Robert W. Wood

Overcoming barriers to HIV testing: preferences for new strategies among clients of a needle exchange, a sexually transmitted disease clinic, and sex venues for men who have sex with men:

Objective: To determine strategies to overcome barriers to HIV testing among persons at risk. Methods: We developed a survey that elicited testing motivators, barriers, and preferences for new strategies among 460 participants at a needle exchange, three sex venues for men who have sex with men, and a sexually transmitted disease clinic. Results: Barriers to testing included factors influenced by individual concern (fear and discrimination); by programs, policies, and laws (named reporting and inability to afford treatment); and by counseling and testing strategies (dislike of counseling, anxiety waiting for results, and venipuncture). The largest proportions of participants preferred rapid testing strategies, including clinic‐based testing (27%) and home selftesting (20%); roughly equal proportions preferred oral fluid testing (18%), urine testing (17%), and standard blood testing (17%). One percent preferred home specimen collection. Participants who had never tested before were significantly more likely to prefer home self‐testing compared with other strategies. Blacks were significantly more likely to prefer urine testing. Conclusions: Strategies for improving acceptance of HIV counseling and testing include information about access to anonymous testing and early treatment. Expanding options for rapid testing, urine testing, and home self‐testing; providing alternatives to venipuncture; making pretest counseling optional; and allowing telephone results disclosure may encourage more persons to learn their HIV status.

Association of anal dysplasia and human papillomavirus with immunosuppression and HIV infection among homosexual men

OBJECTIVE To examine and quantify the association between anal squamous intraepithelial lesions (ASIL), anal human papillomavirus (HPV) infection and immunosuppression among HIV-seropositive and HIV-seronegative homosexual men. DESIGN Cross-sectional study among homosexual men presenting at a community-based clinic for HIV serologic screening. RESULTS Anal HPV DNA was detected in 55 and 23% of 285 HIV-seropositive and 204 HIV-seronegative men, respectively, by Southern transfer hybridization (STH) [odds ratio (OR), 4.0; 95% confidence interval (CI), 2.7-6.2], and in 92 and 78% by polymerase chain reaction (PCR) (OR, 3.1; 95% CI, 1.6-5.8). ASIL was noted in 26% of HIV-seropositive men and in 8% of HIV-seronegative men (compared with men with negative cytologic findings: OR, 5.6; 95% CI, 3.0-10.5), with high-grade lesions noted in 4% of HIV-seropositive and in 0.5% of HIV-seronegative men. Among HIV-infected men, ASIL, detection of specific anal HPV types, and detection of high levels of anal HPV DNA (i.e., levels of HPV DNA detectable by both STH and PCR) were all associated with immunosuppression. Nevertheless, HIV-seropositive men with CD4 counts > 500 x 10(6)/l had a higher prevalence of both anal HPV and ASIL than men without HIV infection. Overall, detection of HPV at high levels was associated with ASIL. However, after adjustment for level of detectable HPV DNA, the risk of ASIL among HIV-seropositive men with CD4 counts < 500 x 10(6)/l was increased 2.9-fold (95% CI, 1.4-6.2) over that of HIV-seropositive men with CD4 counts > 500 x 10(6)/l. CONCLUSION Given the high rates of ASIL in HIV-seronegative and both immunosuppressed and non-immunosuppressed HIV-seropositive homosexual men, natural history studies are now needed to assist in the development of strategies for the detection and management of such lesions. The increased prevalence of ASIL seen among immunosuppressed HIV-seropositive men may be the result of both a non-specific increase in productive HPV infection and HIV-induced immune alterations of HIV-related neoplasia.

Poverty and HIV seropositivity: the poor are more likely to be infected.

We analyzed demographic and behavioral risk factors for HIV seropositivity using data from 3601 clients of the main HIV counseling and testing clinic for high-risk people in Seattle, Washington, USA. Clients with lower income were found to be more likely to be HIV seropositive, before and after controlling for other demographic and risk factors with logistic regression. This result supports the hypothesis that the impoverished are at increased risk for HIV infection due to the physical and social circumstances in which their poverty places them. These may include poor access to risk-reduction information and less support for implementation of risk-reduction strategies.

Targeted screening for primary HIV infection through pooled HIV-RNA testing in men who have sex with men

HIV-RNA testing may identify individuals with primary HIV infection. Men who have sex with men (MSM) having HIV testing through Public Health, Seattle and King County were screened for primary infection through pooled RNA testing. Eighty-one out of 3525 specimens (2.3%) had detectable antibody and RNA, and seven out of 3439 antibody-negative specimens (0.2%) had HIV RNA. Targeted screening for primary infection through pooled RNA testing in MSM is a useful addition to HIV case finding.

Differences in Risk Behavior and Sources of AIDS Information Among Gay, Bisexual, and Straight-Identified Men Who Have Sex with Men

At public sex environments in four U.S. cities, 1,369 men who have sex with men (MSM) were asked about sexual self-identification, recent HIV risk behaviors, and exposures to HIV information. Half of respondents (n = 687) self-identified as gay, 40% (n = 546) as bisexual, and 10% (n = 136) as straight. Ninety-nine percent of both gay and bisexual MSM and 96% of straight MSM reported oral sex with men; 94%, 68%, and 46%, respectively, reported anal sex with men, while 62%, 98%, and 97%, respectively, reported vaginal sex with women. Recent exposure to any HIV information was reported by 96%, 91%, and 89% respectively of gay, bisexual, and straight MSM; gay MSM were most likely to get HIV information from talking with someone. However, television was the only medium to reach more than half of gay, bisexual, and straight MSM. Non-gay-identified MSM and their partners are at high risk for HIV transmission, but more study is needed to identify the most effective channels for conveying risk reduction messages to this population.

Ongoing Risk Behavior Among Persons With HIV in Medical Care

We surveyed randomly selected patients in the largest HIV clinic in Seattle, WA in 2005 and 2006. A total of 397 patients completed usable surveys. Twenty-seven percent of men who have sex with men (MSM) and 22% of women or heterosexual men reported having non-concordant unprotected anal or vaginal intercourse in the preceding year. Compared to 2005, more MSM in 2006 reported meeting a sex partner via the Internet (15% vs. 33%), and fewer met partners in bathhouses (23% vs. 13%). Twenty-four percent of MSM reported deciding not to have sex with a potential partner because he was HIV negative, and 31% of MSM reported that another man had decided not to have sex with them because they were HIV positive. Among all participants, 22% had told a sex partner they were HIV negative since their HIV diagnosis. These findings demonstrate the persistence of high-risk behavior among persons with HIV, a rapid increase in the use of the Internet among MSM to find sex partners, and provide direct evidence for serosorting among MSM.

Sexually Transmitted Diseases and Human Immunodeficiency Virus–Discordant Partnerships among Men Who Have Sex with Men

Sexually active men who have sex with men (MSM) at 5 Seattle clinics were assessed for bacterial sexually transmitted diseases (STDs), human immunodeficiency virus (HIV)-discordant partnerships, sexual behavior, and drug use. Of the HIV-positive men, 45% reported having HIV-negative sex partners and 42% reported having sex partners with unknown serostatus during the past 2 months, whereas 14% and 57% of HIV-negative men reported having HIV-positive and unknown-serostatus sex partners, respectively. Correlates of sex partners with unknown serostatus were recruiting sex partners at bathhouses or parks. Gonorrhea, chlamydia, or syphilis was diagnosed in 12% of HIV-positive and 13% of HIV-negative MSM, and the rates did not differ between men with HIV-concordant and HIV-discordant partnerships. High prevalences of bacterial STDs and HIV-discordant partnerships emphasize the need for interventions to foster serostatus discussion, condom use, fewer anonymous partners, and STD screening.

Designing an HIV counseling and testing program for bathhouses: the Seattle experience with strategies to improve acceptability.

Summary Bathhouses are important venues for providing HIV counseling and testing to high-risk men who have sex with men (MSM), yet relatively few bathhouses routinely provide this service, and few data are available to guide program design. We examine numerous logistic considerations that had been identified in the HIV Alternative Testing Strategies study and that influenced the initiation, effectiveness, and maintenance of HIV testing programs in bathhouses for MSM. Key programmatic considerations in the design of a bathhouse HIV counseling and testing program included building alliances with community agencies, hiring and training staff, developing techniques for offering testing, and providing options for counseling, testing, and disclosure of results. The design included ways to provide client support and follow-up for partner notification and treatment counseling and to maintain relationships with bathhouse management for support of prevention activities. Early detection of HIV infection and HIV prevention can be achieved for some high-risk MSM through an accessible and acceptable HIV counseling and testing program in bathhouses. Keys to success include establishing community prevention collaborations between bathhouse personnel and testing agencies, ensuring that testing staff are supported in their work, and offering anonymous rapid HIV testing. Use of FDA approved, new rapid tests that do not require venipuncture, centrifugation, or laboratory oversight will further decrease barriers to testing and facilitate implementation of bathhouse testing programs in other communities.

An Efficient Strategy for Managing Acute Respiratory Illness in Adults

A safe, effective, and efficient clinical algorithm (management rule) for the care of adults with acute respiratory illness by nonphysician providers is presented. The algorithm was created from a data base collected on more than 5000 patients and prospectively evaluated on an additional 2637. It eliminates unhelpful diagnostic tests and minimizes physician involvement in patient care without compromising clinical standards, illness outcome, or patient satisfaction. Total direct medical care costs when the algorithm was used were approximately 40% of those costs generated by physicians managing similar patients, primarily because the algorithm directed an 80% reduction in a diagnostic test costs. The results suggest that significant savings can result when algorithms are used in the care of ambulatory patients with common illnesses.

The effect of chest radiographs on the management and clinical course of patients with acute cough.

The authors studied 2018 consecutive patients with a cough of less than 1 months duration, presenting for medical care with this problem for the first time. Chest films were taken of all of the last 1819 of these patients. After physicians had specified diagnoses and patient management plans for the last 1531 of these 1819 patients, 98 per cent of the 1531 were randomized either to a group whose chest films were then used in their care, or to a group whose chest films were not available to the physician. The results show that chest radiographs ordered by physicians resulted in potentially beneficial change in the care of only 3 per cent of patients. Only use of chest radiographs not ordered by physicians led to the appropriate addition of antibiotics to the care of patients with infiltrates, and probably to improved illness outcome. Criteria for efficient, effective use of chest radiographs in the management of patients with acute cough are needed.