Marlene LaLota

The Epidemiology of Antiretroviral Drug Resistance among Drug-Naive HIV-1-Infected Persons in 10 US Cities

BACKGROUND The prevalence and characteristics of persons with newly diagnosed human immunodeficiency virus (HIV) infections with or without evidence of mutations associated with drug resistance have not been well described. METHODS Drug-naive persons in whom HIV had been diagnosed during the previous 12 months and who did not have acquired immune deficiency syndrome were sequentially enrolled from 39 clinics and testing sites in 10 US cities during 1997-2001. Genotyping was conducted from HIV-amplification products, by automated sequencing. For specimens identified as having mutations previously associated with reduced antiretroviral-drug susceptibility, phenotypic testing was performed. RESULTS Of 1311 eligible participants, 1082 (83%) were enrolled and successfully tested; 8.3% had reverse transcriptase or major protease mutations associated with reduced antiretroviral-drug susceptibility. The prevalence of these mutations was 11.6% among men who had sex with men but was only 6.1% and 4.7% among women and heterosexual men, respectively. The prevalence was 5.4% and 7.9% among African American and Hispanic participants, respectively, and was 13.0% among whites. Among persons whose sexual partners reportedly took antiretroviral medications, the prevalence was 15.2%. CONCLUSIONS Depending on the characteristics of the patients tested, HIV-genotype testing prior to the initiation of therapy would identify a substantial number of infected persons with mutations associated with reduced antiretroviral-drug susceptibility.

Associations of Race/Ethnicity With HIV Prevalence and HIV-Related Behaviors Among Young Men Who Have Sex With Men in 7 Urban Centers in the United States

Abstract:Using data from a multisite venue-based survey of male subjects aged 15 to 22 years, we examined racial/ethnic differences in demographics, partner type, partner type-specific condom use, drug use, and HIV prevalence in 3316 US black, multiethnic black, Latino, and white men who have sex with men (MSM). We further estimated associations of these factors with HIV infection and their influence on racial/ethnic disparities in HIV prevalence. HIV prevalences were 16% for both black and multiethnic black participants, 6.9% for Latinos, and 3.3% for whites. Paradoxically, potentially risky sex and drug-using behaviors were generally reported most frequently by whites and least frequently by blacks. In a multiple logistic regression analysis, positive associations with HIV included older age, being out of school or work, sex while on crack cocaine, and anal sex with another male regardless of reported condom use level. Differences in these factors did not explain the racial/ethnic disparities in HIV prevalence, with both groups of blacks experiencing more than 9 times and Latinos experiencing approximately twice the fully adjusted odds of infection compared with whites. Understanding racial/ethnic disparities in HIV risk requires information beyond the traditional risk behavior and partnership type distinctions. Prevention programs should address risks in steady partnerships, target young men before sexual initiation with male partners, and tailor interventions to men of color and of lower socioeconomic status.

Unrecognized HIV infection, risk behaviors, and perceptions of risk among young men who have sex with men: opportunities for advancing HIV prevention in the third decade of HIV/AIDS.

This study evaluated the magnitude and distribution of unrecognized HIV infection among young men who have sex with men (MSM) and of those with unrecognized infection, the prevalence and correlates of unprotected anal intercourse (UAI), perceived low risk for infection, and delayed HIV testing. MSM aged 15-29 years were approached, interviewed, counseled, and tested for HIV at 263 randomly sampled venues in 6 US cities from 1994-2000. Of 5649 MSM participants, 573 (10%) tested positive for HIV. Of these, 91% of black, 69% of Hispanic, and 60% of white MSM (77% overall) were unaware of their infection. The 439 MSM with unrecognized infection reported a total of 2253 male sex partners in the previous 6 months; 51% had UAI; 59% perceived that they were at low risk for being infected; and 55% had not tested in the previous year. The HIV epidemic among MSM in the United States continues unabated, in part, because many young HIV-infected MSM are unaware of their infection and unknowingly expose their partners to HIV. To advance HIV prevention in the third decade of HIV/AIDS, prevention programs must reduce unrecognized infection among young MSM by increasing the demand for and availability of HIV testing services.

Regional Patterns and Correlates of Substance Use Among Young Men Who Have Sex With Men in 7 US Urban Areas

OBJECTIVES We sought to characterize substance use patterns in young men who have sex with men (MSM) in 7 US urban areas and sociodemographic characteristics and history associated with such use. METHODS We examined data collected from 1994 through 1998 in a venue-based, cross-sectional survey. RESULTS Among the 3492 participants, 66% reported use of illicit drugs; 28%, use of 3 or more drugs; 29%, frequent drug use (once a week or more); and 4%, injection drug use. These practices were more common among participants who were White, self-identified as bisexual or heterosexual, had run away, or had experienced forced sex. CONCLUSIONS Effective drug prevention and treatment programs addressing local drug-use patterns and associated factors are urgently needed for young MSM, a population with a high rate of illicit drug use.

Associations between substance use and sexual risk among very young men who have sex with men.

Objective: To determine if an association exists in young men who have sex with men (MSM) between being under the influence of alcohol or drugs during sex and participation in sexual behaviors which increase the risk of human immunodeficiency virus (HIV). Study Design: A total of 3492 young MSM were interviewed through the Young Men’s Survey, an anonymous, cross-sectional, multisite, venue-based survey conducted from 1994 through 1998 at 194 public venues frequented by MSM aged 15 to 22 years in 7 US cities. Results: The majority of young MSM reported both receptive and insertive anal intercourse, and of these, approximately half reported not using condoms. Report of unprotected receptive anal intercourse at least once in the prior 6 months was associated with being under the influence of alcohol (adjusted odds ratio [AOR] = 1.5; 95% confidence interval [CI] = 1.2–1.8), cocaine (AOR = 1.6; 95% CI = 1.1–2.2), amphetamines (AOR = 1.5; 95% CI = 1.1–2.0) or marijuana during sex (AOR = 1.3; 95% CI = 1.1–1.6). Report of unprotected insertive anal intercourse at least once in the prior 6 months was associated with being under the influence of alcohol (AOR = 1.2; 95% CI = 1.0–1.5), cocaine (AOR = 1.5; 95% CI = 1.1–2.0) or amphetamines (AOR = 1.9; 95% CI = 1.4–2.6). Conclusions: HIV prevention strategies for young MSM need to incorporate substance use risk reduction.

Detecting Acute Human Immunodeficiency Virus Infection Using 3 Different Screening Immunoassays and Nucleic Acid Amplification Testing for Human Immunodeficiency Virus RNA, 2006-2008

BACKGROUND The yield of nucleic acid amplification testing (NAAT) after routine screening for human immunodeficiency virus (HIV) antibody to detect acute HIV infection (AHI) may vary with different HIV-antibody assays. METHODS From April 24, 2006, through March 28, 2008, patients underwent routine HIV-antibody screening using a first-generation assay at 14 county sexually transmitted disease (STD) clinics and 1 community clinic serving homosexual patients in Los Angeles; using a second-generation rapid test at 3 municipal STD clinics in New York; and using a third-generation assay at 80 public health clinics in Florida. To identify AHI, seronegative specimens were pooled for NAAT, followed by individual NAAT of specimens with positive findings. All AHI samples screened by first- and second-generation assays also underwent third-generation testing. RESULTS We screened 37 012 persons using NAAT after first-generation testing; 35 AHIs were identified, increasing HIV case detection by 8.2%. After a second-generation rapid test, 6547 persons underwent NAAT; 7 AHIs were identified, increasing HIV case detection by 24.1%. After third-generation testing, 54 948 persons underwent NAAT; 12 AHI cases were identified, increasing HIV case detection by 1.4%. Overall, pooled NAAT after negative third-generation test results detected 26 AHI cases, increasing HIV case detection by 2.2%. Most of the AHI cases from Los Angeles (26 of 35 [74%]) were identified at the community clinic where NAAT after third-generation testing increased HIV case detection by 11.9%. CONCLUSIONS Pooled NAAT after third-generation testing increases HIV case detection, especially in venues of high HIV seropositivity. Therefore, targeted AHI screening using pooled NAAT after third-generation testing may be most effective, warranting a cost-benefit analysis.

Recent HIV testing among young men who have sex with men: correlates, contexts, and HIV seroconversion.

Objectives: We evaluated the correlates and contexts of HIV testing within the past year, subsequent risk reduction, and HIV seroconversion among young men who have sex with men (MSM). Methods: Young men aged 23 to 29 years were approached, interviewed, counseled, and tested for HIV at 181 randomly sampled MSM-identified venues in six U.S. cities from 1998 through 2000. Analyses were restricted to 2,797 MSM who reported never testing HIV-positive. Results: Of the 2,797 MSM, 1,281 (46%) either never previously tested or had not tested in the past year (never/remote testers); 1,516 (54%) had tested in the past year (recent testers); and 271 (10%) tested HIV-positive as part of the study. Of 1,885 recent sex partners reported by HIV-infected participants, 68% were partners of never/remote testers. Of recent testers, 50% tested anonymously, 51% tested because of specific risks, 59% were counseled, 47% reported reducing their risks after testing, and 8% tested HIV-positive (percent HIV-infected by race: blacks, 24%; Hispanics, 6%; whites, 4%; Asians, 1%). Conclusion: Nearly half of young MSM participants had not tested in the past year and HIV-infected never/remote testers accounted for approximately two thirds of recent partners potentially exposed to HIV. Of those who had tested recently, many MSM, especially those who are black, had already acquired HIV. To reduce HIV transmission and facilitate early diagnosis and entry into care, increased HIV testing among young at-risk MSM in the United States, especially those who are black, is needed.

Perceptions of Lifetime Risk and Actual Risk for Acquiring HIV Among Young Men Who Have Sex with Men

Among young men who have sex with men (MSM) surveyed in six US cities, we evaluated the magnitude and correlates of perceived lifetime risk for acquiring HIV, and missed opportunities to increase risk perception by providers of health-care and HIV-testing services. Overall, approximately one quarter of young MSM perceived themselves at moderate/high risk for acquiring HIV. Adjusting for demographic, prior testing, and behavioral characteristics, moderate/high perceived risk had the strongest association with unrecognized HIV infection. However, half of the 267 young MSM with unrecognized infection perceived themselves at low lifetime risk for acquiring HIV, and many young MSM with low-risk perception reported considerable risk behaviors. Providers of health-care and HIV-testing services missed opportunities to assess risks and recommend testing for young MSM. To increase HIV testing, prevention providers should intensify efforts to assess, and to increase when needed, perceptions of lifetime risks for acquiring HIV among young MSM.

Voluntary rapid human immunodeficiency virus (HIV) testing in jails.

Objectives: To provide human immunodeficiency virus (HIV) rapid testing to persons in jails, identify previously undiagnosed cases of HIV infection, and refer HIV-infected inmates to care, treatment, and prevention services. Design: Four state health departments (Florida, Louisiana, New York, and Wisconsin) collaborated with jails to implement stand-alone voluntary rapid HIV testing programs. Inmates requested or were referred by medical staff for rapid HIV testing. HIV testing was provided by the health department, correctional facility, or a community-based organization. Inmates whose rapid test was reactive were offered confirmatory testing, medical evaluation, prevention services, and discharge planning. Results: From December 2003 through May 2006, rapid HIV testing was provided to 33,211 inmates, more than 99.9% of whom received their test results. Most of the inmates tested were male (79%), black (58%), and less than 35 years of age (60%). A total of 440 (1.3%) rapid HIV tests were reactive, and 409 (1.2%) of the results were confirmed positive. The testing programs identified 269 (0.8%) previously undiagnosed cases of HIV infection. In the multivariate analyses, new HIV diagnoses were associated with race/ethnicity, report of risky behaviors, and with no report of HIV risk behavior. Almost 40% of diagnoses were for inmates whose only reported risk was heterosexual contact. Conclusions: Rapid HIV testing in jails identified a considerable number of previously undiagnosed cases of HIV infection. Rapid HIV testing should be available to all inmates, regardless of whether inmates reported HIV risky behaviors.

Unintentional HIV exposures from young men who have sex with men who disclose being HIV-negative

Objective:To evaluate the proportion of new sexual partners potentially exposed to HIV from young MSM who disclosed being HIV-negative. Design:Cross-sectional, observational study of men aged 23–29 years recruited from randomly sampled MSM-identified venues in six US cities. Methods:Participants were interviewed and tested for HIV. Analyses were restricted to MSM who reported last testing HIV-negative and having one or more new partners in the prior 6 months. Results:Of 1701 MSM who reported a total of 11 793 new partners, 1075 (63%) disclosed being HIV-negative to 4253 (36%) new partners before having sex with them for the first time. Of disclosers, 352 (33%) reported last testing HIV-negative > 1 year before their interview and 80 (7%) tested HIV-positive (HIV-infected unaware). By race, 24% of black, 5% of Hispanic, and 3% of white disclosers tested HIV-positive. Of the 4253 new partners, 296 (7%) were partners of the 80 HIV-infected unaware MSM. By race, 22% of new partners of black, 3% of new partners of Hispanic, and 4% of new partners of white MSM, were partners of HIV-infected unaware MSM who disclosed being HIV-negative. Conclusions:Many new sex partners may be unintentionally exposed to HIV from young MSM, particularly those who are black and who disclose being HIV-negative based on an earlier test. Young MSM should test for HIV more frequently and consistently use condoms with all partners unless they are in a mutually monogamous relationship in which both partners have tested HIV-negative at least 3 months since their last potential HIV exposure.