Timothy A. Kellogg

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.

Amphetamine use is associated with increased HIV incidence among men who have sex with men in San Francisco

We examined the association between amphetamine use and HIV incidence for 2991 men who have sex with men (MSM) who tested anonymously for HIV in San Francisco. HIV incidence among 290 amphetamine users was 6.3% per year (95% CI 1.9–10.6%), compared with 2.1% per year (95% CI 1.3–2.9%) among 2701 non-users (RR 3.0, 95% CI 1.4–6.5). HIV prevention programmes in San Francisco should include efforts to reduce amphetamine use and associated high-risk sexual behaviors.

Prevalence and predictors of unmet need for supportive services among HIV-infected persons: impact of case management.

BACKGROUND Previous research has indicated that the needs of persons infected with human immunodeficiency virus (HIV) for supportive services often go unmet. Although case management has been advocated as a method of decreasing unmet needs for supportive services, its effectiveness is poorly understood. OBJECTIVES To assess the prevalence of need and unmet need for supportive services and the impact of case managers on unmet need among HIV-infected persons. RESEARCH DESIGN National probability sample. PARTICIPANTS A total of 2,832 HIV-infected adults receiving care. MEASURES Need and unmet need for benefits advocacy, housing, home health, emotional counseling, and substance abuse treatment services. RESULTS Sixty-seven percent of the sample had a need for at least one supportive service, and 26.6% had an unmet need for at least one service in the previous 6 months. Contingent unmet need (unmet need among persons who needed the service) was greatest for benefits advocacy (34.6%) and substance abuse treatment (27.6%). Fifty-seven percent of the sample had had contact with their case manager in the previous 6 months. In multiple logistic regression analysis, with adjustment for covariates, having a case manager was associated with decreased unmet need for home healthcare (OR =0.39; 95% CI = 0.25-0.60), emotional counseling (OR = 0.54; 95% CI = 0.38-0.78), and any unmet need (OR = 0.70; 95% CI = 0.54-0.91). An increased number of contacts with a case manager was significantly associated with lower unmet need for home health care, emotional counseling, and any unmet need. CONCLUSIONS Need and unmet need for supportive services among HIV-infected persons is high. Case management programs appear to lower unmet need for supportive services.

HIV seroprevalence and risk behaviors among lesbians and bisexual women in San Francisco and Berkeley, California.

Few data are available on human immunodeficiency virus (HIV) infection and risk behaviors among lesbians and bisexual women. A total of 498 lesbians and bisexual women was sampled from public venues in San Francisco and Berkeley, Calif, during 1993. The overall HIV seroprevalence was 1.2%. Ten percent of participants reported injecting drugs since 1978. Forty percent of the participants reported unprotected vaginal or anal sex with men during the past 3 years, including unprotected sex with gay and bisexual men and male injection drug users. The high rates of injection drug use and unsafe sexual behaviors suggest that lesbians and bisexual women frequenting public venues in San Francisco and Berkeley are at risk for HIV infection.

Incidence of human immunodeficiency virus among male-to-female transgendered persons in San Francisco.

Objective: To estimate HIV incidence among male‐to‐female transgendered persons (MtF transgendered persons) who repeatedly tested for HIV antibodies at public San Francisco counseling and testing sites between July 1997 and June 2000. Methods: HIV seroconversions were identified and person‐time of observation were estimated using the date and result of the current test and the self‐reported date and result of the previous test. Factors independently associated with HIV seroconversion were determined using multivariable proportional hazard analysis. Results: HIV incidence was 7.8 per 100 person‐years (95% confidence intervals [CI], 4.6‐12.3) based on 13 seroconversions among 155 repeat testers with 167.7 person‐years of observation. African‐American race/ethnicity (adjusted relative hazard ratio [HR], 5.0; 95% CI, 1.5‐16.2) and unprotected receptive anal intercourse (HR, 3.9; 95% CI, 1.2‐13.1) were independent predictors of HIV seroconversion. Conclusions: HIV is currently spreading at an extremely high rate among MtF transgendered persons in San Francisco, especially those who are African Americans.

Detection of early HIV infection and estimation of incidence using a sensitive/less-sensitive enzyme immunoassay testing strategy at anonymous counseling and testing sites in San Francisco.

Timely estimates of HIV incidence are needed to monitor the epidemic and target primary prevention but have been difficult to obtain. We applied a sensitive/ less-sensitive (S/LS) enzyme immunoassay (EIA) testing strategy to stored HIV-positive sera (N = 452) to identify early infections, estimate incidence, and characterize correlates of recent seroconversion among persons seeking anonymous HIV testing in San Francisco from 1996 to 1998 (N = 21,292). Sera positive on a sensitive EIA but negative on a less-sensitive EIA were classified as early HIV infections; sera positive on both EIA were classified as long standing. Seventy-nine sera were from people with early HIV infection. Estimated HIV incidence was 1.1% per year (95% confidence interval [CI], 0.68%-1.6%) overall and 1.9% per year (95% CI, 1.2%-3.0%) among men who have sex with men (MSM). Early HIV infection among MSM was associated with injection drug use, unprotected receptive anal sex, and multiple sex partners in the previous year. No temporal trend in HIV incidence was noted over the study period. The S/LS strategy provides a practical public health tool to identify early HIV infection and estimate HIV incidence in a variety of study designs and settings.

Routine surveillance for the detection of acute and recent HIV infections and transmission of antiretroviral resistance

Objective:To estimate the rate of acute and recent HIV infections and the prevalence of primary antiretroviral resistance. Design, setting, and subjects:A consecutive sample of individuals presenting for HIV testing at the San Francisco municipal sexually transmitted diseased (STD) clinic in 2004 (n = 3789). Main outcome measures:HIV antibody-positive specimens were screened by BED IgG capture enzyme immunoassay to identify recent infections. HIV antibody-negative specimens were screened by nucleic acid amplification testing (NAAT) to detect acute infections. Newly detected infections were genotyped to detect primary antiretroviral resistance. Results:There were 11 acute and 44 recent HIV infections among the total 136 newly detected cases. NAAT increased case identification by 8.08% over standard antibody testing. Acute HIV infections were associated with having a known HIV-positive partner, and a history of hepatitis B, syphilis, and chlamydia. The prevalence of primary antiretroviral resistance was 13.2%, with drug-resistant mutations detected in 17 of 129 cases genotyped. Mutations conferring resistance to non-nucleoside reverse transcriptase inhibitors (NNRTI) were present in 11 of 17 cases. Conclusion:The integration of HIV nucleic acid amplification, recent infection, and antiretroviral resistance testing enhanced HIV/STD surveillance. The high proportion of NNRTI mutations detected suggests they may be more common in source partners or more fit for transmission than other forms of drug-resistant HIV-1. Primary antiretroviral resistance monitoring in STD clinic patients may guide the selection of treatment and post-exposure prophylaxis regimens active against viruses being transmitted in the community, and provide health departments with surveillance data in a sentinel population at risk of HIV transmission.

Low incidence and prevalence of hepatitis C virus infection among sexually active non-intravenous drug-using adults, San Francisco, 1997-2000.

Background The rate of sexual transmission of hepatitis C virus (HCV) is debated. Goal The goal was to measure the risk of sexual transmission of hepatitis C virus (HCV) in a sexually active population. Study Design Sexual behaviors and HCV antibody status were measured in persons seeking repeat HIV testing in San Francisco from October 1997 through March 2000. Results Among 981 repeat testers, the prevalence of HCV antibody was 2.5%. Among men who have sex with men who denied intravenous drug use (n = 746), factors associated with HCV antibody positivity include age greater than 50 years (odds ratio [OR], 8.5; 95% confidence interval [CI], 2.6–27.7), HIV infection (OR, 5.7; 95% CI, 1.6–20.6), and being nonwhite (OR, 3.3; 95% CI, 1.1–10.0). HCV antibody positivity was not associated with sexual risk behaviors. In 576.6 person-years of observation, no new HCV seroconversions occurred (incidence = 0 per 100 person-year; 95% CI, 0–.6), whereas 6 new herpes simplex virus-2 infections (2.8 per 100 person-years) and 10 new HIV infections (1.8 per 100 person-years) occurred. Conclusion The absence of new HCV infections in this sample supports the hypothesis that the risk of sexual transmission of HCV is low.

Risk behaviors and HIV incidence among repeat testers at publicly funded HIV testing sites in San Francisco.

Objective: More than 25% of HIV tests are for individuals who have previously been tested. To characterize repeat testers, we 1) estimated the seroincidence of HIV infection, stratified by risk behavior, and examined the association between 2) testing rates and risk level and 3) repeat testing and tester characteristics. Methods: Records from HIV counseling and testing (C&T) sites were reviewed. Seroincidence was estimated by linking results of current test with date of last reported HIV negative test. A risk hierarchy of behaviors was created. Repeat testing rates were calculated for each risk level strata. Multivariate models explored the association of repeat testing with tester characteristics. Results: The HIV seroincidence among repeaters was 1.3 per 100 person‐years (range 0.7‐7.0 per 100 person‐years). The high‐risk level subject had a repeater rate of 92%, with 5.3 tests/person and was more likely (odds ratio = 4.96, 95% confidence interval 3.8‐6.5) to have tested two or more times, compared with those in the low risk group. Conclusion: The highest users of repeat testing are those who are practicing the highest risk behaviors and have the highest incidence of HIV. This suggests that prevention messages should be modified to more explicitly address the behaviors that are putting individuals at high risk for HIV.

Continuing high prevalence of HIV and risk behaviors among young men who have sex with men : The young men's survey in the San Francisco Bay area in 1992 to 1993 and in 1994 to 1995

Several recent studies have shown high rates of HIV infection and risk behavior among young men who have sex with men (MSM). To assess the direction of the epidemic in this population, we replicated a venue-based study performed in the San Francisco Bay Area during 1992 and 1993. From May 1994 to September 1995, we surveyed 675 MSM aged between 17 and 22. After statistical adjustment for age, ethnicity, residence, and site of recruitment, seroprevalence did not change significantly between the 1992 to 1993 (8.4%) and the 1994 to 1995 (6.7%) surveys. Similarly, no significant changes were found in the rates during the previous 6 months of unprotected receptive anal intercourse (23.4% versus 24.9%), injection drug use (8.0% versus 7.8%), or needle sharing among injection drug users (56.3% versus 64.5%) between the two surveys. Despite the increased attention that the problem of high risk behavior among young MSM has received, effective prevention interventions for MSM are needed as profoundly now as they had been several years ago.