A Spatial Approach for Ending the Human Immunodeficiency Virus Epidemic for the United States-A DC Model.

BACKGROUND: Mode of transmission-based hotspots is a smart approach to HIV mitigation, yet remains poorly evaluated and implemented in the United States. The primary aim was to identifying mode of transmission-based hotspots and populations at risk of lower viral suppression to assist in targeted planning and implementation of programs. METHODS: We implemented spatial statistics to identify global-local hotspots and regression analysis to find populations at risk of lower viral suppression within hotspots. Data were obtained from the District of Columbia's (DC's) active surveillance system, which were geocoded based on current residence address. RESULTS: The analysis identified 6001 HIV-positive men who have sex with men (MSM) and 6077 HIV-positive non-MSM (N = 12 078) living in DC at the end of 2018. The hotspots for MSM were central DC and non-MSM in south DC. Trends of viral suppression within MSM hotspots showed plateauing and, among non-MSM, showed decline. Regression analysis showed MSM aged 21-25 (RR: 3.199; 95% CI: 1.832-5.586) and not linked to care (8.592; 2.907-25.398) were at higher risk of being virally unsuppressed within the hotspots. For non-MSM we found those aged 12-18 (9.025; 3.314-2.581) and with unknown linkages (6.087; 3.346-13.848) were at higher risk of being virally unsuppressed within the hotspots. CONCLUSIONS: Our analysis provides a model that may be used by other jurisdictions to identify areas of priority and plan treatment-adherence programs using surveillance data. Attaining viral suppression is crucial in reducing new diagnoses; a spatial approach can be an important tool in Ending the HIV Epidemic.

Geographic Core Areas of Coinfections in Washington, District of Columbia: Recommendations for Planning Prevention-Intervention to Mitigate Human Immunodeficiency Virus Burden.

BACKGROUND: Research suggests that human immunodeficiency virus (HIV)-positive individuals with a sexually transmitted infection (STI) may be at increased risk of transmitting HIV to someone else through unprotected sex. The primary aim of the analysis is to identify the high-risk geographic areas of transmission of coinfections and factors that may be associated with poor outcomes of viral suppression within these higher-risk geographic areas, thus important in transmission prevention. METHODS: We used surveillance data reported by all providers and laboratories in the District of Columbia (DC). Applied discrete Poisson scan model in SaTScan to identify the geographic areas. The relative risk (RR) for the scan statistic was calculated based on events inside the cluster, and P values evaluated statistical significance. We used multinomial logistical regression to explore care and demographical characteristics associated with being virally unsuppressed within and outside the geographic areas. RESULTS: The coinfected areas (RR, >1; P < .001) were located in the tracts of central and southern DC. Black population (RR, 3.154 [95% confidence interval {CI}, 1.736-5.729]), age 13-19 years (RR, 4.598 [95% CI, 3.176-6.657]), repeat STIs (RR, 1.387 [95% CI, 1.096-1.754]), and not retained in care (RR, 2.546 [95% CI, 1.997-3.245]) were found to be at higher risk of being virally unsuppressed within the coinfected clusters. Those with unknown linkages were found to be at higher risk of being virally unsuppressed outside the coinfected clusters (RR, 5.162 [95% CI, 2.289-11.640]). CONCLUSIONS: This is DC's first effort to identify the geographic core areas of coinfections and factors that may be sustaining them. These results will be used by the health department to plan for prevention-intervention strategies. This model be replicated by any local jurisdiction similar.

Geographic patterns of poor HIV/AIDS care continuum in District of Columbia.

BACKGROUND: Concurrent with the UNAIDS 90-90-90 and NHAS plans, the District of Columbia (DC) launched its 90/90/90/50 plan (Plan) in 2015. The Plan proposes that by 2020, 90% of all DC residents will know their HIV status; 90% of residents living with HIV will be in sustained treatment; 90% of those in treatment will reach "Viral Suppression" and DC will achieve 50% reduction of new HIV cases. To achieve these goals targeted prevention strategies are imperative for areas where the relative risk (RR) of not being linked to care (NL), not retained in any care (NRC) and low viral suppression (NVSP) are highest in the District. These outcomes are denoted in this study as poor outcomes of HIV care continuum. This study applies the Bayesian model for RR for area specific random effects to identify the census tracts with poor HIV care continuum outcomes for DC. METHODS: This analysis was conducted using cases diagnosed from 2010 to 2015 and reported to the surveillance system from the District of Columbia Department of Health (DC DOH), HIV/AIDS, Hepatitis, STD and TB Administration. The jurisdictions of the District of Columbia is divided into 179 census tracts. It is challenging to plot sparse data in 'small' local administrative areas, characteristically which may have a single-count datum for each geographic area. Bayesian methods overcome this problem by assimilating prior information to the underlying RR, making the predicted RR estimates robust. RESULTS: The RR of NL is higher in 59 (33%) out of 179 census tracts in DC. The RR of NRC was high in 46 (26%) of the census tracts while 52 census tracts (29%) show a high risk of having NVSP among its residents. This study also identifies clear correlated heterogeneity or clustering is evident in the northern tracts of the district. CONCLUSION: The study finds census tracts with higher RR of poor linkage to care outcomes in the District. These results will inform the Plan which aims to increase targeted testing leading to early initiation of antiretroviral therapy. The uniqueness of this study lies in its translational scope where surveillance data can be used to inform local public health programs and enhance the quality of health for the people with HIV.

Diagnosed HIV Infection in Transgender Adults and Adolescents: Results from the National HIV Surveillance System, 2009-2014.

Publications on diagnosed HIV infection among transgender people have been limited to state- or local-level data. We analyzed data from the National HIV Surveillance System and present results from the first national-level analysis of transgender people with diagnosed HIV infection. From 2009 to 2014, HIV surveillance jurisdictions from 45 states plus the District of Columbia identified and reported at least one case of newly diagnosed HIV infection for transgender people; jurisdictions from 5 states reported no cases for transgender people. Of 2351 transgender people with newly diagnosed HIV infection during 2009-2014, 84.0% were transgender women (male-to-female), 15.4% were transgender men (female-to-male), and 0.7% were additional gender identity (e.g., gender queer, bi-gender). Over half of both transgender women (50.8%; 1002/1974) and men (58.4%; 211/361) with newly diagnosed HIV infection were non-Hispanic black/African American. Improvements in data collection methods and quality are needed to gain a better understanding of HIV burden among transgender people.

Use of geosocial networking (GSN) mobile phone applications to find men for sex by men who have sex with men (MSM) in Washington, DC.

Current advances have added geosocial networking (GSN) mobile phone applications as an option for men who have sex with men (MSM) to meet other men. This is the first study to assess GSN application use and sex-seeking behaviors of MSM recruited using venue-based sampling. Among the 379 MSM in this study, 63.6 % reported using GSN applications to find men in the past year. Nearly one-quarter of MSM had sex with a man met using a GSN application in the prior year; these men were more likely to be under 35 years old and have had sex with a man met on the Internet; they were also less likely to be HIV-positive and have <5 male sex partners in the last year. GSN applications are a viable option for use in sampling and delivering interventions to young MSM who are often missed through other methods.

Correlates of group sex among a community-based sample of men who have sex with men (MSM) in Washington, DC.

Participation of MSM in group sex events (GSEs) is an understudied phenomenon. Studies on GSEs identified significant proportions of MSM engaging in unprotected anal intercourse (UAI). We sought to identify the prevalence of group sex participation among MSM in Washington, DC and to characterize these experiences. Data were collected for NHBS-MSM-3 in 2011. More than one-quarter of MSM (27.2 %) reported engaging in group sex in the prior year, with one-third reporting no condom use with their sex partners (33.0 %). In multivariable logistic regression, men who participated in a GSE in the prior year were significantly younger, more likely to be white, and to have used crystal meth, poppers, and downers in the past year. The high prevalence of UAI during GSEs, especially in view of the fact that HIV-positive MSM were significantly less likely to report condom use, offers an opportunity to develop risk reduction interventions specific to GSE attendees.

HIV among women in the District of Columbia: an evolving epidemic?

The epidemiology of HIV in urban centers of the United States such as the District of Columbia (DC) is dynamic with rates of new HIV and AIDS diagnoses as well as risk factors elevated. Correlates of HIV among heterosexual women extend beyond traditional, individual risk factors to structural factors. The purpose of this study was to compare proportions of HIV and correlates of HIV among women participating in National HIV behavioral surveillance (NHBS) system in 2006-7 (NHBS Cycle 1) and 2010 (NHBS Cycle 2). Analysis of 677 female participants at elevated risk for HIV revealed high prevalence of individual-level HIV-associated risk factors (e.g., sexual behavior) and socio-structural associated risk factors (e.g., homelessness, incarceration, lack of health insurance). While a greater proportion of women were HIV-infected in Cycle 2, after controlling for the distribution of demographic characteristics to adjust for a change in eligibility criteria, the pooled sample did not reveal a significantly increased proportion of HIV-infected women in Cycle 2. Homelessness and condom use were associated with greater relative odds of HIV after adjustment for confounders, and non-injection drug use was associated with reduced odds. Findings inform our understanding of the continuing HIV epidemic in DC and support development of effective interventions to slow the epidemic among women in DC and similar urban centers.

HIV testing among heterosexuals at elevated risk for HIV in the District of Columbia: has anything changed over time?

The District of Columbia launched a routine HIV testing initiative in 2006. We examined HIV testing behaviors among heterosexuals at risk for HIV over time using CDC National HIV Behavioral Surveillance data from Washington, DC for the heterosexual cycles from 2006 to 2007 (Cycle 1) and 2010 (Cycle 2). Past year and past 2-year HIV testing across study cycles were compared using Chi square tests. Weighted multivariable logistic regression identified correlates of past year testing. The majority of participants across both cycles were black and female. Cycle 1 participants were significantly more likely to have ≥4 partners in the past year, casual sex partners, and have anal sex at last sexual encounter (p < 0.05). Lifetime testing was high, and individuals from Cycle 2 versus Cycle 1 were more likely to have been tested in the past 2 years. There were no significant differences in past year testing or being offered the HIV test at last health care visit by cycle. Independent correlates of past year testing were seeing a health care provider in the past year and using condoms at last vaginal sex. In conclusion, although past year testing did not differ between the two data collection years, the proportion of heterosexuals testing in the past 2 years was higher in Cycle 2 versus Cycle 1, suggesting successful expansion of HIV testing between the two time periods.

Site migration in seeking care services from multiple providers is associated with worse clinical outcomes among HIV-infected individuals in Washington, DC.

Washington, DC, is a metropolitan city with a severe HIV epidemic and faces challenges in retaining people living with HIV (PLWH) in quality care. This study assessed site migration in seeking care services and its correlates among PLWH in DC. PLWH diagnosed before 2008 and living through the end of 2010 were analyzed. Six scenarios of site migration were examined as patients visited =2, =3, and =4 different providers for their CD4 cell count and/or viral load (VL) tests in the past 3 years from 2008 to 2010 and 2 years from 2009 to 2010, respectively. Of 6480 patients analyzed from 2008 to 2010, 18.4% had CD4 < 200 cells/mm(3), 30.5% had VL > 400 copies/mL, and 76.6% were retained in same care sites; 23.4%, 5.0%, and 0.9% visited =2, =3, and =4 sites in the past 3 years from 2008 to 2010, respectively. Of 5954 patients analyzed from 2009 to 2010, 16.8% had CD4 < 200 cells/mm(3), 29.4% had VL > 400 copies/mL, and 81.9% were retained in same care sites; 18.1%, 3.1%, and 0.6% visited =2, =3, and =4 sites in the past 2 years from 2009 to 2010, respectively. Multivariable logistic regression analyses revealed that migration across six scenarios are consistently associated with CD4 < 200 cells/mm(3) and VL > 400 copies/mL. Site migration was common and associated with lower CD4 and higher VL among PLWH in DC. Frequent migration might be a factor in achieving optimal health outcomes for a subset of patients. Site migration might potentially limit effective delivery of high quality care and treatment services. The preliminary findings underscore the need for further research to assess the predictors of migration and its impact on stage of care.

Childhood sexual abuse and HIV-related risks among men who have sex with men in Washington, DC.

Childhood sexual abuse (CSA) has been reported to be disproportionately higher among men who have sex with men (MSM) than among heterosexual men; it has also been found to be significantly positively associated with HIV status and HIV risk factors, including unprotected anal intercourse. The purpose of this study was to assess the correlates of CSA in a sample of community-recruited MSM, investigate race as a potential effect modifier, and describe the independent association between CSA and HIV infection in Washington, DC. A total of 500 MSM were recruited by venue-based sampling in 2008 as part of the National HIV Behavioral Surveillance. More than one-half of MSM identified as White, while one-third identified as Black. CSA was reported by 17.5 % of the 451 MSM, with the first instance of abuse occurring at a median age of 8.3 (interquartile range = 5.0, 11.0). In multivariable analysis, HIV-positive men were significantly more likely to report a history of CSA compared to HIV-negative men after adjusting for intimate partner violence in the last 12 months, having been arrested in the last 12 months, and depressive symptoms. HIV-positive MSM had more than four times the odds of reporting CSA after controlling for other correlates (aOR = 4.19; 95 % CI 2.26, 7.75). Despite hypothesizing that race modified the effect of CSA on HIV infection we found this was not the case in this sample. More research is needed to investigate the potential pathway between a history of CSA and HIV infection, and how this contributes to driving the HIV epidemic among MSM in Washington, DC.

Correlates of frequency of HIV testing among men who have sex with men in Washington, DC.

In Washington, DC, the leading mode of HIV transmission is through men who have sex with men (MSM) behavior. This study explored differences between frequent HIV testers (men testing at least twice a year) and annual or less frequent testers (men testing once a year or less) in DC. Nearly, one-third of MSM reported testing for HIV at least four times in the prior two years. In the multivariable model, frequent testers had significantly higher odds of being aged 18-34 (aOR =1.94), knowing their last partner's HIV status (aOR=1.86), having 5+ partners in the last year (aOR=1.52), and having seen a health-care provider in the last year (aOR=2.28). Conversely, frequent testers had significantly lower odds of being newly HIV positive (aOR=0.27), and having a main partner at last sex (vs. casual/exchange partner; aOR=0.59). Medical providers need to be encouraged to consistently offer an HIV test to their patients, especially those who are sexually active and who have not tested recently.

Differing HIV risks and prevention needs among men and women injection drug users (IDU) in the District of Columbia.

Washington, DC has among the highest HIV/AIDS rates in the US. Gender differences among injection drug users (IDUs) may be associated with adoption of prevention opportunities including needle exchange programs, HIV testing, psychosocial support, and prevention programming. National HIV Behavioral Surveillance data on current IDUs aged ≥18 were collected from 8/09 to 11/09 via respondent-driven sampling in Washington, DC. HIV status was assessed using oral OraQuick with Western Blot confirmation. Weighted estimates were derived using RDSAT. Stata was used to characterize the sample and differences between male and female IDU, using uni-, bi-, and multivariable methods. Factors associated with HIV risk differed between men and women. Men were more likely than women to have had a history of incarceration (86.6 % vs. 66.8 %, p < 0.01). Women were more likely than men to have depressive symptoms (73.9 % vs. 47.4 %, p < 0.01), to have been physically or emotionally abused (66.1 % vs. 16.1 %, p < 0.0001), to report childhood sexual abuse (42.7 % vs. 4.7 %, p < 0.0001), and pressured or forced to have sex (62.8 % vs. 4.0 %, p < 0.0001); each of these differences was significant in the multivariable analysis. Despite a decreasing HIV/AIDS epidemic among IDU, there remain significant gender differences with women experiencing multiple threats to psychosocial health, which may in turn affect HIV testing, access, care, and drug use. Diverging needs by gender are critical to consider when implementing HIV prevention strategies.

HIV Pre-exposure Prophylaxis Persistence and Adherence Among Men Who Have Sex With Men in Four US Cities.

BACKGROUND: HIV pre-exposure prophylaxis (PrEP) persistence and adherence are critical to ending the HIV epidemic in the United States. SETTING: In 2017 National HIV Behavioral Surveillance, HIV-negative men who have sex with men (MSM) in 4 US cities completed a survey, HIV testing, and dried blood spots at recruitment. METHODS: We assessed 3 PrEP outcomes: persistence (self-reported PrEP use at any time in the past 12 months and had tenofovir, emtricitabine, or tenofovir diphosphate detected in dried blood spots), adherence at ≥4 doses/week (self-reported past-month PrEP use and tenofovir diphosphate concentration ≥700 fmol/punch), and adherence at 7 doses/week (self-reported past-month PrEP use and tenofovir diphosphate concentration ≥1250 fmol/punch). Associations with key characteristics were examined using log-linked Poisson regression models with generalized estimating equations. RESULTS: Among 391 MSM who took PrEP in the past year, persistence was 80% and was lower among MSM who were younger, had lower education, and had fewer sex partners. Of 302 MSM who took PrEP in the past month, adherence at ≥4 doses/week was 80% and adherence at 7 doses/week was 66%. Adherence was lower among MSM who were younger, were Black, and had fewer sex partners. CONCLUSIONS: Although persistence and adherence among MSM were high, 1 in 5 past-year PrEP users were not persistent and 1 in 5 past-month PrEP users were not adherent at levels that would effectively protect them from acquiring HIV (ie, ≥4 doses/week). Efforts to support PrEP persistence and adherence should include MSM who are young, are Black, and have less education.

Cost-utility analysis of a female condom promotion program in Washington, DC.

A retrospective economic evaluation of a female condom distribution and education program in Washington, DC. was conducted. Standard methods of cost, threshold and cost-utility analysis were utilized as recommended by the U.S. Panel on cost-effectiveness in health and medicine. The overall cost of the program that distributed 200,000 female condoms and provided educational services was $414,186 (at a total gross cost per condom used during sex of $3.19, including educational services). The number of HIV infections that would have to be averted in order for the program to be cost-saving was 1.13 in the societal perspective and 1.50 in the public sector payor perspective. The cost-effectiveness threshold of HIV infections to be averted was 0.46. Overall, mathematical modeling analyses estimated that the intervention averted approximately 23 HIV infections (even with the uncertainty inherent in this estimate, this value appears to well exceed the necessary thresholds), and the intervention resulted in a substantial net cost savings.

Ending the HIV epidemic using National HIV Behavioral Surveillance (NHBS): Recommendations based on DC model.

INTRODUCTION: Social network strategies have been used by health departments to identify undiagnosed cases of HIV. Heterosexual cycle (HET4) of National HIV Behavioral Surveillance (NHBS) is a social network strategy implemented in jurisdictions. The main objectives of this research are to 1) evaluate the utility of the NHBS HET cycle data for network analysis; 2) to apply statistical analysis in support of previous HIV research, as well as to develop new research results focused on demographic variables and prevention/intervention with respect to heterosexual HIV risk; and 3) to employ NHBS data to inform policy with respect to the EHE plan. METHOD: We used data from the 2016 NHBS HET4 (DC). A total of 747 surveys were collected. We used the free social-network analysis package, GEPHI, for all network visualization using adjacency matrix representation. We additionally conducted logistic regression analysis to examine the association of selected variables with HIV status in three models representing 1) demographic and economic effects, 2) behavioral effects, and 3) prevention-intervention effects. RESULTS: The results showed 3% were tested positive. Seed 1 initiated the largest networks with 426 nodes (15 positives); seed 4 with 273 nodes (6 positives). Seed 3 had 35 nodes (2 positives). All 23 HIV diagnoses were recruited from 4 zip-codes across DC. The risk of testing positive was higher among people high-school dropouts (Relative Risk (RR) (25.645); 95 CI% 5.699, 115.987), unemployed ((4.267); 1.295, 14.064), returning citizens ((14.319); 4.593, 44.645). We also found in the final model higher association of pre-exposure prophylaxis (PrEP) awareness among those tested negative ((4.783); 1.042, 21.944) and HIV intervention in the past 12 months with those tested positive ((17.887); 2.350,136.135). CONCLUSION: The network visualization was used to address the primary aim of the analysis-evaluate the success of the implementation of the NHBS as a social network strategy to find new diagnoses. NHBS remains one of the strongest behavioral supplements for DC's HIV planning activities. As part of the evaluation process our analysis helps to understand the impact of demographic, behavioral, and prevention efforts on peoples' HIV status. We strongly recommend other jurisdictions use network visualizations to evaluate the efficacy in reaching hidden populations.

Comparison of Clinical Outcomes of Persons Living With HIV by Enrollment Status in Washington, DC: Evaluation of a Large Longitudinal HIV Cohort Study.

BACKGROUND: HIV cohort studies have been used to assess health outcomes and inform the care and treatment of people living with HIV disease. However, there may be similarities and differences between cohort participants and the general population from which they are drawn. OBJECTIVE: The objective of this analysis was to compare people living with HIV who have and have not been enrolled in the DC Cohort study and assess whether participants are a representative citywide sample of people living with HIV in the District of Columbia (DC). METHODS: Data from the DC Health (DCDOH) HIV surveillance system and the DC Cohort study were matched to identify people living with HIV who were DC residents and had consented for the study by the end of 2016. Analysis was performed to identify differences between DC Cohort and noncohort participants by demographics and comorbid conditions. HIV disease stage, receipt of care, and viral suppression were evaluated. Adjusted logistic regression assessed correlates of health outcomes between the two groups. RESULTS: There were 12,964 known people living with HIV in DC at the end of 2016, of which 40.1% were DC Cohort participants. Compared with nonparticipants, participants were less likely to be male (68.0% vs 74.9%, P<.001) but more likely to be black (82.3% vs 69.5%, P<.001) and have a heterosexual contact HIV transmission risk (30.3% vs 25.9%, P<.001). DC Cohort participants were also more likely to have ever been diagnosed with stage 3 HIV disease (59.6% vs 47.0%, P<.001), have a CD4 <200 cells/µL in 2017 (6.2% vs 4.6%, P<.001), be retained in any HIV care in 2017 (72.9% vs 59.4%, P<.001), and be virally suppressed in 2017. After adjusting for demographics, DC Cohort participants were significantly more likely to have received care in 2017 (adjusted odds ratio 1.8, 95% CI 1.70-2.00) and to have ever been virally suppressed (adjusted odds ratio 1.3, 95% CI 1.20-1.40). CONCLUSIONS: These data have important implications when assessing the representativeness of patients enrolled in clinic-based cohorts compared with the DC-area general HIV population. As participants continue to enroll in the DC Cohort study, ongoing assessment of representativeness will be required.

Pre-exposure Prophylaxis Use and Detected Sexually Transmitted Infections Among Men Who Have Sex With Men in the United States-National HIV Behavioral Surveillance, 5 US Cities, 2017.

BACKGROUND: Men who have sex with men (MSM) using HIV pre-exposure prophylaxis (PrEP) may be at high risk for bacterial sexually transmitted infections (STIs). We examined the prevalence of extragenital gonorrhea and chlamydia by PrEP status among a multisite sample of US MSM. METHODS: MSM aged ≥18 years were recruited through venue-based sampling to participate in the 2017 National HIV Behavioral Surveillance. In 5 cities (San Francisco, Washington DC, New York City, Miami, and Houston), participants completed a questionnaire, HIV testing, and pharyngeal and rectal STI specimen self-collection. We measured prevalence of pharyngeal and rectal gonorrhea and chlamydia among self-reported non-HIV-positive MSM who reported using or not using PrEP in the previous 12 months. RESULTS: Overall, 29.6% (481/1627) of non-HIV-positive MSM reported PrEP use in the past year. MSM who reported PrEP use were more likely to have any STI (ie, extragenital gonorrhea and/or chlamydia) than MSM not on PrEP [14.6% vs. 12.0%, adjusted prevalence ratio (aPR) = 1.5, 95% confidence interval (CI) : 1.1 to 2.0], reflecting differences in rectal chlamydia prevalence (8.7% vs. 6.0%, aPR = 1.6, 95% CI: 1.1 to 2.4). PrEP use was not associated with pharyngeal chlamydia, pharyngeal gonorrhea, or rectal gonorrhea. CONCLUSIONS: The prevalence of extragenital STI was high for both MSM on PrEP and those not on PrEP in the past year. MSM on PrEP were more likely to have rectal chlamydia but not pharyngeal STIs or rectal gonorrhea. Our findings support regular STI testing at exposed anatomic sites as recommended for sexually active MSM, including those on PrEP.

Detecting spatial clusters of HIV and hepatitis coinfections.

BACKGROUND: People with HIV infection in the United States are often affected by chronic viral hepatitis. These coinfected people with either HBV or HCV are at increased risk for serious, life-threatening complications. Coinfections with viral hepatitis may also complicate the delivery of anti-retroviral therapy (ART) by escalating the risk of drug-related hepatoxicity. According to the Centers for Disease Control and Prevention (CDC), approximately 10 percent of people with HIV in the United States also have HBV, and 25 percent also have HCV coinfection. With the advent of highly active antiretroviral therapy (HAART) and the increased life-expectancy of HIV patients, clinicians are more likely to be confronted with issues related to co-infection and the management challenges that they present, especially in resource-limited settings. The purpose of this analysis was to identify geographical clusters of HIV- (HBV/HCV) co-infection and compared to the geographical clusters of not co-infected using DC, Department of Health surveillance data. The results of the analysis will be used to target resources to areas at risk. METHODS: HIV and Hepatitis surveillance data were matched among cases diagnosed between 1980 and 2016. HIV-hepatitis co-infected and the not co-infected spatial clusters were detected using discrete Poisson model. Kulldorff's spatial scan statistic method was implemented in the free software tool called SaTScan which has been widely adopted for detecting disease cluster. The analysis was conducted by tracts, but for visualization, ease of interpretation and assist in policy making the tract map was overlaid with the ward map using ArcGIS 10.5.1. RESULTS: Between 1980 and 2016, there were 12,965 diagnosed cases of HIV, of which 2,316 HIV/Hepatitis matches were identified. Of the 2316 co-infected people living in DC, 25 percent (N = 590) of people had HBV, and 75 percent (N = 1,726) had HCV. Out of 12,965 diagnosed cases, remaining 10,649 did not have any co-infections (not co-infected). IDU (27.16 percent) and MSM (32.86 percent) were the highest mode of transmission for co-infected population. African-American were reported 83.64 percent (N = 1,937) among co-infection population. Three clusters were identified for both co-infected population in DC. The largest cluster radius for co-infected analysis covers wards 6, 7 and 8 as well as large parts of 2 and 5 (p < 0.001). Multiple clusters were identified for not co-infected population (p < 0.001). IDU (n = 450) was the highest mode of transmission for the co-infected clusters. For all clusters combined of not co-infected population highest mode of transmission were MSM (n = 2,534). This analysis also showed racial disparity, economic deprivation and lack of education were prominent in the co-infected clusters. CONCLUSION: We identified locations of high risk clusters where enhanced hepatitis and HIV prevention, treatment, and care can help combat the epidemic. The clusters radius expands into the neighboring state of Maryland as well. The findings from this analysis will be used to target area based public health policy and healthcare interventions for HIV-hepatitis. It is recommended based on the analysis that needle exchange programs can successfully control new HIV infections as well as hepatitis co-infections.

Defining Care Patterns and Outcomes Among Persons Living with HIV in Washington, DC: Linkage of Clinical Cohort and Surveillance Data.

BACKGROUND: Triangulation of data from multiple sources such as clinical cohort and surveillance data can help improve our ability to describe care patterns, service utilization, comorbidities, and ultimately measure and monitor clinical outcomes among persons living with HIV infection. OBJECTIVES: The objective of this study was to determine whether linkage of clinical cohort data and routinely collected HIV surveillance data would enhance the completeness and accuracy of each database and improve the understanding of care patterns and clinical outcomes. METHODS: We linked data from the District of Columbia (DC) Cohort, a large HIV observational clinical cohort, with Washington, DC, Department of Health (DOH) surveillance data between January 2011 and June 2015. We determined percent concordance between select variables in the pre- and postlinked databases using kappa test statistics. We compared retention in care (RIC), viral suppression (VS), sexually transmitted diseases (STDs), and non-HIV comorbid conditions (eg, hypertension) and compared HIV clinic visit patterns determined using the prelinked database (DC Cohort) versus the postlinked database (DC Cohort + DOH) using chi-square testing. Additionally, we compared sociodemographic characteristics, RIC, and VS among participants receiving HIV care at ≥3 sites versus <3 sites using chi-square testing. RESULTS: Of the 6054 DC Cohort participants, 5521 (91.19%) were included in the postlinked database and enrolled at a single DC Cohort site. The majority of the participants was male, black, and had men who have sex with men (MSM) as their HIV risk factor. In the postlinked database, 619 STD diagnoses previously unknown to the DC Cohort were identified. Additionally, the proportion of participants with RIC was higher compared with the prelinked database (59.83%, 2678/4476 vs 64.95%, 2907/4476; P<.001) and the proportion with VS was lower (87.85%, 2277/2592 vs 85.15%, 2391/2808; P<.001). Almost a quarter of participants (23.06%, 1279/5521) were identified as receiving HIV care at ≥2 sites (postlinked database). The participants using ≥3 care sites were more likely to achieve RIC (80.7%, 234/290 vs 62.61%, 2197/3509) but less likely to achieve VS (72.3%, 154/213 vs 89.51%, 1869/2088). The participants using ≥3 care sites were more likely to have unstable housing (15.1%, 64/424 vs 8.96%, 380/4242), public insurance (86.1%, 365/424 vs 57.57%, 2442/4242), comorbid conditions (eg, hypertension) (37.7%, 160/424 vs 22.98%, 975/4242), and have acquired immunodeficiency syndrome (77.8%, 330/424 vs 61.20%, 2596/4242) (all P<.001). CONCLUSIONS: Linking surveillance and clinical data resulted in the improved completeness of each database and a larger volume of available data to evaluate HIV outcomes, allowing for refinement of HIV care continuum estimates. The postlinked database also highlighted important differences between participants who sought HIV care at multiple clinical sites. Our findings suggest that combined datasets can enhance evaluation of HIV-related outcomes across an entire metropolitan area. Future research will evaluate how to best utilize this information to improve outcomes in addition to monitoring them.

Development of an HIV Testing Dashboard to Complement the HIV Care Continuum Among MSM, PWID, and Heterosexuals in Washington, DC, 2007-2015.

BACKGROUND: We developed an HIV testing dashboard to complement the HIV care continuum in selected high-risk populations. Using National HIV Behavioral Surveillance (NHBS) data, we examined trends in HIV testing and care for men who have sex with men (MSM), persons who inject drugs (PWID), and heterosexuals at elevated risk (HET). METHODS: Between 2007 and 2015, 4792 participants ≥18 years old completed a behavioral survey and were offered HIV testing. For the testing dashboard, proportions ever tested, tested in the past year, testing HIV-positive, and newly testing positive were calculated. An abbreviated care continuum for self-reported positive (SRP) persons included ever engagement in care, past year care, and current antiretroviral (ARV) use. The testing dashboard and care continuum were calculated separately for each population. Chi-square test for trend was used to assess significant trends over time. RESULTS: Among MSM, lifetime HIV testing and prevalence significantly increased from 96% to 98% (P = 0.01) and 14%-20% (P = 0.02) over time; prevalence was highest among black MSM at all time points. HIV prevalence among female persons who inject drugs was significantly higher in 2015 vs. 2009 (27% and 13%; P < 0.01). Among heterosexuals at elevated risk from 2010 to 2013, annual testing increased significantly (45%-73%; P < 0.001) and the proportion newly diagnosed decreased significantly (P < 0.01). Self-reported positive MSM had high levels of care engagement and antiretroviral use; among self-reported positive persons who inject drugs and heterosexuals at elevated risk, past year care engagement and antiretroviral use increased over time. CONCLUSIONS: The HIV testing dashboard can be used to complement the HIV care continuum to display improvements and disparities in HIV testing and care over time.