Pre-exposure prophylaxis (PrEP) use history in people with antiretroviral resistance at HIV diagnosis: Findings from New York City HIV surveillance and partner services, 2015-2022.

BACKGROUND: Drug resistance may be acquired in people starting HIV pre-exposure prophylaxis (PrEP) during undiagnosed infection. Population-based estimates of PrEP-related resistance are lacking. METHODS: We used New York City surveillance and partner services data to measure the effect of PrEP use (tenofovir disoproxil fumarate/tenofivir alafenamide fumarate with emtricitabine) history on baseline prevalence of M184I/V mutations in people diagnosed with HIV, 2015-2022. PrEP use was categorized as "Recent" defined as PrEP stopped ≤ 90 days before diagnosis, "Past" as PrEP stopped >90 days before diagnosis, and "No known use". Resistance associated mutations were determined using the Stanford Algorithm. We used log binomial regression to generate adjusted relative risk (aRR) of M184I/V by PrEP use history in people with and without acute HIV infection (AHI). RESULTS: Of 4,246 newly diagnosed people with a genotype ≤30 days of diagnosis, 560 (13%) had AHI, 136 (3%) reported recent, and 124 (35%) past PrEP use; 98 (2%) harbored M184I/V. In people with AHI, recent PrEP use was associated with 6 times greater risk of M184I/V than no known use (aRR: 5.86; 95% confidence interval [CI]: 2.49-13.77). In people without AHI, risk of M184I/V in recent users was 7 times (aRR:7.26; 95% CI: 3.98-13.24), and in past users, 4 times that of people with no known use (aRR: 4.46; 95% CI: 2.15-9.24). CONCLUSIONS: PrEP use was strongly associated with baseline M184I/V in NYC, regardless of AHI. Ordering a nucleic acid test when indicated after assessment of exposure, antiretroviral history and AHI symptoms can decrease PrEP initiation in people with undetected infection.

Survival Among New Yorkers with HIV from 1981 to 2017: Inequities by Race/Ethnicity and Transmission Risk Persist into the Post-HAART Era.

Data on long-term survival among people with HIV (PWH) can inform the development of services for this population. An estimated 90,000 PWH live in New York City (NYC). Using HIV surveillance data, we conducted survival analysis of PWH diagnosed in NYC before and after introduction of highly active antiretroviral therapy (HAART) (pre-HAART cohort: 1981-1994; post-HAART cohort: 1995-2016). We created Kaplan-Meier curves by cohort and demographic factors, and Cox proportional hazards models to evaluate adjusted mortality risk by cohort. 205,584 adults and adolescents were diagnosed with HIV in NYC from 1981 to 2016, half each in the pre-HAART and post-HAART eras. The pre-HAART cohort had significantly poorer survival compared with the post-HAART cohort. Adjusted mortality risk in the pre-HAART cohort was almost threefold that in the post-HAART cohort (HR 2.84, 95% confidence interval [CI] 2.80-2.88). In sex- and risk-stratified models, men who have sex with men (MSM) had the largest difference in mortality risk pre-HAART versus post-HAART (HR 5.41, 95% CI 5.23-5.59). Race/ethnic disparities were pronounced among MSM, with Latino/Hispanic and White MSM having lower mortality than Black MSM. Females with heterosexual risk born outside the US had lower mortality than US-born women. The improvement in survival post-HAART was most pronounced for White people. Survival among persons diagnosed with HIV in NYC increased significantly since the introduction of HAART. However, among MSM and among PWH overall, improvements even post-HAART lagged for Black and Latino/Hispanic people, underscoring the need to address structural barriers, including racism, to achieve optimal health outcomes among people with HIV.

Calculating Age-Standardized Death Rates Among People With HIV Comparable Across Jurisdictions and Over Time.

The Centers for Disease Control and Prevention (CDC) and local health jurisdictions have been using HIV surveillance data to monitor mortality among people with HIV in the United States with age-standardized death rates, but the principles of age standardization have not been consistently followed, making age standardization lose its purpose-comparison over time, across jurisdictions, or by other characteristics.We review the current practices of age standardization in calculating death rates among people with HIV in the United States, discuss the principles of age standardization including those specific to the HIV population whose age distribution differs markedly from that of the US 2000 standard population, make recommendations, and report age-standardized death rates among people with HIV in New York City.When we restricted the analysis population to adults aged between 18 and 84 years in New York City, the age-standardized death rate among people with HIV decreased from 20.8 per 1000 (95% confidence interval [CI] = 19.2, 22.3) in 2013 to 17.1 per 1000 (95% CI = 15.8, 18.3) in 2017, and the age-standardized death rate among people without HIV decreased from 5.8 per 1000 in 2013 to 5.5 per 1000 in 2017.

Addressing Ethical Challenges in US-Based HIV Phylogenetic Research.

In recent years, phylogenetic analysis of HIV sequence data has been used in research studies to investigate transmission patterns between individuals and groups, including analysis of data from HIV prevention clinical trials, in molecular epidemiology, and in public health surveillance programs. Phylogenetic analysis can provide valuable information to inform HIV prevention efforts, but it also has risks, including stigma and marginalization of groups, or potential identification of HIV transmission between individuals. In response to these concerns, an interdisciplinary working group was assembled to address ethical challenges in US-based HIV phylogenetic research. The working group developed recommendations regarding (1) study design; (2) data security, access, and sharing; (3) legal issues; (4) community engagement; and (5) communication and dissemination. The working group also identified areas for future research and scholarship to promote ethical conduct of HIV phylogenetic research.

An expanded HIV screening strategy in the Emergency Department fails to identify most patients with undiagnosed infection: insights from a blinded serosurvey.

Screening for HIV in Emergency Departments (EDs) is recommended to address the problem of undiagnosed HIV. Serosurveys are an important method for estimating the prevalence of undiagnosed HIV and can provide insight into the effectiveness of an HIV screening strategy. We performed a blinded serosurvey in an ED offering non-targeted HIV screening to determine the proportion of patients with undiagnosed HIV who were diagnosed during their visit. The study was conducted in a high-volume, urban ED and included patients who had blood drawn for clinical purposes and had sufficient remnant specimen to undergo deidentified HIV testing. Among 4752 patients not previously diagnosed with HIV, 1403 (29.5%) were offered HIV screening and 543 (38.7% of those offered) consented. Overall, undiagnosed HIV was present in 12 patients (0.25%): six among those offered screening (0.4%), and six among those not offered screening (0.2%). Among those with undiagnosed HIV, two (16.7%) consented to screening and were diagnosed during their visit. Despite efforts to increase HIV screening, more than 80% of patients with undiagnosed HIV were not tested during their ED visit. Although half of those with undiagnosed HIV were missed because they were not offered screening, the yield was further diminished because a substantial proportion of patients declined screening. To avoid missed opportunities for diagnosis in the ED, strategies to further improve implementation of HIV screening and optimize rates of consent are needed.

Proposing a New Indicator for the National Human Immunodeficiency Virus/AIDS Strategy: Percentage of Newly Diagnosed Persons Achieving Viral Suppression Within 3 Months of Diagnosis.

We propose an outcome indicator, the percentage of newly diagnosed persons achieving viral suppression within 3 months of diagnosis, to be included in the US National HIV/AIDS Strategy to monitor the progress in human immunodeficiency virus (HIV) care among persons newly diagnosed with HIV. Using HIV registry data, we reported that the percentage in New York City increased from 9% in 2007 to 37% in 2016. We recommend that the Centers for Disease Control and Prevention and local health agencies use this new indicator to monitor the progress in HIV care among persons newly diagnosed with HIV in the United States.

Social and Genetic Networks of HIV-1 Transmission in New York City.

BACKGROUND: Sexually transmitted infections spread across contact networks. Partner elicitation and notification are commonly used public health tools to identify, notify, and offer testing to persons linked in these contact networks. For HIV-1, a rapidly evolving pathogen with low per-contact transmission rates, viral genetic sequences are an additional source of data that can be used to infer or refine transmission networks. METHODS AND FINDINGS: The New York City Department of Health and Mental Hygiene interviews individuals newly diagnosed with HIV and elicits names of sexual and injection drug using partners. By law, the Department of Health also receives HIV sequences when these individuals enter healthcare and their physicians order resistance testing. Our study used both HIV sequence and partner naming data from 1342 HIV-infected persons in New York City between 2006 and 2012 to infer and compare sexual/drug-use named partner and genetic transmission networks. Using these networks, we determined a range of genetic distance thresholds suitable for identifying potential transmission partners. In 48% of cases, named partners were infected with genetically closely related viruses, compatible with but not necessarily representing or implying, direct transmission. Partner pairs linked through the genetic similarity of their HIV sequences were also linked by naming in 53% of cases. Persons who reported high-risk heterosexual contact were more likely to name at least one partner with a genetically similar virus than those reporting their risk as injection drug use or men who have sex with men. CONCLUSIONS: We analyzed an unprecedentedly large and detailed partner tracing and HIV sequence dataset and determined an empirically justified range of genetic distance thresholds for identifying potential transmission partners. We conclude that genetic linkage provides more reliable evidence for identifying potential transmission partners than partner naming, highlighting the importance and complementarity of both epidemiological and molecular genetic surveillance for characterizing regional HIV-1 epidemics.

Reduction in Gaps in High CD4 Count and Viral Suppression Between Transgender and Cisgender Persons Living With HIV in New York City, 2007-2016.

Objectives. To compare trends in HIV outcomes for cisgender and transgender persons living with HIV (PLWH) in New York City.Methods. We used HIV surveillance data for the analysis. We based CD4 count on the last measurement in a calendar year and defined viral suppression as the last viral load being less than or equal to 200 copies per milliliter in the calendar year.Results. The estimated number of PLWH increased from 73 415 in 2007 to 83 299 in 2016, including 606 transgender persons (0.8%) in 2007 and 1054 transgender persons (1.3%) in 2016. The proportion with CD4 count of 500 cells per cubic millimeter or more increased from 38% in 2007 to 61% in 2016 among cisgender persons versus 32% to 60% among transgender persons. The proportion with a suppressed viral load increased from 52% in 2007 to 80% in 2016 among cisgender persons versus 42% to 73% among transgender persons.Conclusions. Among PLWH in New York City, CD4 count and viral suppression improved during 2007 to 2016, with larger improvements among transgender persons, leading to narrower gaps. However, continuing efforts to improve HIV outcomes among transgender PLWH are needed to further eliminate disparities, particularly in viral suppression.

Healthcare facility characteristics associated with achievement and maintenance of HIV viral suppression among persons newly diagnosed with HIV in New York City.

Health care facility characteristics have been shown to influence intermediary health outcomes among persons with HIV, but few longitudinal studies of suppression have included these characteristics. We studied the association of these characteristics with the achievement and maintenance of HIV viral suppression among New York City (NYC) residents aged 13 years and older newly diagnosed with HIV between 2006 and 2012. The NYC HIV surveillance registry provided individual and facility data (N = 12,547 persons). Multivariable proportional hazards models estimated the likelihood of individual achievement and maintenance of suppression by type of facility, patient volume, and distance from residence, accounting for facility clustering and for individual-level confounders. Viral suppression was achieved within 12 months by 44% and at a later point by another 29%. Viral suppression occurred at a lower rate in facilities with low HIV patient volume (e.g., 10-24 diagnoses per year vs. ≥75, adjusted hazard ratio [AHR] = 0.87, 95% confidence interval [CI] 0.79-0.95) and in screening/diagnosis sites (vs. hospitals, AHR = 0.86, 95% CI 0.80-0.92). Among persons achieving viral suppression, 18% experienced virologic failure within 12 months and 24% later. Those receiving care at large outpatient facilities or large private practices had a lower rate of virologic failure (e.g., large outpatient facilities vs. large hospitals, AHR = 0.63, 95% CI 0.53-0.75). Achievement and maintenance of viral suppression were associated with facilities with higher HIV-positive caseloads. Some facilities with small caseloads and screening/diagnosis sites may need stronger care or referral systems to help persons with HIV achieve and maintain viral suppression.

Growth of HIV-1 Molecular Transmission Clusters in New York City.

Background: HIV-1 genetic sequences can be used to infer viral transmission history and dynamics. Throughout the United States, HIV-1 sequences from drug resistance testing are reported to local public health departments. Methods: We investigated whether inferred HIV transmission network dynamics can identify individuals and clusters of individuals most likely to give rise to future HIV cases in a surveillance setting. We used HIV-TRACE, a genetic distance-based clustering tool, to infer molecular transmission clusters from HIV-1 pro/RT sequences from 65736 people in the New York City surveillance registry. Logistic and LASSO regression analyses were used to identify correlates of clustering and cluster growth, respectively. We performed retrospective transmission network analyses to evaluate individual- and cluster-level prioritization schemes for identifying parts of the network most likely to give rise to new cases in the subsequent year. Results: Individual-level prioritization schemes predicted network growth better than random targeting. Across the 3600 inferred molecular transmission clusters, previous growth dynamics were superior predictors of future transmission cluster growth compared to individual-level prediction schemes. Cluster-level prioritization schemes considering previous cluster growth relative to cluster size further improved network growth predictions. Conclusions: Prevention efforts based on HIV molecular epidemiology may improve public health outcomes in a US surveillance setting.

Undiagnosed HIV and HCV Infection in a New York City Emergency Department, 2015.

OBJECTIVES: To measure undiagnosed HIV and HCV in a New York City emergency department (ED). METHODS: We conducted a blinded cross-sectional serosurvey with remnant serum from specimens originally drawn for clinical indications in the ED. Serum was deduplicated and matched to (1) the hospital's electronic medical record and (2) the New York City HIV and HCV surveillance registries for evidence of previous diagnosis before being deidentified and tested for HIV and HCV. RESULTS: The overall prevalence of HIV was 5.0% (250/4990; 95% confidence interval [CI] = 4.4%, 5.7%); the prevalence of undiagnosed HIV was 0.2% (12/4990; 95% CI = 0.1%, 0.4%); and the proportion of undiagnosed HIV was 4.8% (12/250; 95% CI = 2.5%, 8.2%). The overall prevalence of HCV (HCV RNA ≥ 15 international units per milliliter) was 3.9% (196/4989; 95% CI = 2.8%, 5.1%); the prevalence of undiagnosed HCV was 0.8% (38/4989; 95% CI = 0.3%, 1.3%); and the proportion of undiagnosed HCV was 19.2% (38/196; 95% CI = 11.4%, 27.0%). CONCLUSIONS: Undiagnosed HCV was more prevalent than undiagnosed HIV in this population, suggesting that aggressive testing initiatives similar to those directed toward HIV should be mounted to improve HCV diagnosis.

Persons living with diagnosed HIV in New York City: over 50% over 50 years old.

Using NYC HIV surveillance data, we estimated the annual median age of persons living with diagnosed HIV (PLWDH) and the proportion of PLWDH over 50 years old in NYC between 2008 and 2015, and described the characteristics, retention in care and viral suppression status among PLWDH in NYC in 2015, by age (<50 vs. ≥50 years old). The median age of PLWDH in NYC increased from 46.4 years (interquartile range [IQR]: 39.4, 53.2) in 2008 to 50.2 years (IQR: 39.8, 57.5) in 2015, and the proportion of PLWDH over 50 years old increased from 35.9% in 2008 to 50.6% in 2015. In 2015, by race/ethnicity, whites had the highest proportion over 50 years old (57.0%) and Asian/Pacific Islanders had the lowest (36.2%); by transmission risk, men who have sex with men were the lowest (40.0%) and injection drug users were the highest (76.1%). A large and increasing proportion of PLWDH over 50 years old presents challenges for HIV-infected individuals and healthcare system. Better social support services for HIV-infected individuals and additional training for medical and public health staff are needed.

Using the Revised Centers for Disease Control and Prevention Staging System to Classify Persons Living With Human Immunodeficiency Virus in New York City, 2011-2015.

The proportion of persons living with human immunodeficiency virus (HIV) in New York City in stage 1 (CD4 ≥ 500 cells/mm) increased from 50.6% in 2011 to 59.6% in 2015. The revised Centers for Disease Control and Prevention staging system of HIV infection is a useful tool with which to classify persons living with HIV.

Neighborhood Characteristics Associated with Achievement and Maintenance of HIV Viral Suppression Among Persons Newly Diagnosed with HIV in New York City.

We investigated the effect of neighborhood characteristics on achievement and maintenance of HIV viral suppression among New York City (NYC) residents aged 13 years and older diagnosed between 2006 and 2012. Individual records from the NYC HIV surveillance registry (n = 12,547) were linked to U.S. Census and American Community Survey data by census tract of residence. Multivariable proportional hazards regression models indicated the likelihood of achievement and maintenance of suppression by neighborhood characteristics including poverty, accounting for neighborhood clustering and for individual characteristics. In adjusted analyses, no neighborhood factors were associated with achievement of suppression. However, residents of high- or very-high-poverty neighborhoods were less likely than residents of low-poverty neighborhoods to maintain suppression. In conclusion, higher neighborhood poverty was associated with lesser maintenance of suppression. Assistance with post-diagnosis retention in care, antiretroviral therapy prescribing, or adherence targeted to residents of higher-poverty neighborhoods may improve maintenance of viral suppression in NYC.

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.

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.

Linkage and retention in care and the time to HIV viral suppression and viral rebound - New York City.

The success of antiretroviral therapy (ART) as treatment for the individual patient and as prevention requires the achievment and maintenance of human immunodeficiency virus (HIV) viral suppression. Linkage to and retention in care are required for access to ART. We describe the impact of care on viral suppression using routinely reported surveillance data. We included New York City residents ≥13 years of age, diagnosed with HIV/AIDS from 1 July 2005 to 30 June 2009 with a viral load (VL) or CD4 reported within six months of diagnosis and ≥1 VL reported from 1 July 2005 to 30 June 2011. To examine viral rebound, we restricted the analysis to those who achieved viral suppression and had a subsequent VL measure reported by 30 June 2011. Cox proportional hazards models were used to evaluate factors associated with time to viral suppression (VL ≤ 400 copies/mL) and rebound (VL > 1000 copies/mL). Initiation of care within three months of diagnosis (CD4/VL report within three months of diagnosis), female sex, and an initial CD4 < 350 (cells/mm(3)) at diagnosis significantly increased the likelihood of viral suppression. Irregular care (no CD4/VL reported every six months), younger age, non-white race/ethnicity, having an initial CD4 ≥ 350 at diagnosis, and AIDS diagnosis by 2010 increased the likelihood of rebound. These findings lend support to interventions for improving linkage to and maintenance in regular care as a way to achieve and maintain suppression. Surveillance data represent an ideal means for monitoring engagement in care and viral suppression at the population level.

The high proportion of late HIV diagnoses in the USA is likely to stay: findings from a mathematical model.

A static model of undiagnosed and diagnosed HIV infections by year of infection and year of diagnosis was constructed to examine the impact of changes in HIV case-finding and HIV incidence on the proportion of late diagnoses. With no changes in HIV case-finding or incidence, the proportion of late diagnoses in the USA would remain stable at the 2010 level, 32.0%; with a 10% increase in HIV case-finding and no changes in HIV incidence, the estimated proportion of late diagnoses would steadily decrease to 28.1% in 2019; with a 5% annual increase in HIV incidence and no changes in case-finding, the proportion would decrease to 25.2% in 2019; with a 5% annual decrease in HIV incidence and no change in case-finding, the proportion would steadily increase to 33.2% in 2019; with a 10% increase in HIV case-finding, accompanied by a 5% annual decrease in HIV incidence, the proportion would decrease from 32.0% to 30.3% in 2011, and then steadily increase to 35.2% in 2019. In all five scenarios, the proportion of late diagnoses would remain stable after 2019. The stability of the proportion is explained by the definition of the measure itself, as both the numerator and denominator are affected by HIV case-finding making the measure less sensitive. For this reason, we should cautiously interpret the proportion of late diagnoses as a marker of the success or failure of expanding HIV testing programs.

Retention in care and viral suppression among persons living with HIV/AIDS in New York City, 2006-2010.

OBJECTIVES: We estimated the proportions of persons living with HIV/AIDS (PLWHA) in New York City (NYC) retained in care and virally suppressed. METHODS: We used routinely reported laboratory surveillance data to measure trends in retention in care and viral suppression in PLWHA in NYC from 2006 through 2010. Our denominator excluded persons lacking any HIV-related laboratory tests during the 5 years prior to the year of analysis. RESULTS: The proportion of patients retained in care (≥ 1 care visit in a calendar year) was stable, at 82.5% in 2006 and 81.8% in 2010. However, the proportion of persons with evidence of viral suppression increased significantly, from 44.3% to 59.1%. Blacks were least likely to have viral suppression (adjusted prevalence ratio [APR] = 0.89; 95% confidence interval [CI] = 0.87, 0.90). A U-shaped relationship between age and viral suppression was observed, with the 20- to 29-year age group least likely to have a suppressed viral load. CONCLUSIONS: Higher and more plausible proportions retained in care and virally suppressed than national estimates may reflect the difference in methodology and our comprehensive HIV-related laboratory reporting system.