Sarah L. Braunstein

Men who have sex with men have a 140-fold higher risk for newly diagnosed HIV and syphilis compared with heterosexual men in New York City.

ObjectivesTo describe the population of men who have sex with men (MSM) in New York City, compare their demographics, risk behaviors, and new HIV and primary and secondary (P&S) syphilis rates with those of men who have sex with women (MSW), and examine trends in infection rates among MSM. DesignPopulation denominators and demographic and behavioral data were obtained from population-based surveys during 2005–2008. Numbers of new HIV and P&S syphilis diagnoses were extracted from city-wide disease surveillance registries. MethodsWe calculated overall, age-specific and race/ethnicity-specific case rates and rate ratios for MSM and MSW and analyzed trends in MSM rates by age and race/ethnicity. ResultsThe average prevalence of male same-sex behavior during 2005–2008 (5.0%; 95% CI: 4.5 to 5.6) differed by both age and race/ethnicity (2.3% among non-Hispanic black men; 7.4% among non-Hispanic white men). Compared with MSW, MSM differed significantly on all demographics and reported a higher prevalence of condom use at last sex (62.9% vs. 38.3%) and of past-year HIV testing (53.6% vs. 27.2%) but also more past-year sex partners. MSM HIV and P&S syphilis rates were 2526.9/100,000 and 707.0/100,000, each of which was over 140 times MSW rates. Rates were highest among young and black MSM. Over 4 years, HIV rates more than doubled and P&S syphilis rates increased 6-fold among 18-year-old to 29-year-old MSM. ConclusionsThe substantial population of MSM in New York City is at high risk for acquisition of sexually transmitted infections given high rates of newly diagnosed infections and ongoing risk behaviors. Intensified and innovative efforts to implement and evaluate prevention programs are required.

HIV Incidence Among Men With and Those Without Sexually Transmitted Rectal Infections: Estimates From Matching Against an HIV Case Registry

BACKGROUND Sexually transmitted bacterial rectal infections are objective markers of HIV risk behavior. Quantifying HIV risk among men who have sex with men (MSM) who have had these infections can inform prevention efforts. We measured HIV risk among MSM who have and those who have not been diagnosed with rectal Chlamydia trachomatis (CT) and/or rectal Neisseria gonorrhoeae (GC). METHODS HIV incidence among a cohort of 276 HIV-negative MSM diagnosed with rectal CT and/or GC in New York City sexually transmitted disease (STD) clinics was compared to HIV incidence among HIV-negative MSM without these infections. Matches against the citywide HIV/AIDS registry identified HIV diagnoses from STD clinics, and by other providers. Cox proportional hazards models were used to explore factors associated with HIV acquisition among MSM with rectal infections. RESULTS HIV-negative MSM with rectal infections (>70% of which were asymptomatic) contributed 464.7 person-years of follow-up. Among them, 31 (11.2%) were diagnosed with HIV, of whom 14 (45%) were diagnosed by non-STD clinic providers. The annual HIV incidence was significantly higher among MSM with rectal infections (6.67%; 95% confidence interval [CI], 4.61%-9.35%) than among MSM without rectal infections (2.53%; 95% CI, 1.31%-4.42%). Black race (hazard ratio, 4.98; 95% CI, 1.75-14.17) was associated with incident HIV among MSM with rectal CT/GC. CONCLUSIONS One in 15 MSM with rectal infections was diagnosed with HIV within a year, a higher risk than for MSM without rectal infections. Such data have implications for screening for rectal STD, and may be useful for targeting populations for risk-reduction counseling and other HIV prevention strategies, such as preexposure prophylaxis.

High human immunodeficiency virus incidence in a cohort of Rwandan female sex workers

Background: Measurement of human immunodeficiency virus (HIV) incidence among female sex workers in Rwanda is a key part of preparing for HIV prevention trials. Methods: HIV-negative, nonpregnant female sex workers (N = 397) were tested for HIV-1, sexually transmitted infections, and pregnancy quarterly for 12 months, and again at a 1-time year 2 visit. Additional women (N = 156) were tested for HIV at baseline and 6 to 12 months thereafter in a parallel study. Results: A total of 19 participants seroconverted during follow-up, with 13 in the first 12 months. The 12-month HIV incidence rate (IR) was 3.5 (95% confidence interval: 1.6, 5.4) per 100 person-years (PY). There was a nonsignificant downward trend from 4.6/100 PY (1.6, 7.7) in the first 6 months to 2.2 (0.1, 4.4) in the second 6 months (IR ratio: 2.1 [95% confidence interval: 0.7, 7.8]). The year 2 IR was 2.1 (0.4, 3.7), and the HIV IR in the parallel study (in the absence of frequent study visits) was 3.3/100 PY (0, 7.0). HIV testing history, lifetime pregnancies, recent initiation of sex work, gonorrhea, syphilis, and change in reproductive intentions were associated with incident HIV infection. Incidence of pregnancy, herpes simplex virus-type 2, trichomoniasis, gonorrhea, chlamydia, and syphilis per 100 PY were as follows: 26.3 (21.9, 30.7), 8.7 (4.0, 13.4), 16.9 (12.7, 21.1), 12.1 (8.2, 15.9), 8.1 (5.1, 11.2), and 6.2 (3.7, 8.7). Conclusions: The HIV/sexually transmitted infections burden in this group was high. HIV IR was highest in the first 6 months of the cohort, and in the parallel study in which there were no risk-reduction procedures. HIV prevention and family planning interventions are needed.

Barriers and facilitators of linkage to HIV primary care in New York City

Abstract:One in 5 people living with HIV are unaware of their status; they account for an estimated 51% of new infections. HIV transmission can be reduced through a “Test and Treat” strategy, which can decrease both viral load and risk behaviors. However, linkage of newly diagnosed HIV-positive persons to care has proved challenging. We report quantitative and qualitative data on linkage to care from HIV testing sites that partnered with the New York City Department of Health and Mental Hygiene to implement “The Bronx Knows” (TBK), an initiative that tested 607,570 residents over 3 years. During TBK, partner agencies reported the aggregate number of HIV tests conducted, the number of confirmed positives (overall and new), and the number of confirmed positives linked to medical care. We conducted qualitative interviews with directors of 24 of 30 TBK HIV testing agencies to identify linkage barriers and selected 9 for case studies. Barriers to linkage fell into 3 domains: (1) health care system factors (long wait for provider appointments, requirement of a positive confirmatory test before scheduling an appointment, system navigation, and disrespect to patients); (2) social factors (HIV stigma); and (3) characteristics of risk populations (eg, mental illness, homelessness, substance use, and immigrant). Best practices for linkage included networking among community organizations, individualized care plans, team approach, comprehensive and coordinated care services, and patient peer navigation. Research and public health implications are discussed.

Carraguard Vaginal Gel Safety in HIV-Positive Women and Men in South Africa

Objective:To assess the safety of the candidate microbicide Carraguard gel in HIV-positive women and men. Design:A randomized, placebo-controlled, triple-blinded clinical trial of Carraguard gel when applied vaginally once per day for 14 intermenstrual days by sexually abstinent and sexually active HIV-positive women; and when applied directly to the penis once per day for 7 days by sexually abstinent HIV-positive men. Methods:In each cohort (n = 20 per cohort), participants were randomized to Carraguard, methylcellulose placebo, or no product (1:1:1). In addition to traditional microbicide trial safety endpoints, the effects of microbicide use on vaginal shedding of HIV-1 RNA and markers of genital inflammation, epithelial sloughing, and microhemorrhage were also explored. Results:Gel compliance was high in both gel-use groups in the 3 cohorts. Carraguard use was not associated with abnormal genital findings, other abnormal clinical findings, markers of genital inflammation, epithelial sloughing or microhemorrhage, or self-reported symptoms in women and men, or with abnormal vaginal flora or genital shedding of HIV-1 RNA in women. Adverse events were mostly mild, not attributed to gel use, and similarly distributed between groups. Conclusions:Once-daily use of Carraguard for 7 to 14 days appeared to be safe in HIV-positive women and men.

Acceptability of Carraguard, a candidate microbicide and methyl cellulose placebo vaginal gels among HIV-positive women and men in Durban, South Africa

Background and MethodsWhen on the market, microbicides are likely to be used by individuals who do not know their HIV status. Hence, assessment of safety and acceptability among HIV positive men and women is important. Acceptability of Carraguard, the Population Councils lead microbicide candidate was assessed in a Phase I safety study among healthy HIV-positive sexually abstinent women and men, and sexually active women (20 per group), in Durban, South Africa. Participants were randomized to use Carraguard gel, placebo gel, or no product. All women in the gel arms applied 4 ml gel vaginally every evening for 14 intermenstrual days (women in the sexually active group inserted gel within 1 hour prior to sex on days when sex occurred), and sexually abstinent men applied gel directly to the penis every evening for 7 days. Acceptability was assessed by face-to-face structured questionnaires and semi-structured in-depth interviews with all participants. Gel use questions were applicable to participants in the gel arms only (13 sexually abstinent women, 14 sexually active women, and 13 abstinent men).ResultsOverall, 93% of the women liked the study gel (Carraguard or placebo) very much, 4% disliked it somewhat, and 4% were neutral. 15% of men and women disliked the gels color, smell, or packaging. Most women and men reported never experiencing pain or irritation during or after gel application. Although over two thirds of the women preferred some lubrication during sex, some of the women felt that the gel was frequently too wet. Twenty-one percent of women and 42% of men said they felt covert use of a microbicide would be acceptable. Over 60% of women and men would prefer to use a microbicide alone instead of using it with a condom.ConclusionAcceptability of Carraguard among HIV-positive women and men in Durban was good. The wetness experienced by the women may be attributed to the delivery of gel volume. The applicator was designed to deliver 4 mls whereas in fact between 4 ml to 5 mls were actually dispensed. Condom migration in the event of a partially effective product is of concern.

Elevated Risk for Invasive Meningococcal Disease Among Persons With HIV

Context Invasive meningococcal disease (IMD) is life-threatening. Current recommendations for receipt of meningococcal vaccine to prevent IMD do not include HIV-infected adults. Contribution HIV infection and IMD are reportable diseases in New York City. Investigators linked databases and found that, compared with the general population, people living with HIV/AIDS (PLWHA) had a relative risk for IMD of 10. Risk was greatest in persons with CD4+ counts less than 0.200109 cells/L. Serotypes in nearly 90% of IMD cases in adult PLWHA are included in current meningococcal vaccines. Implication Studies of vaccine effectiveness are needed in adult PLWHA, who may be appropriate candidates for routine immunization with meningococcal vaccine. The Editors Infection with HIV is associated with an increased risk for several bacterial infections, most notably Mycobacterium tuberculosis, Streptococcus pneumonia, nontyphoid Salmonella, Haemophilus influenzae, and Staphylococcus aureus(1, 2). Data on the relationship between HIV and Neisseria meningitidis are limited. An analysis of surveillance data from 1988 to 1993 from the 8-county metropolitan area of Atlanta, Georgia, found that HIV-infected adults aged 25 to 49 years had a nearly 24-fold increased risk for invasive meningococcal disease (IMD) (3). More recently, Cohen and colleagues reported that the incidence of IMD in HIV-infected individuals of all ages in South Africa was 11 times greater than that among HIV-uninfected individuals (4). Moreover, the Centers for Disease Control and Prevention (CDC) recently published data from its Active Bacterial Core surveillance sites indicating that the cumulative annual incidence of IMD in individuals who meet the case definition for AIDS is approximately 13 times greater than in those who do not (5). In 2005, a new tetravalent meningococcal polysaccharideprotein conjugate vaccine (MCV4) was approved and recommended for routine use in young adolescents (aged 11 to 12 years) on the basis of an increased risk for IMD in college students living in dormitories and a cost-effectiveness analysis (6). Current MCV4 recommendations, however, do not include people living with HIV/AIDS (PLWHA), other than HIV-infected adolescents (5). The absence of meningococcal vaccine recommendations in HIV-infected adults is due, in part, to insufficient data on vaccine efficacy in HIV-infected adults, the duration of immunity, and the concern over the cost-effectiveness of such recommendations. To explore the relationship between HIV and IMD in New York City (NYC), we matched population-based IMD surveillance data with HIV and vital statistics registries to calculate rates of IMD and IMD-related death from 2000 to 2011 among PLWHA and persons not known to be HIV-infected. We also analyzed the serogroup distribution among IMD cases and evaluated the effect of immune status and viral load (VL) on risk for IMD among PLWHA.An outbreak of serogroup C IMD was recognized in NYC among men who have sex with men (MSM) in the fall of 2012 after the data analysis for this article was completed (7). A total of 17 cases and 6 deaths were identified in 2012 and 2013, with 10 of the cases having occurred in PLWHA. These 17 cases were not included in the analysis. Methods Study Population Both IMD and HIV are reportable diseases in NYC. We included IMD cases in NYC that were diagnosed during 2000 to 2011, met the Council of State and Territorial Epidemiologists case definitions for confirmed or probable meningococcal disease (8), and were reported to the NYC Department of Health and Mental Hygiene (DOHMH). The IMD diagnosis date was defined as the date of the clinical specimen or findings that met the case definition. Cases of IMD from 2000 to 2011 were matched to the DOHMHs Office of Vital Statistics death registry to determine vital status and underlying cause of death. Death due to IMD was defined as death occurring within 30 days of diagnosis with a final cause consistent with meningococcal disease. When IMD was not specifically listed as the cause of death, the record was reviewed by 2 independent medical reviewers who both needed to concur that the death was due to IMD. The state of New York mandated confidential, name-based reporting of HIV-related events in 1998, with implementation in June 2000. The law requires reporting of all diagnoses of HIV and AIDS, all HIV-related illness, all positive Western blot test results for HIV antibody, all VL and CD4+ cell count values, and all HIV genotypes (914). The NYC HIV Surveillance Registry (HSR) is a population-based registry of all AIDS cases diagnosed in NYC since 1981 and all HIV cases diagnosed since 2000. The HSR is regularly matched to local and national vital statistics death registries to update vital status for PLWHA and is continuously updated with HIV-related laboratory reports. Since 2005, all CD4+ cell count and HIV VL results have been electronically reported to the HSR. Incoming laboratory reports from providers and laboratories that cannot be matched to an existing person in the registry initiate a field investigation to confirm through medical record review that the case meets surveillance definitions for HIV, AIDS, or both (15) and to record data elements to be used to establish a date of diagnosis and collect other data required for surveillance. We matched case patients with IMD to the HSR by using a deterministic automated algorithm comprising 36 keys based on combinations of first name; last name; date of birth; Social Security number; and the soundex function in SAS, version 9.2 (SAS Institute, Cary, North Carolina), which adjusts for names spelled phonetically. The algorithm was ordered hierarchically such that lower keys were considered to represent matches more likely to be true. Exact matches on keys 1 to 7 were accepted as true matches without further review. Matches on keys 8 to 36 prompted a manual review by 2 independent reviewers with access to additional information about potentially matching pairs of case patients, such as residential address (16). To account for the W-shaped age distribution of IMD (17) and control for the confounding effect of age on the relative risk (RR) for IMD in PLWHA, we excluded case patients younger than 15 years and older than 64 years from the study population. The primary IMD syndrome was determined by clinical and laboratory findings per the following hierarchy if multiple syndromes existed: meningococcemia > meningitis > bacteremia > other (for example, joint or pneumonia). The IMD serogroup was determined by slide agglutination at the NYC Public Health Laboratory or by polymerase chain reaction at the Wadsworth Center State Public Health Laboratory. Statistical Analysis The number of PLWHA was estimated as the product of age-specific HIV prevalence rates (calculated from HSR data as persons diagnosed with HIV in NYC and reported to DOHMH by 30 September 2012) and intercensal population estimates for persons aged 15 to 64 years and was then averaged for 2000 to 2011. Populations for 3-year intervals were similarly estimated. The population of HIV-uninfected persons aged 15 to 64 years was calculated as the difference between the average total NYC populations and the interval-specific PLWHA population estimates. Descriptive statistics and the chi-square test were used to compare case patients with IMD on categorical variables by HIV status and also to test for trend in the proportion of patients with IMD who were HIV-infected over time. Means and SDs were used to compare continuous variables by HIV status. The average annual incidence rate of IMD per 100000 persons was computed for the 12-year period (20002011) and by 3-year intervals (20002002, 20032005, 20062008, and 20092011) among both PLWHA and HIV-uninfected persons. The RRs for IMD among PLWHA and 95% CIs were calculated for the 12- and 3-year intervals. The RR for IMD was also stratified by 3 age categories (15 to 24, 25 to 44, and 45 to 64 years) and by sex over the entire interval. Cigarette smoking frequently appears in the literature as a risk factor for IMD (1821). Questions on smoking were added to IMD case investigations in 2006, and data were available for three quarters of IMD cases during this period (cases with missing data were excluded). We used population-based estimates of smoking prevalence from the NYC Community Health Survey for 2006 and 2007 (39.6% among respondents self-reporting HIV infection and 18.8% among those self-reporting no HIV/AIDS) (22) to estimate the smoking prevalence among individuals without IMD in order to stratify the RR for IMD in PLWHA by smoking status. A sensitivity analysis of HIV ascertainment was also conducted using data from a serosurvey of undiagnosed HIV infection. The RR was recalculated by adding 14% to the PLWHA population with no additional cases of IMD (23). To compare the IMD case-fatality ratio (CFR) among patients with IMD and HIV and those with IMD only, we divided the CFR among the former for 2000 to 2011 by the CFR among the latter. A multivariate logistic regression model was used to obtain an age-adjusted odds ratio (OR) of death in case patients with IMD and HIV. The proportion of IMD cases potentially preventable by MCV4 vaccination (serogroups A, C, Y, and W) was compared by HIV status. To explore whether immune suppression and lack of HIV viral suppression were associated with higher IMD risk in PLWHA, we performed separate casecontrol analyses of the odds of IMD by CD4+ cell count and HIV VL among a subset of case patients with IMD and HIV. People living with HIV/AIDS with CD4+ cell counts and VL from the HSR in 2005 or later and test dates within 91 days of the IMD diagnosis date were eligible for selection (before 2005, only low CD4+ cell counts and detectable VL were reportable). All persons without IMD in the HSR who had CD4+ cell counts and VL were eligible to serve as control patients. For the 2 analyses, case patients w

Improvements in HIV Care Engagement and Viral Load Suppression Following Enrollment in a Comprehensive HIV Care Coordination Program

BACKGROUND Substantial evidence gaps remain regarding human immunodeficiency virus (HIV) intervention strategies that improve engagement in care (EiC) and viral load suppression (VLS). We assessed EiC and VLS before and after enrollment in a comprehensive intervention for persons at risk of poor HIV care outcomes. METHODS New York Citys Ryan White Part A HIV Care Coordination Program (CCP), launched at 28 agencies in 2009, applies multiple strategies to promote optimal utilization of medical and social services. Using laboratory test records from an HIV surveillance registry, we examined pre-post outcomes among 3641 CCP clients enrolled before April 2011. For the year before and after enrollment, we assessed EiC (defined as ≥2 tests, ≥90 days apart, with ≥1 in each half-year) and VLS (defined as viral load [VL] ≤200 copies/mL on latest VL test in the second half of the year). We estimated relative risks (RRs), comparing pre- and postenrollment proportions achieving EiC and VLS. RESULTS Among newly diagnosed clients, 90.5% (95% confidence interval [CI], 87.9%-93.2%) and 66.2% (95% CI, 61.9%-70.6%) achieved EiC and VLS, respectively. Among previously diagnosed clients, EiC increased from 73.7% to 91.3% (RR = 1.24; 95% CI, 1.21-1.27) and VLS increased from 32.3% to 50.9% (RR = 1.58; 95% CI, 1.50-1.66). Clients without evidence of HIV care during the 6 months preenrollment contributed most to overall improvements. Pre-post improvements were robust, retaining statistical significance within most sociodemographic and clinical subgroups, and in 89% (EiC) and 75% (VLS) of CCP agencies. CONCLUSIONS Clients in comprehensive HIV care coordination for persons with evident barriers to care showed substantial and consistent improvement in short-term outcomes.

Assessing the impact of a community-wide HIV testing scale-up initiative in a major urban epidemic.

Background:The Bronx, one of 5 boroughs in New York City (NYC), bears a high burden of HIV. We evaluated the impact of HIV testing initiatives in the Bronx, including the 2008 The Bronx Knows campaign. Methods:We used data from an annual telephone survey representative of NYC adults to compare 2005 and 2009 estimates of HIV testing prevalence among Bronx residents and to identify correlates of testing. We used NYC HIV surveillance data to evaluate changes in the percentage of persons concurrently being diagnosed with HIV and AIDS, an indicator of delayed HIV diagnosis. Results:Between 2005 and 2009, relative increases of 14% and 32% were found in the proportion of Bronx adults who have ever been HIV tested and who have been tested in the past year, respectively (P < 0.001). The largest increases were among those aged 24–44 years, men, non-Hispanic blacks and Hispanics, and those with low income or education, nonheterosexual identity, a personal doctor/provider, or health insurance. Factors independently associated with being recently tested included black or other race, Hispanic ethnicity, and bisexual identity. The proportion concurrently diagnosed with HIV and AIDS fell 22% from 2005 to 2009, and decreases generally occurred among subgroups experiencing increases in testing. Conclusion:Community-wide testing in the Bronx increased the proportion of people with known HIV status and reduced the proportion with delayed diagnoses.

The epidemiology of human papillomavirus infection in HIV-positive and HIV-negative high-risk women in Kigali, Rwanda

BackgroundThe prevalence, incidence and persistence of human papillomavirus (HPV) types in sub-Saharan Africa are not well established. The objectives of the current study are to describe (predictors of) the epidemiology of HPV among high-risk women in Kigali, Rwanda.MethodsHIV-negative, high-risk women were seen quarterly for one year, and once in Year 2. HIV serostatus, clinical, and behavioral information were assessed at each visit, HPV types at Month 6 and Year 2, and other sexually transmitted infections (STI) at selected visits. HPV prevalence was also assessed in HIV-positive, high-risk women.ResultsPrevalence of any HPV was 47.0% in HIV-negative women (median age 25 years) compared to 72.2% in HIV-positive women (median age 27 years; OR 2.9, 95% CI 1.9-4.6). Among HIV-negative women, cumulative incidence of high-risk (HR)-HPV was 28.0% and persistence 32.0% after a mean period of 16.6 and 16.9 months, respectively. Prior Chlamydia trachomatis and Neisseria gonorrhoeae infection, concurrent low-risk (LR)-HPV infection and incident HSV-2 were associated with HR-HPV prevalence among HIV-negative women; prior C. trachomatis infection and co-infection with LR-HPV and HPV16-related HPV types with HR-HPV acquisition. HPV16-related types were the most prevalent and persistent.ConclusionsHigh HPV prevalence, incidence and persistence were found among high-risk women in Kigali. HPV52 had the highest incidence; and, together with HPV33 and HPV58, were strongly associated with acquisition of other HR-HPV types in HIV-negative women.