Wayne A. Duffus

Effect of risk-reduction counseling with rapid HIV testing on risk of acquiring sexually transmitted infections: The AWARE randomized clinical trial

IMPORTANCEnTo increase human immunodeficiency virus (HIV) testing rates, many institutions and jurisdictions have revised policies to make the testing process rapid, simple, and routine. A major issue for testing scale-up efforts is the effectiveness of HIV risk-reduction counseling, which has historically been an integral part of the HIV testing process.nnnOBJECTIVEnTo assess the effect of brief patient-centered risk-reduction counseling at the time of a rapid HIV test on the subsequent acquisition of sexually transmitted infections (STIs).nnnDESIGN, SETTING, AND PARTICIPANTSnFrom April to December 2010, Project AWARE randomized 5012 patients from 9 sexually transmitted disease (STD) clinics in the United States to receive either brief patient-centered HIV risk-reduction counseling with a rapid HIV test or the rapid HIV test with information only. Participants were assessed for multiple STIs at both baseline and 6-month follow-up.nnnINTERVENTIONSnParticipants randomized to counseling received individual patient-centered risk-reduction counseling based on an evidence-based model. The core elements included a focus on the patients specific HIV/STI risk behavior and negotiation of realistic and achievable risk-reduction steps. All participants received a rapid HIV test.nnnMAIN OUTCOMES AND MEASURESnThe prespecified outcome was a composite end point of cumulative incidence of any of the measured STIs over 6 months. All participants were tested for Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum (syphilis), herpes simplex virus 2, and HIV. Women were also tested for Trichomonas vaginalis.nnnRESULTSnThere was no significant difference in 6-month composite STI incidence by study group (adjusted risk ratio, 1.12; 95% CI, 0.94-1.33). There were 250 of 2039 incident cases (12.3%) in the counseling group and 226 of 2032 (11.1%) in the information-only group.nnnCONCLUSION AND RELEVANCEnRisk-reduction counseling in conjunction with a rapid HIV test did not significantly affect STI acquisition among STD clinic patients, suggesting no added benefit from brief patient-centered risk-reduction counseling.nnnTRIAL REGISTRATIONnclinicaltrials.gov Identifier: NCT01154296.

Predictors of time to enter medical care after a new HIV diagnosis: a statewide population-based study

Abstract Public health benefits of expanded HIV screening will be adequately realized only if an early diagnosis is followed by prompt linkage to care. We characterized rates and factors associated with failure to enter into medical care within three months of HIV diagnosis and assessed the predictors of time to enter care over a follow-up period of up to 60 months. The study cohort included 3697 South Carolina (SC) residents’≥13 years who were newly HIV-diagnosed in 2004–2008. Date of first laboratory report of CD4+ T-cell count or viral load (VL) test after 30 days of confirmatory HIV diagnosis was used to define time to linkage to care. Results showed that of the total 3697 persons, 1768 (48%) entered care within three months, 1115 (30%) in four–12 months after diagnosis, and 814 (22%) failed to initiate care within 12 months of HIV diagnosis. At the end of study follow-up period of up to 60 months from the date of HIV diagnosis, 472/3697 (13%) individuals remained out of care. Multivariable Cox proportional hazards analysis showed that compared with hospitals, time to enter care was shorter in those diagnosed at state mental health/correctional facilities (adjusted hazards ratio [aHR] 1.16; 95% confidence interval [CI] 1.02–1.34) and longer in those diagnosed at county health departments (aHR 0.87; 95% CI 0.80–0.96) and at “Other/unknown” facilities (aHR 0.79; 95% CI 0.70–0.89). Time to entry into care was longer for men (aHR 0.82; 95% CI 0.75–0.89) compared with women, blacks (aHR 0.91; 95% CI 0.83–0.98) compared with whites, and males who have sex with males (MSM) (aHR 0.89; 95% CI 0.80–0.98) compared with heterosexual exposure. Delayed entry into HIV care remains a challenge in controlling HIV transmission in SC. Better integration of testing and care facilities could improve the proportion of newly HIV-diagnosed persons who enter care in a timely manner.

Associations of rural residence with timing of HIV diagnosis and stage of disease at diagnosis, South Carolina 2001-2005.

CONTEXTnRural areas in the southern United States face many challenges, including limited access to health care services and stigma, which may lead to later HIV diagnosis among rural residents.nnnPURPOSEnTo investigate the associations of rural residence with timing of HIV diagnosis and stage of disease at diagnosis.nnnMETHODSnTiming of HIV diagnosis was categorized as a diagnosis of acquired immune deficiency syndrome within 1 year of a first positive HIV test or HIV-only. Stage of disease was based on initial CD4+ T-cell count taken within 1 year of diagnosis. County of residence at HIV diagnosis was classified as urban if the population of the largest city was at least 25,000; it was classified as rural otherwise. Logistic regression was used to analyze timing of HIV diagnosis, and analysis of covariance was used to analyze stage of disease.nnnFINDINGSnFrom 2001 to 2005, 4,137 individuals were diagnosed with HIV infection. Of these, 1,129 (27%) were rural and 3,008 (73%) were urban residents. Among rural residents, 533 (47%) were diagnosed late, compared with 1,258 (42%) urban residents. Rural residents were significantly more likely to be diagnosed late (OR 1.19 [95% CI, 1.02-1.38]). Rural residence was associated with lower initial CD4+ T-cell count in crude analysis (P= .01) but not after adjustment (P > .05).nnnCONCLUSIONSnRural residence is a risk factor for late HIV diagnosis. This may lead to reduced treatment response to antiretroviral medications, increased morbidity and mortality, and greater HIV transmission risks among rural residents. New testing strategies are needed that address challenges to HIV testing and diagnosis specific to rural areas.

Incidence of diabetes mellitus in a population-based cohort of HIV-infected and non-HIV-infected persons: the impact of clinical and therapeutic factors over time.

To examine incidence density rate and correlates of incident diabetes mellitus in a cohort of HIV‐infected individuals compared with matched non‐HIV‐infected persons.

Estimating populations of men who have sex with men in the southern United States.

Population estimates of men who have sex with men (MSM) by state and race/ethnicity are lacking, hampering effective HIV epidemic monitoring and targeting of outreach and prevention efforts. We created three models to estimate the proportion and number of adult males who are MSM in 17 southern states. Model A used state-specific census data stratified by rural/suburban/urban area and national estimates of the percentage MSM in corresponding areas. Model B used a national estimate of the percentage MSM and state-specific household census data. Model C partitioned the statewide estimates by race/ethnicity. Statewide Models A and B estimates of the percentages MSM were strongly correlated (ru2009=u20090.74; r-squaredu2009=u20090.55; pu2009<u20090.001) and had similar means (5.82% and 5.88%, respectively) and medians (5.5% and 5.2%, respectively). The estimated percentage MSM in the South was 6.0% (range 3.6–13.2%; median, 5.4%). The combined estimated number of MSM was 2.4 million, including 1,656,500 (69%) whites, 339,400 (14%) blacks, 368,800 (15%) Hispanics, 34,600 (1.4%) Asian/Pacific Islanders, 7,700 (0.3%) American Indians/Alaska Natives, and 11,000 (0.5%) others. The estimates showed considerable variability in state-specific racial/ethnic percentages MSM. MSM population estimates enable better assessment of community vulnerability, HIV/AIDS surveillance, and allocation of resources. Data availability and computational ease of our models suggest other states could similarly estimate their MSM populations.

Rural-urban differences in HIV viral loads and progression to AIDS among new HIV cases.

Objective The human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic in the United States has shifted to the South, where an increasing proportion is occurring in rural areas. We sought to gain a better understanding of the affected rural population in this region. Methods The statewide HIV/AIDS Electronic Reporting System database was used to examine the epidemiological characteristics of newly diagnosed HIV cases in South Carolina from 2005 to 2011. Rural–urban differences were examined in sociodemographic and clinical characteristics, including progression to AIDS and a decline in HIV viral load (VL) to undetectable levels within 1 year of diagnosis. Results Of the 5336 individuals newly diagnosed as having HIV, 1433 (26.9%) were from rural areas. Compared with urban residents, a higher proportion of rural residents were black, non-Hispanic (80.1% vs 68.5%; P ⩽ 0.0001) and reported heterosexual risk (28.8% vs 22.9%; P = 0.0007). The proportion of female patients was higher in rural areas (29.7% vs 26.4%; P = 0.016). No significant rural–urban differences were found in initial CD4+ T-cell and VL counts or proportion obtaining an undetectable VL at 1 year. Rural residents were significantly more likely than urban residents to have AIDS at diagnosis or within 1 year of the HIV diagnosis (adjusted odds ratio 1.15; 95% confidence interval 1.007–1.326). Conclusions The reasons behind differences in proportions of rural and urban residents who were diagnosed as having AIDS or progressed to AIDS despite similar initial CD4+ T-cell counts and VL suppression at 1 year are unclear and should be explored in future studies. Future prevention and treatment efforts may need to consider the unique characteristics of rural populations in the South.

Mycobacterium chelonae vertebral osteomyelitis.

Mycobacterium chelonae is a rapidly growing mycobacterium (RGM) in Runyon group IV. This group includes all other nontuberculous mycobacterium (NTM) except the mycobacterium tuberculosis complex. The most commonly infected organ by RGM is the lung, usually in immunosuppressed patients or those with underlying lung disease. Vertebral infection is very rare. Osteomyelitis is rarely caused by M. chelonae, and only one other case of M. chelonae vertebral osteomyelitis has been reported. A case of M. chelonae vertebral osteomyelitis in a man with intravenous drug abuse is reported, and NTM osteomyelitis is reviewed with a focus on M. chelonae and appropriate treatment options for M. chelonae vertebral osteomyelitis.

Impact of Clinical and Therapeutic Factors on Incident Cardiovascular and Cerebrovascular Events in a Population‐Based Cohort of HIV‐Infected and Non–HIV‐Infected Adults

Cardiovascular and cerebrovascular (CVD) events/diseases are a common cause of non–acquired immunodeficiency syndrome (AIDS)‐related mortality in the aging human immunodeficiency virus (HIV)‐infected population. The incidence rate and clinical correlates of CVD in people living with HIV/AIDS compared to the general population warrants further investigation.

Disparities in Viral Load and CD4 Count Trends Among HIV-Infected Adults in South Carolina

On a population level, trends in viral load (VL) and CD4 cell counts can provide a marker of infectivity and an indirect measure of retention in care. Thus, observing the trend of CD4/VL over time can provide useful information on disparities in populations across the HIV care continuum when stratified by demography. South Carolina (SC) maintains electronic records of all CD4 cell counts and HIV VL measurements reported to the state health department. We examined temporal trends in individual HIV VLs reported in SC between January 1, 2005 and December 31, 2012 by using mixed effects models adjusting for gender, race/ethnicity, age, baseline CD4 count, HIV risk category, and residence. Overall VL levels gradually decreased over the observation period. There were significant differences in the VL decline by gender, age groups, rural/urban residence, and HIV risk exposure group. There were significant differences in CD4 increases by race/ethnicity, age groups, and HIV risk exposure group. However, the population VL declines were slower among individuals aged 13-19 years compared to older age groups (p<0.0001), among men compared to women (p=0.002), and among people living with HIV/AIDS (PLWHA) with CD4 count ≤200 cell/mm(3) compared to those with higher CD4 counts (p<0.0001). Significant disparities were observed in VL decline by gender, age, and CD4 counts among PLWHA in SC. Population based data such as these can help streamline and better target local resources to facilitate retention in care and adherence to medications among PLWHA.

Epidemiological Characteristics of HIV-Infected Women With and Without a History of Criminal Justice Involvement in South Carolina

The circumstances that lead to incarceration may potentiate the HIV/AIDS epidemic and this has become an emerging public health concern. In the United States and in most jurisdictions, HIV prevalence in the correctional setting is higher among female inmates than male inmates. This dichotomy is not fully understood and few studies have focused on women in the South. Using data from the South Carolina (SC) electronic HIV/AID Reporting System, the SC Law Enforcement Criminal History database, and a public access website of the SC Department of Corrections, the authors describe the epidemiological characteristics and correctional history of a population of HIV-infected women in SC diagnosed between January 1, 1996, and December 31, 2005.