R. Luke Shouse

Homelessness and HIV-Associated Risk Behavior Among African American Men Who Inject Drugs and Reside in the Urban South of the United States

This study determined whether homeless injection drug users (IDUs) were more likely than stably housed IDUs to engage in HIV-associated risk behaviors. Respondent driven sampling was used to recruit 343 African American male IDUs. About 69% of men had been homeless in the past year and 13% were HIV positive. Controlling for age and income, homeless men as compared to stably housed men were 2.6 times more likely to report sharing needles, 2.4 times more likely to have 4 or more sex partners and 2.4 times more likely to have had sex with other men. Homeless men were also twice as likely to report having unprotected sex with a casual partner and about two-thirds less likely to report never using sterile needles. Self-reported HIV status was an effect modifier of these associations such that the observed relationships applied mostly only to men who were not knowingly HIV positive.

Connecting Race and Place: A County-Level Analysis of White, Black, and Hispanic HIV Prevalence, Poverty, and Level of Urbanization

OBJECTIVES We evaluated the role of poverty in racial/ethnic disparities in HIV prevalence across levels of urbanization. METHODS Using national HIV surveillance data from the year 2009, we constructed negative binomial models, stratified by urbanization, with an outcome of race-specific, county-level HIV prevalence rates and covariates of race/ethnicity, poverty, and other publicly available data. We estimated model-based Black-White and Hispanic-White prevalence rate ratios (PRRs) across levels of urbanization and poverty. RESULTS We observed racial/ethnic disparities for all strata of urbanization across 1111 included counties. Poverty was associated with HIV prevalence only in major metropolitan counties. At the same level of urbanization, Black-White and Hispanic-White PRRs were not statistically different from 1.0 at high poverty rates (Black-White PRR = 1.0, 95% confidence interval [CI] = 0.4, 2.9; Hispanic-White PRR = 0.4, 95% CI = 0.1, 1.6). In nonurban counties, racial/ethnic disparities remained after we controlled for poverty. CONCLUSIONS The association between HIV prevalence and poverty varies by level of urbanization. HIV prevention interventions should be tailored to this understanding. Reducing racial/ethnic disparities will require multifactorial interventions linking social factors with sexual networks and individual risks.

Using HIV Surveillance Data to Monitor Missed Opportunities for Linkage and Engagement in HIV Medical Care

Monitoring delayed entry to HIV medical care is needed because it signifies that opportunities to prevent HIV transmission and mitigate disease progression have been missed. A central question for population-level monitoring is whether to consider a person linked to care after receipt of one CD4 or VL test. Using HIV surveillance data, we explored two definitions for estimating the number of HIV-diagnosed persons not linked to HIV medical care. We used receipt of at least one CD4 or VL test (definition 1) and two or more CD4 or VL tests (definition 2) to define linkage to care within 12 months and within 42 months of HIV diagnosis. In five jurisdictions, persons diagnosed from 12/2006-12/2008 who had not died or moved away and who had zero, or less than two reported CD4 or VL tests by 7/31/2010 were considered not linked to care under definitions 1 and 2, respectively. Among 13,600 persons followed up for 19-42 months; 1,732 (13%) had no reported CD4 or VL tests; 2,332 persons (17%) had only one CD4 or VL test and 9,536 persons (70%) had two or more CD4 or VL tests. To summarize, after more than 19 months, 30% of persons diagnosed with HIV had less than two CD4 or VL tests; more than half of them were considered to have entered care if entering care is defined as having one CD4 or VL test. Defining linkage to care as a single CD4 or VL may overestimate entry into care, particularly for certain subgroups.

Contact-tracing outcomes among male syphilis patients in Fulton County, Georgia, 2003.

Objectives: Contact tracing may be less effective in populations with casual sex partners such as male syphilis patients who report sex with men; this opinion is widely held, but few quantitative comparisons are available. Goal: The goal of this study was to compare contact-tracing outcomes among male syphilis patients reporting sex with men (MSM) or with women only (MSWO). Study Design: The authors conducted a record review of cases of early syphilis among MSM and MSWO comparing contact-tracing outcomes. Results: Interviews of MSM case-patients resulted in higher mean numbers of contacts named and located per case than interviews of MSWO. Mean numbers of contacts of MSM and MSWO diagnosed with syphilis per case were not significantly different. The mean number of unlocatable sex partners per case was slightly higher for MSM than MSWO. Conclusion: This study comparing contact tracing by the same trained health department personnel demonstrated that outcomes of contact tracing were similar for MSM and MSWO.

Increased antiretroviral therapy prescription and HIV viral suppression among persons receiving clinical care for HIV infection

Objective:To assess trends during 2009–2013 in antiretroviral therapy (ART) prescription and viral suppression among adults receiving HIV clinical care in the United States. Design:We used data from the Medical Monitoring Project, a surveillance system producing national estimates of characteristics of HIV-infected adults receiving clinical care in the United States. Methods:We estimated weighted proportions of persons receiving HIV medical care who were prescribed ART and achieved HIV viral suppression (<200 copies/ml) at both last test and at all tests in the previous 12 months during 2009–2013. We assessed trends overall and by gender, age, race/ethnicity, and sexual behavior/orientation. Results:ART prescription and viral suppression increased significantly during 2009–2013, overall and in subgroups. ART prescription increased from 89 to 94% (P for trend <0.01). Viral suppression at last measurement increased from 72 to 80% (P for trend <0.01). The largest increases were among 18–29 year olds (56–68%), 30–39 year olds (62–75%), and non-Hispanic blacks (64–76%). Sustained viral suppression increased from 58 to 68% (P for trend <0.01). The largest increases were among 18–29 year olds (32–51%), 30–39 year olds (47–63%), and non-Hispanic blacks (49–61%). Conclusion:Adults receiving HIV medical care are increasingly likely to be prescribed ART and achieve viral suppression. Recent efforts to promote early antiretroviral therapy use may have contributed to these increases, bringing us closer to realizing key goals of the National HIV/AIDS Strategy.

Correlates of Unprotected Anal Sex with Casual Partners: A Study of Gay Men Living in the Southern United States

This study identified demographic and behavioral correlates of engaging in unprotected anal sex (UAS) with non-main partners among men having sex with men (MSM). Just over 1,000 men completed anonymous surveys with 25% of the men reporting their most recent sexual act with a non-main male partner was UAS. These men tended to be white, older, HIV seropositive, and high (or drunk) when having sex. In multivariate analysis being seropositive, and being high or drunk retained significance. Subsequent research may build upon these findings to determine the causal pathway to UAS among MSM having sex with non-main partners. Findings may be useful in constructing prevention interventions for MSM frequenting gay venues.

Increased STD testing among sexually active persons receiving medical care for HIV infection in the United States, 2009 – 2013

Background Current guidelines recommend that all sexually active human immunodeficiency virus (HIV)-infected persons be tested at least annually for syphilis, chlamydia, and gonorrhea. We examined temporal trends in syphilis, chlamydia, and gonorrhea testing among sexually active HIV-infected adults receiving medical care in the United States during 2009-2013. Methods Using medical record data from the Medical Monitoring Project, a population-based HIV surveillance system, we assessed the proportion of adults receiving HIV medical care who were tested for syphilis, chlamydia, and gonorrhea in the past 12 months by year and stratified by sex and sexual behavior, age, and race/ethnicity. Results During 2009-2013, the proportion of sexually active HIV-infected adults receiving medical care who were tested in the past year for all 3 examined sexually transmitted diseases (STDs) increased from 20% to 36% (PTREND < .01). Overall testing for syphilis increased from 55% to 65% (PTREND < .01), and significant increases were noted for the following subgroups: men who have sex with men (58% to 69%), non-Hispanic whites (48% to 64%), and all age groups with the exception of persons aged 18-29 year. Overall testing for chlamydia and gonorrhea increased from 22% to 42% (PTREND < .01), and significant increases were noted for most subgroups. Conclusions STD testing significantly increased among sexually active HIV-infected adults receiving medical care; however, the majority of persons were not tested for all 3 STDs in 2013. While increased testing indicates progress, testing remained far below recommended guidelines. Our findings suggest enhanced efforts may be warranted to screen all sexually active HIV-infected adults for syphilis, chlamydia, and gonorrhea.

Trends in cigarette smoking among adults with HIV compared with the general adult population, United States - 2009–2014

Smoking increases HIV-related and non-HIV-related morbidity and mortality for persons with HIV infection. We estimated changes in cigarette smoking among adults with HIV and adults in the general U.S. population from 2009 to 2014 to inform HIV smoking cessation programs. Among HIV-positive adults, rates of current smoking declined from 37.6% (confidence interval [CI]: 34.7-40.6) in 2009 to 33.6% (CI: 29.8-37.8) in 2014. Current smoking among U.S. adults declined from 20.6% (CI: 19.9-21.3) in 2009 to 16.8% (CI: 16.2-17.4) in 2014. HIV-positive adults in care were significantly more likely to be current smokers compared with the general U.S. population; they were also less likely to quit smoking. For both HIV-positive adults in care and the general population, disparities were noted by racial/ethnic, educational level, and poverty-level subgroups. For most years, non-Hispanic blacks, those with less than high school education, and those living below poverty level were more likely to be current smokers and less likely to quit smoking compared with non-Hispanic whites, those with greater than high school education, and those living above poverty level, respectively. To decrease smoking-related causes of illness and death and to decrease HIV-related disparities, smoking cessation interventions are vital as part of routine care with HIV-positive persons. Clinicians who care for HIV-positive persons who smoke should utilize opportunities to discuss and implement smoking cessation strategies during routine clinical visits.

Recruitment by a Geospatial Networking Application for Research and Practice: The New York City Experience

REFERENCES 1. Newman RG. Risk reduction with buprenorphine– naloxone and methadone: patient’s choice. J Acquir Immune Defic Syndr. 2014;67:e142. 2. Mattick RP, Kimber J, Breen C, et al. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. The Cochrane Collaboration. John Wiley and Sons, Ltd; 2008. 3. Saxon AJ, Ling W, Hillhouse M, et al. Buprenorphine/naloxone and methadone effects on laboratory indices of liver health: a randomized trial. Drug Alcohol Depend. 2013;128:71–76.

Trends in ART prescription and viral suppression among HIV-positive young adults in care in the United States, 2009–2013

Background: Only 13% of HIV-positive young adults are estimated to be virally suppressed and, even among those receiving medical care, HIV-positive young adults are less likely than older adults to take antiretroviral therapy (ART), be adherent, and be virally suppressed. We sought to examine trends in treatment and health outcomes from 2009 to 2013 among HIV-positive young adults (aged 18–24 years) in care. Setting: The Medical Monitoring Project is a complex sample survey of HIV-infected adults receiving medical care in the United States. Methods: We used weighted interview and medical record data collected from June 2009 to May 2014 to estimate trends in the prevalence of ART prescription, adherence, side effects, single-tablet ART regimens, regular care utilization, and viral suppression among young adults. Results: From 2009 to 2013, there were significant increases in ART prescription (76%–87%) and the proportion of young adults taking ART who reported taking single-tablet regimens (49%–62%). There was no significant change in adherence, side effects, or regular care utilization. Although viral suppression at last test did not change (65% at both time periods), the proportion of young adults who were sustainably virally suppressed significantly increased (29%–46%). Accounting for ART prescription and single-tablet regimen use attenuated the sustained viral suppression trend. Conclusions: Although the level of viral suppression among young adults in care remains suboptimal, the observed increases in ART prescription and sustained viral suppression may be a cause for optimism regarding efforts to improve outcomes for this vulnerable population.