Impact of HIV preexposure prophylaxis prescriptions on HIV diagnoses in New York City.

BACKGROUND: HIV preexposure prophylaxis (PrEP) has proven to be efficacious and effective in preventing HIV infections, but few studies have reported its impact in the real world. METHODS: We conducted an ecological analysis and compared the trends in HIV PrEP prescriptions with the trends in age-adjusted HIV diagnosis rates in New York City (NYC). Joinpoint regression analyses were used to identify any temporal trends in HIV diagnosis rates in NYC. RESULTS: The number of people filling at least one PrEP prescription in NYC increased from 2551 in 2014 to 35 742 in 2022. The overall age-adjusted HIV diagnosis rate steadily decreased from 48.1 per 100 000 in 2003 to 17.1 per 100 000 in 2022. After the rollout of PrEP, accelerated decreases were detected in some subpopulations including white men [2014-2019 annual percentage change (APC): -16.6%; 95% confidence interval (CI) -22.7 to -10.0], Asian/Pacific Islander men (2016-2022 APC: -9.8%), men aged 20-29 years (2017-2020 APC: -9.4%) and 40 -49 years (2014-2020 APC: -12.2%), Latino/Hispanic people aged 40-49 years (2015-2020 APC: -13.0%), white people aged 20-29 years (2012-2022 APC: -11.4%) and 40-49 years (2014-2018 APC: -27.8%), and Asian/Pacific Islander people aged 20-29 years (2017-2022 APC: -13.0%). CONCLUSION: With a high coverage, PrEP can have a long-term impact in reducing HIV infections in a population, but if preexisting social determinants that contribute to racial, ethnic, and gender inequities are not well addressed, the implementation of PrEP can exacerbate these inequalities.

Five Waves of an Online HIV Self-Test Giveaway in New York City, 2015 to 2018.

BACKGROUND: HIV self-tests increase HIV status awareness by providing convenience and privacy, although cost and access may limit use. Since 2015, the New York City (NYC) Health Department has conducted 5 waves of an online Home Test Giveaway. METHODS: We recruited adult cisgender men who have sex with men (MSM) and transgender and gender-nonconforming (TGNC) individuals who had sex with men, who were living in NYC, not previously HIV diagnosed, and using paid digital advertisements (4-8 weeks per wave). Eligible respondents were e-mailed a code to redeem on the manufacturer's website for a free HIV self-test and an online follow-up survey ~2 months later. For key process and outcome measures, we present means across 5 waves. RESULTS: Across the 5 waves of Home Test Giveaway, there were 28,921 responses to the eligibility questionnaire: 17,383 were eligible, 12,182 redeemed a code for a free HIV self-test, and 7935 responded to the follow-up survey (46% of eligible responses). Among eligible responses, approximately half were Latino/a (mean, 32%) or non-Latino/a, black (mean, 17%). Mean report of never testing before was 16%. Among 5903 follow-up survey responses who reported test use, 32 reported reactive results with no known previous diagnosis (0.54%), of whom 78% reported receiving confirmatory testing. Report of likelihood of recommending the Home Test Giveaway to friends was high (mean, 96%). CONCLUSIONS: We recruited diverse NYC MSM and TGNC and distributed a large number of HIV self-tests to them. Among respondents who reported newly reactive tests, the majority reported confirmatory testing. This seems to be one acceptable way to reach MSM and TGNC for HIV testing, including those who have never tested before.

Estimating the probability of diagnosis within 1 year of HIV acquisition.

BACKGROUND: Early diagnosis of HIV is important for the prevention of ongoing transmission and development of HIV-related illness. The purpose of this study is to develop an outcome indicator to monitor the progress in early HIV diagnosis. METHODS: Persons diagnosed with HIV in New York City and their first CD4 test results were used to estimate the distribution of HIV diagnosis delay, based on a CD4 count depletion model. The distribution was then used to estimate the probability of diagnosis within 1 year of HIV acquisition, which is the number of cases diagnosed in a given calendar year for which diagnosis occurred within 1 year of acquisition divided by the number of incident cases in that calendar year. RESULTS: In 2012-2016, the estimated annual probability of diagnosis within 1 year of HIV acquisition in New York City was 43.0% [95% confidence interval (CI): 37.9-48.2%), 42.5% (95% CI: 36.8--48.3%), 42.8% (95% CI: 36.3--49.2%), 42.9% (95% CI: 35.4--50.3%), and 42.2% (95% CI: 33.1--51.2%), respectively. CONCLUSION: National and local health jurisdictions should consider using this new outcome indicator, the probability of diagnosis within 1 year of HIV acquisition, to monitor their progress in early HIV diagnosis.

Evaluating the 2010 New York State HIV testing law in NYC ambulatory practices using electronic health records.

INTRODUCTION: In 2010, the New York State Legislature made it mandatory to offer an HIV test to people aged 13-64 years receiving hospital or primary care services, with limited exceptions. In this study, we used data from New York City practices to evaluate the impact of the law on HIV testing rates in ambulatory care. METHODS: We collected quarterly testing data from the electronic health records of 218 practices. We calculated overall and stratified crude testing rates. Using univariate and multivariate generalized estimating equation models, we assessed the odds of testing in the year before the law (baseline) versus the first and second year after the law's implementation (year 1 and year 2). RESULTS: During baseline, the odds of testing did not increase significantly. During year 1, the odds of testing significantly increased by 50% in the univariate model and 200% after adjusting for confounders. During year 2, the odds of testing increased 10%. This was only significant in the univariate model. The crude quarterly testing rate increased from 2.8% to 5.7% from baseline to year 2. CONCLUSIONS: Our evaluation showed that after the implementation of the HIV testing law, there was an increase in HIV testing among NYC ambulatory practices. Testing rates remained modest, but considerable improvement was seen in community health centers, in age ranges targeted by the law and in practices that were screening for HIV at baseline. This study suggests that legislation may be effective when used in a comprehensive prevention strategy.

HIV testing experience in New York City: offer of and willingness to test in the context of new legal support of routine testing.

BACKGROUND: In the United States, routine HIV testing is recommended for persons aged 13-64 years. In 2010, New York State passed a law mandating offer of testing in most health-care settings. We report on the consumer perspective in New York City (NYC) shortly after the law's enactment. METHODS: We analyzed data from a 2011 telephone survey representative of NYC adults aged 18-64 years (n = 1,846). This analysis focused on respondents' report of HIV test offer at last clinical visit and of willingness to test if recommended by their doctor. Offer and willingness were estimated by age, gender, race/ethnicity, education, income, marital status, sexual identity, partner number, and HIV testing history; associations were examined using multivariable regression. RESULTS: Among NYC adults, 35.7% reported an HIV test in the past year and 31.8% had never tested. Among 86.7% with a clinical visit in the past year, 31.4% reported being offered a test at last visit. Offer was associated with younger age, race/ethnicity other than white, non-Hispanic, lower income, and previous testing. Only 6.7% of never-testers were offered a test at last clinical visit. Willingness to test if recommended was high overall (90.2%) and across factors examined. CONCLUSIONS: After a new law was enacted in support of routine HIV testing, approximately 1 in 3 New Yorkers aged 18-64 years were offered a test at last clinical visit; 9 in 10 were willing to test if recommended by their doctor. This suggests that patient attitudes will not be a barrier to complete implementation of the law.

Assessing the impact of a community-wide HIV testing scale-up initiative in a major urban epidemic.

BACKGROUND: The Bronx, one of 5 boroughs in New York City (NYC), bears a high burden of HIV. We evaluated the impact of HIV testing initiatives in the Bronx, including the 2008 The Bronx Knows campaign. METHODS: We used data from an annual telephone survey representative of NYC adults to compare 2005 and 2009 estimates of HIV testing prevalence among Bronx residents and to identify correlates of testing. We used NYC HIV surveillance data to evaluate changes in the percentage of persons concurrently being diagnosed with HIV and AIDS, an indicator of delayed HIV diagnosis. RESULTS: Between 2005 and 2009, relative increases of 14% and 32% were found in the proportion of Bronx adults who have ever been HIV tested and who have been tested in the past year, respectively (P < 0.001). The largest increases were among those aged 24-44 years, men, non-Hispanic blacks and Hispanics, and those with low income or education, nonheterosexual identity, a personal doctor/provider, or health insurance. Factors independently associated with being recently tested included black or other race, Hispanic ethnicity, and bisexual identity. The proportion concurrently diagnosed with HIV and AIDS fell 22% from 2005 to 2009, and decreases generally occurred among subgroups experiencing increases in testing. CONCLUSION: Community-wide testing in the Bronx increased the proportion of people with known HIV status and reduced the proportion with delayed diagnoses.

Most positive HIV western blot tests do not diagnose new cases in New York City: implications for HIV testing programs.

OBJECTIVE: To evaluate HIV testing efforts based on surveillance data. METHODS: We determined the contribution of new diagnoses to all positive confidential HIV-1 Western blotting conducted in New York City between 2004 and 2006 based on clinical history recorded in the HIV Surveillance Registry, by testing site type. RESULTS: Of 31,504 positive Western blots reported and linked to Registry cases, 36.8% were new diagnoses and 63.2% were repeat positive tests. City health department clinics and private physicians' offices reported greater proportions of new diagnoses than other testing sites (64.4% and 58.3% vs. 31.1%). The percentage of positive tests at health department clinics that were new diagnoses increased from 59.8% in 2004 to 69.0% in 2006 (P = 0.001), coinciding with efforts to expand HIV testing. Repeat positive testers were significantly older, more likely to have an injection drug use history or AIDS, and less likely to be foreign-born. CONCLUSIONS: Repeat testing of known HIV-infected persons is common and an inefficient use of HIV prevention resources when the purpose of testing is to diagnose previously unidentified infections. Initiatives to increase HIV testing should be evaluated routinely using surveillance data to determine the proportion of infected persons identified who are newly diagnosed.

Why don't physicians test for HIV? A review of the US literature.

OBJECTIVE: In its 2006 HIV testing guidelines, the Centers for Disease Control and Prevention (CDC) recommended routine testing in all US medical settings. Given that many physicians do not routinely test for HIV, the objective of this study was to summarize our current understanding of why US physicians do not offer HIV testing. DESIGN: A comprehensive review of the published and unpublished literature on HIV testing barriers was conducted. METHODS: A literature search was conducted in Pubmed using defined search terms. Other sources included Google, recent conference abstracts, and experts in the field. Studies were divided into three categories: prenatal; emergency department; and other medical settings. These categories were chosen because of differences in physician training, practice environment, and patient populations. Barriers identified in these sources were summarized separately for the three practice settings and compared. RESULTS: Forty-one barriers were identified from 17 reports. Twenty-four barriers were named in the prenatal setting, 20 in the emergency department setting, and 23 in other medical settings. Eight barriers were identified in all three categories: insufficient time; burdensome consent process; lack of knowledge/training; lack of patient acceptance; pretest counselling requirements; competing priorities; and inadequate reimbursement. CONCLUSION: US physicians experience many policy-based, logistical, and educational barriers to HIV testing. Although some barriers are exclusive to the practice setting studied, substantial overlap was found across practice settings. Some or all of these barriers must be addressed before the CDC recommendation for routine HIV testing can be realized in all US medical settings.