Understanding the Intersection of Behavioral Risk and Social Determinants of Health and the Impact on an Outbreak of Human Immunodeficiency Virus Among Persons Who Inject Drugs in Philadelphia.

BACKGROUND: In 2018, Philadelphia identified an outbreak of new human immunodeficiency virus (HIV) infections among persons who inject drugs (PWID). Although conventional HIV surveillance systems capture individual-level behavioral risk, they are not able to capture the social and environmental factors contributing to rapid transmission. METHODS: HIV surveillance data were used to assess demographic, clinical, and behavioral factors for PWID with HIV diagnosed during 2017 and 2018. Social factors such as homelessness, disruption of encampments, and trends in sexual behaviors, drug use and syringe availability among PWID were captured through National HIV Behavioral Surveillance, routine hepatitis and sexually transmitted infection surveillance, and shelter and homeless outreach data. RESULTS: In 2018, there were 71 new infections among PWID, an increase of 115% since 2016. During this time, opioid overdose deaths peaked at 59 deaths per 100 000 persons, 85% of which involved the use of fentanyl. While overall reported homelessness increased, rates of those living unsheltered rose by 13%. The Philadelphia Department of Public Health identified increased injection frequency, encampment closures, and lack of syringe access as promoters of continued HIV transmission. CONCLUSION: The use of conventional surveillance methods only is inadequate for determining HIV risk during outbreaks. Incorporation of individual and aggregate level data on social and environmental determinants is necessary to develop effective outbreak response interventions.

Interdisciplinary HIV Sentinel Case Review: Identifying Practices to Prevent Outbreaks in Philadelphia.

INTRODUCTION: The Ending the HIV Epidemic in the U.S. initiative considers cluster and outbreak response essential. This article describes the design, implementation, and early findings of a Philadelphia-based project to systematically assess sentinel cases among priority populations for improving public health infrastructure and preventing future outbreaks. METHODS: Sentinel HIV cases (i.e., early-stage or acute infection or molecular cluster cases) were identified among priority populations (Black and Hispanic/Latino men who have sex with men, youth aged 18-24 years, and transgender people who have sex with men). Chart abstraction and structured interview data were reviewed to determine themes and service gaps and to identify, prioritize, and implement recommendations. Interdisciplinary review teams included individuals with lived experience, frontline staff, and local agency leadership. RESULTS: Data were collected during July 2019-December 2020 and analyzed for 53 of 126 sentinel cases of HIV diagnosed since July 1, 2018. The majority were men who have sex with men (79.3%), those aged 18-24 years (67.9%), and non-Hispanic Black (67.9%). More than half received sexually transmitted infection and HIV testing ≤3 years preceding HIV diagnosis (56.6% and 54.7%, respectively), had a healthcare visit within 12 months before diagnosis (64.2%), and had no evidence of pre-exposure prophylaxis awareness (58.5%). Project recommendations effectuated actions to improve pre-exposure prophylaxis provision, integrate sexually transmitted infection and HIV testing, and educate primary care providers. CONCLUSIONS: HIV sentinel case review is a model for health departments to rapidly respond to recent transmission, identify missed HIV prevention opportunities, strengthen community partnerships, and implement programmatic and policy changes. Such efforts may prevent outbreaks and inform longer-term strategies.

I Am Men's Health: Generating Adherence to HIV Pre-Exposure Prophylaxis (PrEP) in Young Men of Color Who Have Sex with Men.

In 2012, the US Food and Drug Administration approved Truvada as a pre-exposure prophylaxis (PrEP) for adults at risk of HIV. PrEP is highly effective at preventing HIV when taken daily, but no gold standard exists for consistently administering PrEP to populations at highest risk. The "I Am Men's Health" program used an innovative methodology to generate adherence to PrEP in 23 mostly young men who have sex with men of color (yMSMc), during a 28-week period from February to September 2013. Adherence was measured using weekly medication pickup rates. The average age of the participants was 21 years, and the majority were black and lived below the poverty line. Time on PrEP ranged from 1 to 28 weeks (2723 person-days), and the weighted average adherence was 73%. The methodology used in this study was preliminarily effective at generating adherence to PrEP among high-risk yMSMc in a community setting and may help inform large-scale future HIV prevention interventions.