Nikhil Prachand

Drug Use, High-Risk Sex Behaviors, and Increased Risk for Recent HIV Infection among Men who Have Sex with Men in Chicago and Los Angeles

We examined how drugs, high-risk sexual behaviors, and socio-demographic variables are associated with recent HIV infection among men who have sex with men (MSM) in a case–control study. Interviewers collected risk factor data among 111 cases with recent HIV infection, and 333 HIV-negative controls from Chicago and Los Angeles. Compared with controls, cases had more unprotected anal intercourse (UAI) with both HIV-positive and HIV-negative partners. MSM with lower income or prior sexually transmitted infections (STI) were more likely to be recently HIV infected. Substances associated with UAI included amyl nitrate (“poppers”), methamphetamine, Viagra® (or similar PDE-5 inhibitors), ketamine, and gamma hydroxybutyrate (GHB). Cases more frequently used Viagra®, poppers, and methamphetamine during UAI compared with controls. In multivariate analysis, income, UAI with HIV-positive partners, Viagra®, and poppers remained associated with recent HIV seroconversion. Better methods are needed to prevent HIV among MSM who engage in high-risk sex with concurrent drug use.

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.

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.

Agent-Based Model Forecasts Aging of the Population of People Who Inject Drugs in Metropolitan Chicago and Changing Prevalence of Hepatitis C Infections

People who inject drugs (PWID) are at high risk for blood-borne pathogens transmitted during the sharing of contaminated injection equipment, particularly hepatitis C virus (HCV). HCV prevalence is influenced by a complex interplay of drug-use behaviors, social networks, and geography, as well as the availability of interventions, such as needle exchange programs. To adequately address this complexity in HCV epidemic forecasting, we have developed a computational model, the Agent-based Pathogen Kinetics model (APK). APK simulates the PWID population in metropolitan Chicago, including the social interactions that result in HCV infection. We used multiple empirical data sources on Chicago PWID to build a spatial distribution of an in silico PWID population and modeled networks among the PWID by considering the geography of the city and its suburbs. APK was validated against 2012 empirical data (the latest available) and shown to agree with network and epidemiological surveys to within 1%. For the period 2010–2020, APK forecasts a decline in HCV prevalence of 0.8% per year from 44(±2)% to 36(±5)%, although some sub-populations would continue to have relatively high prevalence, including Non-Hispanic Blacks, 48(±5)%. The rate of decline will be lowest in Non-Hispanic Whites and we find, in a reversal of historical trends, that incidence among non-Hispanic Whites would exceed incidence among Non-Hispanic Blacks (0.66 per 100 per years vs 0.17 per 100 person years). APK also forecasts an increase in PWID mean age from 35(±1) to 40(±2) with a corresponding increase from 59(±2)% to 80(±6)% in the proportion of the population >30 years old. Our studies highlight the importance of analyzing subpopulations in disease predictions, the utility of computer simulation for analyzing demographic and health trends among PWID and serve as a tool for guiding intervention and prevention strategies in Chicago, and other major cities.

Anal Intercourse and HIV Risk Among Low-Income Heterosexual Women: Findings from Chicago HIV Behavioral Surveillance

Background: Anal intercourse (AI) is a highly efficient route for HIV transmission and has not been well elucidated among heterosexual (HET) women. Heterosexual women living in impoverished urban areas in the US are at increased risk for HIV acquisition. We aim to describe rates of AI and characteristics associated with AI among heterosexual women at increased risk for HIV acquisition living in Chicago. Methods: The Chicago Department of Public Health conducted a survey of HET during 2007 as part of the National HIV Behavioral Surveillance System. Venue-based, time-location sampling was used to select participants from venues in high-risk areas (census tracts with concurrently high rates of heterosexual AIDS and household poverty). Eligible participants were interviewed anonymously and offered a HIV test. Results: In total, 407 heterosexual women were interviewed. Seventy-one (17%) women reported having AI in the past 12 months, with 61 of the 71 (86%) reporting unprotected AI. In multivariate analysis, women who engaged in AI were more than three times as likely to have three or more sex partners in the past 12 months (OR=3.27, 95% CI 1.53-6.99). AI was also independently associated with STI diagnosis in the past 12 months (2.13, 95% CI 1.06-4.26), and having sexual intercourse for the first time before the age of 15 years (2.23, 95% CI 1.28-3.89). Conclusion: AI was associated with multiple high risk behaviors including a greater number of sexual partners, STI diagnosis, and earlier age at first sex. The combination of risk factors found to be associated with AI call for new HIV prevention services tailored to the needs of women and young girls living in poverty.

Health Care Use and HIV-Related Behaviors of Black and Latina Transgender Women in 3 US Metropolitan Areas: Results From the Transgender HIV Behavioral Survey

Purpose: HIV prevalence estimates among transgender women in the United States are high, particularly among racial/ethnic minorities. Despite increased HIV risk and evidence of racial disparities in HIV prevalence among transgender women, few data are available to inform HIV prevention efforts. Methods: A transgender HIV-related behavioral survey conducted in 2009 in 3 US metropolitan areas (Chicago, Houston, and Los Angeles County), used respondent-driven sampling to recruit 227 black (n = 139) and Latina (n = 88) transgender women. We present descriptive statistics on sociodemographic, health care, and HIV-risk behaviors. Results: Of 227 transgender women enrolled, most were economically and socially disadvantaged: 73% had an annual income of less than

High Human Immunodeficiency Virus Incidence and Prevalence and Associated Factors Among Adolescent Sexual Minority Males—3 Cities, 2015

15,000; 62% lacked health insurance; 61% were unemployed; and 46% reported being homeless in the past 12 months. Most (80%) had visited a health care provider and over half (58%) had tested for HIV in the past 12 months. Twenty-nine percent of those who reported having an HIV test in the past 24 months self-reported being HIV positive. Most of the sample reported hormone use (67%) in the past 12 months and most hormone use was under clinical supervision (70%). Forty-nine percent reported condomless anal sex in the past 12 months and 16% reported ever injecting drugs. Conclusion: These findings reveal the socioeconomic challenges and behavioral risks often associated with high HIV risk reported by black and Latina transgender women. Despite low health insurance coverage, the results suggest opportunities to engage transgender women in HIV prevention and care given their high reported frequency of accessing health care providers.

Injection-related Risk Behavior and Engagement in Outreach, Intervention and Prevention Services Across 20 Us Cities

Background Much has been written about the impact of human immunodeficiency virus (HIV) among young (13-24) sexual minority men (SMM). Evidence for concern is substantial for emerging adult (18-24 years) SMM. Data documenting the burden and associated risk factors of HIV among adolescent SMM (<18 years) remain limited. Methods Adolescent SMM aged 13-18 years were recruited in 3 cities (Chicago, New York City, and Philadelphia) for interview and HIV testing. We used χ2 tests for percentages of binary variables and 1-way analysis of variance for means of continuous variables to assess differences by race/ethnicity in behaviors. We calculated estimated annual HIV incidence density (number of HIV infections per 100 person-years [PY] at risk). We computed Fishers exact tests to determine differences in HIV prevalence by selected characteristics. Results Of 415 sexually active adolescent SMM with a valid HIV test result, 25 (6%) had a positive test. Estimated annual HIV incidence density was 3.4/100 PY; incidence density was highest for blacks, followed by Hispanics, then whites (4.1, 3.2, and 1.1/100 PY, respectively). Factors associated with higher HIV prevalence included black race; ≥4 male partners, condomless anal sex, and exchange sex in the past 12 months; and a recent partner who was older, black, HIV-infected, or had ever been in jail or prison (P < .05). Conclusions HIV-related risk behaviors, prevalence, and estimated incidence density for adolescent SMM were high, especially for minority SMM. Our findings suggest that initiating intervention efforts early may be helpful in combating these trends.

HIV infection and risk, prevention, and testing behaviors among injecting drug users - National HIV behavioral surveillance system, 20 U.S. Cities, 2009

Background: Monitoring the effects of HIV prevention efforts on risk behaviors among persons who inject drugs is a key to inform prevention programs and policy. Methods: Using data from the 2012 National HIV Behavioral Surveillance interviews with persons who inject drugs across 20 US cities (n = 10,171), we conducted latent class analysis to identify injection risk classes and assess the relationship between engagement in prevention services and injection-related risk behavior. We conducted stratified analyses to examine the consistency of these associations across different geographical regions. Results: The latent class analysis identified 6 distinct classes of injection-related risk behavior. The class structure was consistent across regions of the United States, but the distribution of risk classes varied significantly across regions. With covariate adjustment, the South had the most high-risk behavior (21%) and the Midwest had the least (6%). Participation in syringe access services and other prevention services was the lowest in the South. Syringe access was associated with a significantly lower likelihood of membership in the highest risk class in all regions except the Midwest. Participation in individual or group intervention with a practical skills component was associated with less risky injection behavior in all regions except the Northeast. Interventions that featured only safer injection information and discussion had no relationship with risk class. Conclusions: Our findings support evidence of the effectiveness of syringe service programs and safer injection skills training in reducing high-risk injection behavior and underscore the need to improve access to these prevention interventions in the South of the United States.