Iatrogenic Hepatitis C Virus Transmission and Safe Injection Practices.

Hepatitis C virus (HCV) infection poses significant adverse health effects. Improper use of vials, needles, syringes, intravenous bags, tubing, and connectors for injections and infusions is a current preventable cause of iatrogenic HCV transmission. Numerous cases have demonstrated the need for continued vigilance and the widespread nature of this iatrogenic infection risk across a variety of medical practice settings in the United States. Failure to implement the evidence-based Centers for Disease Control and Prevention (CDC) infection prevention guidelines exposes patients to preventable harm. The guidelines establish the requirement to notify patients in cases of suspected virus transmission, as well as to screen those patients who would not otherwise have been at risk for HCV seroconversion and other bloodborne pathogens. Legal and regulatory ramifications, including state, criminal, and tort laws, hold physicians and other health care professionals accountable to use safe injection practices. This article reviews the major health risks of HCV infection, significant effects of iatrogenic infection transmission, CDC guidelines for safe injection practices, and legal regulations and ramifications designed to promote safe injection practices.

Effect of a Rapid Test Algorithm on Linkage to Medical Care and Viral Suppression Among New Jersey Residents, 2007 to 2015.

BACKGROUND: Efforts to identify and link human immunodeficiency virus-infected persons to medical care are the first steps to achieving viral suppression. In the United States, the goals are to link 85% of newly diagnosed persons to medical care in 30 days or less and for 80% to become virally suppressed by 2020. Among newly diagnosed residents from 2007 to 2015, in New Jersey, we evaluated the impact of a rapid testing algorithm (RTA) on linkage to medical care and viral suppression. METHODS: This is a retrospective review of data from New Jersey's Enhanced HIV/AIDS Reporting System for residents, newly diagnosed at 13 years or older, from 2007 to 2015. We used survival analysis methods to estimate the proportion of residents and time to linkage to medical care and viral suppression. RESULTS: Of 8508 newly diagnosed residents, 60.3% and 72.3% were linked to medical care in 30 days or less and 90 days or less, respectively; 45.7% achieved viral suppression in 365 days or less. Linkage to medical care in 90 days or less and viral suppression in 365 days or less were more likely among those tested by RTA than laboratory testing. The adjusted hazard ratios for linkage to medical care, in clinical sites were 1.41, (95% confidence interval [CI], 1.22-1.63 and 1.08, 95% CI, 0.97-1.2 in community sites. The adjusted hazard ratios for viral suppression in clinical sites were 1.25 (95% CI, 1.05-1.47 and 1.16, 95% CI, 1.01-1.32, in community sites. CONCLUSIONS: Implementation of a RTA may eliminate barriers to linkage to medical care and viral suppression leading to decreased morbidity, mortality, and transmission.

Cancer Among Children With Perinatal Exposure to HIV and Antiretroviral Medications--New Jersey, 1995-2010.

BACKGROUND: Concerns remain regarding the cancer risk associated with perinatal antiretroviral (ARV) exposure among infants. No excessive cancer risk has been found in short-term studies. METHODS: Children born to HIV-infected women (HIV-exposed) in New Jersey from 1995 to 2008 were identified through the Enhanced HIV/AIDS Reporting System and cross-referenced with data from the New Jersey State Cancer Registry to identify new cases of cancer among children who were perinatally exposed to ARV. Matching of individuals in the Enhanced HIV/AIDS Reporting System to the New Jersey State Cancer Registry was conducted based on name, birth date, Social Security number, residential address, and sex using AutoMatch. Age- and sex-standardized incidence ratio (SIR) and exact 95% confidence intervals (CIs) were calculated using New Jersey (1979-2005) and US (1999-2009) cancer rates. RESULTS: Among 3087 children (29,099 person-years; median follow-up: 9.8 years), 4 were diagnosed with cancer. Cancer incidence among HIV-exposed children who were not exposed to ARV prophylaxis (22.5 per 100,000 person-years) did not differ significantly from the incidence among children who were exposed to any perinatal ARV prophylaxis (14.3 per 100,000 person-years). Furthermore, the number of cases observed among individuals exposed to ARV did not differ significantly from cases expected based on state (SIR = 1.21; 95% CI: 0.25 to 3.54) and national (SIR = 1.27; 95% CI: 0.26 to 3.70) reference rates. CONCLUSIONS: Our findings are reassuring that current use of ARV for perinatal HIV prophylaxis does not increase cancer risk. We found no evidence to alter the current federal guidelines of 2014 that recommend ARV prophylaxis of HIV-exposed infants.

The misuse and abuse of prescription medications: part 1 current trends.

The epidemic of prescription drug abuse has triggered a resurgence in heroin abuse by young people. Heroin is a less-expensive analogue of prescription painkillers that delivers a stronger high and is currently more readily available than ever in areas with suburban and rural ZIP codes. The abuse and misuse of prescription medications and consequent heroin addiction have directly impacted rates of admission to drug treatment facilities; additional, injection may put users at risk of transmitting or acquiring blood-borne pathogens, particularly hepatitis C and HIV. This article reviews national and New Jersey-specific data on the misuse of prescription medications, the relationship between prescription painkillers and heroin use, some of the reasons why prescription painkiller sales have increased dramatically in the United States, the importance of screening for addiction and resources for referrals.

Integrating health and prevention services in syringe access programs: a strategy to address unmet needs in a high-risk population.

Injection drug users are at a high risk for a number of preventable diseases and complications of drug use. This article describes the implementation of a nurse-led health promotion and disease prevention program in New Jersey's syringe access programs. Initially designed to target women as part of a strategy to decrease missed opportunities for perinatal HIV prevention, the program expanded by integrating existing programs and funding streams available through the state health department. The program now offers health and prevention services to both men and women, with 3,488 client visits in 2011. These services extend the reach of state health department programs, such as adult vaccination and hepatitis and tuberculosis screening, which clients would have had to seek out at multiple venues. The integration of prevention, treatment, and health promotion services in syringe access programs reaches a vulnerable and underserved population who otherwise may receive only urgent and episodic care.

An anonymous unlinked sero-prevalence survey of HIVHCV in an urban Emergency Department.

BACKGROUND: In 2002, the sero-prevalence of human immunodeficiency virus-1 (HIV) in the Emergency Department (ED), University Hospital, Newark, New Jersey was 10.4%. Both HIV and hepatitis C virus (HCV) are transmitted by injection drug use (IDU) or sexual contact. However, the degree of concurrent positive HCV antibody status in HIV-infected ED patients is unknown. OBJECTIVES: In this study we determined the sero-prevalence of HIV and HIVHCV in HIV-positive patients in the ED. STUDY DESIGN: A cross-sectional study using an anonymous sero-prevalence survey was conducted from 7/1/2008 to 8/23/2008. Medical records were reviewed and de-identified; remnant blood specimens were also de-identified and tested for HIV antibody, and if positive, HCV antibody. RESULTS: Of 3488 specimens, 225 (6.5%, 95% CI: 5.7-7.3%) were positive for HIV antibody. Seventy-four patients 74/225 (32.9%, 95% CI: 33.8-46.5%) were unaware of their sero-positivity. Forty percent of HIV positive patients (90/225, 95% CI: 33.8-46.5%) were HCV antibody positive. The highest seroprevalence of HIVHCV antibody was among older patients (≥ 45 years), and patients with positive urine toxicology and elevated liver function tests. DISCUSSION: Given the high prevalence of HIV and HIVHCV antibody in the ED, routine testing is important for patients ≥ 45 years with positive urine toxicology and elevated liver function tests.

Finding those at risk: acute HIV infection in Newark, NJ.

BACKGROUND: A screening strategy combining rapid HIV-1/2 (HIV) antibody testing with pooled HIV-1 RNA testing increases identification of HIV infections, but may have other limitations that restrict its usefulness to all but the highest incidence populations. OBJECTIVE: By combining rapid antibody detection and pooled nucleic acid amplification testing (NAAT) testing, we sought to improve detection of early HIV-1 infections in an urban Newark, NJ hospital setting. STUDY DESIGN: Pooled NAAT HIV-1 RNA testing was offered to emergency department patients and outpatients being screened for HIV antibodies by fingerstick-rapid HIV testing. For those negative by rapid HIV and agreeing to NAAT testing, pooled plasma samples were prepared and sent to the University of Washington where real-time reverse transcription-polymerase chain reaction (RT-PCR) amplification was performed. RESULTS: Of 13,226 individuals screened, 6381 had rapid antibody testing alone, and 6845 agreed to add NAAT HIV screening. Rapid testing identified 115 antibody positive individuals. Pooled NAAT increased HIV-1 case detection by 7.0% identifying 8 additional cases. Overall, acute HIV infection yield was 0.12%. While males represent only 48.1% of those tested by NAAT, all samples that screened positive for HIV-1 RNA were obtained from men. CONCLUSION: HIV-1 RNA testing of pooled, HIV antibody-negative specimens permits identification of recent infections. In Newark, pooled NAAT increased HIV-1 case detection and provided an opportunity to focus on treatment and prevention messages for those most at risk of transmitting infection. Although constrained by client willingness to participate in testing associated with a need to return to receive further results, use of pooled NAAT improved early infection sensitivity.

Factors associated with condom use problems during vaginal sex with main and non-main partners.

BACKGROUND: Incorrect condom use is a common problem that can undermine their prevention impact. We assessed the prevalence of 2 condom use problems, breakage/slippage and partial use, compared problems by partnership type, and examined associations with respondent, partner, and partnership characteristics. METHODS: Data were collected at 3-month intervals during a 12-month period (1999-2000) among urban sexually transmitted disease (STD) clinic users. Condom use problems were compared between partnership types using z tests for equality of proportions. Logistic generalized estimating equations modeling accounted for within-participant correlation of repeated measures. RESULTS: Overall 3297 respondents reported 9304 main and 6793 non-main partnerships; condoms were used at least once in 4942 (53.0%) and 4523 (66.6%) of these partnerships, respectively. Condom breakage/slippage was reported during 6.0% of uses (5.1% main, 9.4% non-main) and partial use during 12.5% of uses (12.8% main, 11.5% non-main). The proportion of respondents experiencing any condom use problem in the prior 3 months was higher among main compared with non-main partnerships: 39.1% versus 29.9% had either problem; 22.5% versus 19.0% had breakage/slippage only; 21.8% versus 18.7% had partial use; and 8.7% versus 7.1% had both use problems. In multivariable analysis, factors associated with condom use problems varied by partnership type and respondent sex. The most common predictors of problems across models were sex while high and inconsistent condom use. CONCLUSIONS: This study highlights the diverse set of risk factors for condom use problems at the individual, partner, and partnerships levels.

Cost effectiveness analysis of the New Jersey rapid testing algorithm for HIV testing in publicly funded testing sites.

BACKGROUND: Before 2009, New Jersey (NJ) publicly funded counseling and testing sites (CTS) tested for HIV using a single rapid test followed, when positive, by a Western Blot (WB) for confirmation. With this strategy, 74.8% of confirmed positive clients returned to receive test results. To improve the client notification rate at these centers, the New Jersey (NJ) Division of HIV, STD and TB Services (DHSTS) implemented a rapid testing algorithm (RTA) which utilizes a second, different, rapid test to verify a preliminary positive. OBJECTIVE: To compare the cost-effectiveness of the two testing algorithms. STUDY DESIGN: This was a retrospective cost-effectiveness analysis. DATA SOURCES: New Jersey HIV Rapid Testing Support Program (NJHIV) records, DHSTS grant documents, counseling time estimates from an online survey of site supervisors. Costs included test kits and personnel costs from month of RTA implementation through 11/30 in 2008 and 2009. The incremental cost of the RTA was calculated per additional percent of positive clients who were notified and per day earlier notification. RESULTS: In 2008, 215 of 247 clients with a positive rapid HIV test were confirmed positive by WB. 90.9% of clients were notified a mean of 11.4 days after their initial test. 12 refused confirmatory WB. In 2009, 152 of 170 clients with one positive rapid test had a confirmatory second positive rapid test and were notified on the same day. The incremental cost of the RTA was $20.31 per additional positive person notified and $24.31 per day earlier notification or $3.23 per additional positive person and $3.87 per day earlier notification if the WB were eliminated. CONCLUSIONS: The RTA is a cost-effective strategy achieving 100% notification of newly HIV positive clients a mean of 11.4 days earlier compared to standard testing.

Use of a rapid HIV testing algorithm to improve linkage to care.

BACKGROUND: Awaiting definitive diagnosis before scheduling healthcare visits complicates HIV screening and referral. Clients screened by rapid tests as initially reactive often fail to return to receive definitive test results, are not linked to care and enter care late or not at all. OBJECTIVES: To evaluate statewide, (1) the accuracy of a single-visit, two test HIV rapid testing algorithm (RTA) and (2) its effect on referral to care for positive clients. STUDY DESIGN: A two-test RTA was implemented at 24 sites in New Jersey beginning in December 2008. All clients with a reactive rapid HIV test were offered a second rapid HIV test, and RTA results were compared with Western blot (WB). Referral to care occurred based upon two sequential positive rapid tests. RESULTS: The RTA program has screened 51,413 individuals obtaining 426 reactive rapid test results; 394 (92.5%) were reactive by a second rapid test, 32 (7.5%) had a negative second rapid test. Twenty-eight individuals refused WB testing. Of 369 RTA-positive individuals who have WB results, 368 (99.5%) were confirmed positive. Of RTA-positive clients, 290 (73.6%), including 25 (6.6%) who refused Western blot, were immediately referred for care including one individual with a false-positive RTA. CONCLUSIONS: The RTA reduced false positive results by 6.2% and agreed with WB results 99.5% of the time. Improved referral to care compared to traditional rapid HIV screening occurs when immediate referral is based on RTA verification of a preliminary positive rapid test. WB confirmation is not essential for effective screening and contributes to difficulties linking individuals to care.

Heterosexual anal sex activity in the year after an STD clinic visit.

OBJECTIVES: To describe heterosexual anal sex activity during a year and to identify factors associated with heterosexual anal sex and condom use during anal sex. METHODS: Secondary analysis of data from a trial conducted in 3 public sexually transmitted disease (STD) clinics. Patients described sexual behaviors every 3-months for the year. Logistic regression models with generalized estimating equations were used to include multiple observations for each subject. RESULTS: Two thousand three hundred fifty-seven heterosexual subjects reported on 6611 3-month intervals that included 9235 partnerships. About 18.3% of subjects had anal sex in a particular 3-month interval and 39.3% in the year. About 23.5% of subjects had anal sex in at least two 3-month intervals in the year. Anal sex was associated with having more sex acts, 2 or more sex partners, unprotected vaginal sex, and a main partner. For anal sex in the past 3 months, 27.3% of subjects consistently used condoms, and 63% of subjects never used condoms. Consistent condom use for anal sex was associated with having consistent condom use for vaginal sex, 2 or more partners, and anal sex with casual or new partner. CONCLUSION: STD clinic patients were commonly engaged in heterosexual anal sex, and most of them never used condoms during anal sex. Patients who had anal sex tended to also engage in other risk behaviors that put them at risk of STD/human immunodeficiency virus. Clinicians should ask about anal sex, appropriately examine and test patients who have had anal sex, and recommend condom use for both anal and vaginal sex.

Risk factors for prevalent and incident Trichomonas vaginalis among women attending three sexually transmitted disease clinics.

GOAL: Trichomonas vaginalis is the most common nonviral sexually transmitted infection in the United States and may be associated with adverse birth outcomes and may also increase susceptibility to or transmissibility of human immunodeficiency virus. The purpose of this analysis is to describe the epidemiology of T. vaginalis in Sexually Transmitted Disease clinics and characterize the risk factors associated with prevalent and incident T. vaginalis within the same population. METHODS: We analyzed data from visits occurring during February 1999-December 2001 from 3 sexually transmitted disease clinics in Newark, NJ; Long Beach, CA; and Denver, CO. Data were analyzed from 1462 women aged 15 to 39 years who were tested by culture at their initial visit for T. vaginalis, and for 1269 women with at least 1 follow-up visit. Risk factors for prevalent infections at baseline and incident infections among treated or previously uninfected women were assessed. RESULTS: At baseline, 13.0% of the women had a prevalent infection; risk factors included the following: older age (> or =20 years), black race, having less than 12 years of education, and having a concurrent chlamydial infection. At follow-up, 4.6% of women had an incident infection; risk factors included the following: older age (35-39 years), black race, having a concurrent chlamydial infection, having had multiple sexual partners in the 3 months before incident infection, and having had T. vaginalis at the visit before their incident infection. CONCLUSIONS: T. vaginalis incidence is high in women. Risk factors for prevalent and incident infection are similar. T. vaginalis was associated with older age in women, unlike other sexually transmitted infections.