Uptake and Acceptability of MyChoices: Results of a Pilot RCT of a Mobile App Designed to Increase HIV Testing and PrEP Uptake Among Young American MSM.

Young men who have sex with men (YMSM) remain at disproportionate risk for HIV acquisition in the United States (US), yet use of evidence-based prevention strategies, including routine HIV testing and pre-exposure prophylaxis (PrEP), remain low. Smartphones and mobile app usage are nearly ubiquitous in this population. Given the potential for scalability, a mobile app to increase HIV testing and PrEP use among YMSM has the potential to make an extraordinary public health impact if efficacious. Based on extensive formative, community-engaged research, we developed a theory-driven mobile app-MyChoices-to increase HIV testing and PrEP uptake among YMSM. In a pilot randomized controlled trial (RCT), participants (n = 60) were randomized 2:1 to receive MyChoices or standard of care (SOC). Data from 3 to 6-month post-baseline assessments demonstrate that the app was highly acceptable (System Usability Score; mean = 75.8, SD = 10.7) and feasible (94% used the MyChoices app at least once; mean = 15.3 sessions, SD = 9.8). While not powered to assess efficacy, those in the MyChoices arm had 22% higher prevalence of HIV testing over follow-up compared to those in the SOC arm (NS). There was no difference in PrEP uptake. A fully-powered efficacy trial is warranted; if efficacy is demonstrated, the MyChoices app could be easily scaled to reach YMSM across the US.

High Prevalence of Anal High-Grade Squamous Intraepithelial Lesions, and Prevention Through Human Papillomavirus Vaccination, in Young Men Who Have Sex With Men Living With Human Immunodeficiency Virus.

BACKGROUND: Men who have sex with men (MSM) are at high risk for human papillomavirus (HPV)-related anal cancer. Little is known about the prevalence of low-grade squamous intraepithelial lesions (LSILs) and the anal cancer precursor, high-grade squamous intraepithelial lesions (HSILs), among young MSM with HIV (MSMLWH). HPV vaccination is recommended in this group, but its safety, immunogenicity, and protection against vaccine-type HPV infection and associated LSILs/HSILs have not been studied. METHODS: Two hundred and sixty MSMLWH aged 18-26 years were screened at 17 US sites for a clinical trial of the quadrivalent (HPV6,11,16,18) HPV (qHPV) vaccine. Those without HSILs were vaccinated at 0, 2, and 6 months. Cytology, high-resolution anoscopy with biopsies of lesions, serology, and HPV testing of the mouth/penis/scrotum/anus/perianus were performed at screening/month 0 and months 7, 12, and 24. RESULTS: Among 260 MSMLWH screened, the most common reason for exclusion was detection of HSILs in 88/260 (34%). 144 MSMLWH were enrolled. 47% of enrollees were previously exposed to HPV16. No incident qHPV type-associated anal LSILs/HSILs were detected among men naive to that type, compared with 11.1, 2.2, 4.5, and 2.8 cases/100 person-years for HPV6,11,16,18-associated LSILs/HSILs, respectively, among those previously exposed to that type. qHPV was immunogenic and safe with no vaccine-associated serious adverse events. CONCLUSIONS: 18-26-year-old MSMLWH naive to qHPV vaccine types were protected against incident qHPV type-associated LSILs/HSILs. Given their high prevalence of HSILs, there is an urgent need to vaccinate young MSMLWH before exposure to vaccine HPV types, before initiating sexual activity, and to perform catch-up vaccination.

Development and Evaluation of a Mobile App Designed to Increase HIV Testing and Pre-exposure Prophylaxis Use Among Young Men Who Have Sex With Men in the United States: Open Pilot Trial.

BACKGROUND: HIV disproportionately affects young men who have sex with men (YMSM) in the United States. Uptake of evidence-based prevention strategies, including routine HIV testing and use of pre-exposure prophylaxis (PrEP), is suboptimal in this population. Novel methods for reaching YMSM are required. OBJECTIVE: The aim of this study is to describe the development and evaluate the feasibility and acceptability of the MyChoices app, a mobile app designed to increase HIV testing and PrEP use among YMSM in the United States. METHODS: Informed by the social cognitive theory, the MyChoices app was developed using an iterative process to increase HIV testing and PrEP uptake among YMSM. In 2017, beta theater testing was conducted in two US cities to garner feedback (n=4 groups; n=28 YMSM). These findings were used to refine MyChoices, which was then tested for initial acceptability and usability in a technical pilot (N=11 YMSM). Baseline and 2-month postbaseline assessments and exit interviews were completed. Transcripts were coded using a deductive approach, and thematic analysis was used to synthesize data; app acceptability and use data were also reported. RESULTS: The MyChoices app includes personalized recommendations for HIV testing frequency and PrEP use; information on types of HIV tests and PrEP; ability to search for nearby HIV testing and PrEP care sites; and ability to order free home HIV and sexually transmitted infection test kits, condoms, and lube. In theater testing, YMSM described that MyChoices appears useful and that they would recommend it to peers. Participants liked the look and feel of the app and believed that the ability to search for and be pinged when near an HIV testing site would be beneficial. Some suggested that portions of the app felt repetitive and preferred using casual language rather than formal or medicalized terms. Following theater testing, the MyChoices app was refined, and participants in the technical pilot used the app, on average, 8 (SD 5.0; range 2-18) times over 2 months, with an average duration of 28 (SD 38.9) minutes per session. At the 2-month follow-up, the mean System Usability Scale (0-100) score was 71 (ie, above average; SD 11.8). Over 80% (9/11) of the participants reported that MyChoices was useful and 91% (10/11) said that they would recommend it to a friend. In exit interviews, there was a high level of acceptability for the content, interface, and features. CONCLUSIONS: These data show the initial acceptability and user engagement of the MyChoices app. If future studies demonstrate efficacy in increasing HIV testing and PrEP uptake, the app is scalable to reach YMSM across the United States. TRIAL REGISTRATION: Clinicaltrials.gov NCT03179319; https://clinicaltrials.gov/ct2/show/NCT03179319. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/10694.

An expanded HIV screening strategy in the Emergency Department fails to identify most patients with undiagnosed infection: insights from a blinded serosurvey.

Screening for HIV in Emergency Departments (EDs) is recommended to address the problem of undiagnosed HIV. Serosurveys are an important method for estimating the prevalence of undiagnosed HIV and can provide insight into the effectiveness of an HIV screening strategy. We performed a blinded serosurvey in an ED offering non-targeted HIV screening to determine the proportion of patients with undiagnosed HIV who were diagnosed during their visit. The study was conducted in a high-volume, urban ED and included patients who had blood drawn for clinical purposes and had sufficient remnant specimen to undergo deidentified HIV testing. Among 4752 patients not previously diagnosed with HIV, 1403 (29.5%) were offered HIV screening and 543 (38.7% of those offered) consented. Overall, undiagnosed HIV was present in 12 patients (0.25%): six among those offered screening (0.4%), and six among those not offered screening (0.2%). Among those with undiagnosed HIV, two (16.7%) consented to screening and were diagnosed during their visit. Despite efforts to increase HIV screening, more than 80% of patients with undiagnosed HIV were not tested during their ED visit. Although half of those with undiagnosed HIV were missed because they were not offered screening, the yield was further diminished because a substantial proportion of patients declined screening. To avoid missed opportunities for diagnosis in the ED, strategies to further improve implementation of HIV screening and optimize rates of consent are needed.

Sexual Partner Characteristics, Relationship Type, and HIV Risk Among a Community Venue-based Sample of Urban Adolescent and Young Adult Men Who Have Sex with Men.

Few studies have examined sexual partnerships and HIV risk in diverse samples of African American/black and Hispanic/Latino adolescent and young adult men who have sex with men (YMSM), a group that have a high burden of HIV in the U.S. A community-venue recruitment approach was used, which identified significant differences in HIV risk by sexual partner type among 1215 YMSM. Those with casual partners had a higher number of sexual partners, had more STIs, and were more likely to engage in transactional sex, to use alcohol, marijuana, or other substances compared with those with main partners only. Among those with female sexual partners, many used condoms "every time" when engaging in vaginal sex with casual partners, but a sizeable proportion "never/rarely" used condoms with their main partners. Our findings demonstrate a need for tailored HIV prevention education and counseling with necessary skills regarding consistent and correct condom use with all sexual partnerships.

Missing the mark: ongoing missed opportunities for HIV diagnosis at an urban medical center despite universal screening recommendations.

BACKGROUND: Despite established recommendations from the Centers for Disease Control (CDC) to scale up testing efforts in the USA, this study shows full scale implementation of these recommendations may still be lacking. We hypothesize that patients experience ongoing missed opportunities for earlier diagnosis of HIV, despite frequent encounters to Montefiore Medical Center (MMC), an integrated hospital system in the Bronx, NY. METHODS: Retrospective chart review via electronic medical records of patients newly diagnosed with HIV in 2012 and 2013 at varied MMC clinical sites. Missed opportunities were defined as > 1 prior health care encounter at MMC within three calendar years of diagnosis, in which HIV testing was not offered for those who had a prior negative test or no prior test. RESULTS: There were 218 patients newly diagnosed with HIV at MMC during the study period; 31% presented with a CD4 <200 cells/mm3; 22% were asymptomatic at diagnosis. Patients (56%) without a prior HIV test had an average 4.72 clinical encounters at MMC within the 3 years prior to their HIV diagnosis. Over 95% of visits prior to diagnosis occurred in emergency departments (EDs) or primary care outpatient department (OPDs) and accounted for the vast majority of missed opportunities. CONCLUSIONS: HIV infected patients continue to present late to care, with low CD4 and commonly utilize OPDs and EDs, where missed opportunities for earlier diagnosis are common. Practices that address augmentation of current HIV testing strategies are needed, especially in outpatient and first-contact acute care settings.

Correlates of HIV testing history among urban youth recruited through venue-based testing in 15 US cities.

BACKGROUND: Adolescents and young adults comprise disproportionately high percentages of individuals living with human immunodeficiency virus (HIV) and those with undiagnosed HIV. Our objective was to determine factors associated with history of HIV testing and receipt of results among a sample of urban, high-risk, sexually active adolescents in 15 US cities. METHODS: A total of 20 to 30 sexually active youths, aged 12 to 24 years, were recruited to participate in an anonymous survey and HIV antibody testing at 2 to 3 venues per city identified by young men who have sex with men, young women of color, or intravenous drug users. RESULTS: Of the 1457 participants, 72% reported having been previously tested for HIV (89% of whom were aware of their test results). Our sample was diverse in terms of gender, race/ethnicity, and sexual orientation. Factors found to be predictive of testing typically reflect high risk for HIV, except for some high-risk partner characteristics, including having had a partner that made the youth have sex without a condom or had a partner with unknown HIV status. Factors associated with knowledge of serostatus are reported. HIV testing seems to be more associated with sexually transmitted infection testing services than with primary care. CONCLUSIONS: More strategies are needed that increase testing, including targeting partners of high-risk individuals, insuring receipt of test results, and increasing testing in primary care settings.

HIV self-testing and STI self-collection via mobile apps: experiences from two pilot randomized controlled trials of young men who have sex with men.

BACKGROUND: Young men who have sex with men (YMSM) are disproportionately impacted by HIV and other sexually transmitted infections (STIs) in the United States (US) and have low rates of HIV/STI testing. Provision of HIV self-testing and STI self-collection can increase testing rates, and access to these kits through mobile applications (apps) could help facilitate YMSM using HIV self-testing and STI self-collection. METHODS: Data for this study comes from two pilot randomized controlled trials (RCTs) of mobile apps within the Adolescent Trials Network-LYNX and MyChoices-aimed to increase HIV/STI testing among YMSM (age 15-24) who had not recently tested for HIV and were at high risk for HIV acquisition across five US cities. Both apps include the ability to order a HIV self-test with rapid results and a kit for STI self-collection and mailing of samples for syphilis, gonorrhea and chlamydia to a lab for testing. Using assessments of app users (n=80) at pre-randomization and at 3- and 6-months post-randomization and online interview data from a purposive sample of app users (n=37), we report on experiences and lessons learned with HIV self-testing and STI self-collection kits ordered via the apps. RESULTS: Participants were on average 20.7 years of age (SD =2.4), and 49% were non-White or multiple race/ethnicity. Sixty-three percent had a prior HIV test. Over half (58%) had a prior STI test, but only 3% had tested within the past 3 months. Nearly two-thirds ordered an HIV self-testing kit; of whom, 75% reported using at least one self-test kit over the study period. STI self-collection kit ordering rates were also high (54%); however, STI self-collection kit return rates were lower (13%), but with a high positivity rate (5.3%). Both HIV self-testing and STI self-collection kits were highly acceptable, and 87% reported that it was extremely/very helpful to be able to order these kits through the apps. The most common reason for not ordering the HIV/STI kits was preferring to test at a clinic. In interviews, participants expressed feeling empowered by being able to test at home; however, they also raised concerns around STI sample collection. CONCLUSIONS: HIV self-testing and STI self-collection kit ordering via mobile apps is feasible, acceptable and may show promise in increasing testing rates among YMSM. The LYNX and MyChoices apps are currently being tested in a full-scale efficacy trial, and if successful, these innovative mobile apps could be scaled up to efficiently increase HIV/STI testing among youth across the US.

Qualitative Study on the Acceptability of and Adherence to a Vaginal Ring for HIV Prophylaxis Among Adolescent Girls.

OBJECTIVE: This study aims to assess the product-related, relationship-related, and sex-related factors that act as facilitators and barriers to the acceptability of a vaginal ring (VR) for HIV prevention among adolescent girls. DESIGN: Qualitative study. METHODS: Ninety-six girls aged 15-17 years from 6 urban US sites were enrolled in MTN-023/IPM 030, a 24-week randomized controlled trial, for assessing the safety and acceptability of a dapivirine VR for HIV prevention. At week 24, 21 girls were randomly selected to participate in in-depth interviews. Interviews were transcribed verbatim and data analyzed using a thematic analysis approach. Facilitators and barriers to VR acceptability related to participants' relationships, sexual activity, and characteristics of the VR product were identified. RESULTS: Factors related to relationships rarely seemed to act as barriers to VR acceptability; most participants disclosed VR use to sexual partners, and positive reactions from sexual partners, which were common, seemed to facilitate VR acceptability. Emotional and/or physical discomfort surrounding VR use during sex was mentioned occasionally as a barrier to VR acceptability. Product characteristics were most frequently mentioned as barriers to VR acceptability. Many participants reported concerns about the large size of the VR on first impression. Although most found the VR comfortable, some reported pain with VR insertion. Several participants were concerned about VR cleanliness, particularly during menstruation. CONCLUSION: Product considerations, specifically size and use during menstruation, were the most commonly reported barriers to VR acceptability in this study. Adolescent girls may require additional counseling to assuage product concerns regarding a VR for HIV prevention.

Mamekhaya: a pilot study combining a cognitive-behavioral intervention and mentor mothers with PMTCT services in South Africa.

Nearly 30% of pregnant women in South Africa are estimated to be HIV seropositive, yet adherence to guidelines for the prevention of mother-to-child transmission of HIV (PMTCT) is often low. A pilot study was developed to see whether PMTCT services provided by the South African Government could be enhanced by the Mamekhaya program, a combination of the mothers2mothers peer-mentoring program and a culturally adapted cognitive-behavioral intervention (CBI) from the USA. Pregnant women attending two maternity clinics offering PMTCT in Gugulethu and Vanguard Townships, Cape Town, South Africa, were invited to participate in the study. Women at the intervention site (Gugulethu) received the support of a mentor mother and also attended an eight-session Mamekhaya CBI. At the control site (Vanguard), women received standard services provided by midwives and counselors. Baseline assessments were completed by all participants at enrollment (n=160), and follow-ups were completed six months later by 44% of participants. Self-reports of adherence to PMTCT practices were high across both sites (90% or more engaging in the core practices). Women at the Mamekhaya site showed significantly greater improvement in establishing social support and reducing depression scores than women at the control site. Mamekhaya participants also showed trends for better attendance at follow-up medical visits, and greater improvements in positive coping. The greatest effect of the Mamekhaya program was to increase HIV knowledge scores, particularly with regard to understanding the meaning and importance of viral load and CD4 test results. Results from this pilot study show promise that augmenting basic PMTCT services with mentor mothers and a culturally adapted CBI can be effective in conveying information and in improving the emotional outlook and hopefulness of HIV-positive pregnant women in South Africa.

Brief Report: Phase IIa Safety Study of a Vaginal Ring Containing Dapivirine in Adolescent Young Women.

BACKGROUND: Young women aged 15-24 years are disproportionately affected by the HIV epidemic. Two phase III trials of a vaginal ring containing 25-mg dapivirine demonstrated HIV-1 risk reduction in adult women older than 21 years but not in those aged 18-21 years. Lack of protection was correlated with low adherence. METHODS: In this phase-IIa, randomized, double-blind, placebo-controlled, US, multicenter trial of the dapivirine ring in sexually active females, aged 15-17 years, participants were randomized 3:1 to a dapivirine or placebo ring to be inserted monthly for 6 months (NCT02028338). Primary safety end points included grade 2 product related adverse events and any grade 3 and higher adverse events. Adherence to ring use was assessed by plasma dapivirine concentrations, residual levels in used rings, and self-report. A plasma dapivirine concentration of >95 pg/mL was used to define short-term adherence; a residual ring level of <23.5 mg was used to define long-term adherence. Acceptability was assessed through computer-assisted self-interviews. RESULTS: Ninety-six participants were enrolled across 6 US sites. The median age was 16.0 years. There were no differences in safety outcomes between treatment arms. Adherence to the dapivirine ring was demonstrated by both plasma measurements (87%) and residual drug levels in rings (95%). Forty-two percent (95% confidence interval: 32 to 52) of participants reported that they never removed the ring. Participants noted no discomfort due to the ring at 87% of visits and "liking" the ring at 93% of visits. CONCLUSION: The dapivirine vaginal ring, a promising topical microbicide, was well tolerated and acceptable in young US adolescents.

Adolescents and HIV: prevention and clinical care.

The incidence of HIV infection has increased to alarming proportions among minority youth, in particular among young men who have sex with men and among teenage girls. The unique socioeconomic, behavioral, and emotional vulnerability of adolescents for sexually transmitted diseases, including HIV, requires early identification of HIV infection for linkage to care. Differences in the clinical and psychosocial presentations of youth with perinatally versus behavioral acquired HIV infection are important and influence the acceptance of illness, self-efficacy, and antiretroviral treatment adherence. The ideal multidisciplinary team approach of culturally sensitive services for youth integrates clinical care, psychosocial and peer support interventions, transition planning, primary and secondary prevention, as well as comprehensive reproductive adolescent health services.

Pre-vaccination prevalence of anogenital and oral human papillomavirus in young HIV-infected men who have sex with men.

The aims of this study were to: 1) determine prevalence of anogenital and oral HPV, 2) determine concordance between HPV at anal, perianal, scrotal/penile, and oral sites; and 3) describe factors associated with anogenital HPV types targeted by the 9-valent vaccine. Data were collected from 2012 to 2015 among men who have sex with men 18-26 years of age enrolled in a vaccine trial (N = 145). Penile/scrotal, perianal, anal, and oral samples were tested for 61 HPV types. Logistic regression was used to identify factors associated with types in the 9-valent vaccine. Participants' mean age was 23.0 years, 55.2% were African-American, and 26.2% were Hispanic; 93% had anal, 40% penile, and 6% oral HPV. Among those with anogenital infection, 18% had HPV16. Concordance was low between anogenital and oral sites. Factors independently associated with a 9-valent vaccine-type HPV were: race (African-American vs. White, OR=2.67, 95% CI=1.11-6.42), current smoking (yes vs. no, OR=2.37, 95% CI=1.03-5.48), and number of recent receptive anal sex partners (2+ vs. 0, OR=3.47, 95% CI=1.16-10.4). Most MSM were not infected with HPV16 or HPV18, suggesting that they may still benefit from HPV vaccination, but anogenital HPV was very common, highlighting the importance of vaccinating men before sexual initiation. CLINICAL TRIAL NUMBER: NCT01209325.

Acceptance of Routine HIV Testing by Hospitalized Adolescents and Young Adults.

BACKGROUND AND OBJECTIVES: Youth carry a disproportionate burden of new HIV infections. With our study, we aimed to characterize HIV testing experiences among adolescents and young adults admitted to a children's hospital that is located in a high HIV-prevalent community and implemented routine HIV testing for all patients ≥13 years of age. METHODS: A total of 120 patients aged 13 to 24 years old who were admitted to our hospital and had a documented offer of routine HIV testing on admission were invited to complete a self-administered survey that asked about sex, race and/or ethnicity, HIV risk behaviors, and attitudes toward routine HIV testing in the hospital. Date of birth, admission diagnosis, and verification of HIV testing and results were collected by chart review. RESULTS: Study participants (N = 99) were 17.4 ± 2.3 years old, 52% female, 47% Hispanic, and 29% African American. Additional characteristics include the following: 65% had previous sexual activity, 11% had a history of sexually transmitted infections, and 12% were worried about their risk for HIV. Forty-seven percent of participants accepted HIV testing, with older patients (P < .01) and those reporting previous sexual activity (P < .01) and a previous HIV test (P < .01) being more likely to accept testing. A total of 96% of participants agreed that the hospital is a good place to offer HIV testing. CONCLUSIONS: Our findings support offering routine HIV testing to youth admitted to children's hospital. Given the high incidence of new and undiagnosed HIV infections among youth, additional venues for HIV testing are essential.

Expanded HIV Testing Strategy Leveraging the Electronic Medical Record Uncovers Undiagnosed Infection Among Hospitalized Patients.

BACKGROUND: Routine HIV testing of hospitalized patients is recommended, but few strategies to expand testing in the hospital setting have been described. We assessed the impact of an electronic medical record (EMR) prompt on HIV testing for hospitalized patients. METHODS: We performed a pre-post study at 3 hospitals in the Bronx, NY. We compared the proportion of admissions of patients 21-64 years old with an HIV test performed, characteristics of patients tested, and rate of new HIV diagnoses made by screening while an EMR prompt recommending HIV testing was inactive vs. active. The prompt appeared for patients with no previous HIV test or a high-risk diagnosis after their last HIV test. RESULTS: Among 36,610 admissions while the prompt was inactive, 9.5% had an HIV test performed. Among 18,943 admissions while the prompt was active, 21.8% had an HIV test performed. Admission while the prompt was active was associated with increased HIV testing among total admissions [adjusted odds ratio (aOR) 2.78, 95% confidence interval (CI): 2.62 to 2.96], those without a previous HIV test (aOR 4.03, 95% CI: 3.70 to 4.40), and those with a previous negative test (aOR 1.52, 95% CI: 1.37 to 1.68) (P < 0.0001 for all). Although the prompt was active, testing increased across all patient characteristics. New HIV diagnoses made by screening increased from 8.2/100,000 admissions to 37.0/100,000 admissions while the prompt was inactive and active, respectively (OR 4.51 95% CI: 1.17 to 17.45, P = 0.03). CONCLUSIONS: An EMR prompt for hospitalized patients was associated with a large increase in HIV testing, a diversification of patients tested, and an increase in diagnoses made by screening.

Ten Sites, 10 Years, 10 Lessons: Scale-up of Routine HIV Testing at Community Health Centers in the Bronx, New York.

OBJECTIVE: In response to the current CDC recommendations for routine HIV testing in clinical settings, the Adolescent AIDS Program at Montefiore Medical Center in the Bronx, New York, developed the Advise, Consent, Test, Support routine HIV testing model (ACTS) in 2003. ACTS was piloted in 10 community health centers operated by Montefiore because they serve populations most at risk for HIV/AIDS. METHODS: ACTS streamlined and codified the counseling and testing process, provided a routine HIV testing practice change plan, and provided training and communication materials that promoted routine HIV testing. To determine program success, we measured the number of patients seen at the clinics, the number of HIV test-eligible patients (those aged 13-64 years and not pregnant), the number and percent of patients receiving HIV testing, HIV test results, and the number of patients linked to care. RESULTS: HIV testing in the 10 sites increased nearly threefold during the pilot period (2003-2007), from 3,944 of 49,125 eligible patients (8%) tested in 2003 to 11,212 of 55,629 eligible patients (20%) tested in 2007. With little ongoing support, the sites continued or maintained improvements: 13,226 of 56,686 eligible patients (23%) were tested in 2008, 15,965 of 57,025 eligible patients (28%) were tested in 2011, 17,483 of 60,514 eligible patients (29%) were tested in 2012, and 17,971 of 63,172 eligible patients (28%) were tested in 2013. Sites identified 433 HIV-positive patients from 2006 to 2013 (0.2%-0.6% annual seropositivity), and 96% of them were linked to care within 90 days of HIV diagnoses (range: 92% to 98% annually). CONCLUSION: ACTS demonstrated that substantial and sustained increases in routine HIV testing can be achieved in health-care settings, not by adding personnel or financial resources, but by using the model's practice change plan and streamlined HIV testing approach.

Increased Antiretroviral Therapy Use and Virologic Suppression in the Bronx in the Context of Multiple HIV Prevention Strategies.

Multiple population-based HIV prevention strategies from national, state, local, and institutional levels have been implemented in the Bronx, which has one of the highest HIV prevalences in the U.S. We examined changes in antiretroviral therapy (ART) use and associated outcomes between 2007 and 2014 among patients seen at one of >20 outpatient clinics affiliated with the largest Bronx HIV care provider. Among eligible HIV-infected patients age ≥13 years, we examined annual trends in ART use, mean HIV RNA level, and virologic suppression (<200 copies/ml) overall and among prespecified subgroups. In a subset with suppressed HIV RNA at the end of each year, we determined the percentage whose levels remained suppressed within the next year. Regression models assessed disparities in outcomes. Among 7,196 patients (median age 50, 47% Hispanic, 45% black), we identified consistent increases over time in the percent prescribed ART (78% in 2007 to 93% in 2014) and with virologic suppression (58% to 80%), as mean HIV RNA decreased (351 to 73 copies/ml) (all p < .001). Sustained virologic suppression improved markedly beginning in 2011, coinciding with local test-and-treat initiatives and adoption of expanded treatment guidelines. While disparities among population groups were most pronounced for sustained virologic suppression, those aged 13-24 fared relatively poorly for all outcomes examined (e.g., rate ratio 0.57 for virologic suppression, 95% confidence interval 0.52-0.62, vs. age 65+). Population-wide HIV prevention strategies coincided with improvements in virologic suppression among most population groups. However, more attention is needed to address continued disparities in the HIV care continuum among young people.

HIV in adolescents and young adults: half of all new infections in the United States.

Half of new HIV infections in the United States are in individuals aged 13 to 24 years, accounting for 20,000 new infections annually, or 1 every hour. Two thirds of infected youth contract HIV sexually, and more than 60% of new infections are in young women. Approximately 75% of infected youth are in racial or ethnic minority groups. More than one third of HIV-infected young people have not been tested for HIV infection, and the majority of homosexual HIV-infected youth are unaware of their infection status. Increased efforts are needed in comprehensive sex education, including safer sex practices, bringing young people into health care networks, increasing health care provider awareness of risk, and extending counseling and testing to young people. This article summarizes a presentation by Donna Futterman, MD, at the 7th Annual Clinical Conference for Ryan White CARE Act Title I, II, III, and IV Grantees, held in August 2004 in Washington, DC.

HIV and AIDS in adolescents.

HIV infection in adolescents continues to challenge health providers, policymakers, and advocates for youth. There will be no relief from its complexities soon. Primary care providers are in a unique position to use effective HIV prevention and care interventions. Successful programs move beyond moralism to realism. They show a willingness to engage young people and their families in a sensitive dialogue about the needs of youthful sexual development. Youth at high risk for HIV should be identified and referred to comprehensive care and counseling as soon as possible. HIV-positive youth need intensive individual and group interventions to remain healthy and reduce transmission to others. To protect their patient population, health care providers will need to commit time and effort to making adolescents services visible, flexible, affordable, confidential, culturally appropriate, and universally available.