Assessing acceptability and feasibility of provider-initiated HIV testing and counseling in Ghana.

t In Ghana, HIV voluntary counseling and testing remains poorly utilized. The World Health Organization (WHO) has recommended opt-out, provider-initiated testing and counseling (PITC) in order to increase utilization and earlier intervention. Yet implementation challenges remain in resource-scarce settings. This study sought to better understand the dynamics of providing PITC at Apam Catholic Hospital, a district referral hospital in Ghana. Semi-structured interviews were conducted with healthcare providers and patients exploring attitudes regarding PITC, community stigma, and HIV knowledge. Results showed healthcare providers believed PITC would lead to earlier diagnosis and intervention, but concerns persisted over increased costs. Patients welcomed PITC, but expressed discomfort in opting-out. Patients demonstrated incomplete HIV knowledge and widely believed spiritual healers and prayer can cure the infection. Acceptance of PITC by both healthcare providers and patients remains high, but concerns over resource costs and HIV knowledge persist as challenges. [Full article available at http://rimed.org/rimedicaljournal-2017-08.asp].

Characterizing the Burden of Hepatitis C Infection Among Entrants to Pennsylvania State Prisons, 2004 to 2012.

Although hepatitis C (HCV) infection is common among prisoners, relatively few undergo evaluation for treatment. This study reports the prevalence of chronic infection and the genotype distribution among an incarcerated population. HCV antibody testing was provided to adults entering Pennsylvania prisons; confirmatory and genotype testing were offered to those eligible for treatment. Antibody prevalence among 101,727 individuals was 18.1%. Among 7,633 individuals who underwent confirmatory testing, 69.3% had detectable RNA. Among 3,247 individuals who underwent genotype testing, genotype 1 was the most common (76.6%). The rate of chronic infection after HCV exposure is similar to that reported in the community, as is genotype distribution. Correctional facilities provide access to a population with a high disease burden, creating a public health opportunity for evaluation and treatment.

Clinical impact and cost-effectiveness of expanded voluntary HIV testing in India.

BACKGROUND: Despite expanding access to antiretroviral therapy (ART), most of the estimated 2.3 to 2.5 million HIV-infected individuals in India remain undiagnosed. The questions of whom to test for HIV and at what frequency remain unclear. METHODS: We used a simulation model of HIV testing and treatment to examine alternative HIV screening strategies: 1) current practice, 2) one-time, 3) every five years, and 4) annually; and we applied these strategies to three population scenarios: 1) the general Indian population ("national population"), i.e. base case (HIV prevalence 0.29%; incidence 0.032/100 person-years [PY]); 2) high-prevalence districts (HIV prevalence 0.8%; incidence 0.088/100 PY), and 3) high-risk groups (HIV prevalence 5.0%; incidence 0.552/100 PY). Cohort characteristics reflected Indians reporting for HIV testing, with a median age of 35 years, 66% men, and a mean CD4 count of 305 cells/µl. The cost of a rapid HIV test was $3.33. Outcomes included life expectancy, HIV-related direct medical costs, incremental cost-effectiveness ratios (ICERs), and secondary transmission benefits. The threshold for "cost-effective" was defined as 3x the annual per capita GDP of India ($3,900/year of life saved [YLS]), or for "very cost-effective" was <1x the annual per capita GDP ($1,300/YLS). RESULTS: Compared to current practice, one-time screening was very cost-effective in the national population (ICER: $1,100/YLS), high-prevalence districts (ICER: $800/YLS), and high-risk groups (ICER: $800/YLS). Screening every five years in the national population (ICER: $1,900/YLS) and annual screening in high-prevalence districts (ICER: $1,900/YLS) and high-risk groups (ICER: $1,800/YLS) were also cost-effective. Results were most sensitive to costs of care and linkage-to-care. CONCLUSIONS: In India, voluntary HIV screening of the national population every five years offers substantial clinical benefit and is cost-effective. Annual screening is cost-effective among high-risk groups and in high-prevalence districts nationally. Routine HIV screening in India should be implemented.

HIV among persons incarcerated in the USA: a review of evolving concepts in testing, treatment, and linkage to community care.

PURPOSE OF REVIEW: People who are incarcerated have a disproportionately high risk of HIV infection. They also tend to have risk factors associated with underutilization of antiretroviral therapy (ART) such as substance abuse, mental illness, and poor access to care. In this review, we describe how incarceration is a marker of vulnerability for suboptimal HIV care, and also how criminal justice settings may be leveraged as a platform for promoting testing, linkage, and retention in HIV care for a high-risk, marginalized population. RECENT FINDINGS: In both prisons and jails, routine, opt-out HIV testing strategies are more appropriate for screening correctional populations than traditional, risk-based strategies. Rapid HIV testing is feasible and acceptable in busy, urban jail settings. Although ART is successfully administered in many prison settings, release to the community is strongly associated with inconsistent access to medications and other structural factors leading to loss of viral suppression. SUMMARY: Collaborations among HIV clinicians, criminal justice personnel, and public health practitioners represent an important strategy for turning the tide on the HIV epidemic. Success will depend upon scaled-up efforts to seek individuals with undiagnosed infection and bring those who are out-of-care into long-term treatment.

Viral decay rates are similar in HIV-infected patients with and without TB coinfection during treatment with an Efavirenz-based regimen.

Viral decay rates during efavirenz-based therapy were compared between human immunodeficiency virus (HIV)-infected patients without tuberculosis (n = 40) and those with tuberculosis coinfection who were receiving concurrent antituberculous therapy (n = 34). Phase I and II viral decay rates were similar in the 2 groups (P > .05). Overall, concurrent antituberculous therapy did not reduce the efficacy of the HIV treatment.

HIV and infectious disease care in jails and prisons: breaking down the walls with the help of academic medicine.

Health care within correctional facilities has traditionally been marginalized from excellence in academic medicine. The armamentarium of a medical school, which includes excellence in research, teaching and clinical care, can be successfully applied to the correctional setting both in the United States and internationally. At any one time, there are over 2 million people incarcerated in the US who are disproportionately poor and from communities of color. Rates of human immunodeficiency virus (HIV) and hepatitis C virus infection (HCV) in prisons are 5 and 17-28-times higher than in the general population, respectively. The correctional setting provides an excellent opportunity to screen for and treat sexually transmitted infections (STIs), HIV, HCV, chronic hepatitis B virus (HBV) infections and tuberculosis (TB) and to develop effective prevention programs.

Small reservoirs: jail screening for gonorrhea and Chlamydia in low prevalence areas.

Public health agencies can use jail as an opportunity to reach populations disproportionately affected by sexually transmitted infections (STI). The emphasis that STI control programs place on screening jail entrants varies considerably. Nine million individuals passed through U.S. jails in 2005, many in counties where STIs are rare. A pilot program of screening for Neisseria gonorrhoeae and Chlamydia trachomatis was implemented at the intake sites for the combined jail and prison system of Rhode Island, a state with a low prevalence of STIs. Prevalence of either gonorrhea or chlamydia among detainees was 4.6%, but in women aged 25 and younger, the rate was 24 times that of similar-aged women statewide. Screening led to treatment for 22 (81%) of the infected inmates and 10 of their partners. The heterogeneity of both jail demographics and STI epidemiology suggests a need to tailor the choice of screening strategy to local conditions.

Bacterial pneumonia, HIV therapy, and disease progression among HIV-infected women in the HIV epidemiologic research (HER) study.

BACKGROUND: To determine the rate and predictors of community-acquired bacterial pneumonia and its effect on human immunodeficiency virus (HIV) disease progression in HIV-infected women, we performed a multiple-site, prospective study of HIV-infected women in 4 cities in the United States. METHODS: During the period of 1993-2000, we observed 885 HIV-infected and 425 HIV-uninfected women with a history of injection drug use or high-risk sexual behavior. Participants underwent semiannual interviews, and CD4+ lymphocyte count and viral load were assessed in HIV-infected subjects. Data regarding episodes of bacterial pneumonia were ascertained from medical record reviews. RESULTS: The rate of bacterial pneumonia among 885 HIV-infected women was 8.5 cases per 100 person-years, compared with 0.7 cases per 100 person-years in 425 HIV-uninfected women (P < .001). In analyses limited to follow-up after 1 January 1996, highly active antiretroviral therapy (HAART) and trimethoprim-sulfamethoxazole (TMP-SMX) use were associated with a decreased risk of bacterial pneumonia. Among women who had used TMP-SMX for 12 months, each month of HAART decreased bacterial pneumonia risk by 8% (adjusted hazard ratio [HR(adj)], 0.92; 95% confidence interval [CI], 0.89-0.95). Increments of 50 CD4+ cells/mm3 decreased the risk (HR(adj), 0.88; 95% CI, 0.84-0.93), and smoking doubled the risk (HR(adj), 2.12; 95% CI, 1.26-3.55). Bacterial pneumonia increased mortality risk (HR(adj), 5.02; 95% CI, 2.12-11.87), with adjustment for CD4+ lymphocyte count and duration of HAART and TMP-SMX use. CONCLUSIONS: High rates of bacterial pneumonia persist among HIV-infected women. Although HAART and TMP-SMX treatment decreased the risk, bacterial pneumonia was associated with an accelerated progression to death. Interventions that improve HAART utilization and promote smoking cessation among HIV-infected women are warranted.

A review of the case for hepatitis B vaccination of high-risk adults.

The sequelae of hepatitis B virus infection include fulminant liver failure, chronic liver disease, hepatocellular carcinoma, and death. The hepatitis B vaccine is efficacious, safe, and cost-effective, but has been consistently underutilized in high-risk adults despite long-standing recommendations. Instituting routine hepatitis B vaccination for high-risk adults in settings such as prisons and jails, sexually transmitted disease clinics, drug treatment centers, and needle exchange programs could prevent up to 800 cases of hepatitis, and 10 deaths from hepatitis, per 10,000 vaccinations, with an overall cost savings. Low rates of completion of the three-dose series and lack of funding for adult immunizations have always been challenges to offering hepatitis B vaccines to high-risk adults. However, there is benefit to an incomplete vaccination series, and high-risk populations are accessible for follow-up vaccination outside of traditional medical settings. A clear national objective and federal funding for vaccinating high-risk adults are needed.

Acceptability of sexually transmitted infection screening among women in short-term substance abuse treatment.

BACKGROUND: Substance abuse treatment centers provide an opportunity to offer sexually transmitted infection (STI) screening to a high-risk and hard-to-reach population. GOAL: The goal was to assess STI prevalence, risk factors, and acceptability of STI screening among females at substance abuse treatment centers with use of urine testing by ligase chain reaction and self-collected swab specimens. STUDY DESIGN: Adult, female inpatients were offered free testing and treatment for chlamydia infection, gonorrhea, and trichomonas infection. Interviews were conducted to collect risk behavior data. RESULTS: Eighty-six percent of inpatients (180/209) accepted testing. Twenty-three percent (41/177) had an STI. Of those with an STI, 90% (37/41) had trichomonas infection. All 41 infected patients received treatment. Drug use before sex, exchange of sex for money/drugs, and any gynecological complaint were significantly associated with infection. Most women were uninsured (76%). Only 45% had undergone a medical examination in the past year. CONCLUSION: STI screening is highly acceptable among women in substance abuse treatment centers. Substance users are at high risk for STIs and may not otherwise receive medical care.

Human immunodeficiency virus in correctional facilities: a review.

It is estimated that up to one-fourth of the people living with human immunodeficiency virus (HIV) infection in the United States pass through a correctional facility each year. The majority of persons who enter a correctional facility today will return home in the near future. Most inmates with HIV infection acquire it in the outside community; prison does not seem to be an amplifying reservoir. How correctional health services deal with the HIV-infected person has important implications to the overall care of HIV-infected people in the community. Routine HIV testing is well accepted. Combination antiretroviral therapy has been associated with a reduction in mortality in prisons. A link between area HIV specialists and correctional health care providers is an important partnership for ensuring that HIV-infected patients have optimal care both inside prison and after release.