Factors Associated with the Awareness of and Willingness to Use HIV Pre-exposure Prophylaxis Among Gay, Bisexual, and Other Men Who Have Sex with Men, Baltimore, MD, 2017-2019.

Pre-exposure prophylaxis (PrEP) is an effective tool in protecting persons from acquiring HIV infection through sex or injection drug use. However, awareness and willingness to use PrEP among Black gay, bisexual, and other men who have sex with men (BMSM) remain suboptimal compared to White MSM (WMSM) in the United States. Our aims were to (1) assess the factors associated with PrEP awareness and willingness to use PrEP among MSM and (2) compare the PrEP perceptions among BMSM versus non-Black MSM. Data were drawn from two cross-sectional behavioral surveys in Baltimore, MD: Behavioral Surveillance Research (BESURE) conducted in 2017, and Safe Spaces 4 Sexual Health (SS4SH), conducted in 2018 and 2019. Descriptive statistics were used to summarize the study population. We used Poisson regression models to identify variables associated with awareness of PrEP and willingness to use PrEP. PrEP perceptions were assessed via 13 items scored on a 5-point Likert scale. Finally, we conducted a post-hoc exploratory bivariate analysis of the relationship between PrEP perception and willingness to use PrEP, stratified by race/ethnicity. A total of 261 MSM participated in this study. Many of the participants were aware of PrEP (75.1%). Factors associated with greater PrEP awareness included having greater than a high school education (aRR 1.22, 95% CI 1.04, 1.43); and earning more than $25,000 annually (aRR 1.24, 95% CI 1.08, 1.42). Participants who had received money in exchange for sex one or more times were less likely to be aware of PrEP (aRR 0.59, 95% CI 0.36, 0.95). More than half of the participants were willing to use PrEP (55.3%). In bivariate and multivariable analyses, demographic or behavioral characteristics were not significantly associated with willingness to use PrEP. Higher agreement with the following statements was associated with lower willingness to use PrEP: "Having to take a pill every day is difficult" (RR 0.89, 95% CI 0.82-0.97) and, "I am concerned about the side effects of PrEP" (RR 0.89, 95% CI 0.82-0.96), and "PrEP is for people who have riskier sex lives than I do" (RR 0.86, 95% CI 0.78-0.95). Conversely, higher willingness to use PrEP was associated with comfortable having sex without a condom (RR 1.11, 95% CI 1.02-1.21), less anxious about sex (RR 1.12, 95% CI 1.02-1.24), and my friends think that I should take PrEP (RR 1.19, 95% CI 1.07-1.32). We found BMSM compared to non-Black MSM had higher mean scores related to taking a daily pill (p = 0.041), concerns about side effects (p = 0.012), concerns about people thinking they had HIV (p = 0.001), concerns about the financial costs of PrEP (p = 0.038) and caution when dealing with healthcare organizations/medical mistrust (p = 0.019). Perceptions with a statistically significant lower score among BMSM versus non-Black MSM included statements such as, comfortable having sex without a condom (p = 0.003) and less anxious about sex (p < 0.001). We conclude HIV prevention strategies, programs, and interventions should be cognizant of PrEP perceptions that facilitate or hinder PrEP uptake in Baltimore City, MD.

Reported xylazine exposure highly associated with overdose outcomes in a rapid community assessment among people who inject drugs in Baltimore.

BACKGROUND: Addressing xylazine harms are now a critical harm reduction priority, but relatively little epidemiological information exists to determine prevalence, magnitude, and correlates of xylazine use or related outcomes. METHODS: We conducted a rapid behavioral survey among people who inject drugs (n = 96) in Baltimore November-December 2022. Using a novel indicator of self-reported presumed xylazine effects, we examined prevalence and sociodemographic correlates of past year presumed xylazine effects and association with overdose and wound-related outcomes. Chi-square and descriptive statistics were used to examine bivariate associations overall and separately for those who reported xylazine by name and by reported fentanyl use frequency. RESULTS: Almost two-thirds (61.5%) reported experiencing xylazine effects. There were no differences by socio-demographics, but xylazine effects were more commonly reported among those who reported injecting alone (66% vs 38%%, p < 0.007) and daily fentanyl use (47% vs 24% p < 0.003). Those reporting xylazine exposure was three times as likely to report overdose (32% vs 11%, p < 0.03) and twice as likely to have used naloxone (78% vs 46%, p < 0.003). They also more commonly reported knowing someone who died of an overdose (92% vs 76%, p < 0.09) and to report an abscess requiring medical attention (36% vs 19%, p < 0.80). These associations were higher among respondents who specifically named xylazine and those who used fentanyl more frequently, but fentanyl frequency did not fully explain the heightened associations with xylazine effects. CONCLUSIONS: This study provides insight into the scope of xylazine exposure and associated health concerns among community-based PWID and suggests measures that may be instrumental for urgently needed research.

Injection Behaviors and Use of Syringe Service Programs over Time among People Who Inject Drugs in Baltimore, Maryland.

Introduction: People who inject drugs (PWID) are at increased risk for infectious disease transmission, including hepatitis C and HIV. Understanding trends in injection risk behaviors and syringe service program (SSP) use over time can help improve infectious disease prevention and other harm reduction services. Methods: Using National HIV Behavioral Surveillance System data from Baltimore, Maryland, we examined changes in receptive sharing of (1) syringes, (2) injection equipment, (3) syringes to divide drugs; and (4) receipt of syringes from SSPs among PWID from 2009 to 2018 (n = 518 in 2009, n = 638 in 2012, n = 586 in 2015, and n = 575 in 2018) using unadjusted and adjusted logistic models calculated across time for the total sample. Results: The conditional probability of receptive sharing of syringes and receipt of syringes from SSPs remained relatively stable, while receptive sharing of injection equipment and receptive sharing of syringes to divide drugs dropped substantially after 2009. White race and daily injection frequency were positively associated with sharing syringes and injection equipment and negatively associated with SSP use over time. In 2015, there was a notable shift such that women were twice as likely as men to receive syringes from SSPs and less likely than men to report the use of shared syringes or equipment. Conclusion: Findings indicate overall steady or decreasing trends in injection risk and steady trends in SSP usage over time, with some notable improvements among women and indications of shifting drug market patterns. Injection-related risk behaviors remain high among White PWID and may require targeted outreach and interventions.

Type of Exchange Sex and Associated Behaviors and Outcomes Among Cisgender Men and Women at Increased Risk for HIV via Heterosexual Transmission in Six U.S. Metropolitan Areas.

Exchange sex is associated with sexual risk behaviors and poor outcomes and different types may incur different levels of risk. We assessed risk profiles of different types of exchange sex among non-injecting cisgender men and women who participated in the 2019 National HIV Behavioral Surveillance project at six sites. Six percent of men and 19% of women reported exchange sex in the past year; most engaged in non-commercial exchange sex for drugs/money with smaller percentages reporting formal sex work or non-commercial exchange sex for goods or services other than drugs/money. Exchange sex was associated with sexual risk and prevention behaviors and psychosocial and sexual health outcomes and associations varied by type of exchange sex. Efforts to improve access to STI/HIV testing and PrEP may benefit from tailoring based on type of exchange sex. Findings indicate value in a broader definition of exchange sex with follow-up assessment of exchange sex typology.

Leveraging mHealth and Patient Supporters for African Americans' and Latinxs' Engagement in HIV Care (LEAN): Protocol for a Randomized, Controlled, Effectiveness-Implementation Trial.

BACKGROUND: Despite substantial investments in ending the HIV epidemic, disparities in HIV care persist, and there is an urgent need to evaluate novel and scalable approaches to improving HIV care engagement and viral suppression in real-world settings. OBJECTIVE: This paper aims to describe a study protocol for a pragmatic type II hybrid effectiveness-implementation randomized controlled trial comparing existing standard of care clinic HIV linkage, adherence, and retention (LAR) protocols to a mobile health (mHealth)-enhanced linkage, adherence, and retention (mLAR) intervention. METHODS: The study will enroll 450 participants from clinics in Baltimore City. Eligibility criteria include being ≥18 years of age, having a new HIV diagnosis or being HIV-positive and out of care, or being HIV-positive and deemed by clinic staff as someone who could benefit from linkage and retention services. Participants randomized to the intervention receive mHealth-supported patient navigation for 12 months. Participants in the control group receive the referring clinic's standard of care patient support. The primary outcome is HIV virologic suppression at 12 months. A subset of participants will be interviewed at 12 months to learn about their HIV care experiences and, for those in the intervention arm, their experiences with the mLAR intervention. This protocol was developed in collaboration with the Baltimore City Health Department (BCHD) and the Maryland Department of Health (MDH) and with input from a community advisory board. RESULTS: Enrollment began on February 25, 2020. As of August 11, 2022, 411 of the 450 target participants had been enrolled. CONCLUSIONS: Pragmatic implementation science trials designed with input from key stakeholders, including health departments and community members, can help evaluate the evidence for mHealth interventions to reduce HIV health disparities. TRIAL REGISTRATION: ClinicalTrials.gov NCT03934437; https://clinicaltrials.gov/ct2/show/NCT03934437. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/42691.

Enhancing the ATra Black Box Matching Algorithm: Use of All Names for Deduplication Across Jurisdictions.

OBJECTIVES: Achieving accurate, timely, and complete HIV surveillance data is complicated in the United States by migration and care seeking across jurisdictional boundaries. To address these issues, public health entities use the ATra Black Box-a secure, electronic, privacy-assuring system developed by Georgetown University-to identify and confirm potential duplicate case records, exchange data, and perform other analytics to improve the quality of data in the Enhanced HIV/AIDS Reporting System (eHARS). We aimed to evaluate the ability of 2 ATra software algorithms to identify potential duplicate case-pairs across 6 jurisdictions for people living with diagnosed HIV. METHODS: We implemented 2 matching algorithms for identifying potential duplicate case-pairs in ATra software. The Single Name Matching Algorithm examines only 1 name for a person, whereas the All Names Matching Algorithm examines all names in eHARS for a person. Six public health jurisdictions used the algorithms. We compared outputs for the overall number of potential matches and changes in matching level. RESULTS: The All Names Matching Algorithm found more matches than the Single Name Matching Algorithm and increased levels of match. The All Names Matching Algorithm identified 9070 (4.5%) more duplicate matches than the Single Name Matching Algorithm (n = 198 828) and increased the total number of matches at the exact through high levels by 15.4% (from 167 156 to 192 932; n = 25 776). CONCLUSIONS: HIV data quality across multiple jurisdictions can be improved by using all known first and last names of people living with diagnosed HIV that match with eHARS rather than using only 1 first and last name.

Associations between HIV testing and multilevel stigmas among gay men and other men who have sex with men in nine urban centers across the United States.

BACKGROUND: Complex manifestation of stigma across personal, community, and structural levels and their effect on HIV outcomes are less understood than effects in isolation. Yet, multilevel approaches that jointly assesses HIV criminalization and personal sexual behavior stigma in relation to HIV testing have not been widely employed or have only focused on specific subpopulations. The current study assesses the association of three types of MSM-related sexual behavior-related stigma (family, healthcare, general social stigma) measured at both individual and site levels and the presence/absence of laws criminalizing HIV transmission with HIV testing behaviors to inform HIV surveillance and prevention efforts among HIV-negative MSM in a holistic and integrated way. METHODS: We included nine National HIV Behavioral Surveillance (NHBS) 2017 sites: Baltimore, MD; Denver, CO; Detroit, MI; Houston, TX; Long Island/Nassau-Suffolk, NY; Los Angeles, CA; Portland, OR; San Diego, CA; and Virginia Beach and Norfolk, VA. Multivariable generalized hierarchical linear modeling was used to examine how sexual behavior stigmas (stigma from family, anticipated healthcare stigma, general social stigma) measured at the individual and site levels and state HIV criminalization legislation (no, HIV-specific, or sentence-enhancement laws) were associated with past-year HIV testing behaviors across sites (n = 3,278). RESULTS: The majority of MSM across sites were tested for HIV in the past two years (n = 2,909, 95.4%) with the average number of times tested ranging from 1.79 (SD = 3.11) in Portland, OR to 4.95 (SD = 4.35) in Los Angeles, CA. In unadjusted models, there was a significant positive relationship between stigma from family and being tested for HIV in the past two years. Site-level HIV-specific criminalization laws were associated with an approximate 5% reduction in the prevalence of receiving any HIV test in the past two years after individual level stigma and sociodemographic covariate adjustments (PR = 0.94, 95% CI, 0.90-0.99). CONCLUSIONS: Structural barriers faced by MSM persist and ending the HIV epidemic in the US requires a supportive legal environment to ensure effective engagement in HIV services among MSM. Home-based solutions, such as self-testing, used to deliver HIV testing may be particularly important in punitive settings while legal change is advocated for on the community and state levels.

Metrics of Sexual Behavior Stigma Among Cisgender Men Who Have Sex With Men in 9 Cities Across the United States.

Men who have sex with men (MSM) in the United States are stigmatized for their same-sex practices, which can lead to risky sexual behavior, potentiating risk for human immunodeficiency virus (HIV) infection. Improved measurement is necessary for accurately reporting and mitigating sexual behavior stigma. We added 13 sexual behavior stigma items to local surveys administered in 2017 at 9 sites in the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance system, which uses venue-based, time-sampling procedures to survey cisgender MSM in US Census Metropolitan Statistical Areas. We performed exploratory factor analytical procedures on site-specific (Baltimore, Maryland; Denver, Colorado; Detroit, Michigan; Houston, Texas; Nassau-Suffolk, New York; Portland, Oregon; Los Angeles, California; San Diego, California; and Virginia Beach-Norfolk, Virginia) and pooled responses to the survey items. A 3-factor solution-"stigma from family" (α = 0.70), "anticipated health-care stigma" (α = 0.75), and "general social stigma" (α = 0.66)-best fitted the pooled data and was the best-fitting solution across sites. Findings demonstrate that MSM across the United States experience sexual behavior stigma similarly. The results reflect the programmatic utility of enhanced stigma measurement, including tracking trends in stigma over time, making regional comparisons of stigma burden, and supporting evaluation of stigma-mitigation interventions among MSM across the United States.

An application of agent-based modeling to explore the impact of decreasing incarceration rates and increasing drug treatment access on sero-discordant partnerships among people who inject drugs.

BACKGROUND: People who inject drugs (PWID) lag behind other key populations in HIV care continuum outcomes. The impacts of criminal justice reform and increasing drug treatment access on HIV have been underexplored. METHODS: We developed agent-based models (ABM) of sexual partnerships among PWID and non-PWID, and injection equipment-sharing partnerships among PWID in five US cities (Baltimore, Boston, Miami, New York City, San Francisco) over 3 years. The first set of ABM projected changes in partnership discordance among PWID as a function of decreasing ZIP code-level incarceration rates. The second set projected discordance as a function of increasing ZIP code-level drug treatment access. ABM were parameterized and validated overall, and by city and PWID race/ethnicity (Black, Latino, White) using National HIV Behavioral Surveillance data, administrative ZIP code-level data, surveillance reports and prior literature. Informed by research on prisoner release and community-level HIV prevalence, reductions in incarceration rates were fixed at 5% and 30% and respectively projected to increase ZIP code-level HIV prevalence by 2% and 12%. Increases in drug treatment access were fixed at 30% and 58%. RESULTS: In each city, a 30% reduction in ZIP code-level incarceration rates and 12% increase in ZIP code-level HIV prevalence significantly increased sero-discordance among at least one racial/ethnic group of PWID by 1-3 percentage points. A 5% reduction in incarceration rates, and 30% and 58% increases in drug treatment access, led to isolated significant changes in sero-discordance among Black and White PWID that were less than 1 percentage point. CONCLUSION: Reductions in incarceration rates may lead to short-term increases in sero-discordant partnerships among some PWID by increasing community-level HIV prevalence. Efforts to increase HIV testing, engagement in care and community reintegration post release, should be strengthened in the wake of incarceration reform. Additional research should confirm these findings and explore the lack of widespread impacts of drug treatment in this study.

Early Use of the Palliative Approach to Improve Patient Outcomes in HIV Disease: Insights and Findings From the Care and Support Access (CASA) Study 2013-2019.

Young men of color who have sex with men (yMSM) living with human immunodeficiency virus (HIV) in syndemic environments have been difficult-to-retain in care resulting in their being at-risk for poor health outcomes despite availability of effective once-daily antiretroviral treatment (ART). Multiple methods have been implemented to improve outcomes for this cohort; none with sustainable results. Outpatient HIV staff themselves may be a contributing factor. We introduced multidisciplinary staff to the concept of using a palliative approach early (ePA) in outpatient HIV care management to enable them to consider the patient-level complexity of these young men. Young MSM (18-35 years of age) enrolled in and cared for at the intervention site of the Care and Support Access Study (CASA), completed serial surveys over 18 months. Patients' Global and Summary quality of life (QoL) increased during the study at the intervention site (IS) where staff learned about ePA, compared with patients attending the control site (CS) (p=.021 and p=.018, respectively). Using serial surveys of staff members, we found that in the era of HIV disease control, outpatient staff are stressed more by environmental factors than by patients' disease status seen historically in the HIV epidemic. A Community Advisory Panel of HIV stakeholders contributed to all phases of this study and altered language used in educational activities with staff members to describe the patient cohort.

Social Stability Relates Social Conditions to the Syndemic of Sex, Drugs, and Violence.

The distribution of violence, sexually transmitted infections, and substance use disorders is not random, but rather the product of disease, behavior, and social conditions that co-occur in synergistic ways (syndemics). Syndemics often disproportionately affect urban communities. Studies of syndemics, however, rarely apply consistent measures of social conditions. Here, the construct of social stability (SS) (housing, legal, residential, income, employment, and relationship stability) was evaluated as a consistent measure of social conditions related to sex, drug, and violence exposures in a new population in a Mid-Atlantic urban center. Lower SS predicted greater likelihood of any and combinations of risk. The magnitude varied based on specification: odds of sex-drug-violence exposure were greater for low vs. high latent SS class (OR = 6.25; 95%CI = 2.46, 15.96) compared with low vs. high SS category (OR = 2.64; 95%CI = 1.29, 5.39). A latent class characterized by residential instability was associated with greater likelihood of risk-a relationship that would have been missed with SS characterized only as an ordinal category. SS reliably captured social conditions associated with sexual, drug, and violence risks, and both quantity and quality of SS matter.

Understanding the HIV Epidemic Among MSM in Baltimore: A Modeling Study Estimating the Impact of Past HIV Interventions and Who Acquired and Contributed to Infections.

INTRODUCTION: Men who have sex with men (MSM) in the United States are disproportionately affected by HIV. We estimated the impact of past interventions and contribution of different population groups to incident MSM HIV infections. SETTING: Baltimore, US. METHODS: We used a deterministic model, parameterized and calibrated to demographic and epidemic Baltimore MSM data, to estimate the fraction of HIV infections among MSM averted by condoms and antiretroviral therapy (ART) over 1984-2017 and the fraction of infections acquired and transmission contributed by MSM from different demographic groups and disease and care continuum stages over 10-year periods from 1988 to 2017, using population attributable fractions. RESULTS: Condom use and ART averted 19% (95% uncertainty interval: 14%-25%) and 23% (15%-31%) of HIV infections that would have occurred since 1984 and 1996, respectively. Over 2008-2017, 46% (41%-52%) of incident infections were acquired by and 35% (27%-49%) of transmissions contributed by MSM aged 18-24 years (who constitute 27% of all MSM, 19% of HIV+ MSM). MSM with undiagnosed HIV infection, those with diagnosed infection but not in care, and those on ART contributed to 41% (31%-54%), 46% (25%-56%), and 14% (7%-28%) of transmissions, respectively. CONCLUSION: Condoms and ART have modestly impacted the HIV epidemic among Baltimore MSM to date. Interventions reaching MSM with diagnosed infection who are not in care should be implemented because the largest percentage of HIV transmissions among Baltimore MSM is attributed to this group.

HIV and employment among Black men who have sex with men in Baltimore.

Employment status is a key social determinant of health, and many populations in the United States that are impacted by HIV have unequal access to education and employment opportunities which contributes to HIV-related disparities. Black men who have sex with men (BMSM) are one of the groups most heavily burdened by HIV. With improved health outcomes associated with advancements in HIV treatment, research suggests that more people living with HIV want to work. This study describes employment among BMSM living in Baltimore, assesses differences in employment by HIV status and assesses predictors of full-time employment among BMSM. The study found that BMSM have limited access to full-time employment and that this disparity is even more pronounced among BMSM living with HIV. Men living with HIV were less likely to be employed full-time compared to men not living with HIV controlling for education and social contextual factors (OR 0.40 95% CI (0.22-0.73)). HIV will most likely have important implications for employment patterns and trajectories of BMSM over the life course. Additional research is needed among BMSM living with HIV to understand work histories and experiences, facilitating factors, and the impact of various work experiences on the health and wellbeing.

Association of Enacted Stigma with Depressive Symptoms Among Gay and Bisexual Men Who Have Sex with Men: Baltimore, 2011 and 2014.

Purpose: We assessed differences between gay and bisexual men in enacted stigma, and how the association between stigma and depressive symptoms may vary according to sexual orientation identity. Methods: Participants (671 gay and 331 bisexual men who have sex with men) in Baltimore's 2011 and 2014 National HIV Behavioral Surveillance completed an anonymous survey, including 3 enacted stigma dimensions and the Center for Epidemiologic Studies Depression Scale. Adjusted prevalence ratios were calculated through Generalized Estimating Equation models adjusting for theorized confounders (demographic, socioeconomic, and relational factors). Results: Bisexual men reported stigma experiences less frequently than did gay men (verbal harassment 22.7% vs. 32.3%, and discrimination 15.7% vs. 23.0%). Relevant depressive symptoms were reported by 43.1% of bisexual men and 34.2% of gay men (p < 0.001). Statistically significant differences in depressive symptoms between bisexual and gay men disappeared after adjusting for socioeconomic factors. The three enacted stigma dimensions were significantly associated with depressive symptoms, but their interaction with sexual orientation identity was not. Conclusion: This study confirms the association between enacted stigma and depressive symptoms among gay and bisexual men. However, sexual orientation identity did not modify this association as hypothesized. The bisexual men presented other psychosocial stressors that may explain their higher prevalence of depressive symptoms. The high levels of verbal harassment, discrimination, and physical assault reported by gay and bisexual men and their negative effect on mental health indicate the need to develop new effective public health strategies to avoid these consequences of homophobic and biphobic culture.

Improving HIV Surveillance Data by Using the ATra Black Box System to Assist Regional Deduplication Activities.

BACKGROUND: Focused attention on Data to Care underlines the importance of high-quality HIV surveillance data. This study identified the number of total duplicate and exact duplicate HIV case records in 9 separate Enhanced HIV/AIDS Reporting System (eHARS) databases reported by 8 jurisdictions and compared this approach to traditional Routine Interstate Duplicate Review resolution. METHODS: This study used the ATra Black Box System and 6 eHARS variables for matching case records across jurisdictions: last name, first name, date of birth, sex assigned at birth (birth sex), social security number, and race/ethnicity, plus 4 system-calculated values (first name Soundex, last name Soundex, partial date of birth, and partial social security number). RESULTS: In approximately 11 hours, this study matched 290,482 cases from 799,326 uploaded records, including 55,460 exact case pairs. Top case pair overlaps were between NYC and NYS (51%), DC and MD (10%), and FL and NYC (6%), followed closely by FL and NYS (4%), FL and NC (3%), DC and VA (3%), and MD and VA (3%). Jurisdictions estimated that they realized a combined 135 labor hours in time efficiency by using this approach compared with manual methods previously used for interstate duplication resolution. DISCUSSION: This approach discovered exact matches that were not previously identified. It also decreased time spent resolving duplicated case records across jurisdictions while improving accuracy and completeness of HIV surveillance data in support of public health program policies. Future uses of this approach should consider standardized protocols for postprocessing eHARS data.

Evaluating HIV Surveillance Completeness Along the Continuum of Care: Supplementing Surveillance With Health Center Data to Increase HIV Data to Care Efficiency.

BACKGROUND: HIV surveillance is essential to quantifying the impact of the epidemic and shaping HIV programs. The Maryland Department of Health (MDH) historically conducted HIV Data to Care (D2C) activities using surveillance data to identify individuals who were not in HIV care; however, most case investigations concluded that the individuals in question were currently engaged in care. This suggests that delays and gaps in laboratory reporting to HIV surveillance exist and the proportion of HIV-positive Marylanders who are truly in care is underestimated. Therefore, solely relying on surveillance data might not be an efficient method for identifying not in care HIV cases. SETTING: Through the Partnerships for Care (P4C) project, MDH conducted targeted D2C efforts on HIV patients from 4 health centers. METHODS: The expanded D2C model that MDH created during P4C integrated clinical data as a secondary data source to enhance the surveillance data used to estimate HIV patient care engagement. MDH matched and compared health center electronic health records with HIV surveillance data to assess completeness of HIV case and laboratory reporting. RESULTS: HIV case ascertainment was high (99.9%) for the P4C cohort (N = 927), but differences in estimated care engagement and viral suppression between data sources revealed incomplete laboratory reporting and that patients received care from multiple providers. Analyzing the clinical data leads to the resolution of several reporting gaps, which improved surveillance data quality over time. CONCLUSIONS: Health departments should validate their HIV surveillance completeness. Triangulating surveillance data with clinical data generated more accurate depictions of care engagement and increased D2C efficiency.

Improvements in the HIV care continuum needed to meaningfully reduce HIV incidence among men who have sex with men in Baltimore, US: a modelling study for HPTN 078.

INTRODUCTION: HIV prevalence is high among men who have sex with men (MSM) in Baltimore, Maryland, United States, and the levels of viral suppression among HIV-positive MSM are relatively low. The HIV Prevention Trials Network 078 trial seeks to increase the levels of viral suppression among US MSM by increasing the rates of diagnosis and linkage to care and treatment. We estimated the increases in viral suppression needed to reach different HIV incidence reduction targets, and the impact of meeting diagnosis and treatment targets. METHODS: We used a mathematical model of HIV transmission among MSM from Baltimore, US, parameterised with behavioural data and fitted to HIV prevalence and care continuum data for Baltimore wherever possible, to project increases in viral suppression needed to reduce the HIV incidence rate among Baltimore MSM by 10, 20, 30 or 50% after 2, 5 and 10 years. We also projected HIV incidence reductions achieved if US national targets - 90% of people living with HIV (PLHIV) know their HIV serostatus, 90% of those diagnosed are retained in HIV medical care and 80% of those diagnosed are virally suppressed - or UNAIDS 90-90-90 targets (90% of PLHIV know their status, 90% of those diagnosed receive antiretroviral therapy (ART), 90% of those receiving ART are virally suppressed) are each met by 2020. RESULTS: To reduce the HIV incidence rate by 20% and 50% after five years (compared with the base-case at the same time point), the proportion of all HIV-positive MSM who are virally suppressed must increase above 2015 levels by a median 13 percentage points (95% uncertainty interval 9 to 16 percentage points) from median 49% to 60%, and 27 percentage points (22 to 35) from 49% to 75% respectively. Meeting all three US or 90-90-90 UNAIDS targets results in a 48% (31% to 63%) and 51% (38% to 65%) HIV incidence rate reduction in 2020 respectively. CONCLUSIONS: Substantial improvements in levels of viral suppression will be needed to achieve significant incidence reductions among MSM in Baltimore, and to meet 2020 US and UNAIDS targets. Future modelling studies should additionally consider the impact of pre-exposure prophylaxis for MSM.

Completeness of HIV nucleotide sequence ascertainment and its potential impact on understanding HIV transmission - Maryland, 2011-2013.

HIV nucleotide sequences generated through routine drug resistance testing (DRT) and reported to Maryland's Molecular HIV Surveillance system are most effective for elucidating transmission patterns and identifying outbreaks if DRT is ordered promptly and sequences are reported completely. Among reported cases of HIV infection newly diagnosed during 2011-2013 in Maryland residents aged ≥13 years, we assessed sequence ascertainment completeness. To better understand which populations were most likely to have a sequence, we examined associations between sequence ascertainment and clinical and demographic characteristics. During 2011-2013, 4423 new HIV infection diagnoses were reported; sequences were ascertained for 1282 (29.0%). Among 3267 cases with complete data, odds for having a sequence ascertained were highest for cases in persons living inside Maryland's Central Region with initial CD4 counts ≤500 cells/mm3 (adjusted odds ratio [aOR] 2.4, 95% confidence interval [CI] 1.9-3.1). Sequence ascertainment did not vary significantly by patient age, sex, race/ethnicity or HIV transmission category. Educational interventions, policy changes and improved processes to increase timely DRT and subsequent sequence reporting with a focus on testing at entry to care, particularly for those with higher CD4 counts and those living outside the Central Region, might improve ascertainment completeness.

Impact of Providing Preexposure Prophylaxis for Human Immunodeficiency Virus at Clinics for Sexually Transmitted Infections in Baltimore City: An Agent-based Model.

BACKGROUND: Preexposure prophylaxis (PrEP) greatly reduces the risk of human immunodeficiency virus (HIV) acquisition, but its optimal delivery strategy remains uncertain. Clinics for sexually transmitted infections (STIs) can provide an efficient venue for PrEP delivery. METHODS: To quantify the added value of STI clinic-based PrEP delivery, we used an agent-based simulation of HIV transmission among men who have sex with men (MSM). We simulated the impact of PrEP delivery through STI clinics compared with PrEP delivery in other community-based settings. Our primary outcome was the projected 20-year reduction in HIV incidence among MSM. RESULTS: Assuming PrEP uptake and adherence of 60% each, evaluating STI clinic attendees and delivering PrEP to eligible MSM reduced HIV incidence by 16% [95% uncertainty range, 14%-18%] over 20 years, an impact that was 1.8 (1.7-2.0) times as great as that achieved by evaluating an equal number of MSM recruited from the community. Comparing strategies where an equal number of MSM received PrEP in each strategy (ie, evaluating more individuals for PrEP in the community-based strategy, because MSM attending STI clinics are more likely to be PrEP eligible), the reduction in HIV incidence under the STI clinic-based strategy was 1.3 (1.3-1.4) times as great as that of community-based delivery. CONCLUSIONS: Delivering PrEP to MSM who attend STI clinics can improve efficiency and effectiveness. If high levels of adherence can be achieved in this population, STI clinics may be an important venue for PrEP implementation.

Correlates of exchange sex among a population-based sample of low-income women who have heterosexual sex in Baltimore.

Sex exchange is associated with HIV and other morbidities yet has received little research, surveillance, and programmatic attention in the U.S. This study identified correlates of exchange sex and among low-income women in Baltimore, Maryland. Participants were recruited into the National HIV Behavioral Surveillance (NHBS) system in 2013 using respondent driven sampling (RDS) and completed a survey and HIV testing. The analytic sample (n = 253) consisted of women aged ≥18 years who had recent (past year) heterosexual sex. Multivariable logistic regression identified correlates of recent exchange sex. Independently associated with recent exchange sex were history of injection drug use (adjusted odds ratio (AOR) = 3.4, 95% CI: 1.1-10.3), recent prescription painkiller use (AOR = 3.7, 95% CI: 1.4-9.9), recent crack/cocaine use (AOR = 6.6, 95% CI: 2.1-20.9), recent arrest (AOR = 4.1, 95% CI: 1.2-14.8), and recent consistent condom use (AOR 1.1; 95% CI: 1.0-1.3). Women who exchanged sex exhibited heightened social and structural vulnerability and substance use. These data demonstrate the need for further research examining the context of exchange sex among low-income women and synergies between substance use and HIV risk.