Sandra Schwarcz

Impact of Highly Active Antiretroviral Treatment on HIV Seroincidence Among Men Who Have Sex With Men: San Francisco

OBJECTIVES This study assessed the countervailing effects on HIV incidence of highly active antiretroviral treatment (HAART) among San Francisco men who have sex with men (MSM). METHODS Behavioral risk was determined on the basis of responses to cross-sectional community interviews. HIV incidence was assessed through application of an enzyme-linked immunoassay testing strategy. RESULTS Use of HAART among MSM living with AIDS increased from 4% in 1995 to 54% in 1999. The percentage of MSM who reported both unprotected anal intercourse and multiple sexual partners increased from 24% in 1994 to 45% in 1999. The annual HIV incidence rate increased from 2.1% in 1996 to 4.2% in 1999 among MSM who sought anonymous HIV testing, and the rate was high (5.3%) but stable in a blinded survey of MSM seeking sexually transmitted disease services. CONCLUSIONS Any decrease in per contact risk of HIV transmission due to HAART use appears to have been counterbalanced or overwhelmed by increases in the number of unsafe sexual episodes.

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.

Trends in Causes of Death among Persons with Acquired Immunodeficiency Syndrome in the Era of Highly Active Antiretroviral Therapy, San Francisco, 1994–1998

To understand recent temporal trends in acquired immunodeficiency syndrome (AIDS) mortality in the era of highly active antiretroviral therapy (HAART), trends in causes of death among persons with AIDS in San Francisco who died between 1994 and 1998 were analyzed. Among 5234 deaths, the mortality rate for human immunodeficiency virus (HIV)-related or AIDS-related deaths declined after 1995 (P<.01), whereas the mortality rate for non-HIV- or non-AIDS-related deaths remained stable. The proportion of deaths of persons with AIDS associated with septicemia, non-AIDS-defining malignancy, chronic liver disease, viral hepatitis, overdose, obstructive lung disease, coronary artery disease, and pancreatitis increased (P<.05). The standardized mortality ratio was high for these causes in both pre- and post-HAART periods, except for pancreatitis, a possible complication of HAART, which demonstrated an increasing standardized mortality ratio trend after 1996. With increasing AIDS survival, prevention of chronic diseases, assessment of long-term toxicity from HAART, and surveillance for additional causes of mortality will become increasingly important.

Effect of highly active antiretroviral therapy on diagnoses of sexually transmitted diseases in people with AIDS

BACKGROUND There has been an increase in high-risk sexual behaviour and sexually transmitted diseases (STD) during the time period when highly active antiretroviral therapy (HAART) became widely available. We examined whether taking HAART increased the risk of acquiring an STD--an epidemiological marker of unsafe sex--in people with AIDS. METHODS We did a computerised match of people in the San Francisco STD and AIDS registries. People with AIDS who were diagnosed before 1999 and alive in November, 1995, or later, were classified as having had an STD after AIDS diagnosis or not having had an STD after AIDS diagnosis. We used a Cox proportional hazards model to see whether use of antiretroviral therapy was associated with acquiring an STD after AIDS, after adjustment for sex, age, race, HIV-1 risk category, and CD4 count at AIDS diagnosis. FINDINGS People with AIDS who had had HAART showed an independent increase in the risk of developing an STD (hazard ratio 4.10; 95% CI 2.84-5.94). Americans of African origin, younger age, and higher CD4 count at AIDS diagnosis were also associated with acquiring an STD after AIDS. The number of people living with AIDS who acquired an STD increased over time from 60 (0.66%) in 1995 to 113 (1.32%) in 1998 (p<0.001). INTERPRETATION We have shown that people on HAART are more likely to develop an STD, an epidemiological marker of unsafe sex. More intensive risk-reduction counselling and STD screening for people with AIDS is needed.

Late diagnosis of HIV infection : Trends, prevalence, and characteristics of persons whose HIV diagnosis occurred within 12 months of developing AIDS

Background:Persons diagnosed late in the course of HIV infection may be unknowingly transmitting infection and once diagnosed may have worse outcomes and greater medical expenses. Methods:Persons diagnosed with AIDS in San Francisco between 2001 and 2005 were included. Late testers were persons diagnosed with HIV 12 months or less before their AIDS diagnosis. Prevalence trends, demographic and risk correlates, and predictors of late testing were measured. Results:Among 2139 persons included, 830 (38.8%) were late testers. The prevalence of late testing was stable between 2001 and 2005. Late testing was more likely among persons <30 years old (Odds ratio [OR]: 1.99, 95% confidence interval [CI]: 1.4, 2.8), heterosexuals (OR: 1.88, 95% CI: 1.1, 3.1), persons without a reported risk (OR: 2.88, 95% CI: 1.7, 5.0), persons with private insurance (OR: 1.82, 95% CI: 1.4, 2.4), no insurance (OR: 1.83, 95% CI: 1.4, 2.4), born outside of the United States (OR: 1.64, 95% CI: 1.2, 2.2), and whose initial AIDS diagnosis was an opportunistic infection (OR: 2.24, 95% CI: 1.8, 2.8). Conclusions:A large proportion of persons with AIDS have tested late in the course of HIV infection and this proportion has not declined in recent years. Routine testing in medical settings, and use of rapid oral-fluid testing in traditional and nontraditional settings may increase early HIV diagnosis.

Low socioeconomic status is associated with a higher rate of death in the era of Highly active antiretroviral therapy, San Francisco

Highly active antiretroviral therapy (HAART) has dramatically improved survival after AIDS. The benefits of HAART have not been equally realized for all communities, however. We characterize the association of socioeconomic status (SES) with survival after AIDS diagnosis in San Francisco in the period before (1980-1995) and after (1996 - 2001) the wider use of HAART. Using citywide surveillance data, we examined differences in survival after AIDS diagnosis by neighborhood household income using Kaplan-Meier survival analysis and Cox proportional hazards analysis to adjust for significant covariates. Residing in higher SES neighborhoods significantly predicted better survival after AIDS from 1996 to 2001 (hazard ratio = 0.92 per

Identifying barriers to HIV testing: personal and contextual factors associated with late HIV testing

10,000 increase in neighborhood household income, 95% CI: 0.85-0.99) after adjusting for CD4 count at diagnosis, age, and injection drug user status. Persons living in poorer neighborhoods were less likely to use HAART at any time in the past compared with persons in wealthier neighborhoods. Moreover, no association between survival and neighborhood SES was evident in the era prior to the wide use of HAART. Finally, the difference in survival by neighborhood income level disappeared after controlling for the use of HAART, suggesting that use of or access to treatment explained the association. From 1996 to 2001, survival with AIDS was worse for people living in poorer neighborhoods compared with those living in wealthier neighborhoods of San Francisco as a result of unequal access to or use of HAART.

Disparities in engagement in care and viral suppression among persons with HIV.

Abstract Late diagnosis of HIV is associated with increased morbidity, mortality, and health care costs. Despite the availability of HIV testing, persons continue to test late in the course of HIV infection. We used the HIV/AIDS case registry of San Francisco Department of Public Health to identify and recruit 41 persons who developed AIDS within 12 months of their HIV diagnosis to participate in a qualitative and quantitative interview regarding late diagnosis of HIV. Thirty-one of the participants were diagnosed with HIV because of symptomatic disease and 50% of the participants were diagnosed with HIV and AIDS concurrently. Half of the subjects had not been tested for HIV prior to diagnosis. Fear was the most frequently cited barrier to testing. Other barriers included being unaware of improved HIV treatment, free/low cost care, and risk for HIV. Recommendations for health care providers to increase early diagnosis of HIV include routine ascertainment of HIV risk behaviors and testing histories, stronger recommendations for patients to be tested, and incorporating testing into routine medical care. Public health messages to increase testing include publicizing that (1) effective, tolerable, and low cost/free care for HIV is readily available, (2) early diagnosis of HIV improves health outcomes, (3) HIV can be transmitted to persons who engage in unprotected oral and insertive anal sex and unprotected receptive anal intercourse without ejaculation and from HIV-infected persons whose infection is well-controlled with antiretroviral therapy, (4) persons who may be infected based upon these behaviors should be tested following exposure, (5) HIV testing information will be kept private, and (6) encouraging friends and family to get HIV tested is beneficial.

Viagra, methamphetamine, and HIV risk: results from a probability sample of MSM, San Francisco.

Background:Engagement across the spectrum of HIV care can improve health outcomes and prevent HIV transmission. We used HIV surveillance data to examine these outcomes. Methods:San Francisco residents who were diagnosed with HIV between 2009 and 2010 were included. We measured the characteristics and proportion of persons linked to care within 6 months of diagnosis, retained in care for second and third visits, and virally suppressed within 12 months of diagnosis. Results:Of 862 persons included, 750 (87%) entered care within 6 months of diagnosis; of these, 72% had a second visit in the following 3–6 months; and of these, 80% had a third visit in the following 3–6 months. Viral suppression was achieved in 50% of the total population and in 76% of those retained for 3 visits. Lack of health insurance and unknown housing status were associated with not entering care (P < 0.01). Persons with unknown insurance status were less likely to be retained for a second visit; those younger than 30 years were less likely to be retained for a third visit. Independent predictors of failed viral suppression included age <40 years, homelessness, unknown housing status, and having a single or 2 medical visits compared with 3 visits. Conclusions:Socioeconomic resources and age, not race or gender, are associated with disparities in engagement in HIV care in San Francisco.

Crack cocaine and the exchange of sex for money or drugs. Risk factors for gonorrhea among black adolescents in San Francisco.

Objectives: To determine the prevalence and factors of Viagra use in combination with crystal methamphetamine and its association with HIV risk behavior in a probability sample of men who have sex with men (MSM). Study Design: A cross-sectional, random-digit dial telephone survey of MSM in San Francisco conducted between June 2002 and January 2003. Results: Of the 1976 MSM, 13.5% used Viagra alone, 7.1% used methamphetamine without Viagra, 9.6% used Viagra with a mood-altering substance (excluding methamphetamine), and 5.1% used Viagra with methamphetamine. Of the MSM using Viagra with methamphetamine, 57% were HIV-infected and 24% of these men reported serodiscordant unprotected insertive intercourse. Viagra used with methamphetamine was independently associated with a higher risk of serodiscordant unprotected insertive intercourse, serodiscordant unprotected receptive intercourse, and a recent diagnosis of a sexually transmitted disease. Conclusion: MSM who use Viagra with crystal methamphetamine have high prevalence rates of HIV and engage in HIV risk behaviors.