Respondent-Driven Sampling in a Multi-Site Study of Black and Latino Men Who Have Sex with Men.

PURPOSE: Respondent-driven sampling (RDS) was used to recruit four samples of Black and Latino men who have sex with men (MSM) in three metropolitan areas to measure HIV prevalence and sexual and drug use behaviors. We compared demographic and behavioral risk characteristics of participants across sites, assessed the extent to which the RDS statistical adjustment procedure provides estimates that differ from the crude results, and summarized our experiences using RDS. METHODS: From June 2005 to March 2006 a total of 2,235 MSM were recruited and interviewed: 614 Black MSM and 516 Latino MSM in New York City, 540 Black MSM in Philadelphia, and 565 Latino MSM in Los Angeles County. Crude point estimates for demographic characteristics, behavioral risk factors and HIV prevalence were calculated for each of the four samples. RDS Analysis Tool was used to obtain population-based estimates of each sampled population's characteristics. RESULTS: RDS adjusted estimates were similar to the crude estimates for each study sample on demographic characteristics such as age, income, education and employment status. Adjusted estimates of the prevalence of risk behaviors were lower than the crude estimates, and for three of the study samples, the adjusted HIV prevalence estimates were lower than the crude estimates. However, even the adjusted HIV prevalence estimates were higher than what has been previously estimated for these groups of MSM in these cities. Each site faced unique circumstances in implementing RDS. CONCLUSIONS: Our experience in using RDS among Black and Latino MSM resulted in diverse recruitment patterns and uncertainties in the estimated HIV prevalence and risk behaviors by study site.

Having supportive social relationships is associated with reduced risk of unrecognized HIV infection among black and Latino men who have sex with men.

We examined the hypothesis that black and Latino men who have sex with men (MSM) who have supportive social relationships with other people are less likely to have unrecognized HIV infection compared with MSM of color who report lower levels of social support. We interviewed 1286 black and Latino MSM without known HIV infection in three metropolitan areas who were recruited using respondent driven sampling. Participants completed a computer-administered questionnaire and were tested for HIV. Unrecognized HIV infection was found in 118 men (9.2%). MSM who scored higher on the supportive relationship index had significantly lower odds of testing HIV-positive in the study. The mediation analysis identified two possible behavioral pathways that may partially explain this association: men who had strong supportive relationships were more likely to have had a test for HIV infection in the past 2 years and less likely to have recently engaged in high-risk sexual behavior. The findings illuminate the protective role of social relationships among MSM of color in our sample.

Continuing HIV risk in New York City injection drug users: the association of syringe source and syringe sharing.

Sterile syringe access is an important means to reduce HIV risk, but many injection drug users (IDU) who obtain syringes from sterile sources continue to share syringes. We examined the factors associated with continuing syringe sharing in New York City. We recruited 500 active IDU in 2005 through respondent-driven sampling. In multiple logistic regression, not obtaining all syringes in the past year exclusively from sterile sources was associated with increased syringe sharing. Ensuring adequate syringe availability as well as engaging and retaining nonusers and inconsistent users in sterile syringe services may increase sterile syringe access and decrease syringe sharing.

Missed opportunities for HIV testing among high-risk heterosexuals.

BACKGROUND: HIV testing is an important HIV prevention strategy, yet heterosexuals at high risk do not test as frequently as other groups. We examined the association of past year HIV testing and encounters with institutional settings where the Centers for Disease Control and Prevention recommends annual testing for high-risk heterosexuals. METHODS: We recruited high-risk heterosexuals in New York City in 2006 to 2007 through respondent-driven sampling. Respondents were asked the date of their most recent HIV test and any potential encounters with 4 testing settings (homeless shelters, jails/prisons, drug treatment programs, and health care providers). Analyses were stratified by gender. RESULTS: Of the 846 respondents, only 31% of men and 35% of women had a past year HIV test, but over 90% encountered at least one testing setting. HIV seroprevalence was 8%. In multiple logistic regression, recent HIV testing was significantly associated with recent encounters with homeless shelters and jails/prisons for men, and encounters with health care providers for both men and women. CONCLUSIONS: HIV testing was low overall but higher for those with exposures to potential routine testing settings. Further expansion of testing in these settings would likely increase testing rates and may decrease new HIV infections among high-risk heterosexuals.

Same-sex attraction disclosure to health care providers among New York City men who have sex with men: implications for HIV testing approaches.

BACKGROUND: While the Centers for Disease Control and Prevention recommends at least annual human immunodeficiency virus (HIV) screening for men who have sex with men (MSM), a large number of HIV infections among this population go unrecognized. We examined the association between disclosing to their medical providers (eg, physicians, nurses, physician assistants) same-sex attraction and self-reported HIV testing among MSM in New York City, New York. METHODS: All men recruited from the New York City National HIV Behavioral Surveillance (NHBS) project who reported at least 1 male sex partner in the past year and self-reported as HIV seronegative were included in the analysis. The primary outcome of interest was a participant having told his health care provider that he is attracted to or has sex with other men. Sociodemographic and behavioral factors were examined in relation to disclosure of same-sex attraction. RESULTS: Among the 452 MSM respondents, 175 (39%) did not disclose to their health care providers. Black and Hispanic MSM (adjusted odds ratios, 0.28 [95% confidence interval, 0.14-0.53] and 0.46 [95% confidence interval, 0.24-0.85], respectively) were less likely than white MSM to have disclosed to their health care providers. No MSM who identified themselves as bisexual had disclosed to their health care providers. Those who had ever been tested for HIV were more likely to have disclosed to their health care providers (adjusted odds ratio, 2.10; 95% confidence interval, 1.01-4.38). CONCLUSIONS: These data suggest that risk-based HIV testing, which is contingent on health care providers being aware of their patients' risks, could miss these high-risk persons.

Risk factors for delayed initiation of medical care after diagnosis of human immunodeficiency virus.

BACKGROUND: The full benefit of timely diagnosis of human immunodeficiency virus (HIV) infection is realized only if there is timely initiation of medical care. We used routine surveillance data to measure time to initiation of care in New York City residents diagnosed as having HIV by positive Western blot test in 2003. METHODS: The time between the first positive Western blot test and the first reported viral load and/or CD4 cell count or percentage was used to indicate the interval from initial diagnosis of HIV (non-AIDS) to first HIV-related medical care visit. Using Cox proportional hazards regression, we identified variables associated with delayed initiation of care and calculated their hazard ratios (HRs). RESULTS: Of 1928 patients, 1228 (63.7%) initiated care within 3 months of diagnosis, 369 (19.1%) initiated care later than 3 months, and 331 (17.2%) never initiated care. Predictors of delayed care were as follows: diagnosis at a community testing site (HR, 1.9; 95% confidence interval [CI], 1.5-2.3), the city correctional system (HR, 1.6; 95% CI, 1.2-2.0), or Department of Health sexually transmitted diseases or tuberculosis clinics (HR, 1.3; 95% CI, 1.1-1.6) vs a site with colocated primary medical care; nonwhite race/ethnicity (HR, 1.8; 95% CI, 1.5-2.0); injection drug use (HR, 1.3; 95% CI, 1.1-1.5); and location of birth outside the United States (HR, 1.1; 95% CI, 1.0-1.2). CONCLUSIONS: A total of 1597 persons (82.8%) diagnosed as having HIV in 2003 ever initiated care, most within 3 months of diagnosis. Initiation of care was most timely when diagnosis occurred at a testing site that offered colocated medical care. Improving referrals by nonmedical sites is critical. However, because most diagnoses occur in medical sites, improving linkage in these sites will have the greatest effect on timely initiation of care.

HIV prevalence and associated risk behaviors in New York City's house ball community.

OBJECTIVES: We measured HIV seroprevalence and associated risk factors among persons in New York City's house ball community. METHODS: In 2004 we conducted a venue-based risk-behavior survey and HIV testing in the house ball community. RESULTS: Of the 504 study participants, 67% were male, 14% female, and 18% transgender. Mean age was 24 years (range=15-52 years); 55% were Black, and 40% were Latino. More than 85% of participants had previously been tested for HIV, although only 60% had been tested in the previous 12 months. Of the 84 (17%) persons who tested positive for HIV in our study, 61 (73%) were unaware of their HIV status. A logistic regression analysis on data from 371 participants who had had a male sexual partner in the previous 12 months showed that HIV-infected participants were more likely than were HIV-negative participants to be Black, to be older than 29 years, and not to have been tested for HIV in the previous 12 months. CONCLUSIONS: Culturally specific community-level prevention efforts are warranted to reduce risk behaviors and increase the frequency of HIV testing in New York City's house ball community.

A comparative analysis of sexual risk characteristics of Black men who have sex with men or with men and women.

Many behavioral studies of Black men fail to differentiate between those who have sex exclusively with men (MSM) and those who have sex with both men and women (MSMW). Respondent-driven sampling was used to recruit a total of 1,154 Black MSM and MSMW in New York City and Philadelphia. In descriptive analyses, MSMW and MSM were compared on several demographic, health, and behavioral risk correlates using chi-square tests. Differences in prevalence of unprotected anal intercourse (UAI) between these two groups were examined in two multivariate logistic regressions. Age, country of birth, self-identified sexual orientation, experience of being forced to have sex, self-reported HIV status, exchange sex for money/food/ drug, and drug use in the past 3 months were significantly associated with either insertive or receptive UAI in the past 3 months. The strongest correlate of either insertive or receptive UAI among both groups of men was engaging in exchange sex. Differences between MSMW and MSM were found in the areas of forced sexual experiences, disclosure of same sex behavior, and history of being arrested or incarcerated. Findings from our study highlight the need for specific HIV prevention interventions targeting Black MSMW as distinguished from Black MSM.

Trends in perinatal HIV prevention in New York City, 1994-2003.

OBJECTIVES: We examined trends in perinatal HIV prevention interventions in New York City implemented during 1994 to 2003 to ascertain the success of the interventions in reducing perinatal transmission. METHODS: We used data obtained from infant records at 22 hospitals. We used multiple logistic regression to analyze factors associated with prenatal care and perinatal HIV transmission. RESULTS: We analyzed data for 4729 perinatally HIV-exposed singleton births. Of mothers with prenatal care data, 92% had prenatal care. The overall proportion who received prenatal care and were diagnosed with HIV before delivery was 86% in 1994 to 1996 and 90% in 1997 to 2003. Use of prenatal antiretrovirals among mothers who received prenatal care was 63% in 1994 to 1996 and 82% in 1997 to 2003. From 1994 to 2003, cesarean births among the entire sample increased from 15% to 55%. During 1997 to 2003, the perinatal HIV transmission rate among the entire sample was 7%; 45% of mothers of infected infants had missed opportunities for perinatal HIV prevention. During 1997 to 2003, maternal illicit drug use was significantly associated with lack of prenatal care. Lack of prenatal, intrapartum, and neonatal antiretrovirals; maternal illicit drug use; and low birthweight were significantly associated with perinatal HIV transmission. CONCLUSIONS: Interventions for perinatal HIV prevention can successfully decrease HIV transmission rates. Ongoing perinatal HIV surveillance allows for monitoring the implementation of guidelines to prevent mother-to-child transmission of HIV and determining factors that may contribute to perinatal HIV transmission.

Self-reported tuberculosis disease and tuberculin skin testing in the New York City House Ballroom community.

OBJECTIVES: We sought to describe the history of tuberculosis disease and tuberculin skin testing among the New York City House Ballroom community--a social network of diverse sexual and gender identities or expressions. METHODS: Members of the House Ballroom community were convenience sampled, surveyed, and tested for HIV in 2004. We identified characteristics associated with history of tuberculosis, tuberculin skin testing, and test positivity and described the timing of skin testing. RESULTS: Of 504 participants, 1.4% (n=7) reported a history of tuberculosis and 81.1% (n=404 of 498) had received a tuberculin skin test. Of those tested, 16 (4%) had positive results, which indicated latent infection, and 68% had received a test in the 2 years prior to the survey. Participants with health insurance were more likely and those with little education were less likely to have received a skin test. HIV-infected participants (16%) were not more likely to have received a tuberculin skin test compared with non-HIV-infected individuals. Foreign-born participants and self-identified heterosexuals and bisexuals were more likely to have had positive skin tests. CONCLUSIONS: Self-reported history of tuberculosis was high among the House Ballroom community. Although many community members had a recent skin test, further efforts should target services to those who are HIV infected, have low education, lack health insurance, or are foreign born.

Circumcision status and HIV infection among Black and Latino men who have sex with men in 3 US cities.

OBJECTIVE: To examine characteristics of circumcised and uncircumcised Latino and black men who have sex with men (MSM) in the United States and assess the association between circumcision and HIV infection. METHODS: Using respondent-driven sampling, 1154 black MSM and 1091 Latino MSM were recruited from New York City, Philadelphia, and Los Angeles. A 45-minute computer-assisted interview and a rapid oral fluid HIV antibody test (OraSure Technologies, Bethlehem, PA) were administered to participants. RESULTS: Circumcision prevalence was higher among black MSM than among Latino MSM (74% vs. 33%; P < 0.0001). Circumcised MSM in both racial/ethnic groups were more likely than uncircumcised MSM to be born in the United States or to have a US-born parent. Circumcision status was not associated with prevalent HIV infection among Latino MSM, black MSM, black bisexual men, or black or Latino men who reported being HIV-negative based on their last HIV test. Further, circumcision was not associated with a reduced likelihood of HIV infection among men who had engaged in unprotected insertive and not unprotected receptive anal sex. CONCLUSIONS: In these cross-sectional data, there was no evidence that being circumcised was protective against HIV infection among black MSM or Latino MSM.

Amphetamine use and sexual risk among men who have sex with men: results from the National HIV Behavioral Surveillance study--New York City.

A 2004-2005 survey among 503 men who have sex with men who attend public venues in New York City was used to examine the relationship of amphetamine use with sexual risk behaviors. Among the men recruited, 51.1% were under 30 years of age, 27.4% were Latino, and 23.3% were African American. Most identified as either gay (78.9%) or bisexual (18.1%). A standardized questionnaire collected data on demographics, sexual risk behaviors, drug and alcohol use, history of HIV testing, and occurrences of sexually transmitted infections. Amphetamine use in the past year was reported by 13.8%. Of those, 71.0% used amphetamines with sex. Amphetamine use was associated with unprotected receptive anal intercourse with non-main partners. In event-specific analysis, amphetamine use was higher with unprotected encounters compared with protected encounters. This study confirms the association between amphetamine use and sexual risk furthers our understanding of risky circumstances and lays the groundwork for the design of interventions.

Higher mortality rate among infants of US-born mothers compared to foreign-born mothers in New York City.

This study is to compare infant mortality rates (IMRs) between US- and foreign-born mothers in New York City. The linked live birth-infant death records from 1995 to 1998 were analyzed. Overall US-born mothers had a higher IMR than foreign-born mothers, though there were great variations in IMRs by country of maternal birth among foreign-born mothers. US-born mothers had higher IMRs compared to foreign-born mothers for several maternal/infant characteristics. Logistic regression analyses indicated that infants of foreign-born mothers were less likely to die from prematurity, Sudden Infant Death Syndrome and external causes, but were more likely to die of congenital anomalies than those of US-born mothers. Further analyses on the interactions of maternal race/ethnicity and country of birth showed variations in the IMRs of leading causes of death. Infant mortality reduction strategies should be differentially targeted to minority mothers of different countries of birth, particularly for potentially preventable causes of deaths.

Disparity in maternal mortality in New York City.

OBJECTIVE: To describe maternal deaths and 10-year trends in maternal mortality in New York City. METHODS: All maternal deaths reported by surveillance of vital records (bearing ICD-9 codes 630-676) in New York City between 1989 and 1998 were studied. Were viewed death certificates and medical and autopsy records to collect age, race/ethnicity, country of birth, marital status, education level, residence at time of death, cause of death, and outcome of pregnancy. Trends analysis for maternal mortality rates was conducted, stratified by race. We conducted univariate and multivariate analysis to identify risk factors for maternal death. RESULTS: Two hundred forty-three maternal deaths were reported, for an average maternal mortality rate (MMR) of 18.4 deaths per 100,000 live births during this period. Although the overall MMR decreased from 17.4 in 1989 to 13.7 in 1998, the MMR varied widely during the period with a non significant trend (x2 for trend 2.09, p=.15). However, the individual MMR for whites and blacks decreased significantly from 1989 to 1998. The black-white MMR ratio remained high throughout this period and varied from 2.2 in 1994 to 14.8 in 1998. Women who were 35 years of age or older or non-Hispanic black had an increased risk of a pregnancy-related death. The leading causes of death were hemorrhage, embolism, and infection. CONCLUSION: Racial disparity in maternal mortality is a cause for concern in New York City. Further studies of maternal mortality are needed to develop interventions to reduce the MMR and the black-white gap.

Missed opportunities for perinatal HIV prevention among HIV-exposed infants born 1996-2000, pediatric spectrum of HIV disease cohort.

OBJECTIVE: Despite dramatic reductions in perinatal human immunodeficiency virus (HIV) transmission in the United States, obstacles to perinatal HIV prevention that include lack of prenatal care; failure to test pregnant women for HIV before delivery; and lack of prenatal, intrapartum, or neonatal antiretroviral (ARV) use remain. The objective of this study was to describe trends in perinatal HIV prevention methods, perinatal transmission rates, and the contribution of missed opportunities for perinatal HIV prevention to perinatal HIV infection. METHODS: We analyzed data obtained from infant medical records on 4755 HIV-exposed singleton deliveries in 1996-2000, from 6 US sites that participate in the Centers for Disease Control and Prevention's Pediatric Spectrum of HIV Disease Project. HIV-exposed deliveries refer to deliveries in which the mother was known to have HIV infection during the pregnancy. RESULTS: Of the 4287 women with data on prenatal care, 92% had prenatal care. From 1996 to 2000, among the 3925 women with prenatal care, 92% had an HIV test before delivery; the use of prenatal zidovudine (ZDV) alone decreased from 71% to 9%, and the use of prenatal ZDV with other ARVs increased from 6% to 70%. Complete data on maternal and neonatal ARVs were available for 3284 deliveries. Perinatal HIV transmission was 3% in 1651 deliveries with prenatal ZDV in combination with other ARVs, intrapartum ZDV, and neonatal ZDV; 6% in 1111 deliveries with prenatal, intrapartum, and neonatal ZDV alone; 8% in 152 deliveries with intrapartum and neonatal ZDV alone; 14% of 73 deliveries with neonatal ZDV only started within 24 hours of birth; and 20% in 297 deliveries with no prenatal, intrapartum, and neonatal ARVs. Complete data on prenatal events were available in 328 HIV-infected and 3258 HIV-uninfected infants. A total of 56% of mothers of HIV-infected infants had missed opportunities for perinatal HIV prevention versus 16% of mothers of HIV-uninfected infants. Forty-four percent of the infected infants were born to mothers who had prenatal care, a prenatal HIV diagnosis, and documented prenatal ARV therapy. Seventeen percent of women with reported illicit drug use had no prenatal care versus 3% of women with no reported drug use. In a multivariate analysis, maternal illicit drug use was significantly associated with lack of prenatal care. In a multivariate analysis, year of infant birth and the combination of lack of maternal HIV testing before delivery and lack of prenatal antiretroviral therapies were significantly associated with perinatal HIV transmission. CONCLUSIONS: Missed opportunities for perinatal HIV prevention contributed to more than half of the cases of HIV-infected infants. Prenatal care and HIV testing before delivery are major opportunities for perinatal HIV prevention. Illicit drug use was highly associated with lack of prenatal care, and lack of HIV testing before delivery was highly associated with perinatal HIV transmission.