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HIV pre-exposure prophylaxis (PrEP) is a highly effective prevention method. It is an attractive self-initiated approach to reduce the spread of HIV amongst female sex workers (FSW). PrEP, however, has not yet achieved its potential to reduce HIV infections partially due to a general lack of awareness from women who may benefit. Aims of this cross-sectional study of 1,466 FSW in China were to understand: levels of awareness of and willingness to use PrEP among female sex workers (FSW) in China, and factors contributing to willingness to use PrEP. We found that awareness (10.2%) and willingness (35.5%) to use PrEP were low in our survey areas. Low PrEP willingness is likely reflective of the overall poor knowledge and understanding of HIV risk and prevention. FSW that demonstrated greater HIV knowledge through having been tested or having greater decision-making involvement in condom use were more willing to use PrEP. Study findings may be used to inform future HIV prevention activities, including possible use of PrEP among FSW at higher risk of incident HIV infection in China.

The prevalence of human immunodeficiency virus (HIV) infection in China is low overall (0.06%) (1); however, it is substantially higher (8.0%) among men who have sex with men (MSM) (2), and the stigmatization of same-sex behaviors in China presents challenges for HIV prevention and treatment efforts. In 2015, Blued, a Beijing-based media company that operates an online dating application popular among Chinese MSM, launched an ongoing HIV testing campaign that combined its push-notification† platform and geolocation capabilities to encourage HIV testing among MSM in Beijing. To assess trends in use of HIV testing services, Blued and CDC's China HIV program examined testing at six Blued-operated Beijing HIV testing centers from 2 years before the campaign launch in 2015 through December 31, 2017. A sharp increase in HIV testing followed the launch of Blued's online campaign, indicating that leveraging social media platforms and their geolocation-based text messaging functionality might be useful in increasing HIV testing among MSM, particularly those aged ≤35 years.

OBJECTIVE To examine the relationship between combination antiretroviral therapy (cART) and preterm delivery (PTD) or low delivery weight among pregnant Chinese women with HIV. METHODS The present retrospective cross-sectional medical chart review enrolled pregnant women with HIV who delivered at five tertiary hospitals in China between January 1, 2009, and December 31, 2014. Generalized linear mixed modeling was used to explore PTD (

BACKGROUND There is limited information on antiviral therapy for hepatitis B virus (HBV) infection among pregnant women coinfected with human immunodeficiency virus (HIV) and HBV. METHODS A phase 2 randomized, controlled trial of a regimen containing tenofovir (TDF)/lamivudine (3TC) and a regimen containing 3TC in HIV/HBV-coinfected pregnant women in China. The HBV virological response was compared in study arms. RESULTS The median decline in the HBV DNA level was 2.60 log10 copies/mL in the TDF/3TC arm and 2.24 log10 copies/mL in the 3TC arm (P = .41). All women achieved HBV DNA levels of

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

Introduction: The evidence has begun to mount for diminishing the frequency of CD4 count testing. To determine whether these observations were applicable to an urban US population, we used New York City (NYC) surveillance data to explore CD4 testing among stable patients in NYC, 2007–2013. Methods: We constructed a population-based retrospective open cohort analysis of NYC HIV surveillance data. HIV+ patients aged ≥13 years with stable viral suppression (≥1 viral load the previous year; all 90% among those with initial CD4 ≥350 cells per cubic millimeter, suggesting that limited CD4 monitoring in these patients is appropriate.

The effects of maternal tenofovir use on infant bone mineral content (BMC) and bone mineral density (BMD) were evaluated in a pilot study of HIV/Hepatitis B-coinfected pregnant women in China. BMD and BMC were assessed at age 6 months of life in 14 tenofovir-exposed and 13 unexposed infants. Trends toward lower BMC and BMD were observed in infants exposed to maternal tenofovir but were not statistically significant.

This analysis used data from a randomly selected cross-sectional sample of HIV infected outpatient adults in New York City to assess HIV-related stigma and examine gender-specific differences among factors associated with HIV-related stigma. Data was collected by conducting participant interviews and medical records abstraction. HIV-related stigma was assessed using the internalized AIDS-related stigma scale (IA-RSS). Exploratory factor analysis of the IA-RSS indicated that the scale consisted of two factors: (1) internalized stigma and (2) anticipated stigma. Of the 447 sampled participants 23.9% had a higher level of internalized stigma and 38.3% had a higher level of anticipated stigma. Multivariate analysis indicated that among females, internalized stigma was associated with being diagnosed HIV positive after the introduction of HAART in 1996 (adjusted prevalence ratio [PR]: 1.9; 95% CI: 1.2, 3.1; P0.01) and a diagnosis of depression (adjusted PR: 1.9; 95% CI: 1.2, 2.9; P0.01). Among males, anticipated stigma was associated with younger age (18 and 39 years) (adjusted PR: 1.7; 95% CI: 1.3, 2.2; P0.001) and use of non-injection drugs (adjusted PR: 0.60; 95% CI: 0.41, 0.86; P0.01). Findings suggest that there may be gender-specific differences among factors associated with different dimensions of HIV-related stigma.

BACKGROUND: The purpose of this analysis is to compare 2 newly developed methods (a "likelihood" method and a "weighting" method) with the widely used method (the "include-all" method) to estimate the proportions of HIV-infected persons retained in care and virally suppressed in New York City (NYC). METHODS: The NYC HIV registry data were used for the analysis. The include-all method included all patients in the denominator who were diagnosed and/or receiving care in NYC and not known to be dead by December 31, 2012. The likelihood method included patients in the denominator who were likely to reside in NYC in 2012 based on their length of absence from HIV care. The weighting method included patients in the denominator who were residing in NYC in 2012 by weighting each in-care patient based on their probability of receiving HIV care. RESULTS: The include-all method estimated that 114,926 persons were diagnosed and living with HIV in NYC, 63.7% were retained in care (≥1 care visit in 2012), and 48.9% were virally suppressed (≤200 copies/mL). The likelihood method and the weighting method produced equivalent estimates with 80,074 and 80,509 persons diagnosed and living with HIV in NYC, 91.5% and 91.0% retained in care, and 70.2% and 71.7% virally suppressed, respectively. CONCLUSIONS: Using 2 newly developed methods, we were able to report more accurate estimates of the proportions of patients retained in care and virally suppressed. Other local health jurisdictions should consider using these new methods to measure care outcomes and monitor the National HIV/AIDS Strategy.

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

The chief concerns for antiretroviral therapy (ART) programs considering removal of CD4+ cell count thresholds for treatment are the increased incidence of ART-related adverse events. A nationwide observational cohort study was conducted among patients who initiated ART in 2012. We divided the eligible patients into three groups: an early ART group with a baseline CD4+ cell count of 500 cells/μL or greater, a standard ART group with a baseline CD4+ cell count between 350 and 499 cells/μL, and a late ART group with a baseline CD4+ cell count between 200 and 349 cells/μL. These patients were followed up to December 31, 2014 and observed for three outcomes: virological failure, treatment nonretention, or time to death. Patients who met the eligibility criteria numbered at 26,752. Out of all study participants, 20,827 participants were in late ART group, 4336 were in standard ART group, and 1589 were in early ART group. Patients in late ART group were more likely to become virally suppressed 12 and 24 months after treatment initiation than patients in early ART group [adjusted odds ratio (aOR) 0.81; 95% CI, 0.69–0.95 and aOR, 0.78; 95% CI, 0.65–0.94]. Treatment nonretention was also less likely to occur among patients in late ART group than early ART group 12 months after treatment initiation (aOR, 0.85; 95% CI, 0.75–0.96). Compared with early ART group, neither standard ART group nor late ART group had a statistically significant difference in the time-to-death analysis. Late ART initiates were more likely to be virally suppressed and retained on treatment than early ART initiates. The importance of treatment retention and adherence should be emphasized for high CD4+ patients newly initiated to ART therapy through education and counseling programs.

We sought to calculate rates of HIV diagnoses by area of birth among foreign-born persons in a high-incidence US city with many immigrants, and determine probable place of HIV acquisition. Data from the New York City HIV surveillance registry and American Community Survey were used to calculate HIV diagnosis rates by area of birth and determine probable place of HIV acquisition among foreign-born diagnosed in 2006-2012. HIV diagnosis rates varied by area of birth and were highest among African-born persons; absolute numbers were highest among Caribbean-born persons. Probable place of acquisition was a foreign country for 23 % (from 9 % among Middle Easterners to 43 % among Africans), US for 61 % (from 34 % among Africans to 76 % among South Americans), and not possible to estimate for 16 %. HIV prevention and testing initiatives should take into account variability by foreign area of birth in HIV diagnosis rates and place of acquisition.

Background: Comprehensive laboratory reporting of CD4 and viral load (VL) tests to surveillance has been used to assess HIV care–related outcomes at the population level, but their validity for this purpose has not been comprehensively evaluated. Objective: Assess performance characteristics and validity of surveillance-based measures of linkage to and establishment of HIV primary care among HIV-infected persons in the first 12 months after diagnosis using medical record (MR) data on outpatient HIV primary care visits as the gold standard. Methods: All patients diagnosed with HIV in 2009 at 24 New York City high-volume, HIV diagnostic and treatment facilities who linked to care within 12 months at the same site as defined by the presence of $1 CD4/VL report received by surveillance were selected for MR review to confirm linkage to outpatient HIV primary care within the first year. All HIV care visit dates were abstracted and considered associated with a surveillance laboratory report, if within 14 days of a care visit. The proportion linking to care according to the MR was compared with the proportion linking per CD4/ VL tests reported to surveillance. Four measures of the establishment of outpatient HIV primary care in the first year were assessed: (1) sustained care (first visit within 3 months; second visit, 3–9 months later), (2) continuous care (2 visits at least 90 days apart), (3) trimester visits (visit in each 4-month period), and (4) visit constancy (visit in each 3-month period). The validity of surveillance data for measuring this outcome was assessed by comparing results for each of the 4 measures calculated using surveillance data to those calculated using MR data. Results: Of the 782 patients selected, 20% (N = 157) of patients did not link to outpatient HIV primary care at the co-located care facility within 12 months of diagnosis. Half (48.5%) of patients’ care visits after linkage did not have an associated CD4/VL reported to surveillance. Of the 4 establishment measures, sustained and continuous care had the highest agreement with MR (86.6% and 88.8%, respectively) as compared with the trimester visits and visit constancy (77.8% and 72.8%, respectively). Conclusions: Surveillance data overestimated linkage rates but underestimated the frequency of HIV care in the first year after HIV diagnosis. Of the 4 measures of establishment of HIV care evaluated, “sustained care” is best suited for measurement using surveillance data because of its high level of agreement with MR data and close alignment with national standards for timely linkage and flexible follow-up.

BACKGROUND Identification and characterization of patients in HIV-serodiscordant partnerships can inform strategies to improve HIV prevention efforts for this group. METHODS We conducted a case-control analysis using New York City Department of Health and Mental Hygiene HIV surveillance and partner services (PS) data from July 2006 to July 2010. HIV-infected index patients reported and interviewed for PS who named 1 or more sex and/or syringe-sharing partner (n = 1309) and their sex partners notified by New York City Department of Health and Mental Hygiene with confirmed HIV serostatus (n = 1564) were selected for analysis. Index patients were classified into either serodiscordant or seroconcordant-positive partnerships based on the HIV serostatus of their partner(s). Multivariable regression analysis was conducted to examine the likelihood of membership in a serodiscordant partnership by a range of individual- and partnership-level variables. RESULTS Of the 1309 index patients, 624 (48%) were in HIV-serodiscordant partnerships. In multivariable analysis, the likelihood of serodiscordant partnership membership was slightly higher among women, individuals with unknown HIV transmission risk, and those with 2 to 3 named partners versus 1. Index patients claimed more partners than they named; for example, index patients who named 1 partner claimed an average of 2.3 partners in the past 12 months. CONCLUSIONS Many HIV-infected patients who received PS were in HIV-serodiscordant partnerships, with characteristics indicating potential for HIV transmission. Our findings suggest several potential programmatic and policy needs, including enhanced linkage-to-care efforts for this population, especially HIV-infected individuals with uncontrolled viremia; ongoing PS for individuals with evidence of continuing exposure of others; and participation by patients and their serodiscordant, steady partners in local prevention interventions.

Objective Locate persons living with HIV (PLWH) presumed lost to follow-up (LTFU), and assist them with partner services and linkage to HIV-related care. Design Locate and facilitate re-engagement in care for PLWH-LTFU in New York City (NYC), with longitudinal follow-up using HIV surveillance registry. Settings HIV care facilities and communities in NYC. Patients PLWH, reported in the NYC HIV surveillance registry, who had a NYC care provider and residential address at last report in the registry. Presumed-LTFU was defined as having no CD4+ or viral load during the most recent 9 months during the study period July 2008-December 2010. Intervention Case-workers conducted public health investigation to locate PLWH presumed-LTFU and offered them assistance with partner and linkage-to-care services. Main outcome measures Results of partner and linkage-to-care services, and reasons for LTFU. Results From July 2008 to December 2010, 797 PLWH presumed-LTFU were prioritized for investigation; 14% were never located. Of the 689 located, 33% were current to care, 5% had moved or were incarcerated, 2% had died, and 59% (409) were verified to be LTFU. Once located, 77% (315/409) accepted clinic appointments, and 57% (232/409) returned to care. Among the 161 who provided reasons for LTFU, the most commonly reported was 'felt well' (41%). Conclusions Health department case-workers helped more than half PLWH-LTFU re-engage in HIV medical care. HIV prevention strategies must include efforts to re-engage PLWH-LTFU in care, for treatment consideration under current treatment guidelines to improve their clinical status and decrease transmission risk.

Purpose To determine if sexually active heterosexual HIV-infected 15– to 24–year-old youth have different sexual or other risk behaviors depending on whether they were infected perinatally or heterosexually. Methods We compared youth aged 15 to 24 years who acquired HIV perinatally or sexually and were interviewed in-person or by phone for partner services by the New York City Department of Health and Mental Hygiene. We included heterosexually active youth with at least one sexual partner of the opposite sex in the past 12 months, and excluded men who have sex with men and injection drug users. We used χ 2 tests and t tests to compare demographics, sexual risk behaviors, partner services outcomes, and viral loads. Results Both groups reported few partners (median 1, mean 2), and only 12% of partners of perinatally infected youth were previously diagnosed (18% of sexually infected youths' partners). A minority reported always using condoms. Both groups had similar rates of sexually transmitted infections and median HIV plasma RNA (perinatally infected: 5,140 copies/mL; sexually infected: 6,835 copies/mL). Despite these similarities, among tested partners not previously HIV diagnosed, none of 17 named by perinatally infected youth was newly HIV diagnosed, whereas 21% (8/39, p = .09) of those named by sexually infected youth were newly diagnosed. Conclusions Though perinatally infected youth did not transmit HIV infection to previously undiagnosed partners, they had similar HIV-related risk behaviors to youth infected sexually who reported on risks that led to their infection. HIV prevention among HIV-infected youth remains a critical challenge.

BACKGROUND Men who have sex with men (MSM) account for a higher proportion of HIV diagnoses than any other risk group in the United States. Given that in NYC MSM younger than 30 years represent a growing proportion of new diagnoses among MSM, we examined differences between MSM by age. METHODS We analyzed NYC surveillance and partner services (PS) data for MSM newly diagnosed with HIV from January 2007 to December 2008. We compared demographics, HIV-related risk behaviors, and sexual partner characteristics between younger MSM (

Some patients develop AIDS within a year of HIV infection ("accelerated progression"). Classifying such cases as late HIV diagnosis may lead to inaccurate evaluation of HIV testing efforts. We sought to determine this group's contribution to overall late diagnosis rates. To identify cases of accelerated progression (development of AIDS within 12 months of a negative HIV test), we reviewed published HIV seroconverter cohort studies and used New York City's (NYC) HIV/AIDS surveillance registry. From the literature review, three seroconverter cohort studies revealed that 1.0-3.6% of participants had accelerated progression to AIDS. Applying this frequency estimate to the number of new infections in NYC (4762) for 2006 calculated by the Centers for Diseases Control and Prevention's incidence formula, we estimated that 3.6-13.0% of 1317 NYC HIV cases who are diagnosed with AIDS within 12 months of HIV diagnosis are accelerated progressors, not persons HIV infected for many years who did not test and present with AIDS (i.e., delayed diagnosis). In addition, our analysis of the 2006 NYC surveillance registry confirmed the occurrence of accelerated progression in a population-based setting; 67 accelerated progressors were reported and 9 (13%) could be confirmed through follow-up medical record review. With increased HIV testing initiatives, the irreducible proportion of AIDS cases with accelerated progression must be considered when interpreting late diagnosis data.

Public health usually notifies partners of STD exposure in-person despite availability of other options. We examined trends in in-person versus telephone notification for HIV 3 years after the introduction of a telephone option. Most notifications were made by telephone. Partners notified doubled; however, the proportion HIV testing declined slightly.

Background In June 2005, the Advisory Committee on Immunization Practices recommended the newly licensed quadrivalent meningococcal conjugate vaccine for routine use among all US children aged 11 years. A 1-time catch-up vaccination campaign for children and adolescents aged 11-17 years, followed by routine annual immunization of each child aged 11 years, could generate immediate herd immunity benefits. The objective of our study was to analyze the cost-effectiveness of a catch-up vaccination campaign with quadrivalent meningococcal conjugate vaccine for children and adolescents aged 11-17 years. Methods We built a probabilistic model of disease burden and economic impacts for a 10-year period with and without a program of adolescent catch-up meningococcal vaccination, followed by 9 years of routine immunization of children aged 11 years. We used US age- and serogroup-specific surveillance data on incidence and mortality. Assumptions related to the impact of herd immunity were drawn from experience with routine meningococcal vaccination in the United Kingdom. We estimated costs per case, deaths prevented, life-years saved, and quality-adjusted life-years saved. Results With herd immunity, the catch-up and routine vaccination program for adolescents would prevent 8251 cases of meningococcal disease in a 10-year period (a 48% decrease). Excluding program costs, this catch-up and routine vaccination program would save US$551 million in direct costs and $920 million in indirect costs, including costs associated with permanent disability and premature death. At $83 per vaccinee, the catch-up vaccination would cost society approximately $223,000 per case averted, approximately $2.6 million per death prevented, approximately $127,000 per life-year saved, and approximately $88,000 per quality-adjusted life-year saved. Targeting counties with a high incidence of disease decreased the cost per life-year saved by two-thirds. Conclusions Although costly, catch-up and routine vaccination of adolescents can have a substantial impact on meningococcal disease burden. Because of herd immunity, catch-up and routine vaccination cost per life-year saved could be up to one-third less than that previously assessed for routine vaccination of children aged 11 years.

Objectives. We measured HIV care outcomes of transgender persons, who have high HIV infection rates but are rarely distinguished from men who have sex with men (MSM) in HIV surveillance systems. Methods. New York City’s surveillance registry includes HIV diagnoses since 2000 and HIV laboratory test results for transgender persons since 2005. We determined immunological status at diagnosis, delayed linkage to care, and nonachievement of viral suppression 1 year after diagnosis for transgender persons diagnosed with HIV in 2006 to 2011 and compared transgender women with MSM. Results. In 2006 to 2011, 264 of 23 805 persons diagnosed with HIV were transgender (1%): 98% transgender women and 2% transgender men. Compared with MSM, transgender women had similar CD4 counts at diagnosis and rates of concurrent HIV/AIDS and delayed linkage to care but increased odds of not achieving suppression (adjusted odds ratio = 1.56; 95% confidence interval = 1.13, 2.16). Conclusions. Compared with MSM, transgender women in New York City had similar immunological status at diagnosis but lagged in achieving viral suppression. To provide appropriate assistance along the HIV care continuum, HIV care providers should accurately identify transgender persons.

Purpose: The aim of this study was to assess the exposure to and impact of the It's Never Just HIV mass media campaign aimed at HIV negative men who have sex with men (MSM) in New York City. Methods: Questions about the campaign were included in the local questionnaire of the Centers for Disease Control and Prevention (CDC)-sponsored National HIV Behavioral Surveillance (NHBS) study of MSM in NYC conducted in 2011. Participants in this cross-sectional study were recruited using venue-based sampling. Results: Among 447 NYC National HIV Behavioral Surveillance study participants who self-reported HIV negative or unknown status and answered questions about the NYC Department of Health and Mental Hygiene's It's Never Just HIV campaign, more than one-third (n = 173, 38.7%) reported having seen the campaign. Latinos (34.8%) and blacks (34.4%) were less likely to report seeing the campaign compared to whites (47.7%). Most of those who reported seeing the campaign saw it on the subway (80.1%). Only 9.4% of those who saw the campaign reported having changed their sexual or health behaviors in response to the campaign. Conclusions: These data suggest that thousands of HIV-uninfected MSM in NYC have been reached by the campaign and recalled its message.

Individuals infected with HIV who are out of care are at a higher risk of HIV-related morbidity and mortality. It has been difficult to recruit a representative sample of out-of-care patients for epidemiological studies. Using a novel weighting method, we constructed a representative sample of out-of-care HIV patients from a representative sample of in-care patients. In-care patients were weighted based on the probability of receiving care during the study period and the probability of selection to participate in the study, and out-of-care patients were represented by those who were previously out of care and recently returned. The method can be used in other patient populations, if every patient in the population has a known, non-zero probability of receiving care and a known, non-zero probability of participating in the study.

Objectives To better understand risk behaviours and factors associated with low-fee female sex workers (FSW) and support HIV/sexually transmitted infections (STI) epidemic control among this key population in China. Methods A cross-sectional study using convenience sampling to recruit 1487 eligible low-fee and medium-fee FSW was conducted in 2012 in three provinces. The participants were interviewed using a structured questionnaire and tested for HIV-1, herpes simplex virus (HSV)-2 and syphilis antibody. Log-binomial modelling was used to estimate prevalence ratios (PR) and examine factors associated with low-fee sex work. Results Prevalence of HIV-1, syphilis and HSV-2 antibody positive were 0.5%, 4.8% and 27.8%, respectively. Low-fee FSW were more likely to have HSV-2 infection (adjusted prevalence ratio (APR)=1.3, 95% CI 1.1 to 1.7), but not more likely to have HIV-1 and syphilis infection compared with medium-fee FSW. Compared with medium-fee FSW, low-fee FSW were more likely to be ≥35 years of age (APR=2.1, 95% CI 1.3 to 3.6), engage in sex work ≥6 days/per week (APR=1.7, 95% CI 1.2 to 2.6), have ≥3 clients per day (APR=2.2, 95% CI 1.5 to 3.3), have clients decide condom use (APR=1.6, 95% CI 1.1 to 2.3), fail to persuade clients to use condoms (APR=1.6, 95% CI 1.1 to 2.6), express willingness to have unprotected sex in return for receipt of a higher fee (APR=1.8, 95% CI 1.2 to 2.8), have had genital symptoms in the past year (APR=1.4, 95% CI 1.1 to 1.8) and have migrated from another city. Conclusions Low-fee FSW in China have unique risks for acquiring HIV/STI, in part due to greater economic pressures. Tailored interventions targeting low-fee FSW and incorporating their prevailing perception of HIV/STI risks and condom use negotiation challenges that they face are urgently needed.

Decedents with new HIV diagnosis at autopsy were predominantly male, aged 13-64 years, non-white, unmarried, less than college educated, and residents of an impoverished neighborhood. The strongest independent correlate of new HIV diagnosis at autopsy was age ≥65 years., Background. Studying the most extreme example of late diagnosis, new HIV diagnoses after death, may be instructive to HIV testing efforts. Using the results of routine HIV testing of autopsies performed by the Office of Chief Medical Examiner (OCME), we identified new HIV diagnoses after death in New York City (NYC) from 2008 to 2012. Methods. Population-based registries for HIV and deaths were linked to identify decedents not known to be HIV-infected before death. Multivariable logistic regression models were constructed to determine correlates of a new HIV diagnosis after death among all persons newly diagnosed with HIV and among all HIV-infected decedents receiving an OCME autopsy. Results. Of 264 893 deaths, 24 426 (9.2%) were autopsied by the NYC OCME. Of these, 1623 (6.6%) were infected with HIV, including 142 (8.8%) with a new HIV diagnosis at autopsy. This represents 0.8% (142 of 18 542) of all new HIV diagnoses during the 5-year period. Decedents newly diagnosed with HIV at OCME autopsy were predominantly male (73.9%), aged 13–64 years (85.9%), non-white (85.2%), unmarried (81.7%), less than college educated (83.8%), and residents of an impoverished neighborhood (62.0%). Of all HIV-infected OCME decedents aged ≥65 years (n = 71), 22.0% were diagnosed at autopsy. The strongest independent correlate of new HIV diagnosis at autopsy in both multivariable models was age ≥65 years. Conclusions. Human immunodeficiency virus diagnoses first made after death are rare, but, when observed, these diagnoses are more commonly found among persons ≥65 years, suggesting that despite highly visible efforts to promote HIV testing community-wide, timely diagnosis among older adults living in impoverished, high-prevalence neighborhoods may require additional strategies.

Objectives: To characterize illness and identify the etiology for two nursing home outbreaks of respiratory illness. Design: Multisite outbreak investigations; cohort. Setting: Two nursing homes in Pennsylvania. Participants: Facility A residents (n=170), Facility B residents (n=124), and employees (n=91). Measurements: Medical records for Facility A and B residents were reviewed, and employees from Facility B self-administered a questionnaire to identify risk factors for illness. Serological, oropharyngeal, and nasopharyngeal specimens were collected for both outbreaks, and testing for respiratory pathogens was performed. Results: In Facility A, 40 (24%) of 170 residents were identified with respiratory illness; 13 (33%) case-patients had radiographically confirmed pneumonia, 15 (38%) were taken to a hospital, and two (5%) died. Of 10 specimens collected from symptomatic Facility A case-patients, four (40%) tested positive using reverse transcription polymerase chain reaction for rhinovirus. In Facility B, 77 (62%) of 124 residents had respiratory illness, and 40 (52%) had radiographically confirmed pneumonia; 12 (16%) case-patients were hospitalized, and five (6%) died. Of 19 respiratory specimens collected from symptomatic Facility B case-patients, six (32%) were positive for rhinovirus; one was from an employee. Five (50%) of 10 rhinovirus-positive cases in both outbreaks had clinical and radiographic evidence of pneumonia. Conclusion: These investigations suggest that rhinoviruses may be an underrecognized cause of respiratory outbreaks in nursing homes, capable of causing pneumonia and perhaps death.

Hepatitis C virus (HCV) is a major cause of liver disease worldwide and a potential cause of substantial morbidity and mortality in the future. The complexity and uncertainty related to the geographic distribution of HCV infection and chronic hepatitis C, determination of its associated risk factors, and evaluation of cofactors that accelerate its progression, underscore the difficulties in global prevention and control of HCV. Because there is no vaccine and no post-exposure prophylaxis for HCV, the focus of primary prevention efforts should be safer blood supply in the developing world, safe injection practices in health care and other settings, and decreasing the number of people who initiate injection drug use.

Objectives To measure trends in HIV diagnoses among foreign-born (FB) New Yorkers and compare the epidemic in FB with that in non-FB (NFB). Methods New York City (NYC) HIV/AIDS surveillance registry data were used to measure trends in HIV diagnoses in 2001–2009, calculate HIV diagnosis rates by area of birth, and compare demographic and care characteristics of FB and NFB diagnosed in 2006–2009. The registry contains data on all New Yorkers diagnosed with HIV infection, HIV disease and AIDS, and receives laboratory results on all New Yorkers living with HIV/AIDS. Results From 2001 to 2009, new HIV diagnoses among FB increased modestly in number but significantly as a percent of all cases (17% in 2001 to 28% in 2009; p Conclusions The percentage of HIV diagnoses in NYC attributed to FB persons has increased. HIV infection may remain undiagnosed longer in FB than NFB. FB may benefit from targeted prevention outreach and other services.

On October 4, 2001, we confirmed the first bioterrorism-related anthrax case identified in the United States in a resident of Palm Beach County, Florida. Epidemiologic investigation indicated that exposure occurred at the workplace through intentionally contaminated mail. One additional case of inhalational anthrax was identified from the index patient’s workplace. Among 1,076 nasal cultures performed to assess exposure, Bacillus anthracis was isolated from a co-worker later confirmed as being infected, as well as from an asymptomatic mail-handler in the same workplace. Environmental cultures for B. anthracis showed contamination at the workplace and six county postal facilities. Environmental and nasal swab cultures were useful epidemiologic tools that helped direct the investigation towards the infection source and transmission vehicle. We identified 1,114 persons at risk and offered antimicrobial prophylaxis.

We collected data during postexposure antimicrobial prophylaxis campaigns and from a prophylaxis program evaluation 60 days after start of antimicrobial prophylaxis involving persons from six U.S. sites where Bacillus anthracis exposures occurred. Adverse events associated with antimicrobial prophylaxis to prevent anthrax were commonly reported, but hospitalizations and serious adverse events as defined by Food and Drug Administration criteria were rare. Overall adherence during 60 days of antimicrobial prophylaxis was poor (44%), ranging from 21% of persons exposed in the Morgan postal facility in New York City to 64% of persons exposed at the Brentwood postal facility in Washington, D.C. Adherence was highest among participants in an investigational new drug protocol to receive additional antibiotics with or without anthrax vaccine--a likely surrogate for anthrax risk perception. Adherence of

Epidemiologic studies have shown that syphilis is associated with risk for human immunodeficiency virus (HIV) infection. We used population-level syphilis and HIV data to quantify HIV incidence among men following primary or secondary (PS) syphilis diagnoses and identify the highest-risk subgroups for intensified prevention, such as pre-exposure prophylaxis with antiretroviral medications.Male cases reported to the New York City HIV/AIDS and Sexually Transmitted Disease (STD) surveillance registries were matched using a deterministic algorithm. We measured HIV incidence following PS syphilis diagnosed between 2000 and June 2010 and identified risk factors for HIV infection using Cox proportional hazards models.Of 2805 men with syphilis contributing 11 714 person-years of follow-up, 423 (15.1%) acquired HIV; annual incidence was 3.61% (95% confidence interval [CI], 3.27%, 3.97%). HIV incidence was high among: men who have sex with men (MSM) (5.56%, 95% CI, 5.02%-6.13%); males with secondary compared with primary syphilis (4.10% vs 2.64%, P.0001); and males diagnosed with another bacterial STD after syphilis (7.89%, 95% CI, 6.62%-9.24%).HIV incidence among men diagnosed with syphilis is high; one in 20 MSM were diagnosed with HIV within a year. Our data have implications for syphilis and HIV screening and may be useful for further targeting HIV-negative populations for pre-exposure prophylaxis.

Data from a 2006 telephone survey representative of New York City adults showed that more than half (56.2%) of those aged 18 to 64 years responded favorably to a question about acceptability of a rapid home HIV test. More than two thirds of certain subpopulations at high risk for HIV reported that they would use a rapid home HIV test, but approximately half who expressed interest had indications of financial hardship. The match of acceptability and HIV risk bodes well for self-testing utility, but cost might impede uptake.

BACKGROUND A substantial proportion of recent sex partners named by persons with sexually transmitted infections are not notified about their exposure despite attempts by public health officials. Although text messaging (texting) and Internet-based communications (dating Web sites, e-mail, etc) are used by a large segment of the public for regular communications, these tools have been underused for partner services (PS). METHODS We augmented PS for HIV in New York City using texting and Internet-based means to contact persons for whom traditional information (landline telephone number, postal address) was unavailable. We compared traditional PS (traditionalPS), Internet-based PS (IPS) in January 2011 to October 2012, and texting PS (txtPS) from January 2012 (when txtPS was initiated) through October 2012 on outcomes of contact attempts, notification, and HIV testing. RESULTS From January 2011 to October 2012, of 3319 partners elicited, 2604 and 275 partners had traditional and only Internet-based contact information and were selected for traditionalPS and IPS, respectively. From January to October 2012, 368 of 1569 partners had only texting-enabled cellphone numbers and were selected for txtPS. The contact rate for txtPS (285/368 [77%]) was significantly higher (P < 0.0001) than the contact rates for traditionalPS (1803/2604 [69%]) and IPS (112/275 [41%]). There was a higher likelihood of notifying contacted IPS (odds ratio, 2.1; 1.2-3.4) and txtPS (odds ratio, 2.4; 1.7-3.2) than traditionalPS partners (P ≤ 0.0001). However, among the notified partners, traditionalPS partners were significantly (P < 0.0001) more likely than txtPS or IPS partners to test for HIV after partner notification (69% vs 45% and 34%, respectively). CONCLUSIONS Augmenting traditionalPS with txtPS and IPS enabled notification of hundreds of previously untraceable partners and several new HIV diagnoses.

From October 4 to November 2, 2001, the first 10 confirmed cases of inhalational anthrax caused by intentional release of Bacillus anthracis were identified in the United States. Epidemiologic investigation indicated that the outbreak, in the District of Columbia, Florida, New Jersey, and New York, resulted from intentional delivery of B. anthracis spores through mailed letters or packages. We describe the clinical presentation and course of these cases of bioterrorism-related inhalational anthrax. The median age of patients was 56 years (range 43 to 73 years), 70% were male, and except for one, all were known or believed to have processed, handled, or received letters containing B. anthracis spores. The median incubation period from the time of exposure to onset of symptoms, when known (n=6), was 4 days (range 4 to 6 days). Symptoms at initial presentation included fever or chills (n=10), sweats (n=7), fatigue or malaise (n=10), minimal or nonproductive cough (n=9), dyspnea (n=8), and nausea or vomiting (n=9). The median white blood cell count was 9.8 X 10(3)/mm(3) (range 7.5 to 13.3), often with increased neutrophils and band forms. Nine patients had elevated serum transaminase levels, and six were hypoxic. All 10 patients had abnormal chest X-rays; abnormalities included infiltrates (n=7), pleural effusion (n=8), and mediastinal widening (seven patients). Computed tomography of the chest was performed on eight patients, and mediastinal lymphadenopathy was present in seven. With multidrug antibiotic regimens and supportive care, survival of patients (60%) was markedly higher (

The Centers for Disease Control and Prevention (CDC) recommends that persons diagnosed with HIV receive partner services with health department involvement. CDC describes partner services as not only including partner notification, but also linkage to medical care for HIV-infected persons. The New York City Health Department formed a unit in 2006 to expedite partner services. We examined the contribution of our HIV partner services program in improving timely linkage and retention in HIV medical care.

Background An association between HIV and invasive meningococcal disease (IMD) has been suggested by several previous studies but has not been fully described in the era of highly active antiretroviral therapy in the United States. Objective To estimate the risk for IMD and death in people living with HIV/AIDS (PLWHA) in New York City (NYC) and the contribution of CD4(+) cell count and viral load (VL) to IMD risk. Design Comparison of the incidence rate of IMD among PLWHA with that among HIV-uninfected persons. Surveillance data on IMD for patients aged 15 to 64 years from 2000 to 2011 were matched to death and HIV registries to calculate IMD risk and case-fatality ratios. A subset of PLWHA who had a CD4(+) cell count and VL measurement near the time of their IMD infection was included in age-matched case-control analyses to assess HIV markers and IMD risk. Setting Retrospective cohort from communicable disease surveillance. Patients 265 persons aged 15 to 64 years with IMD during 2000 to 2011. Measurements Meningococcal and HIV data abstracted from surveillance and registry databases, including CD4(+) cell counts and VL. Results The average annual incidence rate of IMD was 0.39 cases per 100 000 persons. The relative risk for IMD among PLWHA in NYC during 2000 to 2011 was 10.0 (95% CI, 7.2 to 14.1). Among PLWHA, patients with IMD were 5.3 times (CI, 1.4 to 20.4 times) as likely as age-matched control patients to have CD4(+) counts less than 0.200 × 10(9) cells/L. Limitation Missing data on smoking status and comorbidity. Conclusion People living with HIV/AIDS in NYC are at increased risk for IMD. Cost-effectiveness and vaccine efficacy studies are needed to evaluate the value of a national recommendation for routine meningococcal vaccination of PLWHA. Primary funding source New York City Tax Levy.

Background New York City (NYC) remains an epicenter of the HIV epidemic in the United States. Given the variety of evidence-based HIV prevention strategies available and the significant resources required to implement each of them, comparative studies are needed to identify how to maximize the number of HIV cases prevented most economically. Methods A new model of HIV disease transmission was developed integrating information from a previously validated micro-simulation HIV disease progression model. Specification and parameterization of the model and its inputs, including the intervention portfolio, intervention effects and costs were conducted through a collaborative process between the academic modeling team and the NYC Department of Health and Mental Hygiene. The model projects the impact of different prevention strategies, or portfolios of prevention strategies, on the HIV epidemic in NYC. Results Ten unique interventions were able to provide a prevention benefit at an annual program cost of less than $360,000, the threshold for consideration as a cost-saving intervention (because of offsets by future HIV treatment costs averted). An optimized portfolio of these specific interventions could result in up to a 34% reduction in new HIV infections over the next 20 years. The cost-per-infection averted of the portfolio was estimated to be $106,378; the total cost was in excess of $2 billion (over the 20 year period, or approximately $100 million per year, on average). The cost-savings of prevented infections was estimated at more than $5 billion (or approximately $250 million per year, on average). Conclusions Optimal implementation of a portfolio of evidence-based interventions can have a substantial, favorable impact on the ongoing HIV epidemic in NYC and provide future cost-saving despite significant initial costs.

Persons living with HIV/AIDS who acquire new sexually transmitted diseases (STDs) pose a risk for enhanced transmission of both HIV and STDs. To describe the frequency of HIV coinfection among gonorrhea cases (GC), HIV and GC surveillance databases (2000-2008) were cross-matched in New York City (NYC), Washington, DC (DC), Miami/Dade County (MDC), and Arizona (AZ). During 2000-2008, 4.6% (9471/205,689) of reported GCs occurred among persons with previously diagnosed HIV: NYC (5.5%), DC (7.3%), MDC (4%), and AZ (2%). The overall HIV-GC coinfection rates increased over the study period in all 4 sites. Real-time data integration could allow for enhanced prevention among persons with HIV infection and acute STDs.

Our survey of kidney and liver transplant centers in New York State found a wide variation among transplant centers in evaluation and screening for HIV risk and infection among prospective living donors. Survey results underscore the need to standardize practices. A recent transmission of human immunodeficiency virus (HIV) from a living donor to a kidney recipient revealed a possible limitation in existing screening protocols for HIV infection in living donors. We surveyed kidney and liver transplant centers (N = 18) in New York State to assess HIV screening protocols for living donors. Although most transplant centers evaluated HIV risk behaviors in living donors, evaluation practices varied widely, as did the extent of HIV testing and prevention counseling. All centers screened living donors for serologic evidence of HIV infection, either during initial evaluation or ≥1 month before surgery; however, only 50% of transplant centers repeated HIV testing within 14 days before surgery for all donors or donors with specific risk behaviors. Forty-four percent of transplant centers used HIV nucleic acid testing (NAT) to screen either all donors or donors with recognized risk behaviors, and 55% never performed HIV NAT. Results suggest the need to standardize evaluation of HIV risk behaviors and prevention counseling in New York State to prevent acquisition of HIV by prospective living organ donors, and to conduct HIV antibody testing and NAT as close to the time of donation as possible to prevent HIV transmission to recipients.

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

In their recently published study, Halkitis et al. [1] compare three HIV testing strategies—alternative venue, partner services, and social network—and conclude that the social network strategy is the most effective in identifying previously undiagnosed HIV-positive African–American men who have sex with men. Though we commend Halkitis and colleagues’ effort to compare testing strategies, we caution readers about their conclusion. Data presented for the three strategies are not comparable because, for two of the strategies, program staff members were unable to check if testers were already known to the health department to be HIV infected. This is because of the legal restrictions in the New York State that protect the confidentiality of persons living with HIV. As staff members within the HIV partner services program within the New York City (NYC) Department of Health and Mental Hygiene, we are, unlike Halkitis et al., able to check if clients have been reported to the NYC HIV Surveillance Registry. When we submitted data to Halkitis et al., we excluded all testers who were previously diagnosed with HIV, regardless of whether they had disclosed their status. Had we included nondisclosers in the numerator, the detection rate for partner services would be 22%, far higher than the 14.3% detection rate reported in the study and also higher than that reported for social networks (19.3%). From our experience, persons living with HIVoften do not disclose their HIV status when testing because of denial, embarrassment, desire for incentives, or other reasons. As noted by Halkitis et al., incentives significantly increased enrollment. Incentives, therefore, may have increased the proportion of known positives who accepted testing. We agree with Halkitis and colleagues’ call for a “rigorous experimental study design to identify the most effective HIV testing strategies” and recommend that such a study include collaboration with local health departments to verify self-reported HIV status with the local HIV surveillance registry. Previously diagnosed repeat testers should be excluded from such analyses.

To describe the population of men who have sex with men (MSM) in New York City, compare their demographics, risk behaviors, and new HIV and primary and secondary (PS) syphilis rates with those of men who have sex with women (MSW), and examine trends in infection rates among MSM.Population denominators and demographic and behavioral data were obtained from population-based surveys during 2005-2008. Numbers of new HIV and PS syphilis diagnoses were extracted from city-wide disease surveillance registries.We calculated overall, age-specific and race/ethnicity-specific case rates and rate ratios for MSM and MSW and analyzed trends in MSM rates by age and race/ethnicity.The average prevalence of male same-sex behavior during 2005-2008 (5.0%; 95% CI: 4.5 to 5.6) differed by both age and race/ethnicity (2.3% among non-Hispanic black men; 7.4% among non-Hispanic white men). Compared with MSW, MSM differed significantly on all demographics and reported a higher prevalence of condom use at last sex (62.9% vs. 38.3%) and of past-year HIV testing (53.6% vs. 27.2%) but also more past-year sex partners. MSM HIV and PS syphilis rates were 2526.9/100,000 and 707.0/100,000, each of which was over 140 times MSW rates. Rates were highest among young and black MSM. Over 4 years, HIV rates more than doubled and PS syphilis rates increased 6-fold among 18-year-old to 29-year-old MSM.The substantial population of MSM in New York City is at high risk for acquisition of sexually transmitted infections given high rates of newly diagnosed infections and ongoing risk behaviors. Intensified and innovative efforts to implement and evaluate prevention programs are required.

OBJECTIVES: To assess barriers to human immunodeficiency virus (HIV) testing, health care contacts history, and HIV testing history among patients diagnosed concurrently with HIV and acquired immunodeficiency syndrome (AIDS). METHODS: We surveyed patients concurrently diagnosed with HIV/AIDS who had participated in the partner notification program of the New York City Department of Health and Mental Hygiene, between January 2008 and December 2008. RESULTS: The most common reason interviewees volunteered for delaying testing (64%) was that they did not believe they were at risk for HIV. When read a list of potential barriers, 69% of interviewees replied affirmatively that they did not test for HIV because they did not believe they were at risk, and 52% replied affirmatively that they did not test because they thought their behaviors kept them safe from getting HIV. Half of all interviewees reported having insurance during part or all of the year before they were diagnosed with HIV/AIDS, and 70% had at least 1 health care visit in the year before they were diagnosed with HIV/AIDS. CONCLUSIONS: A lack of perception of risk was the most common reason for not testing for HIV sooner among these concurrently diagnosed patients. The majority of these patients were accessing medical care, indicating that this population could have benefited from routine HIV testing.

Worldwide, two billion people have been infected with hepatitis B virus (HBV), 360 million have chronic infection, and 600,000 die each year from HBV-related liver disease or hepatocellular carcinoma. This comprehensive review of hepatitis B epidemiology and vaccines focuses on definitive and influential studies and highlights current trends, policies, and directions. HBV can be transmitted vertically, through sexual or household contact, or by unsafe injections, but chronic infections acquired during infancy or childhood account for a disproportionately large share of worldwide morbidity and mortality. Vaccination against HBV infection can be started at birth and provides long-term protection against infection in more than 90% of healthy people. In the 1990s, many industrialized countries and a few less-developed countries implemented universal hepatitis B immunization and experienced measurable reductions in HBV-related disease. For example, in Taiwan, the prevalence of chronic infection in children declined by more than 90%. Many resource-poor nations have recently initiated universal hepatitis B immunization programs with assistance from the Global Alliance for Vaccines and Immunization. Further progress towards the elimination of HBV transmission will require sustainable vaccination programs with improved vaccination coverage, practical methods of measuring the impact of vaccination programs, and targeted vaccination efforts for communities at high risk of infection.