Mi-Suk Kang Dufour

Routine Rapid HIV Screening in Six Community Health Centers Serving Populations at Risk

BackgroundIn 2006, to increase opportunities for patients to become aware of their HIV status, the Centers for Disease Control and Prevention released updated guidelines for routine, opt-out HIV screening of adults, adolescents, and pregnant women in healthcare settings. To date, there are few documented applications of these recommendations.ObjectiveTo measure the impact of application of the guidelines for routine screening in health centers serving communities disproportionately affected by HIV in the southeastern US.DesignA multi-site program implementation study, describing patients tested and not tested and assessing changes in testing frequency before and after new guidelines were implemented.ParticipantsAll patients aged 13 to 64 seen in participating health centers.InterventionsRoutine rapid HIV screening in accord with CDC guidelines.MeasurementsThe frequency of testing before and after routine screening was in place and demographic differences in offering and receipt of testing.Main ResultsCompared to approximately 3,000 patients in the year prior to implementation, 16,148 patients were offered testing with 10,769 tested. Of 39 rapid tests resulting in preliminary positives, 17 were newly detected infections. Among these patients, 12 of 14 receiving referrals were linked to HIV care. Nineteen were false positives. Younger patients, African Americans and Latinos were more likely to receive testing.ConclusionsBy integrating CDC-recommended guidelines and applying rapid test technology, health centers were able to provide new access to HIV testing. Variation across centers in offering and receiving tests may indicate that clinical training could enhance universal access.

The SHAZ! Project: Results from a Pilot Randomized Trial of a Structural Intervention to Prevent HIV among Adolescent Women in Zimbabwe

Adolescent females in Zimbabwe are at high risk for HIV acquisition. Shaping the Health of Adolescents in Zimbabwe (SHAZ!) was a randomized controlled trial of a combined intervention package including life-skills and health education, vocational training, micro-grants and social supports compared to life-skills and health education alone. SHAZ! was originally envisioned as a larger effectiveness trial, however, the intervention was scaled back due to contextual and economic conditions in the country at the time. SHAZ! enrolled 315 participants randomly assigned to study arm within blocks of 50 participants (158 intervention and 157 control). The intervention arm participants showed statistically significant differences from the control arm participants for several outcomes during the two years of follow up including; reduced food insecurity [IOR = 0.83 vs. COR = 0.68, p-0.02], and having their own income [IOR = 2.05 vs. COR = 1.67, p = 0.02]. Additionally, within the Intervention arm there was a lower risk of transactional sex [IOR = 0.64, 95% CI (0.50, 0.83)], and a higher likelihood of using a condom with their current partner [IOR = 1.79, 95% CI (1.23, 2.62)] over time compared to baseline. There was also evidence of fewer unintended pregnancies among intervention participants [HR = 0.61, 95% CI (0.37, 1.01)], although this relationship achieved only marginal statistical significance. Several important challenges in this study included the coordination with vocational training programs, the political and economic instability of the area at the time of the study, and the difficulty in creating a true standard of care control arm. Overall the results of the SHAZ! study suggest important potential for HIV prevention intervention packages that include vocational training and micro-grants, and lessons for further economic livelihoods interventions with adolescent females. Further work is needed to refine the intervention model, and test the impact of the intervention at scale on biological outcomes. Trial Registration ClinicalTrials.gov NCT02034214

BARRIERS AND FACILITATORS TO ENHANCING HIV TESTING IN PUBLICLY FUNDED PRIMARY CARE CLINICS: FINDINGS FROM SAN FRANCISCO

Although the City of San Francisco hosts a number of community-based HIV test sites, about 2,500 infected individuals are unaware of their serostatus. Primary medical care settings may provide improved access to HIV testing, particularly if testing programs are well matched to the setting where they are implemented. To plan for expanding testing in these settings, we assessed trends in testing in publicly supported clinics and conducted qualitative interviews to assess current testing practices, linkage to care and partner services practices, and barriers to implementing and/or expanding HIV testing. We presented the results to stakeholders and asked them to help develop recommendations to expand testing and linkage to care. Since 2007, testing has increased in primary care settings although a gap in access remains. Primary care providers endorsed the concept of routine HIV testing but raised concerns and recommended a staged approach to expanding testing. Stakeholders recommended that the citys public health department provide enhanced capacity building assistance and support a new linkage to care and partner services team. This study holds lessons for other jurisdictions seeking to expand HIV testing in primary care.

Population intervention models to estimate ambient NO2 health effects in children with asthma.

Health effects of ambient air pollution are most frequently expressed in individual studies as responses to a standardized unit of air pollution changes (e.g., an interquartile interval), which is thought to enable comparison of findings across studies. However, this approach does not necessarily convey health effects in terms of a real-world air pollution scenario. In the present study, we use population intervention modeling to estimate the effect of an air pollution intervention that makes explicit reference to the observed exposure data and is identifiable in those data. We calculate the association between ambient summertime nitrogen dioxide (NO2) and forced expiratory flow between 25% and 75% of forced vital capacity (FEF25–75) in a cohort of children with asthma in Fresno, California. We scale the effect size to reflect NO2 abatement on a majority of summer days. The effect estimates were small, imprecise, and consistently indicated improved pulmonary function with decreased NO2. The effects ranged from −0.8% of mean FEF25–75 (95% confidence interval (CI): −3.4, 1.7) to −3.3% (95% CI: −7.5, 0.9). We conclude by discussing the nature and feasibility of the exposure change analyzed here given the observed air pollution profile, and we propose additional applications of population intervention models in environmental epidemiology.

Supporting the Integration of HIV Testing Into Primary Care Settings

OBJECTIVES We examined the efforts of the US network of AIDS Education and Training Centers (AETCs) to increase HIV testing capacity across a variety of clinical settings. METHODS We used quantitative process data from 8 regional AETCs for July 1, 2008, to June 30, 2009, and qualitative program descriptions to demonstrate how AETC education helped providers integrate HIV testing into routine clinical care with the goals of early diagnosis and treatment. RESULTS Compared with other AETC training, HIV testing training was longer and used a broader variety of strategies to educate more providers per training. During education, providers were able to understand their primary care responsibility to address public health concerns through HIV testing. CONCLUSIONS AETC efforts illustrate how integration of the principles of primary care and public health can be promoted through professional training.

Evaluating the Impact of Zimbabwe’s Prevention of Mother-to-Child HIV Transmission Program: Population-Level Estimates of HIV-Free Infant Survival Pre-Option A

Objective We estimated HIV-free infant survival and mother-to-child HIV transmission (MTCT) rates in Zimbabwe, some of the first community-based estimates from a UNAIDS priority country. Methods In 2012 we surveyed mother-infant pairs residing in the catchment areas of 157 health facilities randomly selected from 5 of 10 provinces in Zimbabwe. Enrolled infants were born 9–18 months before the survey. We collected questionnaires, blood samples for HIV testing, and verbal autopsies for deceased mothers/infants. Estimates were assessed among i) all HIV-exposed infants, as part of an impact evaluation of Option A of the 2010 WHO guidelines (rolled out in Zimbabwe in 2011), and ii) the subgroup of infants unexposed to Option A. We compared province-level MTCT rates measured among women in the community with MTCT rates measured using program monitoring data from facilities serving those communities. Findings Among 8568 women with known HIV serostatus, 1107 (12.9%) were HIV-infected. Among all HIV-exposed infants, HIV-free infant survival was 90.9% (95% confidence interval (CI): 88.7–92.7) and MTCT was 8.8% (95% CI: 6.9–11.1). Sixty-six percent of HIV-exposed infants were still breastfeeding. Among the 762 infants born before Option A was implemented, 90.5% (95% CI: 88.1–92.5) were alive and HIV-uninfected at 9–18 months of age, and 9.1% (95%CI: 7.1–11.7) were HIV-infected. In four provinces, the community-based MTCT rate was higher than the facility-based MTCT rate. In Harare, the community and facility-based rates were 6.0% and 9.1%, respectively. Conclusion By 2012 Zimbabwe had made substantial progress towards the elimination of MTCT. Our HIV-free infant survival and MTCT estimates capture HIV transmissions during pregnancy, delivery and breastfeeding regardless of whether or not mothers accessed health services. These estimates also provide a baseline against which to measure the impact of Option A guidelines (and subsequently Option B+).

Messages HIV clinicians use in prevention with positives interventions

Abstract Prevention with Positives (PwP) is a component of the US HIV prevention strategy that targets HIV-infected persons who are aware of their seropositive status. This paper examines the use of prevention messages by clinical providers during the PwP intervention period of the US Health Resources and Services Administrations Special Projects of National Significance program. Quantitative approaches were used to learn which prevention topics were most discussed and qualitative interviews were also utilized to better understand the clinician perspective in providing prevention counseling. At 12-month follow-up, there was a significant increase in the percent of patients receiving all PwP counseling messages (p<0.01). Providers reported discussing safer sex with 91% of patients when sexually transmitted infection (STI) screening was conducted during a visit, an increase from baseline (83.5%). The percent of providers reporting they regularly explained the risk of superinfection to their clients also increased from 75% at baseline to 90% at 12-month follow up (p<0.001). Qualitative data suggest that providers prioritize individual care over public health approaches to PwP in counseling. Discussing superinfection offered providers a way to discuss HIV prevention from a non-judgmental clinical perspective while focusing on a patient-centered philosophy of care. However, the threat of superinfection may not be the best counseling option. Examples such as STI screening, giving messages to reduce the number of sexual partners and adherence to medication, are more evidence-based approaches to changing HIV transmission risk behavior and may be more important in PwP. Findings suggest that in order for HIV care providers to incorporate HIV prevention discussions into their practice, acceptable approaches to speaking about risk behavior and prevention of HIV transmission must be developed.

Option A improved Hiv-free infant survival and mother to child Hiv transmission at 9–18 months in Zimbabwe

Objective: We evaluated the impact of Option A on HIV-free infant survival and mother-to-child transmission (MTCT) in Zimbabwe. Design: Serial cross-sectional community-based serosurveys. Methods: We analyzed serosurvey data collected in 2012 and 2014 among mother–infant pairs from catchment areas of 132 health facilities from five of 10 provinces in Zimbabwe. Eligible infants (alive or deceased) were born 9–18 months before each survey to mothers at least 16 years old. We randomly selected mother–infant pairs and conducted questionnaires, verbal autopsies, and collected blood samples. We estimated the HIV-free infant survival and MTCT rate within each catchment area and compared the 2012 and 2014 estimates using a paired t test and number of HIV infections averted because of the intervention. Results: We analyzed 7249 mother–infant pairs with viable maternal specimens collected in 2012 and 8551 in 2014. The mean difference in the catchment area level MTCT between 2014 and 2012 was −5.2 percentage points (95% confidence interval = −8.1, −2.3, P < 0.001). The mean difference in the catchment area level HIV-free survival was 5.5 percentage points (95% confidence interval = 2.6, 8.5, P < 0.001). Between 2012 and 2014, 1779 infant infections were averted compared with the pre-Option A regimen. The association between HIV-free infant survival and duration of Option A implementation was NS at the multivariate level (P = 0.093). Conclusion: We found a substantial and statistically significant increase in HIV-free survival and decrease in MTCT among infants aged 9–18 months following Option A rollout in Zimbabwe. This is the only evaluation of Option A and shows the effectiveness of Option A and Zimbabwes remarkable progress toward eMTCT.

Helping clinicians deliver consistent HIV prevention counseling to their HIV-infected patients

Abstract The delivery of HIV risk assessment and behavioral counseling by clinicians in HIV clinical settings is one component in a comprehensive “positive prevention” strategy to help patients reduce their transmission risk behavior. Clinicians engage in behavioral prevention inconsistently, however, depending on whether patients are new to a practice or are established in regular care and on their attitudes and characteristics of their practices. We analyzed clinician reports of behavioral prevention delivered before and after participation in a large federal demonstration project of positive prevention interventions. The interventions that were part of this project were successful in increasing behavioral prevention among both new and returning patients. Prior to study interventions, clinicians reported counseling 69% of new patients and 52% of returning patients. In follow-up interviews 12 months after receiving training, clinicians reported delivering prevention messages to 5% more new patients and 9% of returning patients (both p<0.01). After 12 months, clinicians were more likely to engage in behavioral prevention if other providers in their sites were also involved. Clinicians agreeing that behavioral prevention was part of the clinics mission were more likely to conduct it. The interventions were successful in mitigating the influence of provider attitudes precluding prevention delivery. Intervention strategies can help clinicians more consistently deliver behavioral prevention messages to their HIV-infected patients.

HIV voluntary counseling and testing at an abortion clinic: missed opportunities for diagnosis

BACKGROUND Most abortion clinics in the US do not provide opt-out HIV testing, and thus women electing abortion may not receive adequate screening for HIV. We sought to determine whether the standard practice of offering voluntary HIV counseling and testing (VCT) services to women electing abortion results in detection of undiagnosed HIV infection. STUDY DESIGN Two thousand twenty-five women electing abortion were consecutively offered VCT at a public hospital-based, urban abortion clinic. Unlinked, anonymous HIV surveillance testing was conducted subsequent to voluntary testing without patients knowing of the surveillance study testing at the time. Multivariable analysis was used to determine factors associated with opting for VCT. RESULTS Of the 13 women (0.6%) who tested positive for HIV, 8 had been previously diagnosed. Of the 5 women without previous diagnosis, only 1 opted for VCT. Overall, 530 (26%) women opted for VCT. Factors associated with opting for VCT in multivariable analysis (odds ratio, 95% confidence interval) were sex with an injection drug user (1.9, 1.1-3.2), presenting in the second trimester (1.3, 1.0-1.6), economic hardship (1.3, 1.0-1.5), partner difficulties (1.8, 1.3-2.4) and having public health insurance (1.6, 1.2-2.3). CONCLUSIONS HIV testing via VCT did not effectively diagnose previously undiagnosed HIV infections among women seeking abortion in this clinical setting.