Exposure to HIV partner counseling and referral services and notification of sexual partners among persons recently diagnosed with HIV.

OBJECTIVE: Among HIV-infected persons, we evaluated use of client partner notification (CPN) and health-department partner notification strategies to inform sex partners of possible HIV exposure, and prior exposure to partner counseling and referral services. METHODS: We conducted a cross-sectional, observational study of 590 persons diagnosed with HIV in the prior 6 months at 51 HIV test, medical, and research providers in Chicago and Los Angeles in 2003 and 2004. Logistic regression was used to identify independent correlates of using CPN to notify all locatable partners. RESULTS: Participants reported a total of 5091 sex partners in the 6 months preceding HIV diagnosis; 1253 (24.6%) partners were locatable and not known to be HIV-positive. Of 439 participants with ≥1 locatable partners, 332 (75.6%) reported notifying 696 (55.5%) partners by CPN (585, 84.1%), health-department partner notification (94, 13.5%), or other means (17, 2.4%); 208 (47.4%) used CPN to notify all locatable partners. Independent correlates of CPN included having fewer locatable partners and discussing the need to notify partners with an HIV medical-care provider (black and Hispanic participants only). Many participants reported that their HIV test or medical-care provider did not discuss the need to notify partners (48.8%, 33.7%, respectively) and did not offer health-department partner-notification services (60.8%, 52.8%). CONCLUSION: Many locatable sex partners who might benefit from being notified of potential HIV exposure are not notified. In accordance with national policies, HIV test and medical-care providers should routinely provide partner counseling and referral services to HIV-infected clients so that all locatable partners are notified and provided an opportunity to learn their HIV status.

Drug use, high-risk sex behaviors, and increased risk for recent HIV infection among men who have sex with men in Chicago and Los Angeles.

We examined how drugs, high-risk sexual behaviors, and socio-demographic variables are associated with recent HIV infection among men who have sex with men (MSM) in a case-control study. Interviewers collected risk factor data among 111 cases with recent HIV infection, and 333 HIV-negative controls from Chicago and Los Angeles. Compared with controls, cases had more unprotected anal intercourse (UAI) with both HIV-positive and HIV-negative partners. MSM with lower income or prior sexually transmitted infections (STI) were more likely to be recently HIV infected. Substances associated with UAI included amyl nitrate ("poppers"), methamphetamine, Viagra (or similar PDE-5 inhibitors), ketamine, and gamma hydroxybutyrate (GHB). Cases more frequently used Viagra, poppers, and methamphetamine during UAI compared with controls. In multivariate analysis, income, UAI with HIV-positive partners, Viagra, and poppers remained associated with recent HIV seroconversion. Better methods are needed to prevent HIV among MSM who engage in high-risk sex with concurrent drug use.

Control of syphilis outbreaks in men who have sex with men: the role of screening in nonmedical settings.

OBJECTIVE: To quantify the scope and yield of targeted syphilis screening in nonmedical settings in 7 US cities affected by recent syphilis outbreaks among men who have sex with men (MSM). METHODS: Data were collected from syphilis screening activities targeting MSM between 1999 and 2004, conducted in bathhouses or other commercial sex venues, MSM-oriented bars, mobile vans, and other nonmedical settings by the public health departments of Chicago, Houston, Miami/Fort Lauderdale, Los Angeles, NY, and San Francisco. RESULTS: Of 14,143 syphilis screening tests (STS) conducted during community outreach campaigns at a variety of MSM oriented venues, 132 (0.9%) new cases of syphilis were identified. One hundred five (0.8%) new cases of early syphilis were found, including 23 cases of symptomatic syphilis. Screening in jails produced the highest prevalence of early syphilis (1.3%, 51 cases/3853 STS), followed by sex venues, including bathhouses (1.2%, 29 cases/2511 STS). CONCLUSIONS: These data suggest that even nontraditional, highly targeted screening programs conducted during outbreak situations do not detect many persons with syphilis, even though many of the screening venues were locations where men with syphilis met their sex partners. The low prevalence of infectious syphilis identified during these screening events suggests that the direct impact of these programs on decreasing syphilis transmission may be negligible. However, the secondary benefits, such as increasing awareness of syphilis and prompting earlier treatment due to symptom recognition, may be substantial.

Misclassification of the stages of syphilis: implications for surveillance.

SHORT SUMMARY: Syphilis cases were reviewed to see if reported stages met the Centers for Disease Control and Prevention case definition. Classification was excellent for primary and secondary and good for late latent, but half of early latent and unknown duration were misclassified. New surveillance definitions are suggested, comments requested. BACKGROUND: Uncertainty when staging latent syphilis should lead clinicians to call it late latent (requires more treatment) and disease investigators to call it early latent (priority for partner investigation). Accurate surveillance requires consistent case definitions. OBJECTIVE: Assess validity of reported syphilis stages. METHODS: Record reviews in 6 jurisdictions to determine if reported cases met the Centers for Disease Control and Prevention case definitions. RESULTS: Nine hundred seventy-three records from 6 jurisdictions in 2002 showed excellent agreement for reported primary (94.0%) and secondary (95.4%), good agreement for late latent (80.2%), and poor agreement for early latent (48.4%) and unknown duration (49.7%). Unknown duration (age < or =35 and nontreponemal test titer > or =32) was often misinterpreted to mean "not known." Early latent (within the past year, documented: seroconversion, fourfold titer increase, symptoms, or contact with an independently documented early syphilis case) was often misinterpreted to include patients with risky behavior, young age, or high nontreponemal test titers. CONCLUSIONS: The unknown duration stage should be dropped. Surveillance of latent syphilis would be more consistent if cases were reported as having high or low titers on nontreponemal test. Alternative approaches are solicited from readers.

The syphilis reactor grid: help or hindrance for syphilis surveillance?

BACKGROUND: Health departments use reactor grids (sex, age, and serologic test for syphilis [STS] titer criteria) to determine which persons to evaluate for untreated syphilis. GOAL: The goal of the study was to assess reactor grid performance in Chicago and reactor grid use nationally in 1999 to 2000. STUDY DESIGN: We reviewed Chicago health department records to identify characteristics of persons with a reactive STS excluded from evaluation by reactor grid criteria and syphilis cases not meeting evaluation criteria. We surveyed health departments regarding reactor grid use. RESULTS: Of persons with a reactive STS, 46% did not meet criteria for health department evaluation, including 62% of men, 29% of women, and 21% with titers > or =1:8. The reactor grid would have excluded 17% of primary syphilis cases. Overall, 82% of health departments use reactor grids. CONCLUSIONS: Reactor grids are widely used and may exclude persons with infectious syphilis from health department evaluation, especially men. The impact of reactor grid use on syphilis control and surveillance in the United States should be evaluated.

Sexually Transmitted Diseases in Men Who Have Sex with Men: An Epidemiologic Review.

The introduction of highly active antiretroviral therapy (HAART) has led to dramatic reductions in morbidity and mortality due to HIV infection. However, the resulting optimism and improved health status produced by HAART appears to have contributed to unanticipated consequences in men who have sex with men (MSM): loss of fear of acquiring and transmitting HIV, an increase in high-risk sex, decreased use of condoms, and a resurgence of gonorrhea and syphilis. Other factors, such as lack of knowledge of sexually transmitted diseases (STDs), use of the Internet as a venue to find sex partners, the increasing use of Viagra (Pfizer, New York, NY) as a recreational drug, and the apparent expanding role of oral sex in STD transmission are fueling these trends. Since ulcerative and inflammatory STDs facilitate HIV transmission, a new wave of HIV infection in MSM may be on the horizon. The rising STD rates and relapses in high-risk sexual behaviors in MSM, both HIV-infected and -uninfected MSM, have profound implications for public health and the clinical management of these patients. Clinicians should be aware of this turn of events, and implement new screening and counseling guidelines that have been issued in response to these alarming reports.

Occupationally acquired human immunodeficiency virus (HIV) infection: national case surveillance data during 20 years of the HIV epidemic in the United States.

OBJECTIVE: To characterize occupationally acquired human immunodeficiency virus (HIV) infection detected through case surveillance efforts in the United States. DESIGN: National surveillance systems, based on voluntary case reporting. SETTING: Healthcare or laboratory (clinical or research) settings. PATIENTS: Healthcare workers, defined as individuals employed in healthcare or laboratory settings (including students and trainees), who are infected with HIV. METHODS: Review of data reported through December 2001 in the HIV/AIDS Reporting System and the National Surveillance for Occupationally Acquired HIV Infection. RESULTS: Of 57 healthcare workers with documented occupationally acquired HIV infection, most (86%) were exposed to blood, and most (88%) had percutaneous injuries. The circumstances varied among 51 percutaneous injuries, with the largest proportion (41%) occurring after a procedure, 35% occurring during a procedure, and 20% occurring during disposal of sharp objects. Unexpected circumstances difficult to anticipate during or after procedures accounted for 20% of all injuries. Of 55 known source patients, most (69%) had acquired immunodeficiency syndrome (AIDS) at the time of occupational exposure, but some (11%) had asymptomatic HIV infection. Eight (14%) of the healthcare workers were infected despite receiving postexposure prophylaxis (PEP). CONCLUSIONS: Prevention strategies for occupationally acquired HIV infection should continue to emphasize avoiding blood exposures. Healthcare workers should be educated about both the benefits and the limitations of PEP, which does not always prevent HIV infection following an exposure. Technologic advances (eg, safety-engineered devices) may further enhance safety in the healthcare workplace.

Occupational risk of infection with human immunodeficiency virus

The risk of HIV infection in surgical settings is a composite of overlapping risks related to the local prevalence of HIV, the route of exposure to HIV-infected blood, and the susceptibility of the worker. Studies continue to suggest that the risk of blood contact, including percutaneous injuries, remains appreciable. Prevention of such exposures in the operating and delivery room by adoption of safer instruments, work practices, and techniques and by the consistent use of appropriate personnel protective equipment must be viewed as a priority