Increased Life Expectancy in New York City, 2001-2010: An Exploration by Cause of Death and Demographic Characteristics.

OBJECTIVE: New York City's (NYC's) life expectancy gains have been greater than those seen nationally. We examined life-expectancy changes over the past decade in selected NYC subpopulations and explored which age groups and causes of death contributed most to the increases. METHODS: We calculated life expectancy with 95% confidence intervals (CIs) for 2001-2010 by sex and race/ethnicity. Life expectancy was decomposed by age group and cause of death. Logistic regressions were conducted to reinforce the results from decomposition by controlling confounders. RESULTS: Overall, NYC residents' life expectancy at birth increased from 77.9 years (95% CI, 77.8-78.0) in 2001 to 80.9 years (95% CI, 80.8-81.0) in 2010. Decreases in deaths from heart disease, cancer, and HIV disease accounted for 50%, 16%, and 11%, respectively, of the gains. Decreased mortality in older age groups (≥65 years) accounted for 45.6% of the overall change. CONCLUSIONS: Life expectancy increased for both sexes, across all racial/ethnic groups, and for both the US-born and the foreign-born. Disparities in life expectancy decreased as overall life expectancy increased. Decreased mortality among older adults and from heart disease, cancer, and HIV infection accounted for most of the increases.

Evaluating the Use of an Electronic Death Registration System for Mortality Surveillance During and After Hurricane Sandy: New York City, 2012.

OBJECTIVES: We evaluated the use of New York City's (NYC's) electronic death registration system (EDRS) to conduct mortality surveillance during and after Hurricane Sandy. METHODS: We used Centers for Disease Control and Prevention guidelines for surveillance system evaluation to gather evidence on usefulness, flexibility, stability, timeliness, and quality. We assessed system components, interviewed NYC Health Department staff, and analyzed 2010 to 2012 death records. RESULTS: Despite widespread disruptions, NYC's EDRS was stable and collected timely mortality data that were adapted to provide storm surveillance with minimal additional resources. Direct-injury fatalities and trends in excess all-cause mortality were rapidly identified, providing useful information for response; however, the time and burden of establishing reports, adapting the system, and identifying indirect deaths limited surveillance. CONCLUSIONS: The NYC Health Department successfully adapted its EDRS for near real-time disaster-related mortality surveillance. Retrospective assessment of deaths, advanced methods for case identification and analysis, standardized reports, and system enhancements will further improve surveillance. Local, state, and federal partners would benefit from partnering with vital records to develop EDRSs for surveillance and to promote ongoing evaluation.

A comparison of partner notification effectiveness in African-, Caribbean-, and United States-born HIV-infected Blacks in New York City.

HIV disproportionately affects blacks more than other groups in New York City (NYC) as well as nationally. Partner Services (PS) are a proven way to interrupt HIV transmission. In NYC, PS outcomes are worse among blacks compared to other race/ethnic groups. We compared PS outcomes by country of birth to identify opportunities for improved PS effectiveness. We assessed number of sex and needle-sharing partners elicited, notified, and HIV tested, as well as number of newly identified HIV cases and number of interviews needed to identify a new HIV case. Between July 2006 and December 2008, 1049 African Americans, 285 Caribbean-born blacks, and 168 African-born blacks were interviewed for HIV Partner Services. African Americans, Caribbean-born blacks, and African-born blacks had average age of 38, 37, and 43 years and 10.0%, 0.4%, and 0.6% reported intravenous drug use, respectively. All groups had a high proportion of cases with an AIDS-defining CD4 count at HIV diagnosis (30.8%, 34.5%, and 47.9% for African Americans, Africans, and Caribbeans, respectively). The number needed to interview to find one newly diagnosed HIV case was high for all groups (66, 57, and 56 among African Americans, Africans, and Caribbeans, respectively), indicating all had similarly low rates of new HIV case identification. NYC blacks and their partners are benefiting from current Partner Services outreach as PS did identify new HIV cases among partners from all 3 groups. However, further work is needed to improve HIV case finding from Partner Services in these groups, and additional measures to promote early diagnosis are needed.

A mathematical model of comprehensive test-and-treat services and HIV incidence among men who have sex with men in the United States.

BACKGROUND: Early diagnosis and treatment of HIV infection and suppression of viral load are potentially powerful interventions for reducing HIV incidence. A test-and-treat strategy may have long-term effects on the epidemic among urban men who have sex with men (MSM) in the United States and may achieve the 5-year goals of the 2010 National AIDS Strategy that include: 1) lowering to 25% the annual number of new infections, 2) reducing by 30% the HIV transmission rate, 3) increasing to 90% the proportion of persons living with HIV infection who know their HIV status, 4) increasing to 85% the proportion of newly diagnosed patients linked to clinical care, and 5) increasing by 20% the proportion of HIV-infected MSM with an undetectable HIV RNA viral load. METHODS AND FINDINGS: We constructed a dynamic compartmental model among MSM in an urban population (based on New York City) that projects new HIV infections over time. We compared the cumulative number of HIV infections in 20 years, assuming current annual testing rate and treatment practices, with new infections after improvements in the annual HIV testing rate, notification of test results, linkage to care, initiation of antiretroviral therapy (ART) and viral load suppression. We also assessed whether five of the national HIV prevention goals could be met by the year 2015. Over a 20-year period, improvements in test-and-treat practice decreased the cumulative number of new infections by a predicted 39.3% to 69.1% in the urban population based on New York City. Institution of intermediate improvements in services would be predicted to meet at least four of the five goals of the National HIV/AIDS Strategy by the 2015 target. CONCLUSIONS: Improving the five components of a test-and-treat strategy could substantially reduce HIV incidence among urban MSM, and meet most of the five goals of the National HIV/AIDS Strategy.

Barriers to HIV testing among HIV/AIDS concurrently diagnosed persons in New York City.

OBJECTIVES: To assess barriers to human immunodeficiency virus (HIV) testing, health care contacts history, and HIV testing history among patients diagnosed concurrently with HIV and acquired immunodeficiency syndrome (AIDS). METHODS: We surveyed patients concurrently diagnosed with HIV/AIDS who had participated in the partner notification program of the New York City Department of Health and Mental Hygiene, between January 2008 and December 2008. RESULTS: The most common reason interviewees volunteered for delaying testing (64%) was that they did not believe they were at risk for HIV. When read a list of potential barriers, 69% of interviewees replied affirmatively that they did not test for HIV because they did not believe they were at risk, and 52% replied affirmatively that they did not test because they thought their behaviors kept them safe from getting HIV. Half of all interviewees reported having insurance during part or all of the year before they were diagnosed with HIV/AIDS, and 70% had at least 1 health care visit in the year before they were diagnosed with HIV/AIDS. CONCLUSIONS: A lack of perception of risk was the most common reason for not testing for HIV sooner among these concurrently diagnosed patients. The majority of these patients were accessing medical care, indicating that this population could have benefited from routine HIV testing.

NYC condom use and satisfaction and demand for alternative condom products in New York City sexually transmitted disease clinics.

In 2007, via a high-profile media campaign, the New York City Department of Health and Mental Hygiene (NYC DOHMH) introduced the "NYC Condom," the first specially packaged condom unique to a municipality. We conducted a survey to measure NYC Condom awareness of and experience with NYC Condoms and demand for alternative male condoms to be distributed by the DOHMH. Trained interviewers administered short, in-person surveys at five DOHMH-operated sexually transmitted disease (STD) clinics in Spring 2008. We systematically sampled eligible patients: NYC residents aged ≥18 years waiting to see a physician. We approached 539; 532 agreed to be screened (98.7% response rate); 462 completed the survey and provided NYC zip codes. Most respondents were male (56%), non-Hispanic black (64%), aged 18-24 years (43%) or 25-44 years (45%), employed (65%), and had a high school degree/general equivalency diploma or less (53%). Of those surveyed, 86% were aware of the NYC Condom, and 81% of those who obtained the condoms used them. NYC Condom users were more likely to have four or more sexual partners in the past 12 months (adjusted odds ratio [AOR] = 2.0, 95% confidence interval [CI] = 1.0-3.8), use condoms frequently (AOR = 2.1, 95% CI = 1.3-3.6), and name an alternative condom for distribution (AOR = 2.2, 95% CI = 1.3-3.9). The most frequently requested condom types respondents wanted DOHMH to provide were larger size (28%), ultra thin/extra sensitive (21%), and extra strength (16%). We found high rates of NYC Condom use. NYC Condom users reported more sexual partners than others, suggesting the condom initiative successfully reached higher-risk persons within the STD clinic population. Study results document the condom social marketing campaign's success.

The effect of HIV field-based testing on the proportion of notified partners who test for HIV in New York City.

HIV partner services can effectively reach populations with high HIV prevalence. However, located and notified sex and needle-sharing partners of persons infected with HIV often fail to test. Field testing may increase the proportion of notified partners who test for HIV. In 2008, New York City's health department incorporated field testing into partner services. After the introduction of field testing, the proportion of notified partners who tested for HIV rose from 52% to 76% (P<.001). HIV prevalence fell slightly among notified partners who accepted testing (12% to 9%, P=.82), but we identified more than double the number of new positives (11 vs 25). All positive and 97% of negative results were received by the person tested.

Excess mortality among injection drug users with AIDS, New York City (1999-2004).

We calculated proportions and trends in contributing causes of death among persons with AIDS (PWA) and a history of injection drug use (IDU) in New York City and compared the proportions with those among PWA with a transmission risk of high-risk heterosexual sex (HRH) and men who have sex with men (MSM). We included all 10,575 injection drug user, HRH, and MSM residents aged 13+ years with AIDS reported by September 30, 2006 , who died from 1999 through 2004. Accidental drug overdose was the most frequent contributing cause of death among IDUs (20.5%). Overdose prevention initiatives may greatly and immediately reduce deaths among PWA.

Impact of accelerated progression to AIDS on public health monitoring of late HIV diagnosis.

Some patients develop AIDS within a year of HIV infection ("accelerated progression"). Classifying such cases as late HIV diagnosis may lead to inaccurate evaluation of HIV testing efforts. We sought to determine this group's contribution to overall late diagnosis rates. To identify cases of accelerated progression (development of AIDS within 12 months of a negative HIV test), we reviewed published HIV seroconverter cohort studies and used New York City's (NYC) HIV/AIDS surveillance registry. From the literature review, three seroconverter cohort studies revealed that 1.0-3.6% of participants had accelerated progression to AIDS. Applying this frequency estimate to the number of new infections in NYC (4762) for 2006 calculated by the Centers for Diseases Control and Prevention's incidence formula, we estimated that 3.6-13.0% of 1317 NYC HIV cases who are diagnosed with AIDS within 12 months of HIV diagnosis are accelerated progressors, not persons HIV infected for many years who did not test and present with AIDS (i.e., delayed diagnosis). In addition, our analysis of the 2006 NYC surveillance registry confirmed the occurrence of accelerated progression in a population-based setting; 67 accelerated progressors were reported and 9 (13%) could be confirmed through follow-up medical record review. With increased HIV testing initiatives, the irreducible proportion of AIDS cases with accelerated progression must be considered when interpreting late diagnosis data.

Evaluation of HIV incidence surveillance in New York City, 2006.

In 2005, the New York City (NYC) Department of Health and Mental Hygiene implemented a standardized human immunodeficiency virus (HIV) incidence surveillance protocol based on the serologic testing algorithm for recent HIV seroconversion deployed nationwide by the Centers for Disease Control and Prevention (CDC). We evaluated four key attributes of NYC's HIV incidence surveillance system-simplicity, data quality, timeliness, and acceptability--using CDC's guidelines for surveillance system evaluation. The evaluation revealed that the system could potentially provide HIV incidence estimates stratified by borough and major demographic groups at about nine months after the period of interest. The system strengths include its relative simplicity and integration with routine HIV/acquired immunodeficiency syndrome surveillance. Weaknesses include lack of completeness of testing history information, a critical component of incidence estimation. Continued improvements in data completeness and timeliness will improve the currently available information to inform personnel who develop HIV-prevention programs and policy initiatives in NYC and nationally.

High HIV prevalence and diagnosis rates in New York City black men.

We sought to identify population and subpopulation disparities in rates of HIV diagnosis and prevalence among black males 13 years and older in New York City. We used population-based data from the New York City HIV/AIDS surveillance registry and US Census 2000 to calculate HIV prevalence in 2006 and HIV diagnosis rates in 2007. Black males were the largest demographic group of new HIV diagnoses (n = 1,161, 33%) and persons living with HIV/AIDS in New York City (n = 24,294, 29%) and had the highest diagnosis rates (1.7 per 1,000 population) and prevalence (3.7%). Prevalence and diagnosis rates among black males were higher in higher-poverty neighborhoods than in lower-poverty neighborhoods (p < 0.01). However, very high prevalence (19.3%) was found among black males in three adjacent Manhattan neighborhoods with relatively low poverty rates, and where overall diagnosis rates among black males (7.4 per 1,000) and proportions attributable to men who have sex with men (60.0%) were high. HIV-related disparities exist not only between black males and other groups but also within black males. Success addressing the citywide HIV epidemic will be linked to success in the various portions of this highly affected, heterogeneous population.

Unprotected anal intercourse and sexually transmitted diseases in high-risk heterosexual women.

OBJECTIVES: We examined the association between unprotected anal intercourse and sexually transmitted diseases (STDs) among heterosexual women. METHODS: In 2006 through 2007, women were recruited from high-risk areas in New York City through respondent-driven sampling as part of the National HIV Behavioral Surveillance study. We used multiple logistic regression to determine the relationship between unprotected anal intercourse and HIV infection and past-year STD diagnosis. RESULTS: Of the 436 women studied, 38% had unprotected anal intercourse in the past year. Unprotected anal intercourse was more likely among those who were aged 30 to 39 years, were homeless, were frequent drug or binge alcohol users, had an incarcerated sexual partner, had sexual partners with whom they exchanged sex for money or drugs, or had more than 5 sexual partners in the past year. In the logistic regression, women who had unprotected anal intercourse were 2.6 times as likely as women who had only unprotected vaginal intercourse and 4.2 times as likely as women who had neither unprotected anal nor unprotected vaginal intercourse to report an STD diagnosis. We found no significant association between unprotected anal intercourse and HIV infection. CONCLUSIONS: Increased screening for history of unprotected anal intercourse and, for those who report recent unprotected anal intercourse, counseling and testing for HIV and STDs would likely reduce STD infections.

Comparing HIV partner notification effectiveness between blacks and Hispanics in New York City.

Between July 2006 and November 2007, a total of 894 blacks and 491 Hispanics were interviewed to assess partner notification services. Fewer Hispanics needed to be interviewed to identify 1 newly diagnosed partner as compared with blacks (24 vs. 60, P < 0.01), but number needed to be interviewed was similar for identifying partners with any HIV infection.

Provider and client acceptance of a health department enhanced approach to improve HIV partner notification in New York City.

OBJECTIVE: To assess provider and client acceptance of health department-delivered HIV partner services (PS) delivered in clinical and community settings. METHODS: In 2006, New York city (NYC) formed the HIV field services unit (FSU), staffed with experienced sexually transmitted disease intervention specialists (DIS). DIS were stationed at 8 large hospitals to assist clinical providers and their HIV-positive patients with PS in areas with high rates of delayed HIV diagnoses and HIV-related mortality. We surveyed providers (self-administered questionnaire) and clients (staff-administered) to examine provider and patients as well as patients' HIV-exposed partners' acceptance of and concerns regarding PS. RESULTS: Response rates were as follows: 63% (132/211) providers; 90% (492/544) patients who accepted PS; 73% (16/22) patients who declined PS; 83% (139/168) partners who received notification; and 81% (25/31) partners who declined notification. Most providers felt the DIS focus and expert skills in PS was beneficial to providers (87%) and clients (89%). Most patients (91%) had a positive or neutral attitude about the health department-delivered PS. Most providers reported no disadvantage to DIS providing PS (69%); their most commonly cited (24%) concern was potential patient confusion about the roles of providers versus DIS. Patients' most common concerns were the intrusive nature of the interviews and the length of the interview (50/492, 20%). The partners wanted to know who named them (32/139, 23%). CONCLUSIONS: Health department-delivered PS by DIS in clinical and community settings was acceptable to providers, HIV-infected patients, and HIV-exposed partners. Overall, our survey showed strong provider and client support for this approach.

Undiagnosed HIV infection among New York City jail entrants, 2006: results of a blinded serosurvey.

OBJECTIVE: Since 2004, when all New York City jail entrants began being offered rapid testing at medical intake, HIV testing has increased 4-fold. To guide further service improvement, we determined HIV prevalence among jail entrants, including proportion undiagnosed. METHODS: Remnant serum from routine syphilis screening was salvaged for blinded HIV testing in 2006. Using HIV surveillance data and electronic clinical data, we ascertained previously diagnosed HIV infections before permanently removing identifiers. We defined "undiagnosed" as HIV-infected entrants who were unreported to surveillance and denied HIV infection. RESULTS: Among the 6411 jail entrants tested (68.9% of admissions), HIV prevalence was 5.2% overall (males 4.7%; females: 9.8%). Adjusting for those not in the serosurvey, estimated seroprevalence is 8.7% overall (6.5% males, 14% females). Overall, 28.1% of HIV infections identified in the serosurvey were undiagnosed at jail entry; only 11.5% of these were diagnosed during routine jail testing. Few (11.1%) of the undiagnosed inmates reported injection drug use or being men who have sex with men. CONCLUSIONS: About 5%-9% of New York City jail entrants are HIV infected. Of the infected, 28% are undiagnosed; most of whom denied recognized HIV risk factors. To increase inmate's acceptance of routine testing, we are working to eliminate the required separate written consent for HIV testing to allow implementation of the Centers for Disease Control and Prevention-recommended opt out testing model.

Comparing the National Death Index and the Social Security Administration's Death Master File to ascertain death in HIV surveillance.

OBJECTIVES: New York City (NYC) maintains a population-based registry of people with human immunodeficiency virus (HIV) infection to monitor the epidemic and inform resource allocation. We evaluated record linkages with the National Death Index (NDI) and the Social Security Administration's Death Master File (SSDMF) to find deaths occurring from 2000 through 2004. METHODS: We linked records from 32,837 people reported with HIV and not previously known to be dead with deaths reported in the NDI and the SSDMF. We calculated the kappa statistic to assess agreement between data sources. We performed subgroup analyses to assess differences within demographic and transmission risk subpopulations. We quantified the benefit of linkages with each data source beyond prior death ascertainment from local vital statistics data. RESULTS: We discovered 1,926 (5.87%) deaths, which reduced the HIV prevalence estimate in NYC by 2.03%, from 1.19% to 1.16%. Of these, 458 (23.78%) were identified only from NDI, and 305 (15.84%) only from SSDMF. Agreement in ascertainment between sources was substantial (kappa = [K] 0.74, 95% confidence interval [CI] 0.72, 0.76); agreement was lower among Hispanic people (K = 0.65, 95% CI 0.62, 0.69) and people born outside the U.S. (K = 0.60, 95% CI 0.52, 0.68). We identified an additional 13.62% of deaths to people reported with HIV in NYC; white people and men who have sex with men were disproportionately likely to be underascertained without these linkages (p < 0.0001). CONCLUSION: Record linkages with national databases are essential for accurate prevalence estimates from disease registries, and the SSDMF is an inexpensive means to supplement linkages with the NDI to maximize death ascertainment.

The NYC Condom: use and acceptability of New York City's branded condom.

We assessed awareness and experience with the NYC Condom via surveys at 7 public events targeting priority condom distribution populations during 2007. Most respondents (76%) were aware of NYC Condoms. Of those that had obtained them, 69% had used them. Most (80%) wanted alternative condoms offered for free: 22% wanted ultra-thin, 18% extra-strength, and 14% larger-size. Six months after the NYC Condom launch, we found high levels of awareness and use. Because many wanted alternative condoms, the Department of Health and Mental Hygiene began distributing the 3 most-requested alternatives.