Coronavirus Disease 2019 (COVID-19) Infection Among People With Human Immunodeficiency Virus in New York City: A Population-Level Analysis of Linked Surveillance Data.

BACKGROUND: New York City (NYC) was hard-hit by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic and is also home to a large population of people with human immunodeficiency virus (PWH). METHODS: We matched laboratory-confirmed coronavirus disease 2019 (COVID-19) case and death data reported to the NYC Health Department as of 2 June 2020 against the NYC HIV surveillance registry. We describe and compare the characteristics and COVID-19-related outcomes of PWH diagnosed with COVID-19 with all NYC PWH and with all New Yorkers diagnosed with COVID-19. RESULTS: Through 2 June, 204 583 NYC COVID-19 cases were reported. The registry match identified 2410 PWH with diagnosed COVID-19 eligible for analysis (1.06% of all COVID-19 cases). Compared with all NYC PWH and all New Yorkers diagnosed with COVID-19, a higher proportion of PWH with COVID-19 were older, male, Black, or Latino, and living in high-poverty neighborhoods. At least 1 underlying condition was reported for 58.9% of PWH with COVID-19. Compared with all NYC COVID-19 cases, a higher proportion of PWH with COVID-19 experienced hospitalization, intensive care unit admission, and/or death; most PWH who experienced poor COVID-19-related outcomes had CD4 <500 cells/µL. CONCLUSIONS: Given NYC HIV prevalence is 1.5%, PWH were not overrepresented among COVID-19 cases. However, compared with NYC COVID-19 cases overall, a greater proportion of PWH had adverse COVID-19-related outcomes, perhaps because of a higher prevalence of factors associated with poor COVID-19 outcomes. Given the pandemic's exacerbating effects on health inequities, HIV public health and clinical communities must strengthen services and support for people living with and affected by HIV.

Sex- and Poverty-Specific Patterns in Cardiovascular Disease Mortality Associated With Human Immunodeficiency Virus, New York City, 2007-2017.

BACKGROUND: Human immunodeficiency virus (HIV) may affect the risk of death due to cardiovascular disease (CVD) differently in men versus women. METHODS: We examined CVD mortality rates between 2007 and 2017 among all New York City residents living with HIV and aged 13+ by sex, using data from city HIV surveillance and vital statistics and the National Death Index. Residents without HIV were enumerated using modified US intercensal estimates. We determined associations of HIV status with CVD mortality by sex and neighborhood poverty, defined as the percent of residents living below the federal poverty level, after accounting for age, race/ethnicity, and year. RESULTS: There were 3234 CVD deaths reported among 147 915 New Yorkers living with HIV, with the proportion of deaths due to CVD increasing from 11% in 2007 to 22% in 2017. The age-standardized CVD mortality rate was 2.7/1000 person-years among both men and women with HIV. The relative rate of CVD mortality associated with HIV status was significantly higher among women (adjusted rate ratio [aRR] 1.7, 95% confidence interval [CI] 1.6-1.8) than men (aRR 1.2, 95% CI 1.1-1.3) overall, and within strata defined by neighborhood poverty. Sex differences in CVD mortality rates were the greatest when comparing individuals living with HIV and having detectable HIV RNA and CD4+ T-cell counts <500 cells/uL with individuals living without HIV. CONCLUSIONS: Among people with HIV, 1 in 5 deaths is now associated with CVD. HIV providers should recognize the CVD risk among women with HIV, and reinforce preventive measures (eg, smoking cessation, blood pressure control, lipid management) and viremic control among people living with HIV regardless of neighborhood poverty to reduce CVD mortality.Human immunodeficiency virus (HIV) increases cardiovascular disease mortality risks to a greater degree among women than men, even after accounting for neighborhood poverty. HIV providers should emphasize cardiovascular disease prevention (eg, smoking cessation, hypertension control, lipid management) and viremic control.

Estimates of the Time From Seroconversion to Antiretroviral Therapy Initiation Among People Newly Diagnosed With Human Immunodeficiency Virus From 2006 to 2015, New York City.

BACKGROUND: We estimated the time from human immunodeficiency virus (HIV) seroconversion to antiretroviral therapy (ART) initiation during an era of expanding HIV testing and treatment efforts. METHODS: Applying CD4 depletion parameters from seroconverter cohort data to our population-based sample, we related the square root of the first pretreatment CD4 count to time of seroconversion through a linear mixed model and estimated the time from seroconversion. RESULTS: Among 28 162 people diagnosed with HIV during 2006-2015, 89% initiated ART by June 2017. The median CD4 count at diagnosis increased from 326 (interquartile range [IQR], 132-504) cells/µL to 390 (IQR, 216-571) cells/µL from 2006 to 2015. The median time from estimated seroconversion to ART initiation decreased by 42% from 6.4 (IQR, 3.3-11.4) years in 2006 to 3.7 (IQR, 0.5-8.3) years in 2015. The time from estimated seroconversion to diagnosis decreased by 28%, from a median of 4.6 (IQR, 0.5-10.5) years to 3.3 (IQR, 0-8.1) years from 2006 to 2015, and the time from diagnosis to ART initiation reduced by 60%, from a median of 0.5 (IQR, 0.2-2.1) years to 0.2 (IQR, 0.1-0.3) years from 2006 to 2015. CONCLUSIONS: The estimated time from seroconversion to ART initiation was reduced in tandem with expanded HIV testing and treatment efforts. While the time from diagnosis to ART initiation decreased to 0.2 years, the time from seroconversion to diagnosis was 3.3 years among people diagnosed in 2015, highlighting the need for more effective strategies for earlier HIV diagnosis.

Timeliness of Human Immunodeficiency Virus Diagnosis and Antiretroviral Treatment Initiation in the Era of Universal Testing and Treatment.

BACKGROUND: We describe the timing of human immunodeficiency virus (HIV) diagnosis and antiretroviral treatment (ART) initiation after implementation of universal testing and treatment policies in New York City (NYC). METHODS: Using NYC population-based HIV registry data for persons with HIV diagnosed from 2012 through 2015 and followed up through June 2017, we examined trends in the proportion with diagnosis soon after HIV infection (ie, with CD4 cell count ≥500/µL or with acute HIV infection) and used Kaplan-Meier plots and proportional hazards regression to examine the timing of ART initiation after diagnosis. RESULTS: Among 9987 NYC residents with HIV diagnosed from 2012 to 2015, diagnosis was early in 35%, and 87% started ART by June 2017. The annual proportion of persons with early diagnosis did not increase appreciably (35% in 2012 vs 37% in 2015; P = .08). By 6 months after diagnosis, 62%, 67%, 72% and 77% of persons with HIV diagnosed in 2012, 2013, 2014, or 2015, respectively, had started ART, with median (interquartile range) times to ART initiation of 3.34 (1.34-12.75), 2.62 (1.28-10.13), 2.16 (1.15-7.11), and 2.03 (1.11-5.61) months, respectively. CONCLUSIONS: Although recommendations for ART initiation on diagnosis are increasingly being implemented, the findings of the current study suggest that immediate treatment initiation is not universal. Continued efforts are needed to expand and better target HIV testing to promote earlier diagnosis.

Multilevel Factors Associated with a Lack of Viral Suppression Among Persons Living with HIV in a Federally Funded Housing Program.

Persons with HIV who are receiving housing services often have high rates of engagement in care, yet many are not virally suppressed. We linked data from the New York City Housing Opportunities for Persons with AIDS (HOPWA) program to electronically reported laboratory tests from the HIV surveillance registry to examine factors associated with a lack of viral suppression. Of 1491 HOPWA consumers, 523 (35.1%) were not durably suppressed, and 253 (17.0%) were unsuppressed at their last viral load test. Substance use, age < 27 years, and emergency housing all independently predicted lack of durable viral suppression and lack of viral suppression at last viral load test.

Testing for comorbid conditions among people with HIV in medical care.

People living with HIV (PLWH) are frequently affected by comorbid medical conditions. Despite the importance of diagnosing and treating these conditions, testing rates for common comorbidities often fall short of primary care recommendations for PLWH. Clinical care data were obtained from the 2012 New York City (NYC) Medical Monitoring Project (MMP), a multi-site surveillance project that includes demographically representative cohorts of PLWH receiving medical care. Medical record abstraction data were analyzed to determine testing frequencies for potential comorbid conditions, including tuberculosis, hepatitis B and C, diabetes, syphilis, gonorrhea, and chlamydia, and to assess demographic, behavioral, and clinical factors associated with testing. Among the NYC MMP cohort (N = 439), testing frequencies ranged from 18% for hepatitis B to 66% for diabetes in a 12-month period. In multivariate analyses, having three or more medical visits with a CD4 or HIV viral load test over 12 months was significantly associated with sexually transmitted infection (STI) and hepatitis C testing. Compared with Black PLWH, Latino/Hispanics were more likely to be tested for hepatitis C and Whites were less likely to be tested for diabetes. Self-reported sexual risk behaviors were not associated with testing for STI, and history of injection drug use was not associated with testing for hepatitis C. These results indicate a need for improved risk assessment, adherence to clinical guidelines, and integration of primary care services with HIV care.

Proposing a New Indicator for the National Human Immunodeficiency Virus/AIDS Strategy: Percentage of Newly Diagnosed Persons Achieving Viral Suppression Within 3 Months of Diagnosis.

We propose an outcome indicator, the percentage of newly diagnosed persons achieving viral suppression within 3 months of diagnosis, to be included in the US National HIV/AIDS Strategy to monitor the progress in human immunodeficiency virus (HIV) care among persons newly diagnosed with HIV. Using HIV registry data, we reported that the percentage in New York City increased from 9% in 2007 to 37% in 2016. We recommend that the Centers for Disease Control and Prevention and local health agencies use this new indicator to monitor the progress in HIV care among persons newly diagnosed with HIV in the United States.

Trends in Cardiovascular Disease Mortality Among Persons With HIV in New York City, 2001-2012.

BACKGROUND: Cardiovascular disease (CVD) has become more prominent among human immunodeficiency virus (HIV)-infected individuals. The extent to which CVD mortality rates are changing is unclear. METHODS: We analyzed surveillance data for all persons aged ≥13 years with HIV infection between 2001 and 2012 reported to the New York City HIV Surveillance Registry. We examined age-specific and age-standardized mortality rates due to major CVDs. We compared mortality time trends among persons with HIV with the general population, and examined differences among HIV-infected persons by RNA level. RESULTS: There were 29 588 deaths reported among 145 845 HIV-infected persons. Ten percent of deaths were attributed to CVD as the underlying cause, including chronic ischemic heart disease (42% of CVD deaths), hypertensive diseases (27%), and cerebrovascular diseases (10%). While proportionate mortality due to CVD among persons with HIV increased (6% in 2001 to 15% in 2012, P < .001), the CVD mortality rate decreased from 5.1 to 2.7 per 1000 person-years. After controlling for sex, race/ethnicity, borough of residence, and year, those with HIV had significantly higher CVD mortality than the general population in all age groups through age 65. The CVD mortality rate was highest among viremic persons (adjusted rate ratio [RR], 3.53 [95% confidence interval {CI}, 3.21-3.87]) but still elevated among virally suppressed (<400 copies/mL) persons (adjusted RR, 1.53 [95% CI, 1.41-1.66]) compared with the general population. CONCLUSIONS: Our findings support continued emphasis by HIV care providers on both viremic control and preventive measures including smoking cessation, blood pressure control, and lipid management.

Elevated risk for invasive meningococcal disease among persons with HIV.

BACKGROUND: An association between HIV and invasive meningococcal disease (IMD) has been suggested by several previous studies but has not been fully described in the era of highly active antiretroviral therapy in the United States. OBJECTIVE: To estimate the risk for IMD and death in people living with HIV/AIDS (PLWHA) in New York City (NYC) and the contribution of CD4(+) cell count and viral load (VL) to IMD risk. DESIGN: Comparison of the incidence rate of IMD among PLWHA with that among HIV-uninfected persons. Surveillance data on IMD for patients aged 15 to 64 years from 2000 to 2011 were matched to death and HIV registries to calculate IMD risk and case-fatality ratios. A subset of PLWHA who had a CD4(+) cell count and VL measurement near the time of their IMD infection was included in age-matched case-control analyses to assess HIV markers and IMD risk. SETTING: Retrospective cohort from communicable disease surveillance. PATIENTS: 265 persons aged 15 to 64 years with IMD during 2000 to 2011. MEASUREMENTS: Meningococcal and HIV data abstracted from surveillance and registry databases, including CD4(+) cell counts and VL. RESULTS: The average annual incidence rate of IMD was 0.39 cases per 100 000 persons. The relative risk for IMD among PLWHA in NYC during 2000 to 2011 was 10.0 (95% CI, 7.2 to 14.1). Among PLWHA, patients with IMD were 5.3 times (CI, 1.4 to 20.4 times) as likely as age-matched control patients to have CD4(+) counts less than 0.200 × 10(9) cells/L. LIMITATION: Missing data on smoking status and comorbidity. CONCLUSION: People living with HIV/AIDS in NYC are at increased risk for IMD. Cost-effectiveness and vaccine efficacy studies are needed to evaluate the value of a national recommendation for routine meningococcal vaccination of PLWHA. PRIMARY FUNDING SOURCE: New York City Tax Levy.

The epidemiology of human papillomavirus infection in HIV-positive and HIV-negative high-risk women in Kigali, Rwanda.

BACKGROUND: The prevalence, incidence and persistence of human papillomavirus (HPV) types in sub-Saharan Africa are not well established. The objectives of the current study are to describe (predictors of) the epidemiology of HPV among high-risk women in Kigali, Rwanda. METHODS: HIV-negative, high-risk women were seen quarterly for one year, and once in Year 2. HIV serostatus, clinical, and behavioral information were assessed at each visit, HPV types at Month 6 and Year 2, and other sexually transmitted infections (STI) at selected visits. HPV prevalence was also assessed in HIV-positive, high-risk women. RESULTS: Prevalence of any HPV was 47.0% in HIV-negative women (median age 25 years) compared to 72.2% in HIV-positive women (median age 27 years; OR 2.9, 95% CI 1.9-4.6). Among HIV-negative women, cumulative incidence of high-risk (HR)-HPV was 28.0% and persistence 32.0% after a mean period of 16.6 and 16.9 months, respectively. Prior Chlamydia trachomatis and Neisseria gonorrhoeae infection, concurrent low-risk (LR)-HPV infection and incident HSV-2 were associated with HR-HPV prevalence among HIV-negative women; prior C. trachomatis infection and co-infection with LR-HPV and HPV16-related HPV types with HR-HPV acquisition. HPV16-related types were the most prevalent and persistent. CONCLUSIONS: High HPV prevalence, incidence and persistence were found among high-risk women in Kigali. HPV52 had the highest incidence; and, together with HPV33 and HPV58, were strongly associated with acquisition of other HR-HPV types in HIV-negative women.

High burden of prevalent and recently acquired HIV among female sex workers and female HIV voluntary testing center clients in Kigali, Rwanda.

OBJECTIVES: To estimate HIV prevalence and risk factors in population-based samples of female sex workers (FSW) and female voluntary counseling and testing (VCT) clients in Rwanda. METHODS: We conducted a cross-sectional survey of 800 FSW and 1,250 female VCT clients in Rwanda, which included interviewing and testing for HIV-1/2, HSV-2 and pregnancy, and BED-CEIA and Avidity Index (AI) to identify recent infections among HIV-infected women. RESULTS: Prevalence of HIV-1, HSV-2, and pregnancy were 24% (95% CI: 21.0-27.0), 59.8% (56.4-63.2), and 7.6% (5.8-9.5) among FSW, and 12.8% (10.9-14.6), 43.2% (40.4-46.0), and 11.4% (9.7-13.3) among VCT clients, respectively. Thirty-five percent of FSW and 25% of VCT clients had never been HIV tested. Per national guidelines, 33% of newly HIV-diagnosed FSW and 36% of VCT clients were already eligible for ART based on CD4<350 cells/µl. Condom use at last sex was higher among FSW (74%) than VCT clients (12%). In age and district of residence-adjusted models, HIV-1 seropositivity was associated with HSV-2 co-infection; recent treatment for sexually transmitted infection (STI); genital symptoms; forced sex; imprisonment; widowhood; and alcohol consumption. Eleven percent of FSW and 12% of VCT clients had recently acquired HIV-1 per BED-CEIA and AI. HSV-2 infection and recent STI treatment were associated with recent HIV infection in both groups, and being married and vaginal cleansing were associated with recent infection before last sex among VCT clients. CONCLUSIONS: This population-based survey reveals a high HIV prevalence and incidence among FSW and female VCT clients in Kigali, the scale of which is masked by the low general-population HIV prevalence in Rwanda. HIV/STI and family planning services should be strengthened.