Neighborhood social cohesion and viral suppression after HIV diagnosis.

Social cohesion has varying effects on health. We investigated the association of perceived neighborhood social cohesion with HIV viral suppression using individual-level data from the New York City HIV registry and surveillance-based interviews (n = 92). Suppression was achieved within 12 months of HIV diagnosis by 60 percent of persons perceiving low cohesion and 71 percent of those perceiving high (p = 0.31). Controlling for demographic and clinical characteristics and neighborhood poverty, per proportional hazards regression, cohesion was not associated with suppression (adjusted hazards ratio (95% confidence interval) for high versus low cohesion: 0.79 (0.49-1.28)). Cohesion may have heterogeneous effects on HIV medication adherence.

Enrollment Length, Service Category, and HIV Health Outcomes Among Low-Income HIV-Positive Persons Newly Enrolled in a Housing Program, New York City, 2014-2017.

Objectives. To evaluate the impact of duration and service category on HIV health outcomes among low-income adults living with HIV and enrolled in a housing program in 2014 to 2017.Methods. We estimated relative risk of engagement in care, viral suppression, and CD4 improvement for 561 consumers at first and second year after enrollment to matched controls through the New York City HIV surveillance registry, by enrollment length (enrolled for more than 1 year or not) and service category (housing placement assistance [HPA], supportive permanent housing [SPH], and rental assistance [REN]).Results. The SPH and REN consumers were enrolled longer and received more services, compared with HPA consumers. Long-term SPH and REN consumers had better engagement in care, viral suppression, and CD4 count than controls at both first and second year after enrollment, but the effect did not grow bigger from year 1 to 2. HPA consumers did not have better outcomes than controls regardless of enrollment length.Conclusions. Longer enrollment with timely housing placement and a higher number and more types of services are associated with better HIV health outcomes for low-income persons living with HIV with unmet housing needs.

Housing Subsidies and Housing Stability are Associated with Better HIV Medical Outcomes Among Persons Who Experienced Homelessness and Live with HIV and Mental Illness or Substance Use Disorder.

Among 958 applicants to a supportive housing program for low-income persons living with HIV (PLWH) and mental illness or a substance use disorder, we assessed impacts of housing placement on housing stability, HIV care engagement, and viral suppression. Surveillance and administrative datasets provided medical and residence information, including stable (e.g., rental assistance, supportive housing) and unstable (e.g., emergency shelter) government-subsidized housing. Sequence analysis identified a "quick stable housing" pattern for 67% of persons placed by this program within 2 years, vs. 28% of unplaced. Compared with unplaced persons not achieving stable housing quickly, persons quickly achieving stable housing were more likely to engage in care, whether placed (per Poisson regression, ARR: 1.14;95% CI 1.09-1.20) or unplaced (1.19;1.13-1.25) by this program, and to be virally suppressed, whether placed (1.22;1.03-1.44) or unplaced (1.26, 1.03-1.56) by this program. Housing programs can help homeless PLWH secure stable housing quickly, manage their infection, and prevent transmission.

RESUMEN: Unas 958 personas de bajos recursos y quienes viven con VIH y enfermedades mentales o bien presentan problemas de abuso de sustancias solicitaron a un programa de vivienda complementada con servicios de apoyo. Entre ellas, se evaluó los impactos de la colocación en viviendas sobre la estabilidad en la misma, así como la participación en los cuidados médicos para el VIH, y la supresión de la carga viral. Las bases de datos administrativas y del registro de vigilancia brindaron información médica y domiciliar, incluyendo información sobre vivienda estable (por ejemplo, asistencia de pago de renta a largo plazo, o vivienda complementada con servicios de apoyo) y vivienda inestable (por ejemplo, alojamiento de emergencia temporal) subsidiada por el gobierno. El método "análisis de secuencia" permitió identificar una pauta caracterizada por estabilidad domiciliar conseguida de modo ligero (es decir, de forma oportuna) en el 67% de las personas quienes fueron colocadas por este programa dentro de un lapso de dos años, comparado con 28% de las personas quienes no fueron colocadas. En comparación con las personas quienes no fueron colocadas y no lograron estabilidad de vivienda de modo ligero, las personas quienes lograron estabilidad de vivienda de modo ligero tuvieron una mayor probabilidad de participar en cuidados médicos, ya sea que fueran colocadas (según regresión de Poisson, cociente de riesgo ajustado: 1.14; intervalo de confianza de 95%: 1.09-1.20) o no fueran colocadas (1.19, 1.13-1.25) por este programa, así como de lograr la supresión de la carga viral, ya sea que fueran colocadas (1.22, 1.03-1.44) o no fueran colocadas (1.26, 1.03-1.56) por este programa. Los programas que facilitan la colocación en o el pago de vivienda y apoyo en el mismo pueden ayudar a las personas con VIH y sin hogar obtener vivienda estable de modo ligero, controlar su infección, y prevenir la transmisión.

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.

Multilevel Factors Associated with a Lack of Viral Suppression Among Persons Living with HIV in a Federally Funded Housing Program.

Persons with HIV who are receiving housing services often have high rates of engagement in care, yet many are not virally suppressed. We linked data from the New York City Housing Opportunities for Persons with AIDS (HOPWA) program to electronically reported laboratory tests from the HIV surveillance registry to examine factors associated with a lack of viral suppression. Of 1491 HOPWA consumers, 523 (35.1%) were not durably suppressed, and 253 (17.0%) were unsuppressed at their last viral load test. Substance use, age < 27 years, and emergency housing all independently predicted lack of durable viral suppression and lack of viral suppression at last viral load test.

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.

Long-Term Supportive Housing is Associated with Decreased Risk for New HIV Diagnoses Among a Large Cohort of Homeless Persons in New York City.

It is unknown whether providing housing to persons experiencing homelessness decreases HIV risk. Housing, including access to preventive services and counseling, might provide a period of transition for persons with HIV risk factors. We assessed whether the new HIV diagnosis rate was associated with duration of supportive housing. We linked data from a cohort of 21,689 persons without a previous HIV diagnosis who applied to a supportive housing program in New York City (NYC) during 2007-2013 to the NYC HIV surveillance registry. We used time-dependent Cox modeling to compare new HIV diagnoses among recipients of supportive housing (defined a priori, for program evaluation purposes, as persons who spent > 7 days in supportive housing; n = 6447) and unplaced applicants (remainder of cohort), after balancing the groups on baseline characteristics with propensity score weights. Compared with unplaced applicants, persons who received ≥ 3 continuous years of supportive housing had decreased risk for new HIV diagnosis (HR 0.10; CI 0.01-0.99). Risk of new HIV diagnosis decreased with longer duration placement in supportive housing. Supportive housing might aid in primary HIV prevention.

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.

Brief Report: HIV Prevalence and the Prevalence of Unsuppressed HIV in New York City, 2010-2014.

BACKGROUND: The widespread use of antiretroviral treatment made HIV prevalence no longer a good measure of population-level transmission risk. The objective of this analysis was to use the prevalence of unsuppressed HIV to describe population-level HIV transmission risk. METHODS: Using New York City (NYC) HIV surveillance data, we reported HIV prevalence and the prevalence of unsuppressed HIV, defined as the number of persons living with HIV with an unsuppressed viral load divided by population size. RESULTS: The estimated number of persons living with HIV in NYC increased from 79,100 [95% confidence interval (CI): 78,200 to 80,000] in 2010 to 81,700 (95% CI: 80,500 to 82,900) in 2014. HIV prevalence (≥18 years old) remained unchanged at 1.22% (95% CI: 1.21% to 1.24%) in 2010 and 1.22% (95% CI: 1.20% to 1.24%) in 2014. The prevalence of unsuppressed HIV (≥18 years old) steadily decreased from 0.49% (95% CI: 0.48% to 0.51%) in 2010 to 0.34% (95% CI: 0.32% to 0.36%) in 2014. Men had both higher HIV prevalence (1.86% vs. 0.65% in 2014) and higher prevalence of unsuppressed HIV (0.51% vs. 0.18% in 2014) than women. In 2014, the black-white ratio of prevalence of unsuppressed HIV was 5.8 among men and 26.3 among women, and the Hispanic-white ratio was 2.7 among men and 10.0 among women. CONCLUSIONS: The prevalence of unsuppressed HIV has been steadily decreasing in NYC. As antiretroviral treatment continues to expand, programs should consider using the prevalence of unsuppressed HIV to measure population-level transmission risk.

Persistent Racial Disparities in HIV Infection in the USA: HIV Prevalence Matters.

OBJECTIVES: Despite increased funding and efforts to prevent and control HIV infections in the black and Hispanic communities, racial disparities persist in the USA. We used a mathematical model to explain the phenomena. METHODS: A mathematical model was constructed to project HIV prevalence ratio (PR), incidence rate ratio (IRR), and HIV-specific mortality rate ratio (MRR) among blacks and Hispanics vs. whites in two scenarios: (1) an annual reduction in HIV incidence rate at the 2007-2010 level and (2) an annual reduction in HIV incidence rate at the 2007-2010 level among whites (4.2 %) and twice that of whites among blacks and Hispanics (8.4 %). RESULTS: In scenario no. 1, the PR, IRR, and MRR among blacks would decrease from 7.6 to 5.8, 7.9 to 5.9, and 11.3 to 5.3 and among Hispanics from 2.8 to 1.8, 3.1 to 1.9, and 2.3 to 1.0, respectively. In scenario no. 2, the PR, IRR, and MRR among blacks would decrease from 7.6 to 5.1, 7.9 to 2.5, and 11.3 to 4.7 and among Hispanics from 2.8 to 1.6, 3.1 to 0.8, and 2.3 to 0.9, respectively. CONCLUSIONS: Much of the persistent racial disparities in HIV infection in the USA, as measured by PR, IRR, and MRR, can be explained by higher HIV prevalence among blacks and Hispanics. The public health community should continue its efforts to reduce racial disparities, but also need to set realistic goals and measure progress with sensitive indicators.

Estimated HIV Incidence in the United States, 2003-2010.

OBJECTIVE: To estimate HIV incidence in the United States using a newly developed method. METHODS: The analysis period (2002-2011) was broken down into 3-year periods with overlaps, and HIV incidence was estimated based on the relationship between number of new diagnoses and HIV incidence in each of these 3-year periods, by assuming that all HIV infections would eventually be diagnosed and within each 3-year period HIV incidence and case finding were stable. RESULTS: The estimated HIV incidence in the United States decreased from 52,721 (range: 47,449-57,993) in 2003 to 39,651 (range: 35,686-43,617) in 2010, among males from 38,164 (range: 35,051-42,840) to 33,035 (range: 29,088-35,553), and among females from 13,557 (range: 12,133-14,830) to 6616 (range: 5825 to 7120). CONCLUSIONS: Using a simple and novel method based on the number of new HIV diagnoses, we were able to estimate HIV incidence and report a declining trend in HIV incidence in the United States since 2003.

Persons Living With HIV in the United States: Fewer Than We Thought.

OBJECTIVES: To estimate the number of persons living with HIV (PLWH) in the United States and to describe their care status. METHODS: Estimates of diagnosed PLWH in New York City and other 19 jurisdictions based on HIV case reporting were compared with those based on HIV laboratory reporting. A revised HIV care continuum was constructed based on previously published data. RESULTS: The estimate of PLWH based on HIV case reporting was 25.6% higher than that based on HIV laboratory reporting data in New York City. There were 819,200 PLWH in the United States at the end of 2011 (plausible range: 809,800-828,800), of whom 86% were diagnosed, 72% were retained in care (≥1 care visit in 2011), 68% were on antiretroviral therapy, and 55% were virally suppressed (≤200 copies/mL). CONCLUSIONS: The current method based on HIV case reporting may have overestimated PLWH in the United States. While we continue cleaning HIV case reporting data to improve its quality, we should take the opportunity to use comprehensive HIV laboratory reporting data to estimate PLWH at both the national and local levels.

The Association Between Neighborhood Poverty and HIV Diagnoses Among Males and Females in New York City, 2010-2011.

OBJECTIVE: We assessed the association of neighborhood poverty with HIV diagnosis rates for males and females in New York City. METHODS: We calculated annual HIV diagnosis rates by ZIP Code, sex, and neighborhood poverty level using 2010-2011 New York City (NYC) HIV surveillance data and data from the U.S. Census 2010 and American Community Survey 2007-2011. Neighborhood poverty levels were percentage of residents in a ZIP Code with incomes below the federal poverty threshold, categorized as 0%-<10% (low poverty), 10%-<20% (medium poverty), 20%-<30% (high poverty), and 30%-100% (very high poverty). We used sex-stratified negative binomial regression models to measure the association between neighborhood-level poverty and HIV diagnosis rates, controlling for neighborhood-level education, race/ethnicity, age, and percentage of men who have sex with men. RESULTS: In 2010-2011, 6,184 people were newly diagnosed with HIV. Median diagnosis rates per 100,000 population increased by neighborhood poverty level overall (13.7, 34.3, 50.6, and 75.6 for low-, medium-, high-, and very high-poverty ZIP Codes, respectively), for males, and for females. In regression models, higher neighborhood poverty remained associated with higher diagnosis rates among males (adjusted rate ratio [ARR] = 1.63, 95% confidence interval [CI] 1.34, 1.97) and females (ARR=2.14, 95% CI 1.46, 3.14) for very high- vs. low-poverty ZIP Codes. CONCLUSION: Living in very high- vs. low-poverty urban neighborhoods was associated with increased HIV diagnosis rates. After controlling for other factors, the association between poverty and diagnosis rates was stronger among females than among males. Alleviating poverty may help decrease HIV-related disparities.

Comparison of indicators measuring the proportion of human immunodeficiency virus-infected persons with a suppressed viral load.

PURPOSE: The Centers for Disease Control and Prevention uses the last viral load to estimate the proportion of human immunodeficiency virus (HIV)-infected persons with a suppressed viral load. Several recent studies report that it may overestimate viral suppression in the population and have suggested using sustained viral suppression. The objective of this analysis is to compare these indicators. METHODS: Using New York City HIV surveillance data, two indicators were compared with a new one, weighted viral suppression, which accounts for both the status and duration of viral suppression. RESULTS: Among 72,315 HIV-infected persons with at least one viral load measurement in New York City in 2013, 62,829 had at least one suppressed viral load, 58,041 had a suppressed last viral load, and 47,948 had sustained viral suppression. Compared with the weighted proportion (77.5%), the proportion based on last viral load suppression (80.3%) was slightly higher, and the proportion based on sustained viral suppression (66.3%) was substantially lower. CONCLUSIONS: The indicator based on last viral load suppression is the most straightforward to calculate and understand and also approximates the weighted indicator, which measures viral suppression for the entire analysis period. Therefore, we support using the indicator based on last viral load suppression to monitor the National HIV/AIDS Strategy.

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.

Monitoring outcomes for newly diagnosed and prevalent HIV cases using a care continuum created with New York city surveillance data.

BACKGROUND: The HIV care continuum has been used to show the proportion of persons living with HIV/AIDS (PWHA) who are engaged in each stage of HIV care. We present 1 care continuum for persons newly diagnosed with HIV and 1 for PWHA using New York City HIV surveillance registry data. METHODS: Persons newly diagnosed with HIV in 2011 or PWHA as of December 31, 2011, were included. We constructed each continuum for persons engaged at each stage of HIV care and calculated the proportion achieving each step as both dependent on or independent of preceding steps. RESULTS: Of the 3408 newly diagnosed persons, 67% had timely linkage to care (≤3 months after diagnosis), 58% were established in care 3-9 months after timely linkage, and 43% achieved viral suppression (≤200 copies/mL) ≤6 months after establishment in care; losses were highest from diagnosis to linkage. Independent measures showed 84% linked, 72% established, and 61% suppressed ≤18 months after diagnosis. Of the 87,268 PWHA, 83% were in care in 2011 (≥1 visit), 70% retained in care (≥2 visits ≥3 months apart), and 52% suppressed at their last visit; losses were highest from retention to suppression. When measured independently, suppression increased to 58%. CONCLUSIONS: A minority of persons newly diagnosed with HIV and a narrow majority of PWHA achieved viral suppression and all intermediate care-related steps. Outcomes measured independently of previous care-related steps were higher, particularly for newly diagnosed persons. To improve outcomes among persons with HIV and reduce transmissibility, clinical and public health efforts should focus on linkage to care among newly diagnosed persons and viral suppression among PWHA.

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.