HIV among African-born persons in the United States: a hidden epidemic?

BACKGROUND: Although a large proportion of HIV diagnoses in Western Europe occur in African-born persons, analyses of US HIV surveillance data do not routinely assess the proportion of diagnoses occurring in African-born US residents. OBJECTIVE: To determine the percentage of newly reported HIV diagnoses occurring in African-born persons in selected areas of the United States with large African-born immigrant populations. METHODS: We collated and analyzed aggregate data on persons diagnosed with HIV in 2003-2004 and reported to HIV surveillance units in the states of California, Georgia, Massachusetts, Minnesota, and New Jersey and in King County, Washington; New York City; and the portion of Virginia included in the Washington, DC, metropolitan area. RESULTS: African-born persons accounted for 0.6% of the population and 3.8% of HIV diagnoses in participating areas (HIV diagnoses range: 1%-20%). Across all areas, up to 41% of diagnoses in women (mean: 8.4%, range: 4%-41%) and up to 50% of diagnoses in blacks (mean: 8.0%, range: 2%-50%) occurred among African-born individuals. CONCLUSIONS: In some areas, classifying HIV cases among foreign-born blacks as occurring in African Americans dramatically alters the epidemiological picture of HIV. Country of birth should be consistently included in local and national analyses of HIV surveillance data.

Factors associated with zidovudine receipt and prenatal care among HIV-infected pregnant women in New Jersey.

Despite reductions in perinatal HIV transmission, cases continue to occur. To determine factors associated with zidovudine (ZDV) receipt among HIV-infected pregnant women we merged three data sets for women in New Jersey in 1995-1997, identifying 395 HIV-infected pregnant women. Half received two arms of ZDV prophylaxis. Attendance at five or more prenatal visits was the strongest independent factor related to ZDV receipt (OR 6.37, 95% CI 3.84, 10.57). Half (49.0%) had limited prenatal care. AIDS diagnosis, race/ethnicity, and drug use were also independently related to ZDV receipt. Post hoc analysis revealed that being unmarried, Black, multiparous, having no insurance, and illegal drug use were associated with limited prenatal care. Although the U.S. has seen reductions in HIV perinatal transmission, our research showed that HIV-infected women who did not get prenatal care were less likely to receive two arms of ZDV prophylaxis. A wide public health net that brings all women into care is necessary to reduce perinatal transmission further.

Cancer risk in people infected with human immunodeficiency virus in the United States.

Data are limited regarding cancer risk in human immunodeficiency virus (HIV)-infected persons with modest immunosuppression, before the onset of acquired immunodeficiency syndrome (AIDS). For some cancers, risk may be affected by highly active antiretroviral therapy (HAART) widely available since 1996. We linked HIV/AIDS and cancer registries in Colorado, Florida and New Jersey. Standardized incidence ratios (SIRs) compared cancer risk in HIV-infected persons (initially AIDS-free) during the 5-year period after registration with the general population. Poisson regression was used to compare incidence across subgroups, adjusting for demographic factors. Among 57,350 HIV-infected persons registered during 1991-2002 (median CD4 count 491 cells/mm(3)), 871 cancers occurred during follow-up. Risk was elevated for Kaposi sarcoma (KS, SIR 1,300 [n = 173 cases]), non-Hodgkin lymphoma (NHL, 7.3 [n = 203]), cervical cancer (2.9 [n = 28]) and several non-AIDS-defining malignancies, including Hodgkin lymphoma (5.6 [n = 36]) and cancers of the lung (2.6 [n = 109]) and liver (2.7 [n = 14]). KS and NHL incidence declined over time but nonetheless remained elevated in 1996-2002. Incidence increased in 1996-2002 compared to 1991-1995 for Hodgkin lymphoma (relative risk 2.7, 95%CI 1.0-7.1) and liver cancer (relative risk infinite, one-sided 95%CI 1.1-infinity). Non-AIDS-defining cancers comprised 31.4% of cancers in 1991-1995, versus 58.0% in 1996-2002. For KS and NHL, risk was inversely related to CD4 count, but these associations attenuated after 1996. We conclude that KS and NHL incidence declined markedly in recent years, likely reflecting HAART-related improvements in immunity, while incidence of some non-AIDS-defining cancers increased. These trends have led to a shift in the spectrum of cancer among HIV-infected persons.

High incidence of new sexually transmitted infections in the year following a sexually transmitted infection: a case for rescreening.

BACKGROUND: Studies show 11% to 15% of women treated for Chlamydia trachomatis are reinfected 3 to 4 months after treatment, suggesting the need for rescreening. There is little information on infections among men, infections with Neisseria gonorrhoeae or Trichomonas vaginalis, or long-term follow-up. OBJECTIVE: To determine the incidence of new sexually transmitted infections during the year after a visit to a sexually transmitted disease (STD) clinic and associated risk factors. DESIGN: Secondary analysis of data from a randomized, controlled trial (RESPECT-2). SETTING: 3 urban STD clinics. PATIENTS: Sexually active patients enrolled in an HIV prevention counseling trial. MEASUREMENTS: Patient characteristics at the initial visit; behaviors during follow-up; and new infections with C. trachomatis, N. gonorrhoeae, or T. vaginalis (women only) detected during 4 scheduled return visits and any other interim visits. RESULTS: 2419 persons had 8129 three-month follow-up intervals. Among 1236 women, 25.8% had 1 or more new infections (11.9% acquired C. trachomatis, 6.3% acquired N. gonorrhoeae, and 12.8% acquired T. vaginalis); among 1183 men, 14.7% had 1 or more new infections (9.4% acquired C. trachomatis, and 7.1% acquired N. gonorrhoeae). Black persons and those with sexually transmitted infections at baseline were at highest risk for recurrent infection (adjusted odds ratio, 2.5 and 2.4, respectively). For persons infected at baseline, the risk for infection was high at 3 and 6 months (16.3 per 100 three-month intervals) and remained high at 9 and 12 months (12.0 per 100 three-month intervals). Most (67.2%) infections were diagnosed during study-related visits, and 66.2% of these patients reported no symptoms. LIMITATIONS: Because patients were recruited from STD clinics, results may not be generalizable. CONCLUSIONS: Men and women who receive diagnoses of C. trachomatis, N. gonorrhoeae, or T. vaginalis infections should return in 3 months for rescreening because they are at high risk for new asymptomatic sexually transmitted infections. Although single-dose therapy may adequately treat the infection, it often does not adequately treat the patient.

Efficacy of a booster counseling session 6 months after HIV testing and counseling: a randomized, controlled trial (RESPECT-2).

BACKGROUND: HIV counseling prevents sexually transmitted diseases (STDs), with most of the benefit accumulating in the first 6 months. STUDY: The authors conducted a multicenter, randomized, controlled trial of a 20-minute additional (booster) counseling session 6 months after HIV counseling compared with no additional counseling for prevention of STDs (gonorrhea, chlamydia, trichomoniasis). Participants were 15- to 39-year-old STD clinic patients in Denver, Long Beach, and Newark. RESULTS: Booster counseling was completed by 1120 (67.8%) of 1653 assigned to receive it. An incident STD during the 6 to 12 months after initial counseling (and within the 6 months after scheduled booster counseling) was detected in 141 of 1653 (8.5%) participants in the booster counseling group and 144 of 1644 (8.8%) in the no-booster group (relative risk, 0.97; 95% confidence interval, 0.78-1.22). Three months after booster counseling, sexual risk behaviors were reported less frequently by the booster group than the no-booster group. CONCLUSIONS: Booster counseling 6 months after HIV testing and counseling reduced reported sexual risk behavior but did not prevent STDs.

Relative efficacy of prevention counseling with rapid and standard HIV testing: a randomized, controlled trial (RESPECT-2).

BACKGROUND: Two risk-reduction counseling sessions can prevent sexually transmitted diseases (STDs); however, return rates for test results are low. STUDY: A randomized, controlled trial compared rapid HIV testing and counseling in 1 visit with standard HIV testing and counseling in 2 visits. Main outcomes were STDs (gonorrhea, chlamydia, trichomoniasis, syphilis, HIV) within 12 months. Participants were 15- to 39-year-old STD clinic patients in Denver, Long Beach, and Newark. STD screening and questionnaires were administered every 3 months. RESULTS: Counseling was completed by 1632 of 1648 (99.0%) of the rapid-test group and 1144 of 1649 (69.4%) of the standard-test group. By 12 months, STD was acquired by 19.1% of the rapid group and 17.1% of the standard group (relative risk [RR], 1.11; confidence interval [CI], 0.96-1.29). STD incidence was higher in the rapid-test group than in the standard-test group among men (RR, 1.34; CI, 1.06-1.70), men who had sex with men (RR, 1.86; 95% CI, 0.92-3.76), and persons with no STDs at enrollment (RR, 1.21; 95% CI, 0.99-1.48). Behavior was similar in both groups. CONCLUSIONS: Counseling with either test had similar effects on STD incidence. For some persons, counseling with standard testing may be more effective than counseling with rapid testing.

HIV infection and zidovudine use in childbearing women.

OBJECTIVE: The risk of vertical HIV transmission from mother to child has been shown to be markedly decreased through HIV education, counseling, testing, and zidovudine (ZDV) use. The US Public Health Service published guidelines in 1994 for the use of ZDV on the basis of results of the AIDS Clinical Trials Group Protocol, a multicenter clinical trial of ZDV. The Public Health Service followed these guidelines with recommendations for routine HIV counseling and testing with informed consent for all pregnant women. New Jersey adopted these guidelines as the standard of care and created a program implementing the standard in all hospitals with maternity units. The purpose of this report was to study the trends in the rate of HIV infection in childbearing women over the past decade and to follow patterns of use of ZDV in the HIV-positive women, as a marker for the success of New Jersey's policy and program to reduce mother-to-child transmission. METHODS: Since 1988 in New Jersey, blood from heel-stick filter papers has been tested for the presence of HIV antibody through anonymous, unlinked surveys. Excess blood from screening for inborn errors of metabolism for all infants who were born in the state from July through September of each year was tested using a Food and Drug Administration-approved HIV-1 and Western blot test. Age, race, and ethnicity were recorded, as well as the results from the HIV-1 and Western blot tests. Since 1994, specimens confirmed to be HIV-1 positive by Western blot test were tested for the presence of ZDV, and the results were recorded. RESULTS: The number of New Jersey women included in the study for the period 1990 through 2002 numbered 372305. The percentage of childbearing women who tested positive for HIV declined by 55% during the period, although the declines were not uniform in all subgroups. In the early 1990s, women who were <30 years old had higher infection rates than older women, but this has not been a consistent pattern during the period. Younger women again had a higher rate in 2002. When HIV-positive rates are examined by 5-year age groups, the declines are dramatic for younger women. The rate per 100 women 20 through 24 years decreased from 0.46 per 100 tested women in 1990 to 0.29 in 2002 and for women 25 through 29 years from 0.51 per 100 in 1990 to 0.25 in 2002. The rate for women 30 through 34 years of age declined from 0.54 in 1990 to 0.13 in 2002. During the same time period, the rate per 100 tested women 35 though 39 years of age increased from 0.23 to 0.33. Black non-Hispanic women who give birth to live infants have the highest HIV-positive rates, followed by Hispanic women and white non-Hispanic women. In 2002, this rate was 0.74 per 100 in black non-Hispanic women, 0.22 per 100 in Hispanic women, and 0.08 in white non-Hispanic women. Although major disparities continue, the infection rate in black non-Hispanic women demonstrated the greatest decrease during the period, followed by the decline among Hispanic women. The use of ZDV in HIV-positive women increased dramatically during the period, from 13.3% in 1994, when it was first tested in New Jersey, to an all-time high of 88.5% in 2002. CONCLUSIONS: Reducing perinatal HIV transmission is a priority for the New Jersey Department of Health and Senior Services. Reducing perinatal transmission can be accomplished by reducing the number of infants who are exposed perinatally or decreasing the percentage of exposed infants for whom transmission occurs or both. The decrease in prevalence of HIV-positive status in childbearing women is in opposition to an overall increasing trend in prevalence rates. This decrease is thought to be attributable in part to the positive impact of numerous education and prevention programs but may also be the result of a voluntary decision on the part of HIV-infected women not to become pregnant or not to carry to term. In addition, the cohort of women who became infected in the early years of the epidemic may be aging out of their childbearing years, may have more advanced disease with a concomitant difficulty with fertility and carrying to term, or may have died. In New Jersey, a greater proportion of women with newly diagnosed HIV disease are past their childbearing years as compared with earlier years. Increased use of ZDV is thought to be attributable to several factors: dissemination of information to health care providers via continuing medical education activities; dissemination of information to the public, in particular to women; outreach via community-based organizations; and New Jersey Department of Health and Senior Service regulations and policies for mandatory counseling and voluntary testing of all pregnant women. A recent addition to New Jersey's comprehensive program to decrease perinatal transmission occurred in 2002 with dissemination to hospitals of the department's standard of care for women who present in labor with unknown HIV status. Physicians, nurses, and hospitals play vital roles in preventing vertical transmission of HIV by providing preconception and postconception counseling, testing with consent of pregnant women, and treatment for HIV-positive mothers, including administration of ZDV. This study not only provides an estimate of the prevalence of HIV infection in the population of childbearing women but also provides a means of examining the vertical transmission of HIV infection from mother to child. Continued research on this subpopulation as well as on other groups will provide additional knowledge to help in the overall goal of reducing HIV prevalence.

HIV disease surveillance. Collaboration between medicine and public health.

Public Health Surveillance is critical to the management of programs designed to control the epidemic of HIV-AIDS. Surveillance defines changing trends, helps to formulate preventive initiatives and evaluate their effectiveness, and to allocate resources. Collaboration between clinical medicine and public health is essential to achieve reliable surveillance.