Building the Case for Localized Approaches to HIV: Structural Conditions and Health System Capacity to Address the HIV/AIDS Epidemic in Six US Cities.

Since the discovery of the secondary preventive benefits of antiretroviral therapy, national and international governing bodies have called for countries to reach 90% diagnosis, ART engagement and viral suppression among people living with HIV/AIDS. The US HIV epidemic is dispersed primarily across large urban centers, each with different underlying epidemiological and structural features. We selected six US cities, including Atlanta, Baltimore, Los Angeles, Miami, New York, and Seattle, with the objective of demonstrating the breadth of epidemiological and structural differences affecting the HIV/AIDS response across the US. We synthesized current and publicly-available surveillance, legal statutes, entitlement and discretionary funding, and service location data for each city. The vast differences we observed in each domain reinforce disparities in access to HIV treatment and prevention, and necessitate targeted, localized strategies to optimize the limited resources available for each city's HIV/AIDS response.

Don't ask, don't tell: patterns of HIV disclosure among HIV positive men who have sex with men with recent STI practising high risk behaviour in Los Angeles and Seattle.

OBJECTIVES: A high incidence of HIV continues among men who have sex with men (MSM) in industrialised nations and research indicates many MSM do not disclose their HIV status to sex partners. Themes as to why MSM attending sexually transmitted infection (STI) clinics in Los Angeles and Seattle do and do not disclose their HIV status are identified. METHODS: 55 HIV positive MSM (24 in Seattle, 31 in Los Angeles) reporting recent STI or unprotected anal intercourse with a serostatus negative or unknown partner from STI clinics underwent in-depth interviews about their disclosure practices that were tape recorded, transcribed verbatim, coded, and content analysed. RESULTS: HIV disclosure themes fell into a continuum from unlikely to likely. Themes for "unlikely to disclose" were HIV is "nobody's business," being in denial, having a low viral load, fear of rejection, "it's just sex," using drugs, and sex in public places. Themes for "possible disclosure" were type of sex practised and partners asking/disclosing first. Themes for "likely to disclose" were feelings for partner, feeling responsible for partner's health, and fearing arrest. Many reported non-verbal disclosure methods. Some thought partners should ask for HIV status; many assumed if not asked then their partner must be positive. CONCLUSIONS: HIV positive MSM's decision to disclose their HIV status to sex partners is complex, and is influenced by a sense of responsibility to partners, acceptance of being HIV positive, the perceived transmission risk, and the context and meaning of sex. Efforts to promote disclosure will need to address these complex issues.

Partner management for gonococcal and chlamydial infection: expansion of public health services to the private sector and expedited sex partner treatment through a partnership with commercial pharmacies.

BACKGROUND: Public health partner notification (PN) services currently affect only a small minority of patients with gonorrhea or chlamydial infection and new approaches to PN are needed. OBJECTIVES: To expand PN for gonorrhea and chlamydial infection to private sector patients and to assess the feasibility of treating sex partners through commercial pharmacies. METHODS: Selected patients were offered PN assistance and were randomly offered medication to deliver to their partners. RESULTS: Providers permitted the health department to contact 3613 (91%) of 3972 potentially eligible patients, and 1693 (67%) of 2531 successfully contacted patients consented to interview. Of these, 1095 (65%) reported at least one untreated partner. Most patients (90%) wished to notify partners themselves. Patients were more likely to have partners who had not yet been treated and to request PN assistance if they had more than one sex partner in the preceding 60 days or a partner they did not anticipate having sex with in the future. These two factors characterized 49% of all patients interviewed, 70% of those with a partner that was untreated 7 or more days after index patient treatment, and 83% of those accepting PN assistance. Among 458 randomly selected patients with untreated partners at time of study interview, 346 (76%) agreed to deliver treatment to a partner. Of these, most (266) chose to obtain medication for a partner at a pharmacy, of whom 223 (84%) successfully did so. CONCLUSION: A substantial minority of private sector patients have untreated partners more than 7 days after their own treatment; some need help with PN, but most will agree to deliver medication to partners themselves.

Evaluation of laboratory testing methods for Chlamydia trachomatis infection in the era of nucleic acid amplification.

Diagnostic tests presently available for Chlamydia trachomatis have widely varying performance characteristics. To assess evolving laboratory testing practices since the introduction of nucleic acid amplification tests (NAAT), we surveyed laboratories in Washington State about their testing practices in 1998 and compared our findings to a similar survey conducted in 1995. Laboratory directors of 61 (87%) of 70 laboratories performing chlamydial tests in 1998 returned a survey. Between 1995 and 1998, 36 laboratories discontinued chlamydial testing, and the total number of laboratories performing tests in the state decreased from 92 to 70, a 24% decline. Of the 36 laboratories that discontinued testing, 25 (69%) had previously used rapid tests. While no laboratory routinely used NAAT in 1995, ligase chain reaction (LCR) was used in 23% of laboratories in 1998 and accounted for 113,624 (36%) of the 318,133 tests performed that year. Among the remaining 204,509 tests performed in 1998, other tests employed included DNA probe (29%), enzyme immunoassay (20%), culture (12%), direct fluorescent antibody assays (3%), and rapid tests (<1%). The majority (65%) of tests performed in 1998 using technologies other than LCR or culture were done in laboratories that did more than 10,000 tests. Cost and loss of revenue to laboratories were the most frequently cited reasons for not adopting NAAT. We conclude that in Washington State, NAAT have been rapidly adopted in larger laboratories, but most patients are still tested with much less sensitive technologies. Financial constraints represent the major barrier to more widespread use of DNA amplification tests.

Duration of untreated genital infections with chlamydia trachomatis: a review of the literature.

BACKGROUND: Estimates of the duration of untreated genital infections with Chlamydia trachomatis vary. Accurately estimating the distribution of the duration of infection would be useful in the counseling patients, and is essential when modeling the burden of chlamydial disease and the potential impact of prevention programs. GOAL: The authors review the scientific literature to summarize what is known about the duration of genital chlamydial infection and the factors that affect it. STUDY DESIGN: Literature review of animal and human studies. RESULTS: Animal studies document a longer duration of infection in primates than in mice or guinea pigs. Although animals spontaneously become culture negative over time, numerous studies document persistent nonculture evidence of chlamydiae in the upper genital tract. Studies in which women have been serially cultured suggest that most untreated infections remain culture positive for more than 60 days. Small series report that some infections may persist for years. Most infections eventually become culture negative; however, non-culture evidence of chlamydiae often persist in women with negative cultures. The duration of chlamydial infection is reduced in animals previously exposed to chlamydiae and in older humans, suggesting that partial immunity may result from exposure. Data are inadequate to define the median duration of untreated infection or to derive a curve that describes the natural history of untreated genital chlamydial infections. CONCLUSION: Current data do not allow one to reliably estimate the duration of genital infections with C trachomatis. Systematic retesting could help to better define the duration of infection in patients who, against medical advice, delay treatment for genital chlamydial infections.

Partner notification for chlamydial infections among private sector clinicians in Seattle-King County: a clinician and patient survey.

BACKGROUND & OBJECTIVES: To describe partner notification practices for chlamydial infections among private sector clinicians. STUDY DESIGN: Telephone interviews of clinicians and patients identified through public health case reports in Seattle-King County, August-October 1998. RESULTS: Clinicians reported advising 135 of 150 (90%) patients to notify their sex partners, but knew that all partners of only 26 (17%) patients received treatment. While 71 (57%) clinicians acknowledged ever providing medicine-to a patient to give to a partner, only 6 (4%) so treated a patient about whom they were interviewed. Most (87%) clinicians believed the health department should routinely contact all patients about partner notification. Almost all patients (72/76-95%) reported that their provider had advised them to notify their partners and 59 (78%) stated they did so. Most patients (11/17-65%) who did not notify all of their partners would have been willing to allow their clinician or the heath department to do it for them. CONCLUSION: Private sector clinicians and their patients are generally unaware of chlamydial partner notification outcomes but are receptive to expanded partner notification services.

Early intervention for human immunodeficiency virus in Baltimore Sexually Transmitted Diseases Clinics. Impact on gonorrhea incidence in patients infected with HIV.

BACKGROUND: High incidences of sexually transmitted diseases (STD) after posttest counseling have been documented in patients diagnosed with human immunodeficiency virus (HIV) in Baltimore STD clinics. In July 1991, the authors instituted an HIV early intervention program providing long-term medical care and social work services. This study compares the incidence of gonorrhea after post-HIV+ test counseling in patients diagnosed with HIV before and after the institution of the early intervention program. METHODS: Medical records of a cohort composed of all patients newly diagnosed with HIV and those who underwent posttest counseling for HIV in 1991 to 1993 in two Baltimore STD clinics were reviewed. Patients were offered early intervention medical and social work services. Gonorrhea incidence in this cohort was compared to a historical cohort diagnosed and counseled for post-HIV+ testing in 1988 to 1989 who were not offered early intervention services. RESULTS: The mean follow-up time was 418 days (range, 26 to 703 days). After post-HIV+ test counseling, gonorrhea developed in 39 of 468 (8.3%) men in the 1989 cohort and 13 of 400 (3.3%) men in the 1991 to 1993 cohort. Controlling for variable length of follow-up, the 1991 to 1993 cohort had a relative risk of 0.442 for the development of gonorrhea during the study period (95% confidence interval, 0.225 to 0.790; P = 0.006). Incident gonorrhea after post-HIV+ test counseling also was associated with a prevalent gonorrhea condition at the time of HIV diagnosis (RR = 3.02; 95% CI, 1.75 to 5.23; P = 0.0001) and failure to return for post-HIV+ test counseling as scheduled (RR = 2.27; 95% CI, 1.17-4.43; P = 0.013). After adjustment for gonorrhea at the time of HIV diagnosis and failure to return for scheduled posttest counseling, the difference in gonorrhea incidence between men in the two cohorts remained statistically significant (RR = 0.494; 95% CI, 0.260 to 0.941; P = 0.032). In comparison, overall gonorrhea rates in Baltimore changed little between 1988 and 1993. No significant difference was found in gonorrhea incidence in women, which may have been the result of active gonorrhea screening during the 1991 to 1993 period, which was not performed in 1988 to 1989. CONCLUSIONS: Providing clinical care to persons with HIV may facilitate the reduction of high-risk behaviors that lead to incident STDs and further HIV transmission.

The relationship of preexisting lung disease to the development of methotrexate pneumonitis in patients with rheumatoid arthritis.

OBJECTIVE: To test the hypothesis that preexisting lung disease is a risk factor for the development of methotrexate (MTX) pneumonitis in patients with rheumatoid arthritis (RA) treated with low dose MTX. METHODS: We measured the proportion of patients with and without preexisting lung disease who developed MTX pneumonitis in a historical cohort from a university affiliated rheumatology private practice in Chicago. Patients comprised 93 women and 32 men with RA treated with MTX for any period of time between January, 1980 and July, 1989. RESULTS: MTX pneumonitis occurred in 4 of 77 patients without preexisting lung disease (5.2%) and 5 of 29 (17.2%) patients with preexisting lung disease (p = 0.0610, Fisher's exact test). Five of 24 (20.1%) patients with preexisting lung disease characterized by the report of an abnormal chest radiograph developed MTX pneumonitis (p = 0.2328, Fisher's exact test) and 4 of 16 (25%) patients with interstitial infiltrates reported on their chest radiograph developed MTX pneumonitis (p = 0.0276, Fisher's exact test). CONCLUSION: The presence of preexisting lung disease characterized by radiographic interstitial infiltrates predisposes patients with RA to develop MTX pneumonitis.