Persons Living With HIV in the United States: Fewer Than We Thought.

OBJECTIVES: To estimate the number of persons living with HIV (PLWH) in the United States and to describe their care status. METHODS: Estimates of diagnosed PLWH in New York City and other 19 jurisdictions based on HIV case reporting were compared with those based on HIV laboratory reporting. A revised HIV care continuum was constructed based on previously published data. RESULTS: The estimate of PLWH based on HIV case reporting was 25.6% higher than that based on HIV laboratory reporting data in New York City. There were 819,200 PLWH in the United States at the end of 2011 (plausible range: 809,800-828,800), of whom 86% were diagnosed, 72% were retained in care (≥1 care visit in 2011), 68% were on antiretroviral therapy, and 55% were virally suppressed (≤200 copies/mL). CONCLUSIONS: The current method based on HIV case reporting may have overestimated PLWH in the United States. While we continue cleaning HIV case reporting data to improve its quality, we should take the opportunity to use comprehensive HIV laboratory reporting data to estimate PLWH at both the national and local levels.

Constructing a representative sample of out-of-care HIV patients from a representative sample of in-care patients.

Individuals infected with HIV who are out of care are at a higher risk of HIV-related morbidity and mortality. It has been difficult to recruit a representative sample of out-of-care patients for epidemiological studies. Using a novel weighting method, we constructed a representative sample of out-of-care HIV patients from a representative sample of in-care patients. In-care patients were weighted based on the probability of receiving care during the study period and the probability of selection to participate in the study, and out-of-care patients were represented by those who were previously out of care and recently returned. The method can be used in other patient populations, if every patient in the population has a known, non-zero probability of receiving care and a known, non-zero probability of participating in the study.

It's Never Just HIV: Exposure to an HIV Prevention Media Campaign and Behavior Change Among Men Who Have Sex with Men Participating in the National HIV Behavioral Surveillance System in New York City.

PURPOSE: The aim of this study was to assess the exposure to and impact of the It's Never Just HIV mass media campaign aimed at HIV negative men who have sex with men (MSM) in New York City. METHODS: Questions about the campaign were included in the local questionnaire of the Centers for Disease Control and Prevention (CDC)-sponsored National HIV Behavioral Surveillance (NHBS) study of MSM in NYC conducted in 2011. Participants in this cross-sectional study were recruited using venue-based sampling. RESULTS: Among 447 NYC National HIV Behavioral Surveillance study participants who self-reported HIV negative or unknown status and answered questions about the NYC Department of Health and Mental Hygiene's It's Never Just HIV campaign, more than one-third (n = 173, 38.7%) reported having seen the campaign. Latinos (34.8%) and blacks (34.4%) were less likely to report seeing the campaign compared to whites (47.7%). Most of those who reported seeing the campaign saw it on the subway (80.1%). Only 9.4% of those who saw the campaign reported having changed their sexual or health behaviors in response to the campaign. CONCLUSIONS: These data suggest that thousands of HIV-uninfected MSM in NYC have been reached by the campaign and recalled its message.

HIV Diagnoses and Care Among Transgender Persons and Comparison With Men Who Have Sex With Men: New York City, 2006-2011.

OBJECTIVES: We measured HIV care outcomes of transgender persons, who have high HIV infection rates but are rarely distinguished from men who have sex with men (MSM) in HIV surveillance systems. METHODS: New York City's surveillance registry includes HIV diagnoses since 2000 and HIV laboratory test results for transgender persons since 2005. We determined immunological status at diagnosis, delayed linkage to care, and nonachievement of viral suppression 1 year after diagnosis for transgender persons diagnosed with HIV in 2006 to 2011 and compared transgender women with MSM. RESULTS: In 2006 to 2011, 264 of 23 805 persons diagnosed with HIV were transgender (1%): 98% transgender women and 2% transgender men. Compared with MSM, transgender women had similar CD4 counts at diagnosis and rates of concurrent HIV/AIDS and delayed linkage to care but increased odds of not achieving suppression (adjusted odds ratio = 1.56; 95% confidence interval = 1.13, 2.16). CONCLUSIONS: Compared with MSM, transgender women in New York City had similar immunological status at diagnosis but lagged in achieving viral suppression. To provide appropriate assistance along the HIV care continuum, HIV care providers should accurately identify transgender persons.

Implementation and Operational Research: CD4 Count Monitoring Frequency and Risk of CD4 Count Dropping Below 200 Cells Per Cubic Millimeter Among Stable HIV-Infected Patients in New York City, 2007-2013.

INTRODUCTION: The evidence has begun to mount for diminishing the frequency of CD4 count testing. To determine whether these observations were applicable to an urban US population, we used New York City (NYC) surveillance data to explore CD4 testing among stable patients in NYC, 2007-2013. METHODS: We constructed a population-based retrospective open cohort analysis of NYC HIV surveillance data. HIV+ patients aged ≥ 13 years with stable viral suppression (≥ 1 viral load the previous year; all <400 copies per milliliter) and immune status (≥ 1 CD4 the previous year; all ≥ 200 cells per cubic millimeter) entered the cohort the following year beginning January 1, 2007. Each subsequent year, eligible patients not previously included entered the cohort on January 1. Outcomes were annual frequency of CD4 monitoring and probability of maintaining CD4 ≥ 200 cells per cubic millimeter. A multivariable Cox model identified factors associated with maintaining CD4 ≥ 200 cells per cubic millimeter. RESULTS: During 1.9 years of observation (median), 62,039 patients entered the cohort. The mean annual number of CD4 measurements among stable patients was 2.8 and varied little by year or characteristic. Two years after entering, 93.4% and 97.8% of those with initial CD4 350-499 and CD4 ≥ 500 cells per cubic millimeter, respectively, maintained CD4 ≥ 200 cells per cubic millimeter. Compared to those with initial CD4 ≥ 500 cells per cubic millimeter, those with CD4 200-349 cells per cubic millimeter and CD4 350-499 cells per cubic millimeter were more likely to have a CD4 <200 cells per cubic millimeter, controlling for sex, race, age, HIV risk group, and diagnosis year. CONCLUSIONS: In a population-based US cohort with well-controlled HIV, the probability of maintaining CD4 ≥ 200 cells per cubic millimeter for ≥ 2 years was >90% among those with initial CD4 ≥ 350 cells per cubic millimeter, suggesting that limited CD4 monitoring in these patients is appropriate.

Effect of HIV Housing Services on Engagement in Care and Treatment, New York City, 2011.

The federal Housing Opportunities for Persons with AIDS (HOPWA) program addresses housing needs of low-income persons living with HIV/AIDS (PLWHA). The New York City (NYC) Department of Health and Mental Hygiene oversees 22 HOPWA contracts for over 2,400 clients, and manages the NYC HIV Registry. HOPWA clients (N = 1,357) were matched to a random 20 % sample of other PLWHA (N = 13,489). Groups were compared on HIV care retention, viral suppression, and rebound. HOPWA clients were, on average, 3 years younger and more likely to be concurrently diagnosed with HIV and AIDS. While HOPWA clients were more likely to be retained in care (94 vs. 82 %; mOR = 2.97, 95 % CI 2.35-3.74), they were no more likely to achieve suppression (84 vs. 86 %; mOR = 0.85, 95 % 0.70-1.03) and were more likely to rebound (11 vs. 7 %; mOR = 1.45; 95 % CI 1.10-1.91). HIV care retention does not fully translate to virologic suppression in this low-income service population.

Monitoring outcomes for newly diagnosed and prevalent HIV cases using a care continuum created with New York city surveillance data.

BACKGROUND: The HIV care continuum has been used to show the proportion of persons living with HIV/AIDS (PWHA) who are engaged in each stage of HIV care. We present 1 care continuum for persons newly diagnosed with HIV and 1 for PWHA using New York City HIV surveillance registry data. METHODS: Persons newly diagnosed with HIV in 2011 or PWHA as of December 31, 2011, were included. We constructed each continuum for persons engaged at each stage of HIV care and calculated the proportion achieving each step as both dependent on or independent of preceding steps. RESULTS: Of the 3408 newly diagnosed persons, 67% had timely linkage to care (≤3 months after diagnosis), 58% were established in care 3-9 months after timely linkage, and 43% achieved viral suppression (≤200 copies/mL) ≤6 months after establishment in care; losses were highest from diagnosis to linkage. Independent measures showed 84% linked, 72% established, and 61% suppressed ≤18 months after diagnosis. Of the 87,268 PWHA, 83% were in care in 2011 (≥1 visit), 70% retained in care (≥2 visits ≥3 months apart), and 52% suppressed at their last visit; losses were highest from retention to suppression. When measured independently, suppression increased to 58%. CONCLUSIONS: A minority of persons newly diagnosed with HIV and a narrow majority of PWHA achieved viral suppression and all intermediate care-related steps. Outcomes measured independently of previous care-related steps were higher, particularly for newly diagnosed persons. To improve outcomes among persons with HIV and reduce transmissibility, clinical and public health efforts should focus on linkage to care among newly diagnosed persons and viral suppression among PWHA.

Foreign-Born Persons Diagnosed with HIV: Where are They From and Where Were They Infected?

We sought to calculate rates of HIV diagnoses by area of birth among foreign-born persons in a high-incidence US city with many immigrants, and determine probable place of HIV acquisition. Data from the New York City HIV surveillance registry and American Community Survey were used to calculate HIV diagnosis rates by area of birth and determine probable place of HIV acquisition among foreign-born diagnosed in 2006-2012. HIV diagnosis rates varied by area of birth and were highest among African-born persons; absolute numbers were highest among Caribbean-born persons. Probable place of acquisition was a foreign country for 23 % (from 9 % among Middle Easterners to 43 % among Africans), US for 61 % (from 34 % among Africans to 76 % among South Americans), and not possible to estimate for 16 %. HIV prevention and testing initiatives should take into account variability by foreign area of birth in HIV diagnosis rates and place of acquisition.

Proportions of patients with HIV retained in care and virally suppressed in New York City and the United States: higher than we thought.

BACKGROUND: The purpose of this analysis is to compare 2 newly developed methods (a "likelihood" method and a "weighting" method) with the widely used method (the "include-all" method) to estimate the proportions of HIV-infected persons retained in care and virally suppressed in New York City (NYC). METHODS: The NYC HIV registry data were used for the analysis. The include-all method included all patients in the denominator who were diagnosed and/or receiving care in NYC and not known to be dead by December 31, 2012. The likelihood method included patients in the denominator who were likely to reside in NYC in 2012 based on their length of absence from HIV care. The weighting method included patients in the denominator who were residing in NYC in 2012 by weighting each in-care patient based on their probability of receiving HIV care. RESULTS: The include-all method estimated that 114,926 persons were diagnosed and living with HIV in NYC, 63.7% were retained in care (≥1 care visit in 2012), and 48.9% were virally suppressed (≤200 copies/mL). The likelihood method and the weighting method produced equivalent estimates with 80,074 and 80,509 persons diagnosed and living with HIV in NYC, 91.5% and 91.0% retained in care, and 70.2% and 71.7% virally suppressed, respectively. CONCLUSIONS: Using 2 newly developed methods, we were able to report more accurate estimates of the proportions of patients retained in care and virally suppressed. Other local health jurisdictions should consider using these new methods to measure care outcomes and monitor the National HIV/AIDS Strategy.

Acceptability of home self-tests for HIV in New York City, 2006.

Data from a 2006 telephone survey representative of New York City adults showed that more than half (56.2%) of those aged 18 to 64 years responded favorably to a question about acceptability of a rapid home HIV test. More than two thirds of certain subpopulations at high risk for HIV reported that they would use a rapid home HIV test, but approximately half who expressed interest had indications of financial hardship. The match of acceptability and HIV risk bodes well for self-testing utility, but cost might impede uptake.

For partner services, do we need "face-time," or FaceTime?: Trends in relative proportion of in-person notifications and HIV testing after introduction of a telephone option for HIV exposure notification by public health.

Public health usually notifies partners of STD exposure in-person despite availability of other options. We examined trends in in-person versus telephone notification for HIV 3 years after the introduction of a telephone option. Most notifications were made by telephone. Partners notified doubled; however, the proportion HIV testing declined slightly.

Bringing HIV partner services into the age of social media and mobile connectivity.

BACKGROUND: A substantial proportion of recent sex partners named by persons with sexually transmitted infections are not notified about their exposure despite attempts by public health officials. Although text messaging (texting) and Internet-based communications (dating Web sites, e-mail, etc) are used by a large segment of the public for regular communications, these tools have been underused for partner services (PS). METHODS: We augmented PS for HIV in New York City using texting and Internet-based means to contact persons for whom traditional information (landline telephone number, postal address) was unavailable. We compared traditional PS (traditionalPS), Internet-based PS (IPS) in January 2011 to October 2012, and texting PS (txtPS) from January 2012 (when txtPS was initiated) through October 2012 on outcomes of contact attempts, notification, and HIV testing. RESULTS: From January 2011 to October 2012, of 3319 partners elicited, 2604 and 275 partners had traditional and only Internet-based contact information and were selected for traditionalPS and IPS, respectively. From January to October 2012, 368 of 1569 partners had only texting-enabled cellphone numbers and were selected for txtPS. The contact rate for txtPS (285/368 [77%]) was significantly higher (P < 0.0001) than the contact rates for traditionalPS (1803/2604 [69%]) and IPS (112/275 [41%]). There was a higher likelihood of notifying contacted IPS (odds ratio, 2.1; 1.2-3.4) and txtPS (odds ratio, 2.4; 1.7-3.2) than traditionalPS partners (P ≤ 0.0001). However, among the notified partners, traditionalPS partners were significantly (P < 0.0001) more likely than txtPS or IPS partners to test for HIV after partner notification (69% vs 45% and 34%, respectively). CONCLUSIONS: Augmenting traditionalPS with txtPS and IPS enabled notification of hundreds of previously untraceable partners and several new HIV diagnoses.

Optimizing the use of surveillance data for monitoring the care status of persons recently diagnosed with HIV in NYC.

BACKGROUND: Comprehensive laboratory reporting of CD4 and viral load (VL) tests to surveillance has been used to assess HIV care-related outcomes at the population level, but their validity for this purpose has not been comprehensively evaluated. OBJECTIVE: Assess performance characteristics and validity of surveillance-based measures of linkage to and establishment of HIV primary care among HIV-infected persons in the first 12 months after diagnosis using medical record (MR) data on outpatient HIV primary care visits as the gold standard. METHODS: All patients diagnosed with HIV in 2009 at 24 New York City high-volume, HIV diagnostic and treatment facilities who linked to care within 12 months at the same site as defined by the presence of ≥1 CD4/VL report received by surveillance were selected for MR review to confirm linkage to outpatient HIV primary care within the first year. All HIV care visit dates were abstracted and considered associated with a surveillance laboratory report, if within 14 days of a care visit. The proportion linking to care according to the MR was compared with the proportion linking per CD4/VL tests reported to surveillance. Four measures of the establishment of outpatient HIV primary care in the first year were assessed: (1) sustained care (first visit within 3 months; second visit, 3-9 months later), (2) continuous care (2 visits at least 90 days apart), (3) trimester visits (visit in each 4-month period), and (4) visit constancy (visit in each 3-month period). The validity of surveillance data for measuring this outcome was assessed by comparing results for each of the 4 measures calculated using surveillance data to those calculated using MR data. RESULTS: Of the 782 patients selected, 20% (N = 157) of patients did not link to outpatient HIV primary care at the co-located care facility within 12 months of diagnosis. Half (48.5%) of patients' care visits after linkage did not have an associated CD4/VL reported to surveillance. Of the 4 establishment measures, sustained and continuous care had the highest agreement with MR (86.6% and 88.8%, respectively) as compared with the trimester visits and visit constancy (77.8% and 72.8%, respectively). CONCLUSIONS: Surveillance data overestimated linkage rates but underestimated the frequency of HIV care in the first year after HIV diagnosis. Of the 4 measures of establishment of HIV care evaluated, "sustained care" is best suited for measurement using surveillance data because of its high level of agreement with MR data and close alignment with national standards for timely linkage and flexible follow-up.

HIV partner services are associated with timely linkage to HIV medical care.

The Centers for Disease Control and Prevention (CDC) recommends that persons diagnosed with HIV receive partner services with health department involvement. CDC describes partner services as not only including partner notification, but also linkage to medical care for HIV-infected persons. The New York City Health Department formed a unit in 2006 to expedite partner services. We examined the contribution of our HIV partner services program in improving timely linkage and retention in HIV medical care.

Identifying the correlates of membership in HIV-serodiscordant partnerships in New York City.

BACKGROUND: Identification and characterization of patients in HIV-serodiscordant partnerships can inform strategies to improve HIV prevention efforts for this group. METHODS: We conducted a case-control analysis using New York City Department of Health and Mental Hygiene HIV surveillance and partner services (PS) data from July 2006 to July 2010. HIV-infected index patients reported and interviewed for PS who named 1 or more sex and/or syringe-sharing partner (n = 1309) and their sex partners notified by New York City Department of Health and Mental Hygiene with confirmed HIV serostatus (n = 1564) were selected for analysis. Index patients were classified into either serodiscordant or seroconcordant-positive partnerships based on the HIV serostatus of their partner(s). Multivariable regression analysis was conducted to examine the likelihood of membership in a serodiscordant partnership by a range of individual- and partnership-level variables. RESULTS: Of the 1309 index patients, 624 (48%) were in HIV-serodiscordant partnerships. In multivariable analysis, the likelihood of serodiscordant partnership membership was slightly higher among women, individuals with unknown HIV transmission risk, and those with 2 to 3 named partners versus 1. Index patients claimed more partners than they named; for example, index patients who named 1 partner claimed an average of 2.3 partners in the past 12 months. CONCLUSIONS: Many HIV-infected patients who received PS were in HIV-serodiscordant partnerships, with characteristics indicating potential for HIV transmission. Our findings suggest several potential programmatic and policy needs, including enhanced linkage-to-care efforts for this population, especially HIV-infected individuals with uncontrolled viremia; ongoing PS for individuals with evidence of continuing exposure of others; and participation by patients and their serodiscordant, steady partners in local prevention interventions.

Lost or just not following up: public health effort to re-engage HIV-infected persons lost to follow-up into HIV medical care.

OBJECTIVE: Locate persons living with HIV (PLWH) presumed lost to follow-up (LTFU), and assist them with partner services and linkage to HIV-related care. DESIGN: Locate and facilitate re-engagement in care for PLWH-LTFU in New York City (NYC), with longitudinal follow-up using HIV surveillance registry. SETTINGS: HIV care facilities and communities in NYC. PATIENTS: PLWH, reported in the NYC HIV surveillance registry, who had a NYC care provider and residential address at last report in the registry. Presumed-LTFU was defined as having no CD4+ or viral load during the most recent 9 months during the study period July 2008-December 2010. INTERVENTION: Case-workers conducted public health investigation to locate PLWH presumed-LTFU and offered them assistance with partner and linkage-to-care services. MAIN OUTCOME MEASURES: Results of partner and linkage-to-care services, and reasons for LTFU. RESULTS: From July 2008 to December 2010, 797 PLWH presumed-LTFU were prioritized for investigation; 14% were never located. Of the 689 located, 33% were current to care, 5% had moved or were incarcerated, 2% had died, and 59% (409) were verified to be LTFU. Once located, 77% (315/409) accepted clinic appointments, and 57% (232/409) returned to care. Among the 161 who provided reasons for LTFU, the most commonly reported was 'felt well' (41%). CONCLUSIONS: Health department case-workers helped more than half PLWH-LTFU re-engage in HIV medical care. HIV prevention strategies must include efforts to re-engage PLWH-LTFU in care, for treatment consideration under current treatment guidelines to improve their clinical status and decrease transmission risk.

Do sexual risk behaviors differ between heterosexual youth infected with HIV perinatally versus sexually?

PURPOSE: To determine if sexually active heterosexual HIV-infected 15- to 24-year-old youth have different sexual or other risk behaviors depending on whether they were infected perinatally or heterosexually. METHODS: We compared youth aged 15 to 24 years who acquired HIV perinatally or sexually and were interviewed in-person or by phone for partner services by the New York City Department of Health and Mental Hygiene. We included heterosexually active youth with at least one sexual partner of the opposite sex in the past 12 months, and excluded men who have sex with men and injection drug users. We used χ(2) tests and t tests to compare demographics, sexual risk behaviors, partner services outcomes, and viral loads. RESULTS: Both groups reported few partners (median 1, mean 2), and only 12% of partners of perinatally infected youth were previously diagnosed (18% of sexually infected youths' partners). A minority reported always using condoms. Both groups had similar rates of sexually transmitted infections and median HIV plasma RNA (perinatally infected: 5,140 copies/mL; sexually infected: 6,835 copies/mL). Despite these similarities, among tested partners not previously HIV diagnosed, none of 17 named by perinatally infected youth was newly HIV diagnosed, whereas 21% (8/39, p = .09) of those named by sexually infected youth were newly diagnosed. CONCLUSIONS: Though perinatally infected youth did not transmit HIV infection to previously undiagnosed partners, they had similar HIV-related risk behaviors to youth infected sexually who reported on risks that led to their infection. HIV prevention among HIV-infected youth remains a critical challenge.

HIV diagnosis and utilisation of HIV-related medical care among foreign-born persons in New York City, 2001-2009.

OBJECTIVES: To measure trends in HIV diagnoses among foreign-born (FB) New Yorkers and compare the epidemic in FB with that in non-FB (NFB). METHODS: New York City (NYC) HIV/AIDS surveillance registry data were used to measure trends in HIV diagnoses in 2001-2009, calculate HIV diagnosis rates by area of birth, and compare demographic and care characteristics of FB and NFB diagnosed in 2006-2009. The registry contains data on all New Yorkers diagnosed with HIV infection, HIV disease and AIDS, and receives laboratory results on all New Yorkers living with HIV/AIDS. RESULTS: From 2001 to 2009, new HIV diagnoses among FB increased modestly in number but significantly as a percent of all cases (17% in 2001 to 28% in 2009; p<0.01). In 2006-2009, the annual rate of diagnosis was lower among FB than NFB (37 vs 56 per 100 000). Compared with NFB, FB persons were significantly more likely to be diagnosed concurrently with AIDS; FB had a lower median CD4 count at initiation of care. FB persons were less likely to have insurance, and 13% needed language interpretation services. CONCLUSIONS: The percentage of HIV diagnoses in NYC attributed to FB persons has increased. HIV infection may remain undiagnosed longer in FB than NFB. FB may benefit from targeted prevention outreach and other services.

HIV screening practices for living organ donors, New York State, 2010: need for standard policies.

Our survey of kidney and liver transplant centers in New York State found a wide variation among transplant centers in evaluation and screening for HIV risk and infection among prospective living donors. Survey results underscore the need to standardize practices. A recent transmission of human immunodeficiency virus (HIV) from a living donor to a kidney recipient revealed a possible limitation in existing screening protocols for HIV infection in living donors. We surveyed kidney and liver transplant centers (N = 18) in New York State to assess HIV screening protocols for living donors. Although most transplant centers evaluated HIV risk behaviors in living donors, evaluation practices varied widely, as did the extent of HIV testing and prevention counseling. All centers screened living donors for serologic evidence of HIV infection, either during initial evaluation or ≥1 month before surgery; however, only 50% of transplant centers repeated HIV testing within 14 days before surgery for all donors or donors with specific risk behaviors. Forty-four percent of transplant centers used HIV nucleic acid testing (NAT) to screen either all donors or donors with recognized risk behaviors, and 55% never performed HIV NAT. Results suggest the need to standardize evaluation of HIV risk behaviors and prevention counseling in New York State to prevent acquisition of HIV by prospective living organ donors, and to conduct HIV antibody testing and NAT as close to the time of donation as possible to prevent HIV transmission to recipients.