Early implementation learnings on acceptability and feasibility of "V": a multi-level PrEP intervention designed with and for adolescent girls and young women in Zimbabwe.

INTRODUCTION: Adolescent girls and young women (AGYW) remain disproportionately affected by HIV in Zimbabwe. Several HIV prevention options are available, including oral tenofovir-based pre-exposure prophylaxis (PrEP), however AGYW face unique barriers to PrEP uptake and continuation and novel approaches are therefore needed to empower AGYW to use PrEP. The objective of this study was to characterize early learnings from implementing a multi-level intervention consisting of fashionable branding (including a "V Starter Kit"), service integration, and peer education and support throughout a young woman's journey using oral PrEP across four phases of implementation, from creating demand, preparing for PrEP, initiation of PrEP, and adherence to PrEP. METHODS: A mixed methods implementation research study was undertaken, including site observations and interviews to explore the acceptability of "V" and its relevance to target users, as well as the feasibility of integrating "V" with existing service delivery models. Interviews (n = 46) were conducted with healthcare workers, Brand Ambassadors, and young women purposively sampled from four implementation sites. Interview data was analyzed thematically using the framework method for qualitative data management and analysis. Project budgets and invoices were used to compile unit cost and procurement data for all "V" materials. RESULTS: "V" was acceptable to providers and young women due to attractive branding coupled with factual and thought-provoking messaging, establishing "a girl code" for discussing PrEP, and addressing a gap in communications materials. "V" was also feasible to integrate into routine service provision and outreach, alongside other services targeting AGYW. Cost for the "V" branded materials ranked most essential-FAQ insert, pill case, makeup bag, reminder sticker-were $7.61 per AGYW initiated on PrEP. CONCLUSION: "V" is a novel approach that is an acceptable and feasible multi-level intervention to improve PrEP access, uptake, and continuation among AGYW, which works through empowering AGYW to take control of their HIV prevention needs. In considering "V" for scale up in Zimbabwe, higher volume procurement and a customized lighter package of "V" materials, while still retaining V's core approach, should be explored.

Lessons Learned From Implementing Prospective, Multicountry Mixed-Methods Evaluations for Gavi and the Global Fund.

INTRODUCTION: As global health programs have become increasingly complex, corresponding evaluations must be designed to assess the full complexity of these programs. Gavi and the Global Fund have commissioned 2 such evaluations to assess the full spectrum of their investments using a prospective mixed-methods approach. We aim to describe lessons learned from implementing these evaluations. METHODS: This article presents a synthesis of lessons learned based on the Gavi and Global Fund prospective mixed-methods evaluations, with each evaluation considered a case study. The lessons are based on the evaluation team's experience from over 7 years (2013-2020) implementing these evaluations. The Centers for Disease Control and Prevention Framework for Evaluation in Public Health was used to ground the identification of lessons learned. RESULTS: We identified 5 lessons learned that build on existing evaluation best practices and include a mix of practical and conceptual considerations. The lessons cover the importance of (1) including an inception phase to engage stakeholders and inform a relevant, useful evaluation design; (2) aligning on the degree to which the evaluation is embedded in the program implementation; (3) monitoring programmatic, organizational, or contextual changes and adapting the evaluation accordingly; (4) hiring evaluators with mixed-methods expertise and using tools and approaches that facilitate mixing methods; and (5) contextualizing recommendations and clearly communicating their underlying strength of evidence. CONCLUSION: Global health initiatives, particularly those leveraging complex interventions, should consider embedding evaluations to understand how and why the programs are working. These initiatives can learn from the lessons presented here to inform the design and implementation of such evaluations.

Partnership and Participation-A Social Network Analysis of the 2017 Global Fund Application Process in the Democratic Republic of the Congo and Uganda.

Background: The Global Fund to Fight AIDS, Tuberculosis and Malaria was founded in 2002 as a public-private partnership between governments, the private sector, civil society, and populations affected by the three diseases. A key principle of the Global Fund is country ownership in accessing funding through "engagement of in-country stakeholders, including key and vulnerable populations, communities, and civil society." Research documenting whether diverse stakeholders are actually engaged and on how stakeholder engagement affects processes and outcomes of grant applications is limited. Objective: To examine representation during the 2017 Global Fund application process in the Democratic Republic of the Congo (DRC) and Uganda and the benefits and drawbacks of partnership to the process. Methods: We developed a mixed-methods social network survey to measure network structure and assess perceptions of how working together in partnership with other individuals/organizations affected perceived effectiveness, efficiency, and country ownership of the application process. Surveys were administered from December 2017-May 2018, initially to a set of central actors, followed by any individuals named during the surveys (up to 10) as collaborators. Network analyses were conducted using R. Findings: Collaborators spanning many organizations and expertise areas contributed to the 2017 applications (DRC: 152 nodes, 237 ties; Uganda: 118 nodes, 241 ties). Participation from NGOs and civil society representatives was relatively strong, with most of their ties being to different organization types, Uganda (63%), and DRC (67%), highlighting their collaborative efforts across the network. Overall, the perceived benefits of partnership were high, including very strong ratings for effectiveness in both countries. Perceived drawbacks of partnership were minimal; however, less than half of respondents thought partnership helped reduce transaction costs or financial costs, suggesting an inclusive and participatory process may come with short-term efficiency tradeoffs. Conclusions: Social network analysis can be useful for identifying who is included and excluded from the process, which can support efforts to ensure stronger, more meaningful engagement in future Global Fund application processes.

Bringing a health systems modelling approach to complex evaluations: multicountry applications in HIV, TB and malaria.

INTRODUCTION: Understanding how to deliver interventions more effectively is a growing emphasis in Global Health. Simultaneously, health system strengthening is a key component to improving delivery. As a result, it is challenging to evaluate programme implementation while reflecting real-world complexity. We present our experience in using a health systems modelling approach as part of a mixed-methods evaluation and describe applications of these models. METHODS: We developed a framework for how health systems translate financial inputs into health outcomes, with in-country and international experts. We collated available data to measure framework indicators and developed models for malaria in Democratic Republic of the Congo (DRC), and tuberculosis in Guatemala and Senegal using Bayesian structural equation modelling. We conducted several postmodelling analyses: measuring efficiency, assessing bottlenecks, understanding mediation, analysing the cascade of care and measuring subnational effectiveness. RESULTS: The DRC model indicated a strong relationship between shipment of commodities and utilisation thereof. In Guatemala, the strongest model coefficients were more evenly distributed. Results in Senegal varied most, but pathways related to community care had the strongest relationships. In DRC, we used model results to estimate the end-to-end cost of delivering commodities. In Guatemala, we used model results to identify potential bottlenecks and understand mediation. In Senegal, we used model results to identify potential weak links in the cascade of care, and explore subnationally. CONCLUSION: This study demonstrates a complementary modelling approach to traditional evaluation methods. Although these models have limitations, they can be applied in a variety of ways to gain greater insight into implementation and functioning of health service delivery.

"Because Even the Person Living With HIV/AIDS Might Need to Make Babies" - Perspectives on the Drivers of Feasibility and Acceptability of an Integrated Community Health Worker Model in Iringa, Tanzania.

BACKGROUND: Countries with health workforce shortages are increasingly turning to multipurpose community health workers (CHWs) to extend integrated services to the community-level. However, there may be tradeoffs with the number of tasks a CHW can effectively perform before quality and/or productivity decline. This qualitative study was conducted within an existing program in Iringa, Tanzania where HIV-focused CHWs working as volunteers received additional training on maternal, newborn, and child health (MNCH) promotion, thereby establishing a dual role CHW model. METHODS: To evaluate the feasibility and acceptability of the combined HIV/MNCH CHW model, qualitative in-depth interviews (IDIs) with 36 CHWs, 21 supervisors, and 10 program managers were conducted following integration of HIV and MNCH responsibilities (n=67). Thematic analysis explored perspectives on task planning, prioritization and integration, workload, and the feasibility and acceptability of the dual role model. Interview data and field observations were also used to describe implementation differences between HIV and MNCH roles as a basis for further contextualizing the qualitative findings. RESULTS: Perspectives from a diverse set of stakeholders suggested provision of both HIV and MNCH health promotion by CHWs was feasible. Most CHWs attempted to balance HIV/MNCH responsibilities, although some prioritized MNCH tasks. An increased workload from MNCH did not appear to interfere with HIV responsibilities but drew time away from other income-generating activities on which volunteer CHWs rely. Satisfaction with the dual role model hinged on increased community respect, gaining new knowledge/skills, and improving community health, while the remuneration-level caused dissatisfaction, a complaint that could challenge sustainability. Conclusions: Despite extensive literature on integration, little research at the community level exists. This study demonstrated CHWs can feasibly balance HIV and MNCH roles, but not without some challenges related to the heavier workload. Further research is necessary to determine the quality of health promotion in both HIV and MNCH domains, and whether the dual role model can be maintained over time among these volunteers.

Integrating Community Health Worker Roles to Improve Facility Delivery Utilization in Tanzania: Evidence from an Interrupted Time Series Analysis.

OBJECTIVES: Despite renewed interest in expansion of multi-tasked community health workers (CHWs) there is limited research on HIV and maternal health integration at the community-level. This study assessed the impact of integrating CHW roles for HIV and maternal health promotion on facility delivery utilization in rural Tanzania. METHODS: A 36-month time series data set (2014-2016) of reported facility deliveries from 68 health facilities in two districts of Tanzania was constructed. Interrupted time series analyses evaluated population-averaged longitudinal trends in facility delivery at intervention and comparison facilities. Analyses were stratified by district, controlling for secular trends, seasonality, and type of facility. RESULTS: There was no significant change from baseline in the average number of facility deliveries observed at intervention health centers/dispensaries relative to comparison sites. However, there was a significant 16% increase (p < 0.001) in average monthly deliveries in hospitals, from an average of 202-234 in Iringa Rural and from 167 to 194 in Kilolo. While total facility deliveries were relatively stable over time at the district-level, during intervention the relative change in the proportion of hospital deliveries out of total facility deliveries increased by 17.2% in Iringa Rural (p < 0.001) and 14.7% in Kilolo (p < 0.001). CONCLUSIONS FOR PRACTICE: Results suggest community-delivered outreach by dual role CHWs was successful at mobilizing pregnant women to deliver at facilities and may be effective at reaching previously under-served pregnant women. More research is necessary to understand the effect of dual role CHWs on patterns of service utilization, including decisions to use referral level facilities for obstetric care.

Can volunteer community health workers manage multiple roles? An interrupted time-series analysis of combined HIV and maternal and child health promotion in Iringa, Tanzania.

Community health workers (CHWs) play a critical role in health promotion, but their workload is often oriented around a single disease. Renewed interest in expansion of multipurpose CHWs to cover an integrated package of services must contend with the debate over how effectively CHWs can perform an increased range of tasks. In this study, we examine whether an existing cadre of HIV-focused paid volunteer CHWs in Iringa, Tanzania, can take on new maternal, newborn and child health (MNCH) promotion tasks without adversely affecting their HIV role. HIV household visits conducted per month were extracted from CHW summary forms covering up to 14 months pre-intervention and 12 months of intervention data. A comparative interrupted time series using a generalized estimating equation assessed population-averaged longitudinal trends in monthly HIV visit count in the intervention ('dual-role' CHWs) vs comparison group ('single-role' CHWs). Analyses were stratified by district, accounting for secular trends, seasonality and covariates. The time series consisted of 4022 observations for HIV visit count from 187 CHWs (41% dual role). Prior to MNCH training, dual-role CHWs averaged 25-30% more HIV visits per month compared with single-role CHWs, with no other significant pre-intervention differences between groups. CHWs began conducting MNCH visits shortly after receiving training, but in the initial month of intervention, there was a 6-9% drop in the mean number of HIV visits per month among dual-role CHWs. Otherwise, there was no significant difference between single- and dual-role CHWs in the trajectories of monthly HIV visits before and after adding MNCH tasks. Dual-role CHWs appeared able to maintain their HIV client workload after adding MNCH tasks to their routines, albeit with an initial slight decline in HIV workload. This dual-role CHW model suggests potential spare capacity in vertically oriented programmes, with productivity gains possible through integration.

Beyond the building blocks: integrating community roles into health systems frameworks to achieve health for all.

Achieving ambitious health goals-from the Every Woman Every Child strategy to the health targets of the sustainable development goals to the renewed promise of Alma-Ata of 'health for all'-necessitates strong, functional and inclusive health systems. Improving and sustaining community health is integral to overall health systems strengthening efforts. However, while health systems and community health are conceptually and operationally related, the guidance informing health systems policymakers and financiers-particularly the well-known WHO 'building blocks' framework-only indirectly addresses the foundational elements necessary for effective community health. Although community-inclusive and community-led strategies may be more difficult, complex, and require more widespread resources than facility-based strategies, their exclusion from health systems frameworks leads to insufficient attention to elements that need ex-ante efforts and investments to set community health effectively within systems. This paper suggests an expansion of the WHO building blocks, starting with the recognition of the essential determinants of the production of health. It presents an expanded framework that articulates the need for dedicated human resources and quality services at the community level; it places strategies for organising and mobilising social resources in communities in the context of systems for health; it situates health information as one ingredient of a larger block dedicated to information, learning and accountability; and it recognises societal partnerships as critical links to the public health sector. This framework makes explicit the oft-neglected investment needs for community health and aims to inform efforts to situate community health within national health systems and global guidance to achieve health for all.

Community Involvement in Health Systems Strengthening to Improve Global Health Outcomes: A Review of Guidelines and Potential Roles.

Definitions of health systems strengthening (HSS) have been limited in their inclusion of communities, despite evidence that community involvement improves program effectiveness for many health interventions. We review 15 frameworks for HSS, highlighting how communities are represented and find few delineated roles for community members or organizations. This review raises the need for a cohesive definition of community involvement in HSS and well-described activities that communities can play in the process. We discuss how communities can engage with HSS in four different areas-planning and priority-setting; program implementation; monitoring, evaluation, and quality improvement; and advocacy-and how these activities could be better incorporated into key HSS frameworks. We argue for more carefully designed interactions between health systems policies and structures, planned health systems improvements, and local communities. These interactions should consider local community inputs, strengths, cultural and social assets, as well as limitations in and opportunities for increasing capacity for better health outcomes.

Implementation of the Community Health Assistant (CHA) Cadre in Zambia: A Process Evaluation to Guide Future Scale-Up Decisions.

Universal health coverage requires an adequate health workforce, including community health workers (CHWs) to reach rural communities. To improve healthcare access in rural areas, in 2010 the Government of Zambia implemented a national CHW strategy that introduced a new cadre of healthcare workers called community health assistants (CHAs). After 1 year of training the pilot class of 307 CHAs deployed in September 2012. This paper presents findings from a process evaluation of the barriers and facilitators of implementation of the CHA pilot, along with how evidence was used to guide ongoing implementation and scale-up decisions. Qualitative inquiry was used to assess implementation during the first 6 months of the program rollout, with 43 in-depth individual and 32 small group interviews across five respondent types: CHAs, supervisors, volunteer CHWs, community members, and district leadership. Potential 'implementation moderators' were explored using deductive coding and thematic analysis of participant perspectives on community acceptance of CHAs, supervision support mechanisms, and coordination with volunteer CHWs, and health system integration of a new cadre. Community acceptance of CHAs was generally high, but coordination between CHAs and existing volunteer CHWs presented some challenges. The supervision support system was found to be inconsistent, limiting assurance of consistent quality care delivered by CHAs. Underlying health system weaknesses regarding drug supply and salary payments furthermore hindered incorporation of a new cadre within the national health system. Recommendations for implementation and future scale based on the process evaluation findings are discussed.

Introduction of Syphilis Point-of-Care Tests, from Pilot Study to National Programme Implementation in Zambia: A Qualitative Study of Healthcare Workers' Perspectives on Testing, Training and Quality Assurance.

Syphilis affects 1.4 million pregnant women globally each year. Maternal syphilis causes congenital syphilis in over half of affected pregnancies, leading to early foetal loss, pregnancy complications, stillbirth and neonatal death. Syphilis is under-diagnosed in pregnant women. Point-of-care rapid syphilis tests (RST) allow for same-day treatment and address logistical barriers to testing encountered with standard Rapid Plasma Reagin testing. Recent literature emphasises successful introduction of new health technologies requires healthcare worker (HCW) acceptance, effective training, quality monitoring and robust health systems. Following a successful pilot, the Zambian Ministry of Health (MoH) adopted RST into policy, integrating them into prevention of mother-to-child transmission of HIV clinics in four underserved Zambian districts. We compare HCW experiences, including challenges encountered in scaling up from a highly supported NGO-led pilot to a large-scale MoH-led national programme. Questionnaires were administered through structured interviews of 16 HCWs in two pilot districts and 24 HCWs in two different rollout districts. Supplementary data were gathered via stakeholder interviews, clinic registers and supervisory visits. Using a conceptual framework adapted from health technology literature, we explored RST acceptance and usability. Quantitative data were analysed using descriptive statistics. Key themes in qualitative data were explored using template analysis. Overall, HCWs accepted RST as learnable, suitable, effective tools to improve antenatal services, which were usable in diverse clinical settings. Changes in training, supervision and quality monitoring models between pilot and rollout may have influenced rollout HCW acceptance and compromised testing quality. While quality monitoring was integrated into national policy and training, implementation was limited during rollout despite financial support and mentorship. We illustrate that new health technology pilot research can rapidly translate into policy change and scale-up. However, training, supervision and quality assurance models should be reviewed and strengthened as rollout of the Zambian RST programme continues.

The cost-effectiveness of 10 antenatal syphilis screening and treatment approaches in Peru, Tanzania, and Zambia.

OBJECTIVE: Rapid plasma reagin (RPR) is frequently used to test women for maternal syphilis. Rapid syphilis immunochromatographic strip tests detecting only Treponema pallidum antibodies (single RSTs) or both treponemal and non-treponemal antibodies (dual RSTs) are now available. This study assessed the cost-effectiveness of algorithms using these tests to screen pregnant women. METHODS: Observed costs of maternal syphilis screening and treatment using clinic-based RPR and single RSTs in 20 clinics across Peru, Tanzania, and Zambia were used to model the cost-effectiveness of algorithms using combinations of RPR, single, and dual RSTs, and no and mass treatment. Sensitivity analyses determined drivers of key results. RESULTS: Although this analysis found screening using RPR to be relatively cheap, most (>70%) true cases went untreated. Algorithms using single RSTs were the most cost-effective in all observed settings, followed by dual RSTs, which became the most cost-effective if dual RST costs were halved. Single test algorithms dominated most sequential testing algorithms, although sequential algorithms reduced overtreatment. Mass treatment was relatively cheap and effective in the absence of screening supplies, though treated many uninfected women. CONCLUSION: This analysis highlights the advantages of introducing RSTs in three diverse settings. The results should be applicable to other similar settings.

Scaling Down to Scale Up: A Health Economic Analysis of Integrating Point-of-Care Syphilis Testing into Antenatal Care in Zambia during Pilot and National Rollout Implementation.

Maternal syphilis results in an estimated 500,000 stillbirths and neonatal deaths annually in Sub-Saharan Africa. Despite the existence of national guidelines for antenatal syphilis screening, syphilis testing is often limited by inadequate laboratory and staff services. Recent availability of inexpensive rapid point-of-care syphilis tests (RST) can improve access to antenatal syphilis screening. A 2010 pilot in Zambia explored the feasibility of integrating RST within prevention of mother-to-child-transmission of HIV services. Following successful demonstration, the Zambian Ministry of Health adopted RSTs into national policy in 2011. Cost data from the pilot and 2012 preliminary national rollout were extracted from project records, antenatal registers, clinic staff interviews, and facility observations, with the aim of assessing the cost and quality implications of scaling up a successful pilot into a national rollout. Start-up, capital, and recurrent cost inputs were collected, including costs of extensive supervision and quality monitoring during the pilot. Costs were analysed from a provider's perspective, incremental to existing antenatal services. Total and unit costs were calculated and a multivariate sensitivity analysis was performed. Our accompanying qualitative study by Ansbro et al. (2015) elucidated quality assurance and supervisory system challenges experienced during rollout, which helped explain key cost drivers. The average unit cost per woman screened during rollout ($11.16) was more than triple the pilot unit cost ($3.19). While quality assurance costs were much lower during rollout, the increased unit costs can be attributed to several factors, including higher RST prices and lower RST coverage during rollout, which reduced economies of scale. Pilot and rollout cost drivers differed due to implementation decisions related to training, supervision, and quality assurance. This study explored the cost of integrating RST into antenatal care in pilot and national rollout settings, and highlighted important differences in costs that may be observed when moving from pilot to scale-up.

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.

Introduction of rapid syphilis testing within prevention of mother-to-child transmission of HIV programs in Uganda and Zambia: a field acceptability and feasibility study.

BACKGROUND: Given that integration of syphilis testing into prevention of mother-to-child transmission of HIV (PMTCT) programs can prevent adverse pregnancy outcomes, this study assessed feasibility and acceptability of introducing rapid syphilis testing (RST) into PMTCT services. METHODS: RST was introduced into PMTCT programs in Zambia and Uganda. Using a pre-post intervention design, HIV and syphilis testing and treatment rates during the intervention were compared with baseline. RESULTS: In Zambia, comparing baseline and intervention, 12,761 of 15,967 (79.9%) and 11,460 of 11,985 (95.6%) first-time antenatal care (ANC) attendees were tested for syphilis (P < 0.0001), 523 of 12,761 (4.1%) and 1050 of 11,460 (9.2%) women tested positive (P < 0.0001); and 267 of 523 (51.1%) and 1000 of 1050 (95.2%) syphilis-positive women were treated (P < 0.0001), respectively. Comparing baseline and intervention, 7479 of 7830 (95.5%) and 11,151 of 11,409 (97.7%) of ANC attendees were tested for HIV (P < 0.0001) and 1303 of 1326 (98.3%) and 2036 of 2034 (100.1%) of those testing positive received combination antiretroviral drugs or single-dose nevirapine prophylaxis (P < 0.0001). In Uganda, 13,131 of 14,540 (90.3%) women were tested for syphilis during intervention, with 690 of 13,131 (5.3%) positive and 715 of 690 (103.6%) treated. Syphilis baseline data were collected, but not included in analysis, as ANC syphilis testing before the study was not consistently practiced. Comparing baseline and intervention, 6479 of 6776 (95.6%) and 11,192 of 11,610 (96.4%) ANC attendees were tested for HIV (P = 0.0009) and 570 of 726 (78.5%) and 964 of 1153 (83.6%) received combination or single-dose prophylaxis (P = 0.007). In Zambia, 254 of 1050 (24.2%) syphilis-positive pregnant women were HIV-positive and 99 of 690 (14.3%) in Uganda. CONCLUSIONS: Integrating RST in PMTCT programs increases screening and treatment for syphilis among HIV-positive pregnant women and does not compromise HIV services.

Oral versus anal sex at last encounter -- behavioral differences among men who have sex with men in the District of Columbia.

Oral sex may be used as a form of harm reduction against HIV transmission. We compared characteristics of men who have sex with men (MSM) in Washington, DC having oral sex versus those having anal sex at last encounter. Data collected through National HIV Behavioral Surveillance in 2008 using venue-based sampling were used. Men ≥18 years old disclosing MSM behavior in the past year were analyzed (n=500); OraQuick and Western Blot confirmation were used to assess HIV status. Multivariable methods were used for data analyses by type of sex at last encounter. A total of 71.8% of MSM had anal sex and 28.2% reported oral sex at last encounter. Men reporting oral sex were more likely to be white, older, insured, HIV-negative, unaware of last partner's HIV status, have a main partner, and not be HIV tested in the previous year. Significant demographic and behavioral differences exist between MSM reporting oral or anal sex; further studies should assess whether oral sex is being used as HIV prevention among MSM.

Elevated HIV prevalence despite lower rates of sexual risk behaviors among black men in the District of Columbia who have sex with men.

The District of Columbia (DC) has among the highest HIV/AIDS rates in the United States, with 3.2% of the population and 7.1% of black men living with HIV/AIDS. The purpose of this study was to examine HIV risk behaviors in a community-based sample of men who have sex with men (MSM) in DC. Data were from the National HIV Behavioral Surveillance system. MSM who were 18 years were recruited via venue-based sampling between July 2008 and December 2008. Behavioral surveys and rapid oral HIV screening with OraQuick ADVANCE ½ (OraSure Technologies, Inc., Bethlehem, PA) with Western blot confirmation on positives were collected. Factors associated with HIV positivity and unprotected anal intercourse were identified. Of 500 MSM, 35.6% were black. Of all men, 14.1% were confirmed HIV positive; 41.8% of these were newly identified HIV positive. Black men (26.0%) were more likely to be HIV positive than white (7.9%) or Latino/Asian/other (6.5%) men (p<0.001). Black men had fewer male sex partners than non-black, fewer had ever engaged in intentional unprotected anal sex, and more used condoms at last anal sex. Black men were less likely to have health insurance, have been tested for HIV, and disclose MSM status to health care providers. Despite significantly higher HIV/AIDS rates, black MSM in DC reported fewer sexual risks than non-black. These findings suggest that among black MSM, the primary risk of HIV infection results from nontraditional sexual risk factors, and may include barriers to disclosing MSM status and HIV testing. There remains a critical need for more information regarding reasons for elevated HIV among black MSM in order to inform prevention programming.

Risk factors driving the emergence of a generalized heterosexual HIV epidemic in Washington, District of Columbia networks at risk.

OBJECTIVES: Washington, District of Columbia has the highest HIV/AIDS rate in the United States, with heterosexual transmission a leading mode of acquisition and African-American women disproportionately affected. The purpose of this study was to examine risk factors driving the emergence of the local epidemic using National HIV Behavioral Surveillance data from the District of Columbia. DESIGN: The design of the study is cross-sectional. METHODS: Individuals at high risk for HIV based on connection to areas with elevated AIDS and poverty were collected from December 2006 to October 2007. Analyses characterized participants from a respondent-driven, nonclinic-based sample; factors associated with preliminary HIV positivity were assessed with logistic regression. RESULTS: Of 750 participants, 61.4% were more than 30 years of age, 92.3% African-American, and 60.0% with an annual household income of less than $10 000; 5.2% (95% confidence interval, 2.9-7.2%) screened HIV positive; women were more likely to screen positive than men (6.3 versus 3.9%). Of those, 47.4% (95% confidence interval, 30.9-78.7%) did not know their status prior to the study. Last vaginal sex was unprotected for 71.2% of respondents; 44.9% reported concurrent sex partners, and 45.9% suspected concurrency in their partners. Correlates of screening HIV positive were identified. CONCLUSION: This study suggests that a generalized heterosexual HIV epidemic among African-Americans in communities at risk may be emerging in the nation's capital alongside concentrated epidemics among men who have sex with men and injecting drug users. Innovation of prevention strategies is necessary in order to slow the epidemic in District of Columbia.