Estimation of HIV incidence among repeat anonymous testers in Catalonia, Spain

A retrospective cohort study of 2124 repeat HIV testers attending at anonymous testing sites (ATS) of Catalonia between 1995 and 2001 registered 3273 person-years (PY) of follow-up and 76 seroconversions (incidence density of 2.32 per 100 PY; 95% CI: 1.83, 2.90). The highest HIV infection incidence was observed among heterosexual injection drug users (IDU) (9.25 per 100 PY; 95% CI: 6.77, 12.25) and the lowest was among heterosexual non-IDU (0.69 per 100 PY; 95% CI: 0.35, 1.24). In multivariate Cox regression, factors independently associated with seroconversion were men having sex with men, IDU, and having sex with a known HIV-infected person. In spite of some limitations, such results suggest that prevention interventions targeting specific groups attending at ATS in Catalonia should be prioritized.     

HIV risk behaviors among Asian drug users in San Francisco.

This study identified patterns of drug use and HIV risk behaviors in relation to cultural factors among Asian drug users in San Francisco. A sample of 92 Asian drug users (35 Chinese, 31 Filipino, 26 Vietnamese) who were not currently enrolled in drug treatment programs were recruited through targeted sampling methods and interviewed using a questionnaire with open-ended questions. The study evaluated responses of the participants based on content analyses. Compared with Chinese and Vietnamese, Filipino drug users had engaged in riskier behaviors in terms of injection drug use, having sex while on drugs, and having sex with injection drug users (IDUs). Cultural factors such as stigma of injection drug use and fear of needles were cited as reasons for not injecting drugs. Among IDUs, half cited trust as a reason for having shared needles. AIDS prevention programs targeting Asian drug users should consider specific cultural factors among high-risk groups (i.e., Filipinos, immigrants, women, and IDUs).     

HIV incidence among repeat HIV testers with sexually transmitted diseases in Italy. STD Surveillance Working Group.

OBJECTIVES: To provide data on the incidence of HIV infection among repeat testers with sexually transmitted diseases (STD) in Italy. DESIGN: Retrospective longitudinal study. METHODS: Study participants, enrolled by 47 STD centres throughout Italy, included individuals with a newly diagnosed STD who were tested for HIV at the time of the STD diagnosis and who had a previous documented HIV-negative test. 'Seroconverters' were defined as those individuals who tested HIV-positive at the time of the STD diagnosis. The cumulative and the annual incidence of HIV in this population were estimated. RESULTS: Of 1950 patients, 47 were seroconverters, with an incidence rate of 1.7 per 100 person-years (PY) (95% confidence interval, 1.2-2.2). HIV incidence was higher among males than among females (2.5 versus 0.6 per 100 PY). The highest incidence rate was found among homosexual injecting drug users (IDU) (13.8 per 100 PY), whereas the lowest rate was observed among heterosexual non-IDU (0.4 per 100 PY). The annual incidence decreased from 1.8 per 100 PY in 1989 to 0.9 per 100 PY in 1996. CONCLUSIONS: Our results show that new HIV infections have occurred among STD patients in Italy since 1988, although a clear decrease in incidence has occurred since 1989. However, the rate of seroconversion appears to be alarmingly high in some high-risk groups. These findings suggest that there is a need for continued monitoring of new HIV infections among STD patients, and these individuals may represent a useful sentinel population for a better understanding of the HIV epidemic.     

HIV risk among Asian women working at massage parlors in San Francisco.

The purpose of this paper is to describe working conditions, health outcomes, social, and psychological factors related to HIV risk among Asian women who work at massage parlors in San Francisco. We conducted environmental mapping to identify communities and massage parlors where Asian women work as masseuses, and conducted survey interviews with 100 masseuses using venue-based snowball sampling. Difficult work conditions contributed to participants' HIV risk, including multiple sex customers each workday, long working hours, physical and verbal abuse from customers, economic pressures, and poor access to health care. Inconsistent condom use for vaginal sex with customers was positively associated with their fatalistic ideas and weak norms toward practicing safe sex with customers. Interventions should address cultural and occupational contexts in which Asian masseuses engage in sex work, and should focus on altering massage parlor policies and work environments.     

AIDS, HIV and STD among Japanese and Japanese-Americans in San Francisco, California, USA

In affluent countries, some people may go abroad specifically for HIV testing or care for greater anonymity, better treatment, and less discrimination. A secondary analysis of data from the San Francisco Department of Public Health was conducted to characterize trends in AIDS incidence, AIDS care, sexually transmitted disease (STD) incidence, and HIV counselling and testing among Japanese in San Francisco. A total of 96 AIDS cases were diagnosed among ethnic Japanese, of whom 32 were born in Japan. From 1985 to 2000, 144 gonorrhoea and chlamydia cases were identified among Japanese. Of 368 self-identified Japanese seeking HIV counselling from 1995 to 1997, three (0.9%) were HIV-positive. The HIV/AIDS and STD epidemics among Japanese in San Francisco temporally parallels, but lags behind in magnitude, the epidemics for San Francisco's population as a whole. Some persons from Japan actively seek HIV/STD services while abroad. Our study points to several areas needing further research and improvements.     

STD screening among HIV-infected patients in care, San Francisco

The Centers for Disease Control and Prevention recommends sexually transmitted disease (STD) screening among human immunodeficiency virus (HIV)-infected persons as a means of HIV prevention. HIV-infected persons in care may be an important target group in which to conduct regular STD screening to prevent enhanced transmission of HIV. We conducted STD screening for syphilis and two causes of urethritis, chlamydia, and gonorrhea, among 447 HIV-infected persons at two busy, urban clinics in San Francisco: a general HIV acquired immune deficiency syndrome (AIDS) care clinic and a methadone maintenance clinic. There were no new cases of syphilis identified and only two prevalent cases of chlamydia. While STD screening was feasible and acceptable in this population, the benefits of screening for asymptomatic gonococcal and chlamydial infection remain to be determined. Because these two pathogens only cause about 20% of urethritis, broader screening tests for urethritis, e.g., leukocyte esterase or urine microscopy, may be more useful. Finally, this study reaffirms the notion that local data should be used to evaluate national screening recommendations.     

Amphetamine use is associated with increased HIV incidence among men who have sex with men in San Francisco

We examined the association between amphetamine use and HIV incidence for 2991 men who have sex with men (MSM) who tested anonymously for HIV in San Francisco. HIV incidence among 290 amphetamine users was 6.3% per year (95% CI 1.9-10.6%), compared with 2.1% per year (95% CI 1.3-2.9%) among 2701 non-users (RR 3.0, 95% CI 1.4-6.5). HIV prevention programmes in San Francisco should include efforts to reduce amphetamine use and associated high-risk sexual behaviors.     

HIV prevention case management in San Francisco: barriers to successful implementation

Prevention case management (PCM) is the most labor-intensive HIV prevention intervention for persons at risk for acquiring or transmitting HIV. However, it has not been thoroughly evaluated. We abstracted client charts (n = 290) from 12 San Francisco PCM programs and interviewed current and former program directors (n=16), case managers (n = 17) and contract managers (n = 4) regarding client characteristics, services delivered, barriers to care, cost and organizational structure, policies and procedures. Most agencies lacked protocols and data collection forms, had high staff turnover, inadequate staff training and supervision, experienced difficulty recruiting and retaining clients and could not implement PCM guidelines. Half the clients lacked behavioral risk assessment, 39% were low or no risk, a third received HIV prevention education and a third received referrals. Including time spent directly with clients and working on their behalf, PCM cost almost four-fold more per client contact than the next most costly individual level prevention intervention. Local PCM guidelines, reimbursement ties to providing and documenting services and increased collaboration between the health department and agencies has greatly improved the situation. Outcome evaluations and cost-effectiveness assessments comparing PCM to less costly prevention interventions are needed.     

Evaluating national HIV prevention indicators: a case study in San Francisco

OBJECTIVES: To field-test the availability, interpretability, and programmatic usefulness of 37 proposed national HIV prevention indicators (HPI) intended to evaluate community-level impact of HIV prevention efforts in San Francisco. METHODS: HPI were defined for four populations (high risk heterosexuals, injecting drug users, men who have sex with men, and childbearing women) and for four domains (biological, behavioral, service, and socio-political). HPI were obtained from existing data sources only. Trends in HPI were examined from 1990 to 1997. RESULTS: Existing data provided 29 (78%) of the 37 proposed HPI; eight HPI were not available because California does not have HIV case reporting. Interpretation was limited for several HPI due to small sample size, inconsistencies in data collection, or lack of contextual information. Data providing behavioral HPI were scarce. HPI were consistent with historical patterns of HIV transmission in San Francisco but also highlighted new and worrisome trends. Notably, HPI identified recent increases in risk for HIV transmission among men who have sex with men. CONCLUSIONS: Despite limitations, the proposed national HPI provided evidence of the aggregate effectiveness of prevention efforts in San Francisco. Supplemental or local HPI are needed to fill data gaps, add context, and increase the scope and programmatic usefulness of the national HPI.     

Regular clinic attendance in two large San Francisco HIV primary care settings

Although poor clinic attendance is associated with increased morbidity and mortality among HIV-infected individuals, less is known about predictors of retention and the acceptability of targeted interventions to increase regular clinic attendance. To better understand which patients are at risk for irregular clinic attendance and to explore interventions to aid in retention to care, we surveyed patients attending two outpatient HIV clinics affiliated with the University of California, San Francisco. A total of 606 participants were surveyed, and the analysis was restricted to the 523 male respondents. Of this group, 45% (N = 299) reported missing at least one visit a year. Missing a clinic visit was associated with being African American (aOR = 1.99; 95%CI 1.12–3.52), being a man who has sex with both men and women (aOR=2.72; 95%CI 1.16–6.37), and reporting at least weekly methamphetamine use (aOR=5.79; 95%CI 2.47–13.57). Participants who reported a monthly income greater than $2000 were less likely to miss an appointment (aOR = 0.56; 95%CI 0.34–0.93). Regarding possible retention interventions, most patients preferred phone calls over other forms of support. These findings support the need for ongoing engagement support with particular attention to at-risk sub-groups.     

Socioeconomic Position and HIV Risk-Relevant Behavior Among Lower-Income Heterosexuals in San Francisco

We assess whether there is evidence of an association between socioeconomic position (SEP) and HIV risk-relevant behavior among lower income heterosexual men and women in San Francisco. Respondents residing in low income areas with high heterosexual AIDS case burden in San Francisco were recruited through long-chain referral in 2006–2007. Risk measures included unprotected vaginal intercourse, concurrency and exchange sex. SEP was defined as household annual income, per capita income, and employment. Analyses utilized mixed and fixed effects models. A total of 164 men and 286 women were included in the study. SEP was only significant in the case of exchange sex among men: men reporting annual income greater than $30,000 had significantly lower odds of exchange sex relative to other men. Evaluating the connection between economic status and HIV requires additional studies covering diverse populations. Future studies should focus on community economic context as well as individual SEP.     

Community-based rapid HIV testing in homeless and marginally housed adults in San Francisco

BACKGROUND: Standard two-step HIV testing is limited by poor return-for-results rates and misses high-risk individuals who do not access conventional testing facilities. METHODS: We describe a community-based rapid HIV testing programme in which homeless and marginally housed adults recruited from shelters, free meal programmes and single room occupancy hotels in San Francisco received OraQuick Rapid HIV-1 Antibody testing (OraSure Technologies, Bethlehem, PA, USA). RESULTS: Over 8 months, 1614 adults were invited to participate and 1213 (75.2%) underwent testing. HIV seroprevalence was 15.4% (187 of 1213 individuals) overall and 3.5% (37 of 1063) amongst high-risk individuals reporting no previous testing, a prior negative test, or previous testing without result disclosure. All 1213 participants received their results. Of 30 newly diagnosed persons who received confirmatory results, 26 (86.7%) reported at least one contact with a primary healthcare provider in the 6 months following diagnosis. CONCLUSIONS: We conclude that community-based rapid testing is feasible, acceptable and effective based on the numbers of high-risk persons tested over a short period, the participation rate, the prevalence of new infection, the rate of result disclosure, and the proportion linked to care.     

HIV testing patterns and unrecognized HIV infection among young Asian and Pacific Islander men who have sex with men in San Francisco.

The HIV epidemic is rising in Asian and Pacific Islander men who have sex with men (API MSM), who are often first diagnosed with HIV at a late stage of disease. We investigated the HIV testing patterns, correlates of prior testing, and awareness of HIV infection of 495 API MSM aged 18-29 years recruited from venues in San Francisco, using standardized face-to-face interviews. One quarter of participants had never tested for HIV, citing reasons such as perceived low risk, fear of results, and fear of needles. Older age, gay sexual orientation, history of sexually transmitted disease, higher lifetime number of sexual partners, and higher acculturation were significantly and independently associated with prior testing. Thirteen (2.6%) tested HIV-positive, of whom eight were unaware of their infection, five perceived themselves to be at low risk for HIV, and five reported recent UAI. These findings underscore the need to increase access to culturally appropriate and targeted HIV testing and to change perceptions of risk in this population.     

The Internet, HIV serosorting and transmission risk among men who have sex with men, San Francisco

In a community-based, time-location sampling survey in San Francisco, Internet-met partners were not more likely to be HIV seroconcordant among HIV-negative and HIV-positive men who have sex with men (MSM) compared with partners met at bars and dance clubs. In addition, HIV-negative MSM were more likely to have unprotected anal intercourse with potentially serodiscordant partners met on the Internet compared with those met at bars and dance clubs (adjusted OR 1.5, 95% CI 1.1-2.0, P = 0.01).