Lou C. Smith

Reductions in hepatitis C virus and HIV infections among injecting drug users in New York City, 1990-2001

Objective:To assess trends in HIV, hepatitis C virus (HCV) and HIV/HCV infection among injecting drug users (IDU) from 1990 to 2001 in New York City. The 1990–2001 time period included a very large expansion of syringe exchange in New York City, from 250 000 to 3 000 000 syringes exchanged annually. Methods:Cross-sectional seroprevalence surveys of IDU entering drug abuse treatment in New York City, with sample sizes for HCV of 72 in 1990–1991 and 412 in 2000–2001. A structured risk behavior questionnaire was administered, and HIV and HCV testing were conducted. HCV testing was performed on de-linked stored serum samples. Results:Over the 1990–2001 period, HIV prevalence declined from 54 to 13%. HCV prevalence declined from 80 to 59% among HIV-seronegative individuals, and from 90 to 63% overall. The estimated HCV incidence in 2000–2001 among new injectors was 18 per 100 person-years at risk. Conclusions:The large-scale expansion of syringe exchange was temporally associated with large reductions in both HIV and HCV prevalence. The prevalence and incidence of HCV, however, still remain at high levels among IDU in New York City.

Acquiring human immunodeficiency virus during pregnancy and mother-to-child transmission in New York: 2002-2006.

OBJECTIVE: To assess perinatal human immunodeficiency virus (HIV) exposure and factors associated with mother-to-child HIV transmission. METHODS: A cohort analysis of HIV-exposed births in New York State from 2002 to 2006 was undertaken using routinely collected public health surveillance and regulatory data, including Newborn Screening HIV antibody results, pediatric HIV diagnostic test results, and maternal and pediatric medical record abstractions. RESULTS: Between January 2002 and December 2006, we identified 3,396 HIV-exposed neonoates. Subsequent analysis of 3,102 (91%) birth events showed that mother-to-child HIV transmission was presumed or confirmed to have occurred in 65 neonates (2.1%) born to 63 mothers. On multivariable analysis, the following significant associations with transmission were identified: maternal HIV diagnosis at or after delivery (odds ratio [OR] 3.24, 95% [CI] 1.15–8.15), maternal acquisition of HIV during pregnancy (OR 15.19, 95% CI 3.98–56.30), illicit substance use during pregnancy (OR 2.66, 95% CI 1.33–5.27), 0–2 prenatal care visits (OR 2.37, 95% CI 1.11–4.91), and neonatal birth weight less than 2,500 g (OR 2.46, 95% CI 1.26–4.74). CONCLUSION: Acquisition of HIV during pregnancy is a significant risk factor for mother-to-child HIV transmission and must be addressed along with other known risks to reduce mother-to-child transmission to the greatest extent possible. LEVEL OF EVIDENCE: II

Prevalence of drug-resistance mutations and non-subtype B strains among HIV-infected infants from New York state

Summary: Prevalence studies indicate that transmission of drug-resistant HIV has been rising in the adult population, but data from the perinatally infected pediatric population are limited. In this retrospective study, we sequenced the pol region of HIV from perinatally infected infants diagnosed in New York State in 2001-2002. Analyses of drug resistance, subtype diversity, and perinatal antiretroviral exposure were conducted, and the results were compared with those from a previous study of HIV-infected infants identified in 1998-1999. Eight of 42 infants (19.1%) had provirus carrying at least 1 drug-resistance mutation, an increase of 58% over the 1998-1999 results. Mutations conferring resistance to nucleoside reverse transcriptase inhibitors, nonnucleoside reverse transcriptase inhibitors, and protease inhibitors were detected in 7.1%, 11.9%, and 2.4% of specimens, respectively. Consistent with previous results, perinatal antiretroviral exposure was not associated with drug resistance (P = 0.70). Phylogenetic analysis indicated that 16.7% of infants were infected with a non-subtype B strain of HIV. It seems that drug-resistant and non-subtype B strains of HIV are becoming increasingly common in the perinatally infected population. Our results highlight the value of resistance testing for all HIV-infected infants upon diagnosis and the need to consider subtype diversity in diagnostic and treatment strategies.

Willingness to Take, Use of, and Indications for Pre-exposure Prophylaxis Among Men Who Have Sex With Men-20 US Cities, 2014.

BACKGROUND Pre-exposure prophylaxis (PrEP) is an effective prevention tool for people at substantial risk of acquiring human immunodeficiency virus (HIV). To monitor the current state of PrEP use among men who have sex with men (MSM), we report on willingness to use PrEP and PrEP utilization. To assess whether the MSM subpopulations at highest risk for infection have indications for PrEP according to the 2014 clinical guidelines, we estimated indications for PrEP for MSM by demographics. METHODS We analyzed data from the 2014 cycle of the National HIV Behavioral Surveillance (NHBS) system among MSM who tested HIV negative in NHBS and were currently sexually active. Adjusted prevalence ratios and 95% confidence intervals were estimated from log-linked Poisson regression with generalized estimating equations to explore differences in willingness to take PrEP, PrEP use, and indications for PrEP. RESULTS Whereas over half of MSM said they were willing to take PrEP, only about 4% reported using PrEP. There was no difference in willingness to take PrEP between black and white MSM. PrEP use was higher among white compared with black MSM and among those with greater education and income levels. Young, black MSM were less likely to have indications for PrEP compared with young MSM of other races/ethnicities. CONCLUSIONS Young, black MSM, despite being at high risk of HIV acquisition, may not have indications for PrEP under the current guidelines. Clinicians may need to consider other factors besides risk behaviors such as HIV incidence and prevalence in subgroups of their communities when considering prescribing PrEP.

Progress in prevention of mother-to-child transmission of HIV in New York State: 1988-2008.

OBJECTIVES To assess the outcomes of efforts to prevent mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) made over the last 2 decades in New York State (NYS), through review of data from multiple sources. METHODS Using available surveillance, laboratory, and program monitoring data, the following were examined for NYS: (1) the rate of prenatal HIV testing, (2) HIV prevalence among childbearing women, (3) maternal prenatal and delivery care, (4) care of HIV-exposed infants, and (5) the rate of MTCT. Trends over time and comparisons among groups were assessed. RESULTS In NYS, HIV prevalence in childbearing women has declined 70% since its peak in 1989. Rates of prenatal HIV testing have been more than 95% in recent years. Rates of MTCT have decreased significantly; since 2003, transmission in HIV-exposed births has ranged from 1.2% to 2.6% annually. On bivariate analysis, MTCT is more likely to occur with breastfeeding or absence of antiretroviral administration in the prenatal, labor/delivery, and newborn periods. CONCLUSIONS Mother-to-child HIV transmission has declined dramatically in all groups in NYS. Universal newborn screening data have provided the foundation for identifying HIV-exposed births and for initiating follow-up to track all aspects of MTCT in NYS. Remaining challenges include universal prenatal care, prevention of acquisition of HIV infection during pregnancy, and adherence to antiretroviral therapy.

Transmitted Antiretroviral Drug Resistance in New York State, 2006-2008: Results from a New Surveillance System

Background HIV transmitted drug resistance (TDR) is a public health concern because it has the potential to compromise antiretroviral therapy (ART) at the population level. In New York State, high prevalence of TDR in a local cohort and a multiclass resistant case cluster led to the development and implementation of a statewide resistance surveillance system. Methodology We conducted a cross-sectional analysis of the 13,109 cases of HIV infection that were newly diagnosed and reported in New York State between 2006 and 2008, including 4,155 with HIV genotypes drawn within 3 months of initial diagnosis and electronically reported to the new resistance surveillance system. We assessed compliance with DHHS recommendations for genotypic resistance testing and estimated TDR among new HIV diagnoses. Principal Findings Of 13,109 new HIV diagnoses, 9,785 (75%) had laboratory evidence of utilization of HIV-related medical care, and 4,155 (43%) had a genotype performed within 3 months of initial diagnosis. Of these, 11.2% (95% confidence interval [CI], 10.2%–12.1%) had any evidence of TDR. The proportion with mutations associated with any antiretroviral agent in the NNRTI, NRTI or PI class was 6.3% (5.5%–7.0%), 4.3% (3.6%–4.9%) and 2.9% (2.4%–3.4%), respectively. Multiclass resistance was observed in <1%. TDR did not increase significantly over time (p for trend = 0.204). Men who have sex with men were not more likely to have TDR than persons with heterosexual risk factor (OR 1.0 (0.77–1.30)). TDR to EFV+TDF+FTC and LPV/r+TDF+FTC regimens was 7.1% (6.3%–7.9%) and 1.4% (1.0%–1.8%), respectively. Conclusions/Significance TDR appears to be evenly distributed and stable among new HIV diagnoses in New York State; multiclass TDR is rare. Less than half of new diagnoses initiating care received a genotype per DHHS guidelines.

Early Linkage to HIV Care and Antiretroviral Treatment among Men Who Have Sex with Men — 20 Cities, United States, 2008 and 2011

Early linkage to care and antiretroviral (ARV) treatment are associated with reduced HIV transmission. Male-to-male sexual contact represents the largest HIV transmission category in the United States; men who have sex with men (MSM) are an important focus of care and treatment efforts. With the release of the National HIV/AIDS Strategy and expanded HIV treatment guidelines, increases in early linkage to care and ARV treatment are expected. We examined differences in prevalence of early linkage to care and ARV treatment among HIV-positive MSM between 2008 and 2011. Data are from the National HIV Behavioral Surveillance System, which monitors behaviors among populations at high risk of HIV infection in 20 U.S. cities with high AIDS burden. MSM were recruited through venue-based, time-space sampling. Prevalence ratios comparing 2011 to 2008 were estimated using linear mixed models. Early linkage was defined as an HIV clinic visit within 3 months of diagnosis. ARV treatment was defined as use at interview. Prevalence of early linkage to care was 79% (187/236) in 2008 and 83% (241/291) in 2011. In multivariable analysis, prevalence of early linkage did not differ significantly between years overall (P = 0.44). Prevalence of ARV treatment was 69% (790/1,142) in 2008 and 79% (1,049/1,336) in 2001. In multivariable analysis, ARV treatment increased overall (P = 0.0003) and among most sub-groups. Black MSM were less likely than white MSM to report ARV treatment (P = 0.01). While early linkage to care did not increase significantly between 2008 and 2011, ARV treatment increased among most sub-groups. Progress is being made in getting MSM on HIV treatment, but more efforts are needed to decrease disparities in ARV coverage.

Consistent Estimates of Very Low HIV Incidence Among People Who Inject Drugs: New York City, 2005–2014

OBJECTIVES To compare methods for estimating low HIV incidence among persons who inject drugs. METHODS We examined 4 methods in New York City, 2005 to 2014: (1) HIV seroconversions among repeat participants, (2) increase of HIV prevalence by additional years of injection among new injectors, (3) the New York State and Centers for Disease Control and Prevention stratified extrapolation algorithm, and (4) newly diagnosed HIV cases reported to the New York City Department of Health and Mental Hygiene. RESULTS The 4 estimates were consistent: (1) repeat participants: 0.37 per 100 person-years (PY; 95% confidence interval [CI] = 0.05/100 PY, 1.33/100 PY); (2) regression of prevalence by years injecting: 0.61 per 100 PY (95% CI = 0.36/100 PY, 0.87/100 PY); (3) stratified extrapolation algorithm: 0.32 per 100 PY (95% CI = 0.18/100 PY, 0.46/100 PY); and (4) newly diagnosed cases of HIV: 0.14 per 100 PY (95% CI = 0.11/100 PY, 0.16/100 PY). CONCLUSIONS All methods appear to capture the same phenomenon of very low and decreasing HIV transmission among persons who inject drugs. Public Health Implications. If resources are available, the use of multiple methods would provide better information for public health purposes.

Estimating HCV Prevalence at the State Level: A Call to Increase and Strengthen Current Surveillance Systems

The degree to which case surveillance captures persons ever infected with HCV is unknown. We determined the discrepancy between HCV seroprevalence, estimated from national survey data, among adults in New York State in 2008 (n = 286 262, or 1.95%) and the number of infected persons reported to the states surveillance hepatitis registries (n = 144 015). Findings suggest the need to strengthen the existing surveillance system.

Correlates of routine HIV testing practices: a survey of New York State primary care physicians, 2011.

Background:The New York State (NYS) HIV Testing Law of 2010 mandates that medical providers offer HIV testing to patients aged between 13 and 64 years during primary care, to increase the number of people aware of their infection status, and to ensure linkage to medical treatment. To assess physician practices related to this legislation, we conducted a study to identify the frequency and correlates of routine HIV testing behavior among primary care physicians approximately 15 months after the new law went into effect. Methods:During September 2011 to January 2012, we mailed self-administered surveys to a representative sample of NYS primary care physicians drawn from the AMA Masterfile of Physicians. Questions included physician practices, knowledge, attitudes, and beliefs related to routine HIV testing. Bivariate and multivariate analyses with a sample of 973 physicians were conducted to identify the most influential predictors of routine HIV testing behaviors. Results:A minority of physicians reported “always” or “frequently” practicing behaviors consistent with routine HIV testing, with 41.7% [95% confidence interval (CI): 37.4 to 46.2] routinely offering tests to patients aged 13–64 years, 40.5% (95% CI: 36.3 to 44.8) to new patients, and 33.3% (95% CI: 29.4 to 37.6) to patients during routine physicals. Only 61.4% (95% CI: 57.4 to 65.6) said they had heard of the new law. In multivariate analyses, specialty, perceived barriers, familiarity with the law, and interaction terms representing familiarity by region and self-efficacy by region were significant predictors across the 3 scenarios of routine HIV testing behavior. Conclusions:Additional technical assistance and training is needed for physicians on adopting routine testing behaviors, minimizing barriers and enhancing skills.