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Objective: Retention in HIV care, particularly among postpartum women, is a challenge to national antiretroviral therapy programs. Retention estimates may be underestimated because of unreported transfers. We explored mobility and clinic switching among patients considered lost to follow-up (LTFU). Design: Observational cohort study. Methods: Of 788 women initiating antiretroviral therapy during pregnancy at 6 public clinics in Johannesburg, South Africa, 300 (38.1%) were LTFU (no visit ≥3 months). We manually searched for these women in the South African National Health Laboratory Services database to assess continuity of HIV care. We used geographic information system tools to map mobility to new facilities. Results: Over one-third (37.6%) of women showed evidence of continued HIV care after LTFU. Of these, 67.0% continued care in the same province as the origin clinic. Compared with those who traveled outside of the province for care, these same-province "clinic shoppers" stayed out-of-care longer {median 373 days [interquartile range (IQR): 175-790] vs. 175.5 days (IQR: 74-371)} and had a lower CD4+ cell count on re-entry [median 327 cells/µL (IQR: 196-576) vs. 493 cells/mL (IQR: 213-557). When considering all women with additional evidence of care as engaged in care, cohort LTFU dropped from 38.1% to 25.0%. Conclusions: We found evidence of continued care after LTFU and identified local and national clinic mobility among postpartum women. Laboratory records do not show all clinic visits and manual matching may have been under- or overestimated. A national health database linked to a unique identifier is necessary to improve reporting and patient care among highly mobile populations. [ABSTRACT FROM AUTHOR]

Health communication is a broad term that applies to the fundamental need for practitioners, policy makers, patients, and community members to understand one another around health promotion and health care issues. Whether in a consultation between nurse and patient, a health clinic director's engagement with the health ministry, or a community campaign for encouraging HIV testing, all have critical health communication elements. When people's needs are not perceived by them to be addressed or clients/ patients do not understand what is being communicated, they are unmotivated to engage. Health communication may be deployed at multiple levels to encourage positive behavior change and affect HIV treatment outcomes. As countries move to treatment for all as soon as possible after testing, health communication can help address significant losses at each stage of the HIV continuum of care, thereby contributing to achieving the 90-90-90 global treatment goals. This JAIDS supplement presents compelling studies that are anchored on the health communication exigencies in highly diverse HIV and AIDS contexts in low and middle income settings. Our special focus is health communication needs and challenges within the HIV continuum of care. We introduce the supplement with thumbnails summaries of the work presented by an experienced array of public health, behavioral, and clinical scientists. [ABSTRACT FROM AUTHOR]

This special issue of JAIDS: Journal of Acquired Immune Deficiency Syndromes is devoted to health communication and its role in and impact on HIV prevention and care. The authors in this special issue have tackled a wide swath of topics, seeking to introduce a wider biomedical audience to core health communication principles, strategies, and evidence of effectiveness. Better awareness of health communication strategies and concepts can enable the broader biomedical community to partner with health communication experts in reducing the risk of HIV, sexually transmitted infections, and tuberculosis and maximize linkage and adherence to care. Interventions can be strengthened when biomedical and health communication approaches are combined in strategic and evidence-based ways. Several of the articles in this special issue present the current evidence for health communication's impact. These articles show how far we have come and yet how much further we have to go to document impact convincingly. Examples of the biomedical approaches to HIV control include treatment as prevention, voluntary medical male circumcision, preexposure prophylaxis, sterile needle exchange, opiate substitution therapy, and prevention of mother-to-child transmission. None will succeed without behavior change, which can be facilitated by effective health communication. [ABSTRACT FROM AUTHOR]

The HIV Prevention Trials Network (HPTN) is conducting the HPTN 071 (PopART) study in 21 communities in Zambia and South Africa with support from a consortium of funders. HPTN 071 (PopART) is a community-randomized trial of a combination prevention strategy to reduce HIV incidence in the context of the generalized epidemic of southern Africa. The full PopART intervention strategy is anchored in home-based HIV testing and facilitated linkage of HIV-infected persons to care through community health workers and universal antiretroviral therapy for seropositive persons regardless of CD4+ cell count or HIV viral load. To further reduce the risk of HIV acquisition among uninfected individuals, the study aims to expand voluntary medical male circumcision, diagnosis and treatment of sexually transmitted infections, behavioral counseling, and condom distribution. The full PopART intervention strategy also incorporates promotion of other interventions designed to reduce HIV and tuberculosis transmission, including optimization of the prevention of mother-to-child HIV transmission and enhanced individual and public health tuberculosis services. Success for the PopART strategy depends on the ability to increase coverage for the study interventions whose uptake is a necessary antecedent to a prevention effect. Processes will be measured to assess the degree of penetration of the interventions into the communities. A randomly sampled population cohort from each community will be used to measure the impact of the PopART strategy on HIV incidence over 3 years. We describe the strategy being tested and progress to date in the HPTN 071 (PopART) study. [ABSTRACT FROM AUTHOR]

Early achievements in biomedical approaches for HIV prevention included physical barriers (condoms), clean injection equipment (both for medical use and for injection drug users), blood and blood product safety, and prevention of mother-to-child transmission. In recent years, antiretroviral drugs to reduce the risk of transmission (when the infected person takes the medicines; treatment as prevention) or reduce the risk of acquisition (when the seronegative person takes them; preexposure prophylaxis) have proven to be efficacious. Circumcision of men has also been a major tool relevant for higher prevalence regions such as sub-Saharan Africa. Well-established prevention strategies in the control of sexually transmitted diseases and tuberculosis are highly relevant for HIV (ie, screening, linkage to care, early treatment, and contact tracing). Unfortunately, only slow progress is being made in some available HIV-prevention strategies such as family planning for HIV-infected women who do not want more children and prevention of mother-to-child HIV transmission. Current studies seek to integrate strategies into approaches that combine biomedical, behavioral, and structural methods to achieve prevention synergies. This review identifies the major biomedical approaches demonstrated to be efficacious that are now available. We also highlight the need for behavioral risk reduction and adherence as essential components of any biomedical approach. [ABSTRACT FROM AUTHOR]

The author reflects on the high risk of sexually transmitted diseases in human immunodeficiency virus (HIV)-infected pregnant women. He examines the safety and efficacy of postexposure prophylaxis with antiretroviral (ARV) medications for HIV-infected mothers and infants. The author notes that the control of sexually transmitted infection (STI) help reduce heterosexual transmission of HIV. [ABSTRACT FROM AUTHOR]

Assesses the cost-effectiveness of alternative strategies of nevirapine (NVP) administration to prevent vertical HIV transmission in sub-Saharan Africa. Decision-analysis model to estimate the costs and effects of NVP-based HIV prevention strategies; Strategies for early and late intervention; Test characteristics for HIV testing; Prodromal labor; Site of delivery.

Background: Because AIDS is increasing in rural areas and small cities of the United States, we sought to further describe the epidemiology of HIV/AIDS in nonurban Alabama.Methods: Extensive interviews of HIV-infected residents of Alabama living outside of urban Birmingham were conducted at clinics throughout the state.Results: Of the 417 HIV-infected persons interviewed from January 1995 through January 1997, 310 (74%) were male, 229 (55%) were white, and 179 (43%) were black. Over time, increasing proportions of HIV infections have likely been acquired in nonurban areas. Of the 417 subjects, 43 (10%) had visited an STD clinic in the past year, and 31 (7%) had smoked crack-cocaine during the past month. Of the 166 persons who had been sexually active in the past month, 59 (36%) had used alcohol before sex and 56 (34%) used condoms inconsistently. Of the 417 subjects, 161 (39%) currently had no health insurance, and 68 (16%) had lost medical insurance since becoming HIV-infected.Conclusion: HIV-infected persons in nonurban Alabama are likely to have practiced high-risk behavior, to have acquired HIV in nonurban settings, and to have inadequate health insurance. [ABSTRACT FROM AUTHOR]

Deals with a study which identified opportunities to improve prevention and services for HIV-infected women in nonurban Alabama and Mississippi. Methods; Results; Discussion.

Editorial. Comments on a series of models that attempted to quantify the chances of heterosexual human immunodeficiency virus (HIV) transmission from HIV infected individuals. Names of models; Analysis of heterosexual couples from various countries; Used of mathematical models; Expansion of models; Distribution of information.

Background: Black men who have sex with men (BMSM) remain at highest risk for HIV in the United States. Internalized HIV stigma and depression contribute to substance use and condomless anal intercourse (CAI). Religion and spirituality (R/S) are associated with decreased HIV-related risk behaviors for some groups, but their impact among BMSM is uncertain. We investigated the main and moderating roles of R/S on pathways from internalized HIV stigma to CAI while under the influence of drugs. Methods: We used baseline data from 1511 BMSM from the HIV Prevention Trials Network (HPTN) 061 study to examine the associations between internalized HIV stigma, depressive symptoms, alcohol use, and CAI while under the influence of drugs, adjusting for covariates in generalized structural equation models. We then tested whether R/S moderated the association between (1) internalized HIV stigma and depressive symptoms, (2) depressive symptoms and alcohol use, and (3) alcohol use and CAI while under the influence of drugs. Results: Spiritual beliefs [F(1,2) = 9.99, P, 0.001], spiritual activities [F(1,2) = 9.99, P, 0.001], and religious attendance [F(1,2) = 9.99, P, 0.001] moderated the pathway between internalized HIV stigma and depressive symptoms. As internalized HIV stigma increased, those with lower spiritual activity scores experienced significantly higher increases in depressive symptoms compared with those with higher spiritual activity scores whose depressive symptom scores remained unchanged [stigma · spiritual activities B = 20.18 (SE = 0.07), P, 0.001]. Conclusions: Religion and spirituality were protective against CAI among BMSM. Future intervention research should explore ways to incorporate religious and/or spiritual activities to reduce internalized HIV stigma as one way to reduce depressive symptoms among BMSM. [ABSTRACT FROM AUTHOR]

Background: Unknown HIV status and consequent low antiretroviral treatment coverage among men living with HIV combined with high-risk behavior is a key driver of the HIV epidemic in high-burden settings. We investigated whether conducting household visits during nontraditional shifts increased the number of men recruited for community-based HIV testing, compared with traditional weekday shifts in the HPTN 071 (PopART) trial in South Africa. Methods: We used data captured during household visits among individuals aged 15 years or older in 6 communities in South Africa from September 2016 to September 2017. Successful recruitment required community HIV care providers (CHiPs) accessing a household member and completing the study questionnaire. Linear regression analysis compared mean successful recruitments between the different shift types stratified by sex. Results: During 187 days, 62,455 successful household visits were completed. Recruitment of men and women was higher in weekends, for men highest on Sundays (Coef: 11.2, 95% CI: 8.7 to 13.7), for women highest on Saturdays (Coef: 11.3, 95% CI: 7.6 to 15.1), indicating a mean of 11.2 more men recruited on Sunday shifts, compared with traditional weekday shifts was similar when comparing traditional weekday shifts with nontraditional weekday shifts for both men and women. Conclusion: Conducting household visits during the weekends led to increased recruitment for participation in the PopART intervention among both men and women. This suggests that targeting households during the weekend can be an effective and easy-to-implement strategy to increase the number of men accessed for HIV testing that can be integrated into a wide range of community-based services. [ABSTRACT FROM AUTHOR]

Abstract: Despite decades of medical, diagnostic, and public health advances related to diagnosis and management of sexually transmitted infections (STIs), rates of reportable STIs continue to grow. A 2021 National Academies of Sciences, Engineering, and Medicine report on the current state of STI management and prevention in the United States, entitled Sexually Transmitted Infections: Adopting a Sexual Health Paradigm, offers recommendations on future public health programs, policy, and research. This new report builds upon the 1997 Institute of Medicine report, The Hidden Epidemic: Confronting Sexually Transmitted Diseases, and provides 11 recommendations organized under 4 action areas: (1) adopt a sexual health paradigm, (2) broaden ownership and accountability for responding to STIs, (3) bolster existing systems and programs for responding to STIs, and (4) embrace innovation and policy change to improve sexual health. We present our interpretive synopsis of this report, highlighting elements of particular interest to STI and sexual health practitioners, including clinicians, researchers, disease intervention specialists, community outreach workers, and public health staff. The report asserts that it is possible to create a healthier and more equitable future where fewer adolescents and adults are infected, fewer babies are born with STIs, and people entering their sexual debut and continuing throughout the life span are taught the language and skills to conceptualize and enact their own vision for what it means to be sexually healthy. [ABSTRACT FROM AUTHOR]

The article presents a study that seeks indicators of successful adoption of HIV testing and nevirapine treatment in maternity wards in Zambia. The study uses counseling and testing to women who are unaware of their status, and nevirapine is given to those positive and calcium medication to those who are negative. Moreover, the study shows that HIV testing is viable in this kind of setting where resources are limited and HIV is prominent to women who is pregnant for the first time.

Objectives: To systematically analyze available prospective evidence on the association between HIV infection and incident heart failure (HF). Methods: A systematic search of PubMed, EMBASE, Web of Science, and manual search of relevant articles through June 1st, 2020, was conducted. Two authors independently performed full-text assessments and data extraction. The pooled relative risk with 95% confidence interval was estimated using DerSimonian and Laird random-effects models, with inverse-variance fixed-effects metaanalysis used as a sensitivity analysis. Heterogeneity was explored using subgroup analyses and meta-regressions. Results: We included 8 reports among 8,848,569 participants with 101,335 incident cases of HF [1941 among 131,632 people living with HIV (PLWH) and 99,394 among 8,716,937 control participants]. In the overall analysis using a random-effect model, HIV infection was positively associated with incident HF [relative risk, 1.80 (95% confidence interval: 1.51 to 2.15)], although with significant heterogeneity. A similar association was observed with a fixed-effects model, 1.59 (1.50 to 1.68). In subgroup analyses, associations between HIV infection and HF were nominally stronger in younger adults (age < 50 years), women, and individuals with low CD4 count (<200 cells/mm³). Publication bias was suggested from visual examination of funnel plots, correcting for this did not abolish the association, 1.52 (1.25 to 1.85). Conclusions: Our meta-analysis provides additional evidence that HIV is associated with an increased risk of HF, particularly among younger adults, women, and individuals with low CD4 count. [ABSTRACT FROM AUTHOR]

Background: Given the magnitude of the global COVID-19 pandemic, persons living with HIV (PLWH) may become coinfected with SARS-CoV-2. Setting: We conducted a survey in Wuhan, China, to characterize the status of coinfected PLWH, their time to clinical improvement, and clinical prognoses. Methods: Using a Wuhan shipping service for antiretroviral medications, the Wuhan LGBT Center screened 2900 PLWH shipping addresses and cross-referenced 36 of them to quarantine sites or hospitals, suggesting possible COVID-19 cases. Through telephone calls and WeChat (social media) messaging, we conducted a survey after obtaining online informed consent. Results: We had 12 HIV-infected respondents (10 men and women) who also reported COVID-19. The median age was 36 years (interquartile range: 33.0-56.3), mean age 42.4 years, and range 25-66 years of age. Nine of 10 persons on antiretroviral therapy (ART) presented with only mild COVID-19 symptoms. The 10th person on ART was a 56-year-old man who died at home early in the outbreak when health care services were overwhelmed. Two additional cases who had been in intensive care with acute COVID-19 were both men, aged 25 and 37 years; both were ART-naive until this hospitalization. Excluding the deceased man, 6 of 11 coinfected persons reported feeling depressed even after clinical improvements. Conclusion: Twelve coinfected persons were identified in Wuhan; 9 of 10 were on long-term ART and had favorable outcomes. Two men identified as having started ART only recently were found to have severe symptoms. Our case series suggests the value of ART for potential mitigation of COVID-19 coinfection. [ABSTRACT FROM AUTHOR]

Background: The role of partner types in modifying HIV seroconversion risk among men who have sex with men (MSM) is complex. We sought to understand the role of regular sexual partners and risky sexual behavior in contributing to incident HIV infection among MSM. Methods: From July 2011 to August 2017, we recruited HIVnegative men who reported having anal or oral homosexual encounters in the past 6 months and they were followed up every 3 months for 2 visits. We collected sociodemographic and behavioral characteristics by a self-administrated questionnaire. HIV status was confirmed by a sequential rapid test and confirmatory test. We used multivariable Cox regression to identify risk factors and interaction models to evaluate the relative excess risk between relevant variables. Results: Among 1218 participants, the HIV seroconversion rate was 3.66/100 person-years. HIV seroconversion was associated with lower educational attainment [adjusted hazards ratio (aHR)] = 1.73, 95% CI: 1.06 to 2.81), having had penetrative sex with male before age of 18 years (aHR = 2.44, 95% CI: 1.20 to 4.99), not using condoms in the last sexual encounter (aHR = 2.19, 95% CI: 1.29 to 3.71), and having regular but not committed partners (aHR = 3.33, 95% CI: 1.77 to 6.93). Among 890 (73%) of men reported having regular partners, HIV seroconversion was more frequent in men whose stable partners were not committed as boyfriends (aHR = 3.31, 95% CI: 1.73 to 6.36) and in men having unprotected anal sex (aHR = 2.61, 95% CI: 1.42 to 4.80). Interaction between these 2 factors was observed (relative excess risk of interaction = 4.53). Conclusions: Incidence among MSM in China was high; unprotected sex with steady but not committed partners was associated with increased seroconversion risk. It is imperative to expand safer sex education and training for MSM to reduce unsafe sexual behaviors, including awareness that casual partners are not the only source of infection. [ABSTRACT FROM AUTHOR]

Background: The role of partner types in modifying HIV seroconversion risk among men who have sex with men (MSM) is complex. We sought to understand the role of regular sexual partners and risky sexual behavior in contributing to incident HIV infection among MSM. Methods: From July 2011 to August 2017, we recruited HIVnegative men who reported having anal or oral homosexual encounters in the past 6 months and they were followed up every 3 months for 2 visits. We collected sociodemographic and behavioral characteristics by a self-administrated questionnaire. HIV status was confirmed by a sequential rapid test and confirmatory test. We used multivariable Cox regression to identify risk factors and interaction models to evaluate the relative excess risk between relevant variables. Results: Among 1218 participants, the HIV seroconversion rate was 3.66/100 person-years. HIV seroconversion was associated with lower educational attainment [adjusted hazards ratio (aHR)] = 1.73, 95% CI: 1.06 to 2.81), having had penetrative sex with male before age of 18 years (aHR = 2.44, 95% CI: 1.20 to 4.99), not using condoms in the last sexual encounter (aHR = 2.19, 95% CI: 1.29 to 3.71), and having regular but not committed partners (aHR = 3.33, 95% CI: 1.77 to 6.93). Among 890 (73%) of men reported having regular partners, HIV seroconversion was more frequent in men whose stable partners were not committed as boyfriends (aHR = 3.31, 95% CI: 1.73 to 6.36) and in men having unprotected anal sex (aHR = 2.61, 95% CI: 1.42 to 4.80). Interaction between these 2 factors was observed (relative excess risk of interaction = 4.53). Conclusions: Incidence among MSM in China was high; unprotected sex with steady but not committed partners was associated with increased seroconversion risk. It is imperative to expand safer sex education and training for MSM to reduce unsafe sexual behaviors, including awareness that casual partners are not the only source of infection. [ABSTRACT FROM AUTHOR]

Background: Four of the largest HIV prevention trials have been conducted in sub-Saharan Africa, enrolling hundreds of thousands of participants in catchment areas of millions of people. The trials have focused on community-level interventions to increase diagnosis and initiation of antiretroviral therapy (ART) to improve health and reduce HIV transmission. Universal test-and-treat strategies are deployed to achieve viral suppression thereby reducing risk to uninfected persons, known as treatment as prevention (TasP). Purpose: We review the work that found HIV plasma load to correlate with transmission risk, demonstrated that ART could reduce genital tract viral expression, and showed early treatment to be beneficial for persons living with HIV, and that HIV-uninfected sexual partners were protected from infection. We review the seemingly inconsistent findings of the major TasP trials: the TasP [National Agency for AIDS Research (ANRS) 12249] study in South Africa, the SEARCH trial in Kenya and Uganda, the Botswana Combination Prevention Project Ya Tsie study, and the HIV Prevention Trials Network 071 (PopART) trial in Zambia and South Africa. Findings: All the trials reinforce the critical need to identify approaches to optimize programs and incentivize uptake and engagement in HIV testing and ART-based care in ways that consistently reduce HIV transmission. That other chronic conditions can be screened for and treated in the same infrastructures suggests added value of HIV investments. Conclusions: Implementation challenges are a principal frontier in the global struggle to reduce HIV transmission and mortality using TasP, complementing efforts to find a cure for HIV and an effective, deployable vaccine. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Background: The continuum of HIV care among black men who have sex with men (BMSM) continues to be the least favorable in the United States. BMSM are disproportionally HIV-infected-but-unaware, despite expanded HIV testing efforts among this subgroup. Methods: We meta-analytically analyzed various HIV testing patterns [lifetime, after 24 months, after 12 months, after 6 months, and frequent (every 3–6 months) testing] among BMSM using the PRISMA guideline. PubMed, MEDLINE, Web of Science, and PsycINFO were searched for relevant articles, reports, conference proceedings, and dissertations published between January 1, 1996, and April 25, 2018. Two independent investigators reviewed and abstracted data into a standardized form. We used the DerSimonian–Laird random-effect model to pool the HIV testing prevalence and I-square statistics to measure heterogeneity. Funnel plots and Egger tests were used to assess for publication bias. We also performed subgroup and meta-regression analyses to explore aggregate-level characteristics that explain the heterogeneity across studies. Results: Our meta-analysis includes a total of 42,074 BMSM pooled from 67 studies. Lifetime HIV testing prevalence was high, 88.2% [95% confidence interval (CI): 86.2% to 90.1%], but recent (after 6 months = 63.4%; 95% CI: 59.3% to 67.4%) and frequent (42.2%, 95% CI: 34.1% to 50.3%) HIV testing prevalence was low. Meta-regression suggests that younger age (borderline significant), lower annual income, and homelessness were correlated with lower lifetime/recent HIV testing prevalence; while ever having condomless insertive/receptive sex, alcohol consumption, and illicit drug use were associated with higher lifetime/recent HIV testing prevalence. Conclusions: Recent and frequent HIV testing remains suboptimal among BMSM. Future testing programs should prioritize strategies to enhance self-initiated, regular HIV testing among BMSM. [ABSTRACT FROM AUTHOR]

Background: Little is known about human papillomavirus (HPV) infection and genotypes when considering both anatomic site and human immunodeficiency virus (HIV) status among men who have sex with men (MSM) in low- and middle-income countries.Methods: A cross-sectional study was conducted among MSM in Beijing, China. HIV serostatus was determined, and genital and anal HPV genotyping were performed from respective swabs.Results: Of 1155 MSM, 817 (70.7%) had testing for genital (611; 52.9%) and/or anal (671; 58.1%) HPV. Preference for insertive anal sex (adjusted odds ratio [aOR], 2.60; 95% confidence interval [CI], 1.42-4.75) and syphilis (aOR, 1.50; 95% CI, 1.01-2.23) were associated with genital HPV. Inconsistent condom use during receptive anal sex (aOR, 1.82; 95% CI, 1.17-2.84), and HIV seropositivity (aOR, 2.90; 95% CI, 1.91-4.42) were associated with anal HPV. Among 465 (40.3%) MSM with specimens from both anatomic sites, anal HPV (68%) was more common than genital HPV (37.8%). Prevalence of anal HPV was higher among HIV-infected than uninfected MSM (P < 0.01). Some oncogenic HPV types were more commonly found at the anal site of HIV-infected MSM (P < 0.01).Conclusions: Human papillomavirus is highly prevalent among Chinese MSM. Anal HPV was more common than genital HPV, and HIV seropositivity was associated with oncogenic HPV types at the anal site. [ABSTRACT FROM AUTHOR]

Background: Perioperative mortality rate is regarded as a credible quality and safety indicator of perioperative care, but its documentation in low- and middle-income countries is poor. We developed and tested an electronic, provider report-driven method in an East African country.Methods: We deployed a data collection tool in a Kenyan tertiary referral hospital that collects case-specific perioperative data, with asynchronous automatic transmission to central servers. Cases not captured by the tool (nonobserved) were collected manually for the last two quarters of the data collection period. We created logistic regression models to analyze the impact of procedure type on mortality.Results: Between January 2014 and September 2015, 8,419 cases out of 11,875 were captured. Quarterly data capture rates ranged from 423 (26%) to 1,663 (93%) in the last quarter. There were 93 deaths (1.53%) reported at 7 days. Compared with four deaths (0.53%) in cesarean delivery, general surgery (n = 42 [3.65%]; odds ratio = 15.80 [95% CI, 5.20 to 48.10]; P < 0.001), neurosurgery (n = 19 [2.41%]; odds ratio = 14.08 [95% CI, 4.12 to 48.10]; P < 0.001), and emergency surgery (n = 25 [3.63%]; odds ratio = 4.40 [95% CI, 2.46 to 7.86]; P < 0.001) carried higher risks of mortality. The nonobserved group did not differ from electronically captured cases in 7-day mortality (n = 1 [0.23%] vs. n = 16 [0.58%]; odds ratio =3.95 [95% CI, 0.41 to 38.20]; P = 0.24).Conclusions: We created a simple solution for high-volume, prospective electronic collection of perioperative data in a lower- to middle-income setting. We successfully used the tool to collect a large repository of cases from a single center in Kenya and observed mortality rate differences between surgery types. [ABSTRACT FROM AUTHOR]

Background: High mother-to-child HIV transmission rates in Nigeria are coupled with a critical shortage of trained health personnel, dearth of infrastructure, and low levels of male involvement in HIV care. This study evaluated maternal and provider satisfaction with services for prevention of mother-to-child transmission within the context of an implementation science cluster-randomized trial that included task shifting to lower-cadre workers, male engagement, point-of-care CD4+ cell counts, and integrated mother-infant care. Methods: Patient and clinician satisfaction were measured at 6 control and 6 intervention sites using a 5-point Likert scale. Patient satisfaction was assessed at 6 weeks postpartum through a 22-item scale about the provider's ability to explain the health problem, time spent with the clinician, and motivation to follow prescribed treatment. Provider satisfaction was assessed through a 12-item scale about motivation, compensation, and training, with 4 additional questions about the impact of task shifting on job satisfaction to intervention arm providers. Results: We measured satisfaction among 340 mothers (intervention n = 160; control n = 180) and 60 providers (intervention n = 36; control n = 24). Total patient satisfaction (maximum 5) was higher in the intervention than control arm [median (interquartile range) = 4.61 (4.22-4.79) vs. 3.84 (3.22-4.22), respectively; P, 0.001]. Provider satisfaction was generally high, and was similar between the intervention and the control arms [median (interquartile range) = 3.60 (3.37-3.91) vs. 3.50 (3.08-4.25), respectively; P = 0.69]. Provider satisfaction dropped when questions on newly acquired provider roles were included [3.47 (3.25-3.72)]. Patient and provider satisfaction were not associated with uptake of antiretroviral therapy or mother-infant retention at 6 and 12 weeks postpartum. Conclusions: Satisfaction was higher among patients at intervention sites, and provider satisfaction decreased when newly assigned roles were factored in. Task shifting should include training and supportive oversight to ensure comfort with assigned tasks. [ABSTRACT FROM AUTHOR]

Background: The HIV epidemic continues to expand among men who have sex with men (MSM) in China. The NIMH Project Accept/ HPTN 043 trial suggested a borderline significant trend toward HIV incidence reduction among persons with higher testing rates. Methods: We assessed HIV testing histories and infection status among a community-based Beijing MSM. HIV serostatus was lab confirmed. We ascertained demographic/behavioral factors through questionnaire-based interviews. Associations of previous HIV testing with odds of current HIV infection were assessed, seeking improved like-with-like risk comparisons through multivariable logistic regression analysis with propensity score adjustment and restricted cubic spline modeling. Results: Among 3588 participants, 12.7% were HIV infected; 70.8% reported having ever tested for HIV. Compared with MSM who never tested, those ever testing had a 41% reduction in the odds of being HIV positive [adjusted odds ratio (aOR): 0.59; 95% confidence interval (CI): 0.48 to 0.74. Higher HIV testing frequencies were associated with a decreasing trend in the odds of being infected with HIV vs. a referent group with no previous testing [>6 tests (aOR: 0.27; 95% CI: 0.18 to 0.41); 4-6 (aOR: 0.55; 95% CI: 0.39 to 0.78); 2-3 (aOR: 0.61; 95% CI: 0.45 to 0.82); P for trend <0.001]. The multivariable-adjusted model with restricted cubic spline of HIV testing frequency showed a higher frequency of previous HIV testing associated with lower odds of HIV infection, particularly among men with ≥10 lifetime male sexual partners. Conclusions: Using risk probability adjustments to enable less biased comparisons, frequent HIV testing was associated with a lower HIV odds among Chinese MSM. [ABSTRACT FROM AUTHOR]

Background: Voluntary medical male circumcision reduces the risk of HIV heterosexual transmission in men, but its effect on male-to-male sexual transmission is uncertain. Methods: Circumcision status of men who have sex with men (MSM) in China was evaluated by genital examination and self-report; anal sexual role was assessed by questionnaire interview. Serostatus for HIV and syphilis was confirmed. Results: Among 1155 participants (242 were seropositive and 913 with unknown HIV status at enrollment), the circumcision rate by self-report (10.4%) was higher than confirmed by genital examination (8.2%). Male circumcision (by examination) was associated with 47% lower odds of being HIV seropositive [adjusted odds ratio (aOR): 0.53; 95% confidence interval (CI): 0.27 to 1.02] after adjusting for demographic covariates, number of lifetime male sexual partners, and anal sex role. Among MSM who predominantly practiced insertive anal sex, circumcised men had 62% lower odds of HIV infection than those who were uncircumcised (aOR: 0.38; 95% CI: 0.09 to 1.64). Among those whose anal sex position was predominantly receptive or versatile, circumcised men have 46% lower odds of HIV infection than did men who were not circumcised (aOR: 0.54; 95% CI: 0.25 to 1.14). Compared to uncircumcised men reporting versatile or predominantly receptive anal sex positioning, those who were circumcised and reported practicing insertive sex had an 85% lower risk (aOR: 0.15; 95% CI: 0.04 to 0.65). Circumcision was not associated clearly with lower syphilis risk (aOR: 0.91; 95% CI: 0.51 to 1.61). Conclusions: Circumcised MSM were less likely to have acquired HIV, most pronounced among men predominantly practicing insertive anal intercourse. A clinical trial is needed. [ABSTRACT FROM AUTHOR]

A new Mozambican guideline for management of fever in HIV-infected adults requires malaria testing and systematic consideration of specific alternative diagnoses (eg, tuberculosis and bacterial infections) in addition to malaria. We conducted a prospective observational study of the guideline's performance. Of 258 HIV-infected subjects with axillary temperature ≥37.5° C or history of fever, 76.0% improved, 13.6% died or were hospitalized, and 10.5% were lost to follow-up. In multivariate analyses, factors associated with adverse outcomes were bacterial blood stream infection, syndromically diagnosed tuberculosis, lower CD4+ T-lymphocyte count, no antiretroviral therapy, lower body mass index, lower hemoglobin, and nonprescription of antibiotics. [ABSTRACT FROM AUTHOR]

Although there is a growing literature on the clinical performance of visual inspection with acetic acid in HIV-infected women, to the best of our knowledge, none have studied visual inspection with acetic acid enhanced by digital cervicography. We estimated clinical performance of cervicography and cytology to detect cervical intraepithelial neoplasia grade 2 or worse. Sensitivity and specificity of cervicography were 84% [95% confidence interval (CI): 72 to 91) and 58% (95% CI: 52 to 64). At the high-grade squamous intraepithelial lesion or worse cutoff for cytology, sensitivity and specificity were 61% (95% CI: 48 to 72) and 58% (95% CI: 52 to 64). In our study, cervicography seems to be as good as cytology in HIV-infected women. [ABSTRACT FROM AUTHOR]

Cancers associated with immunosuppression and infections have long been recognized as a major complication of HIV/AIDS. More recently, persons living with HIV are increasingly diagnosed with a wider spectrum of HIV-associated malignancies (HIVAM) as they live longer on combination antiretroviral therapy. This has spurred research to characterize the epidemiology and determine the optimal management of HIVAM with a focus on low-and middle-income countries (LMICs). Given background coinfections, environmental exposures, host genetic profiles, antiretroviral therapy usage, and varying capacities for early diagnosis and treatment, one can expect the biology of cancers in HIV-infected persons in LMICs to have a significant impact on chronic HIV care, as is now the case in high-income countries. Thus, new strategies must be developed to effectively prevent, diagnose, and treat HIVAM in LMICs; provide physical/clinical infrastructures; train the cancer and HIV workforce; and expand research capacity—particularly given the challenges posed by the limitations on available transportation and financial resources and the population's general rural concentration. Opportunities exist to extend resources supported by the President's Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis, and Malaria to improve the health-care infrastructure and train the personnel required to prevent and manage cancers in persons living with HIV. These HIV chronic care infrastructures could also serve cancer patients regardless of their HIV status, facilitating long-term care and treatment for persons who do not live near cancer centers, so that they receive the same degree of care as those receiving chronic HIV care today. [ABSTRACT FROM AUTHOR]

In this special 2014 issue of JAIDS, international investigator teams review a host of noncommunicable diseases (NCDs) that are often reported among people living and aging with HIV in sub-Saharan Africa. With the longer lifespans that antiretroviral therapy programs have made possible, NCDs are occurring due to a mix of chronic immune activation, medication side effects, coinfections, and the aging process itself. Cancer; cardiovascular and pulmonary diseases; metabolic, body, and bone disorders; gastrointestinal, hepatic, and nutritional aspects; mental, neurological, and substance use disorders; and renal and genitourinary diseases are discussed. Cost-effectiveness, key research methods, and issues of special importance in Asia, Latin America, and the Caribbean are also addressed. In this introduction, we present some of the challenges and opportunities for addressing HIV and NCD comorbidities in low- and middle-income countries, and preview the research agenda that emerges from the articles that follow. [ABSTRACT FROM AUTHOR]

Despite an estimated 59,000 incident pediatric HIV infections in 2012 in Nigeria, rates of early infant diagnosis (EID) of HIV service uptake remain low. We evaluated maternal factors independently associated with EID uptake in rural North Central Nigeria.We performed a cohort study using HIV/AIDS program data of HIV-infected pregnant women enrolled into HIV care/treatment on or before December 31, 2012 (n = 712). We modeled the probability of initiation of EID using multivariable logistic regression.Three hundred fifty-seven HIV-infected pregnant women enrolled their infants in EID across the 4 study sites. Women who enrolled their infants in EID vs. those who did not were similar across age, occupation, referral source, and select laboratory variables. Clinic of enrollment and date of enrollment were strong predictors for EID entry (P < 0.001). Women enrolled more recently were less likely to have their infants undergo EID than those enrolled at the beginning of the project (January 2011 vs. January 2010, adjusted odds ratio = 0.35, 95% confidence interval: 0.22 to 0.56; January 2012 vs. January 2010, adjusted odds ratio = 0.30, 95% confidence interval: 0.14 to 0.61). Women who received care in the more urban setting of Umaru Yar Adua Hospital were more likely to have their infants enrolled in EID than those who received care in the other 3 clinics.HIV-infected women in our prevention of mother-to-child HIV transmission program were more likely to bring in their infants for EID if they were enrolled in a more urbanized clinic location, and if they presented during an earlier phase of the program. The need for more intensive family engagement and program quality improvement is apparent, especially in rural settings. [ABSTRACT FROM AUTHOR]

Delays in HIV diagnosis and initiation of antiretroviral therapy are common even among symptomatic individuals in Africa. We hypothesized that antiretroviral therapy delays might be more common if traditional healers (THs) were the first practitioners consulted.Cross-sectional study.We interviewed 530 newly diagnosed HIV-infected adults (≥18 years of age) who were clinically symptomatic at the time of HIV testing in 2 rural districts in Zambézia Province, Mozambique. We ascertained their previous health care seeking behavior, duration of their symptoms, CD4+ cell counts at the time of entry into care, and treatment provided by TH(s).Of 517 patients (97.5%) with complete histories, 62% sought care from a healer before presenting to the local health facility. The median time to first health facility visit from first relevant symptom was 2 months [interquartile range (IQR): 1-4.5] for persons who had not visited a healer, 3 months (IQR: 2-6) for persons visiting 1 healer, and 9 months (IQR: 5-12) for persons visiting >1 healer (P < 0.001). Healers diagnosed 56% of patients with a social or ancestral curse and treated 66% with subcutaneous herbal remedies. A nonsignificant trend toward lower CD4+ cells for persons who had seen multiple healers was noted.Seeking initial care from healers was associated with delays in HIV testing among symptomatic HIV-seropositive persons. We had no CD4 evidence that sicker patients bypass THs, a potential inferential bias. Engaging THs in a therapeutic alliance may facilitate the earlier diagnosis of HIV/AIDS. [ABSTRACT FROM AUTHOR]

Timely initiation of combination antiretroviral therapy (ART) in eligible HIV-infected patients is associated with substantial reduction in mortality and morbidity. Nigeria has the second largest number of persons living with HIV/AIDS in the world. We examined patient characteristics, time to ART initiation, retention, and mortality at 5 rural facilities in Kwara and Niger states of Nigeria.We analyzed program-level cohort data for HIV-infected ART-naive clients (≥15 years) enrolled from June 2009 to February 2011. We modeled the probability of ART initiation among clients meeting national ART eligibility criteria using logistic regression with splines.We enrolled 1948 ART-naive adults/adolescents into care, of whom, 1174 were ART eligible (62% female). Only 74% of the eligible patients (n = 869) initiated ART within 90 days after enrollment. The median CD4+ count for eligible clients was 156 cells/μL (interquartile range: 81-257), with 67% in WHO stage III/IV disease. Adjusting for CD4+ count, WHO stage, functional status, hemoglobin, body mass index, sex, age, education, marital status, employment, clinic of attendance, and month of enrollment, we found that immunosuppression [CD4 350 vs. 200, odds ratio (OR) = 2.10, 95% confidence interval (CI): 1.31 to 3.35], functional status [bedridden vs. working, OR = 4.17 (95% CI: 1.63 to 10.67)], clinic of attendance [Kuta Hospital vs. referent: OR = 5.70 (95% CI: 2.99 to 10.89)], and date of enrollment [December 2010 vs. June 2009: OR = 2.13 (95% CI: 1.19 to 3.81)] were associated with delayed ART initiation.Delayed initiation of ART was associated with higher CD4+ counts, lower functional status, clinic of attendance, and later dates of enrollment among ART-eligible clients. Our findings provide targets for quality improvement efforts that may help reduce attrition and improve ART uptake in similar settings. [ABSTRACT FROM AUTHOR]

In light of China’s unique ethnic and sociocultural context, and a marked rise in HIV prevalence among MSM, it is important to determine prevalence, genotypes and predictors of anal human papillomavirus (HPV) among HIV-infected and uninfected men who have sex with men (MSM) in Beijing, China.In 2010-2011, we recruited MSM (age range 18-61; median 28 years) through peer volunteers, and collected demographic/behavioral information via interviewer-administrated questionnaires. Trained health workers collected anal swabs for HPV genotyping by PCR and blood samples for HIV/syphilis serologies.We obtained anal specimens from 212 HIV-infected and 459 HIV-uninfected participants. Among HIV-infected MSM, 82.1% were HPV-infected vs. 57.5% in HIV-uninfected (p<0.01). HIV-infected men had the greatest likelihood of multiple types: 17.9% uninfected; 36.3% with one type; 36.8% with 2-3; 9.0% with ≥4. Oncogenic HPV prevalence was higher among HIV- infected (61.3%) than uninfected participants (39.7%; p<0.01). HIV-uninfected MSM reporting always using condoms during insertive anal intercourse (past 6 months) were less likely to be HPV-infected (OR=0.49, 95%CI: 0.31-0.77). Among HIV-uninfected MSM, HPV infection was associated with unprotected receptive anal intercourse (past 6 months; OR=1.92, 95%CI: 1.19-3.11) and being forced to have sex (previous year; OR=3.32, 95%CI: 1.10-10.0). Multivariable logistic analysis among HIV infected MSM suggested that unprotected oral intercourse (past 6 months) was associated with HPV (adjusted OR=2.12, 95%CI: 1.00-4.48). Syphilis occurred in 55.8% of HIV-infected/HPV-infected, 50.0% of HIV-infected/HPV-uninfected, 19.6% of HIV-uninfected/HPV-infected, and 13.0% of HIV-uninfected/HPV-uninfected MSM.HPV anal infections were more common among HIV-infected than uninfected MSM in China, including oncogenic and multiple types. Unprotected oral and receptive anal sex were was independently associated with HPV infection. Promotion of safer sex and HPV vaccination is strongly recommended among MSM. [ABSTRACT FROM AUTHOR]

Background: HIV testing is the gateway for prevention and care. We explored factors associated with HIV testing among Chinese men who have sex with men (MSM).Methods: In Chongqing City, we recruited 492 MSM in 2010 using respondent-driven sampling in a cross-sectional study. Computer-assisted self-interviews were conducted to collect information on history of HIV testing.Results: Only 58% of participants reported ever having taken an HIV test. Men who have sex with men who had a college degree (adjusted odds ratio [AOR], 1.7; 95% confidence interval (CI), 1.2-2.6; P = 0.008) were more likely to take a test; those who preferred a receptive role in anal sex were less likely to do so than those with insertive sex preference (AOR, 0.6; 95% CI, 0.35-0.94; P = 0.03); and those who used condoms with the recent male partner during the past 6 months were more likely to get tested (AOR, 2.87; 95% CI, 1.25-6.62; P = 0.01). Principal perceived barriers to testing included the following: fear of knowing a positive result, fear of discrimination if tested positive, low perceived risk of HIV infection, and not knowing where to take a test. Factors reported to facilitate testing were sympathetic attitudes from health staff and guaranteed confidentiality. Prevalence was high: 11.7% HIV positive and 4.7% syphilis positive.Conclusions: The HIV testing rate among MSM in Chongqing is still low, although MSM prevalence is high compared with other Chinese cities. Men who have sex with men preferring receptive anal sex are less likely to get testing and perceive having lower HIV risk. Along with expanded education and social marketing, a welcoming and nonjudgmental environment for HIV testing is needed. [ABSTRACT FROM AUTHOR]

Early infant diagnosis (EID) is the first step in HIV care, yet 75% of HIV-exposed infants born at 2 hospitals in Mozambique failed to access EID.Before/after study.Two district hospitals in rural Mozambique.HIV-infected mother/HIV-exposed infant pairs (n = 791).We planned 2 phases of improvement using quality improvement methods. In phase 1, we enhanced referral by offering direct accompaniment of new mothers to the EID suite, increasing privacy, and opening a medical record for infants before postpartum discharge. In phase 2, we added enhanced referral activity as an item on the maternity register to standardize the process of referral.The proportion of HIV-infected mothers who accessed EID for their infant <90 days of life.We tracked mother/infant pairs from June 2009 to March 2011 (phase 0: n = 144; phase 1: n = 479; phase 2: n = 168), compared study measures for mother/infant pairs across intervention phases with χ2, estimated time-to-EID by Kaplan-Meier, and determined the likelihood of EID by Cox regression after adjusting for likely barriers to follow-up. At baseline (phase 0), 25.7% of infants accessed EID <90 days. EID improved to 32.2% after phase 1, but only 17.3% had received enhanced referral. After phase 2, 61.9% received enhanced referral and 39.9% accessed EID, a significant 3-phase improvement (P = 0.007). In adjusted analysis, the likelihood of EID at any time was higher in the phase 2 group versus phase 0 (adjusted hazard ratio: 1.68, 95% confidence interval: 1.19 to 2.37, P = 0.003). [ABSTRACT FROM AUTHOR]

Low mother/infant retention has impeded early infant diagnosis of HIV in rural Mozambique. We enhanced the referral process for postpartum HIV-infected women by offering direct accompaniment to the location of exposed infant testing before discharge. Retrospective record review for 395 women/infants (September 2009 to June 2010) found enhanced referral was associated with higher odds of follow-up (adjusted odds ratio = 3.18, 95% confidence interval: 1.76 to 5.73, P < 0.001); and among those followed-up, earlier infant testing (median follow-up: 33 days vs. 59 days, P = 0.01) compared with women receiving standard referral. This simple intervention demonstrates benefits gleaned from attention to system improvement through service integration without increasing staff. [ABSTRACT FROM AUTHOR]

A key challenge inhibiting the timely initiation of pediatric antiretroviral treatment is the loss to follow-up of mothers and their infants between the time of mothers' HIV diagnoses in pregnancy and return after delivery for early infant diagnosis of HIV. We sought to identify barriers to follow-up of HIV-exposed infants in rural Zambézia Province, Mozambique.We determined follow-up rates for early infant diagnosis and age at first test in a retrospective cohort of 443 HIV-infected mothers and their infants. Multivariable logistic regression models were used to identify factors associated with successful follow-up.Of the 443 mother-infant pairs, 217 (49%) mothers enrolled in the adult HIV care clinic, and only 110 (25%) infants were brought for early infant diagnosis. The predictors of follow-up for early infant diagnosis were larger household size (odds ratio [OR], 1.29; 95% confidence interval [CI], 1.09-1.53), independent maternal source of income (OR, 10.8; 95% CI, 3.42-34.0), greater distance from the hospital (OR, 2.14; 95% CI, 1.01-4.51), and maternal receipt of antiretroviral therapy (OR, 3.15; 95% CI, 1.02-9.73). The median age at first test among 105 infants was 5 months (interquartile range, 2-7); 16% of the tested infants were infected.Three of four HIV-infected women in rural Mozambique did not bring their children for early infant HIV diagnosis. Maternal receipt of antiretroviral therapy has favorable implications for maternal health that will increase the likelihood of early infant diagnosis. We are working with local health authorities to improve the linkage of HIV-infected women to HIV care to maximize early infant diagnosis and care. [ABSTRACT FROM AUTHOR]

The article presents a study which evaluates HIV and syphilis infection among men who have sex with men (MSM) in China. It states that a survey was conducted in which the behavioral risk factors were assessed, and blood samples were examined for HIV and syphilis. Results show that 2.9% were HIV affected and 9.8% were syphilis infected in 4,983 MSM participants collected. It concludes that HIV and syphilis have attained alarming rates in China in which proper solution are immediately needed.

The article presents a study which examines the risk factors for human immunodeficiency virus (HIV) infection among adolescents and young adult in Haiti. It mentions that the study was conducted through the assessment of associations between demographic and behavioral factors and HIV status. It reveals several predictors of HIV in females such as the poor education, being married, and having a child. On the other hand, drug use and sexual debut with unknown person are the risk factors for men.

The article presents a preparedness study aimed at evaluating the suitability of sites and populations in urban Zambia following the same study procedures intended for a larger scale microbicide efficacy trial. In this study, researchers evaluated human immunodeficiency virus (HIV) incidence, prevalence, and risk profiles for HIV-acquisition among young women of the said country. Researchers conclude that their general population sample, characterized by high HIV prevalence and ongoing incidence rates despite receiving regular risk reduction counseling and free condoms, qualifies for future microbicide studies. They also found that a microbicide preparedness study in Lusaka have high HIV prevalence and appreciable HIV incidence in a population of women in an urban setting.

The article reports on results of a study of predictors of adherence to antiretroviral therapy in rural Zambia. A description of the study design and methods is presented. The study concluded that patients in Zambia can achieve adherence rates compatible with good clinical outcomes despite long travel distances. It adds that the Macha Mission Hospital was able to provide quality HIV/AIDS care.

The article discusses a study which examines whether targeted HIV programs improve overall care for pregnant women in Lusaka, Zambia. Documented syphilis rapid plasma reagin (RPR) screening improved after the implementation of prevention of mother-to-child (PMTCT) research. The simultaneous operation of PMTCT research and service programs in antenatal clinics was associated with improved antenal RPR screening coverage.

The article studies the use of complete blood cell count as a surrogate CD4 cell marker for HIV monitoring in resource-limited settings. A decision tree was used to develop models with the variables total lymphocyte count, hemoglobin, platelet count, gender, body mass index and antiretroviral treatment status of subjects from the University of Alabama in Birmingham observational database.

The article discusses research on the risk factors of sexually transmitted infections (STI) among truck stand workers in Dhaka, Bangladesh. The aim of the study was to describe the prevalence of selected STIs and their risk factors in and near a truck stand in the city. The study revealed that both behavioral and STI data have proposed that truck stand workers must be included in the STI and HIV intervention programs.

The article discusses a study to determine the correlates of syphilis seroprevalence among HIV-infected and -uninfected antenatal participants in an African multisite clinical trial, to improve the strategies for maternal syphilis prevention. Women without identified risk factors were syphilis-seropositive. Younger HIV-infected women were at highest risk. Integrated antenatal HIV and syphilis screening and treatment are important.

Background: Despite the proven benefits conferred by early human immunodeficiency virus (HIV) diagnosis and presentation to care, delays in HIV medical care are common; these delays are not fully understood, especially in the southern United States.Methods: We evaluated the extent of, and characteristics associated with, delayed presentation to HIV care among 1,209 patients at an HIV/AIDS Outpatient Clinic in Birmingham, Alabama between 1996 and 2005.Results: Two out of five (41.2%) patients first engaged care only after they had progressed to CDC-defined AIDS. Among these, 53.6% were diagnosed with HIV in the year preceding entry to care. Recent presentation (2002 - 2005), male sex, age > or = 25, Medicare or Medicaid insurance coverage, and presentation within six months of HIV diagnosis were independently associated with initiating care after progression to AIDS.Conclusions: A high proportion of patients entered clinical care after experiencing substantial disease progression. Interventions that effectively improve the timing of HIV diagnosis and presentation to care are needed. [ABSTRACT FROM AUTHOR]