Misclassification of Loss to Care Among Persons With Human Immunodeficiency Virus: Improved Capture of Silent Transfers Through Surveillance Linkage Using Statewide Mandatorily Reported Laboratory Measures.

Human Immunodeficiency Virus (HIV)-positive individuals lost to follow-up from particular clinics may not be lost to care (LTC). After linking Vanderbilt's Comprehensive Care Clinic cohort to Tennessee's statewide HIV surveillance database, LTC decreased from 48.4% to 35.0% at 10 years. Routine surveillance linkage by domestic HIV clinics would improve LTC and retention measure accuracy.

Risk of HIV Diagnosis Following Bacterial Sexually Transmitted Infections in Tennessee, 2013-2017.

BACKGROUND: Data on associations between sexually transmitted infections (STIs) and incident human immunodeficiency virus (HIV) diagnoses beyond men who have sex with men (MSM) are lacking. Identifying STIs associated with greatest risk of incident HIV diagnosis could help better target HIV testing and prevention interventions. METHODS: The STI and HIV surveillance data from individuals 13 years or older in Tennessee from January 2013 to December 2017 were cross-matched. Individuals without diagnosed HIV, but with reportable STIs (chlamydia, gonorrhea, syphilis) were followed up from first STI diagnosis until HIV diagnosis or end of study. Cox regression with time-varying STI exposure was used to estimate adjusted hazard ratios (aHRs) and 95% confidence intervals (CI) for subsequent HIV diagnosis; results were stratified by self-reported MSM. RESULTS: We included 148,465 individuals without HIV (3831 MSM; 144,634 non-MSM, including heterosexual men and women) diagnosed with reportable STIs; 473 had incident HIV diagnoses over 377,823 person-years (p-y) of follow-up (median, 2.6 p-y). Controlling for demographic and behavioral factors, diagnoses of gonorrhea, early syphilis, late syphilis, and STI coinfection were independently associated with incident HIV diagnosis compared with chlamydia. Early syphilis was associated with highest HIV diagnosis risk overall (aHR, 5.5; 95% CI, 3.5-5.8); this risk was higher for non-MSM (aHR, 12.3; 95% CI, 6.8-22.3) versus MSM (aHR, 2.9; 95% CI, 1.7-4.7). CONCLUSIONS: While public health efforts often focus on MSM, non-MSM with STIs is also a subgroup at high risk of incident HIV diagnosis. Non-MSM and MSM with any STI, particularly syphilis, should be prioritized for HIV testing and prevention interventions.

Trends and Disparities in Mortality and Progression to AIDS in the Highly Active Antiretroviral Therapy Era: Tennessee, 1996-2016.

Objectives. To use statewide surveillance data to examine trends and disparities in mortality and progression from HIV to AIDS comprehensively in Tennessee over the past 20 years.Methods. Individuals diagnosed with HIV in Tennessee from 1996 to 2016 were identified through the Tennessee Department of Health Enhanced HIV/AIDS Reporting System. Clinical AIDS and all-cause mortality were the outcomes. Cox regression yielded adjusted hazard ratios (AHRs) for death and competing risk regression yielded adjusted subhazard ratios (SHRs) for AIDS, with death as the competing event.Results. Individuals with a history of heterosexual contact (AHR = 1.20; 95% confidence interval [CI] = 1.12, 1.29) and injection drug use (AHR = 1.27; 95% CI = 1.18, 1.38) had increased hazards of death relative to those with a history of male-to-male sexual contact. Hazards of death were lower among White (AHR = 0.79; 95% CI = 0.73, 0.85) and Hispanic (AHR = 0.50; 95% CI = 0.40, 0.63) individuals than among Black individuals. Those with heterosexual contact (SHR = 1.20; 95% CI = 1.12, 1.29) and injection drug use (SHR = 1.27; 95% CI = 1.18, 1.38) had a greater risk of AIDS than those with male-to-male sexual contact. White individuals (SHR = 0.85; 95% CI = 0.81, 0.90) had a lower risk of AIDS than Black individuals, and female individuals (SHR = 0.84; 95% CI = 0.79, 0.90) had a lower risk than male individuals.Conclusions. The trends, disparities, and outcomes assessed in our study will inform HIV testing and care linkage program design and implementation in Tennessee.

Geographic disparities in late HIV diagnoses in Tennessee: Opportunities for interventions in the rural Southeast.

PURPOSE: Incident HIV remains an important public health issue in the US South, the region leading the nation in HIV incidence, rural HIV cases, and HIV-related deaths. Late diagnoses drive incident HIV and understanding factors driving late diagnoses is critical for developing locally relevant HIV testing and prevention interventions, decreasing HIV transmission, and ending the HIV epidemic. METHODS: Retrospective cohort study utilizing Tennessee Department of Health (TDH) surveillance data and US Census Bureau data. Adults of ≥18-year old with a new HIV diagnosis between January 1, 2015 and December 31, 2019 identified in the TDH electronic HIV/AIDS Reporting System were included. Individuals were followed from initial HIV diagnosis until death, 90 days of follow-up for outcome assessment, or administrative censoring 90 days after study enrollment closed. FINDINGS: We included 3652 newly HIV-diagnosed individuals; median age was 31 years (IQR: 25, 42), 2909 (79.7%) were male, 2057 (56.3%) were Black, 246 (6.7%) were Hispanic, 408 (11.2%) were residing in majority-rural areas at diagnosis, and 642 (17.6%) individuals received a late HIV diagnosis. Residents of majority-rural counties (adjusted risk ratios [aRR] = 1.39, 95% confidence intervals [CI]: 1.16-1.67) and Hispanic individuals (aRR = 1.87, 95% CI: 1.50-2.33) had an increased likelihood of receiving a late diagnosis after controlling for race/ethnicity, age, and year of HIV diagnosis. CONCLUSIONS: Rural residence and Hispanic ethnicity were associated with an increased risk of receiving a late HIV diagnosis in Tennessee. Future HIV testing and prevention efforts should be adapted to the needs of these vulnerable populations.

Using an Established Outbreak Response Plan and Molecular Epidemiology Methods in an HIV Transmission Cluster Investigation, Tennessee, January-June 2017.

INTRODUCTION: In April 2017, the Tennessee Department of Health (TDH) was notified of an increase in the number of persons newly diagnosed with HIV in eastern Tennessee in the same month. Two were identified as persons with a history of injection drug use (IDU) and named each other as syringe-sharing partners, prompting an investigation into a possible HIV cluster among persons with a history of IDU. MATERIALS AND METHODS: TDH and public health staff members in eastern Tennessee collaborated to implement procedures outlined in TDH's HIV/hepatitis C virus (HCV) Outbreak Response Plan, including conducting enhanced interviewing and using a preestablished database for data collection and management. To complement contact tracing and enhanced interviewing, TDH partnered with the Centers for Disease Control and Prevention to conduct molecular HIV analyses. RESULTS: By June 27, 2017, the investigation had identified 31 persons newly diagnosed with HIV infection; 8 (26%) self-reported IDU, 4 of whom were also men who have sex with men (MSM). Of the remaining 23 persons newly diagnosed with HIV infection, 10 were MSM who did not report IDU, 9 reported high-risk heterosexual contact, and 4 had other or unknown risk factors. Molecular analysis of the 14 HIV-1 polymerase genes (including 7 of the 8 persons self-reporting IDU) revealed 3 distinct molecular clusters, one of which included 3 persons self-reporting IDU. PRACTICE IMPLICATIONS: This investigation highlights the importance of implementing an established Outbreak Response Plan and using HIV molecular analyses in the event of a transmission cluster or outbreak investigations. Future HIV outbreak surveillance will include using Global Hepatitis Outbreak Surveillance Technology to identify HCV gene sequences as a potential harbinger for HIV transmission networks.