm for recent HIV seroconversion, and pooled plasma HIV viral load to detect and date incident and acute HIV infections. In addition to HIV tests, behavioral and demographic data were collected from 493 presumed HIV-negative participants. RESULTS The pilot program recruited MSM who were at high risk for HIV infection. Of the 493 men tested, 20 (4%) were found to be positive for HIV, and 8 (40%) of these 20 men demonstrated evidence of acute or recent HIV infection. The program tested men often not tested in more traditional medical settings. Significant disparities were demonstrated in the testing habits of MSM who reported having sex with women and had not disclosed same-sex activities to their caregivers. CONCLUSIONS Bathhouse-based testing for HIV infection can be implemented in New York City and would include a population of MSM who are at high risk for HIV infection. Because of the high rate of recent HIV infection, expanded testing in these venues may be a good strategy to reduce the forward transmission of HIV in this highly sexually active population.

A new trend in the HIV epidemic among men who have sex with men, San Francisco, 2004-2011.

Background:In San Francisco, men who have sex with men (MSM) have historically comprised 90% of the HIV epidemic. It has been suggested that given the ongoing HIV transmission among this population, there is the possibility of a high-level endemic of HIV into the future. We report on the possibility of another phase in the HIV epidemic among MSM in San Francisco. Methods:Behavioral surveillance systems monitor HIV prevalence, HIV incidence, and behaviors among populations at high risk for HIV infection. Among MSM, time–location sampling is used to obtain samples for standardized behavioral surveys, HIV-antibody and incidence testing. We analyzed National HIV Behavioral Surveillance data from MSM sampled in 2004, 2008, and 2011. Results:Three hundred eighty-six, 521, and 510 MSM were enrolled in each of the waves. Only slight changes were seen in demographics over time. We detected significant declines in unrecognized HIV infection and methamphetamine use, a significant increase in HIV testing in the past 6 months, and no changes in HIV prevalence, history of gonorrhea infection, or having multiple sex partners. Among HIV-infected men, current antiretroviral treatment (ART) use seems to have risen from 2008 to 2011. Conclusions:The trends of the last 7 years point to stable HIV prevalence as rising ART coverage results in improving survival coupled with decreasing incidence as ART use achieves viral load suppression at levels more than sufficient to offset ongoing sexual risk behavior. “Treatment as prevention” may be occurring among MSM in San Francisco.

Exploring the relationship between sexually transmitted diseases and HIV acquisition by using different study designs

Background:It is hypothesized that sexually transmitted diseases (STDs) increase the risk of HIV acquisition. Yet difficulties establishing an accurate temporal relation and controlling confounders have obscured this relationship. In an attempt to overcome prior methodologic shortcomings, we explored the use of different study designs to examine the relationship between STDs and HIV acquisition. Methods:Acutely HIV-infected patients were included as cases and compared with (1) HIV-uninfected patients (matched case-control), (2) newly diagnosed chronically HIV-infected patients (infected analysis), and (3) themselves at prior clinic visits when they tested HIV negative (case crossover). We used t tests to compare the average number of STDs and logistic regression to determine independent correlates and the odds of acute HIV infection. Results:Between October 2003 and March 2007, 13,662 male patients who had sex with men were tested for HIV infection at San Franciscos municipal STD clinic and 350 HIV infections (2.56%) were diagnosed. Among the HIV-infected patients, 36 cases (10.3%) were identified as acute. We found consistently higher odds of having had an STD within the 12 months [matched case-control, odds ratio 5.2 (2.2-12.6); infected analysis, odds ratio 1.4 (1.0-2.0); and case crossover, odds ratio 1.3 (0.5-3.1)] and 3 months [matched case-control, odds ratio 34.5 (4.1-291.3); infected analysis, odds ratio 2.3 (1.1-4.8); and case crossover, odds ratio 1.8 (0.6-5.6)] before HIV testing among acutely HIV-infected patients. We found higher odds of acute HIV infection among patients with concurrent rectal gonorrhea [17.0 (2.6-111.4), P < 0.01] or syphilis [5.8 (1.1-32.3), P = 0.04] when compared with those HIV-uninfected patients. Conclusions:Acute HIV infection was associated with a recent or concurrent STD, particularly rectal gonorrhea, among men at San Franciscos municipal STD clinic. Given the complex relationship between STDs and HIV infection, no single design will appropriately control for all the possible confounders; studies using complementary designs are required.