An HIV prevalence study by means of sentinel epidemiological surveillance among injection narcotic abusers in Saint Petersburg

The data on the study of the spread of HIV infection among injecting drug users in St. Petersburg, carried out by the method of the random testing of blood remaining in used syringes, are presented. Injecting drug users visiting buses working in accordance with the program "Buses for Assistance to Drug Addicts" were chosen as a study group. The exchange of syringes was one of the elements of this program. The work was carried out in two areas with a high concentration of drug users. The eluates from syringes used by 300 persons were studied. The average rate of the spread of HIV in the cohort under study was 12%. The results were indicative of a high degree of the spread of HIV among injecting drug users in St. Petersburg. Epidemiological patrol surveillance proved to be an effective method for the evaluation of the epidemiological situation in a highly inaccessible group of the population.     

The organization of the work to determine antibodies to the human immunodeficiency virus in the Republic of Byelarus

The study revealed that the method of mass screening for the detection of antibodies to HIV antigen, carried out in the Republic till 1993, proved to be economically and diagnostically unjustified. Starting from 1993, the work on the step-by-step reduction of groups to be tested for the presence of antibodies to HIV began. At the same time from 1997 the proportion of tested donors of blood, organs and tissues, as well as persons belonging to high risk groups, increased in comparison with 1993 (from 23.3% to 40% and from 5.3% to 21% respectively). Voluntary and anonymous testing for the presence of HIV infection was organized and legally introduced. In comparison with 1991, in 1997 the number of persons who voluntarily underwent testing increased 3.7 times. The period of transition from mass screening to selective one was noted to have no effect on the detection of HIV-infected persons. Since 1995 the method of "patrol" epidemiological surveillance was also used. 2,118 persons underwent testing, the results of screening were negative. During the period of 3 years the testing of 12,547 young people called up for military service revealed 28 seropositive persons in the region where an outbreak of HIV infection had been registered among addicts using drugs intravenously.     

The results of sentinel epidemiological surveillance on the level of HIV prevalence among injection narcotic abusers in the city of Poltava

The sentinel epidemiological surveillance on the level of spread of HIV infection among injecting drug users in Poltava, taking part in the program of harm reduction, was carried out. The results of the surveillance revealed that the level of HIV infection among drug users was 37.8%, the level of HIV infection among females being higher than that among males. These data indicate that the level of HIV infection rises with the increase of age and the time of drug consumption. Still in the age group of 30 years and older and among drug addicts using drugs for 7 years and longer the lowest level of HIV infection was noted.     

HIV-1 Transmission during Early Infection in Men Who Have Sex with Men: A Phylodynamic Analysis

Background

Conventional epidemiological surveillance of infectious diseases is focused on characterization of incident infections and estimation of the number of prevalent infections. Advances in methods for the analysis of the population-level genetic variation of viruses can potentially provide information about donors, not just recipients, of infection. Genetic sequences from many viruses are increasingly abundant, especially HIV, which is routinely sequenced for surveillance of drug resistance mutations. We conducted a phylodynamic analysis of HIV genetic sequence data and surveillance data from a US population of men who have sex with men (MSM) and estimated incidence and transmission rates by stage of infection.

Methods and Findings

We analyzed 662 HIV-1 subtype B sequences collected between October 14, 2004, and February 24, 2012, from MSM in the Detroit metropolitan area, Michigan. These sequences were cross-referenced with a database of 30,200 patients diagnosed with HIV infection in the state of Michigan, which includes clinical information that is informative about the recency of infection at the time of diagnosis. These data were analyzed using recently developed population genetic methods that have enabled the estimation of transmission rates from the population-level genetic diversity of the virus. We found that genetic data are highly informative about HIV donors in ways that standard surveillance data are not. Genetic data are especially informative about the stage of infection of donors at the point of transmission. We estimate that 44.7% (95% CI, 42.2%–46.4%) of transmissions occur during the first year of infection.

Conclusions

In this study, almost half of transmissions occurred within the first year of HIV infection in MSM. Our conclusions may be sensitive to un-modeled intra-host evolutionary dynamics, un-modeled sexual risk behavior, and uncertainty in the stage of infected hosts at the time of sampling. The intensity of transmission during early infection may have significance for public health interventions based on early treatment of newly diagnosed individuals. Please see later in the article for the Editors'' Summary     

The epidemiology of the infection caused by the human immunodeficiency virus in the USSR

The existing system of the epidemiological surveillance of HIV infection in the USSR makes it possible to evaluate the present situation as the beginning of epidemic. The main routes of the transfer of HIV infection as per data for April 1989: 50% by the sexual route, 25.8% by parenteral manipulations.     

The monitoring of the spread of drug abuse as an element in the epidemiological surveillance of socially significant infections

The necessity of monitoring the spread of drug addiction in the system of epidemiological surveillance on HIV infection and parenteral virus hepatitides is shown. The results of the epidemiological diagnostics of registered drug addiction are presented. The criteria for the assessment of the epidemiological effectiveness of epidemiological surveillance on drug addiction are determined. As revealed in this study, during the period of 1991-1998 morbidity in drug addiction rose 57-fold in Perm Province, while the number of HIV-infected persons increased 75-fold. Pronounced direct relationship between the number of drug addicts, as well as persons belonging to groups of high risk of developing drug addiction, and the dynamics of morbidity in HIV infection and parenteral virus hepatitides B and C was established.     

Measles: prospects of vaccine prophylaxis and decrease of morbidity in Moscow

The results of the prolonged epidemiological surveillance on measles in Moscow are presented. The detailed analysis of the influence of immunization on the level of measles morbidity has been made. Changes in the age structure of measles patients with an essential increase in the proportion of adolescents and adults due to mass vaccination of the child population are shown. High risk groups have been determined according to the data of serological screening and epidemiological surveillance. The prospects of the vaccinal prophylaxis of measles under present conditions, as the basic intervention for achieving sporadic level of morbidity in this infection and further eradication are evaluated.     

Feasibility and Effectiveness of Provider Initiated HIV Testing and Counseling of TB Suspects in Vizianagaram District, South India

Background

Though internationally recommended, provider initiated HIV testing and counseling (PITC) of persons suspected of tuberculosis (TB) is not a policy in India; HIV seroprevalence among TB suspects has never been reported. The current policy of PITC for diagnosed TB cases may limit opportunities of early HIV diagnosis and treatment. We determined HIV seroprevalence among persons suspected of TB and assessed feasibility and effectiveness of PITC implementation at this earlier stage in the TB diagnostic pathway.

Methods

All adults examined for diagnostic sputum microscopy (TB suspects) in Vizianagaram district (population 2.5 million), in November-December 2010, were offered voluntary HIV counseling and testing (VCT) and assessed for TB diagnosis.

Results

Of 2918 eligible TB suspects, 2465(85%) consented to VCT. Among these, 246(10%) were HIV-positive. Of the 246, 84(34%) were newly diagnosed as HIV (HIV status not known previously). To detect a new case of HIV infection, the number needed to screen (NNS) was 26 among ‘TB suspects’, comparable to that among ‘TB patients’. Among suspects aged 25–54 years, not diagnosed as TB, the NNS was 17.

Conclusion

The seroprevalence of HIV among ‘TB suspects’ was as high as that among ‘TB patients’. Implementation of PITC among TB suspects was feasible and effective, detecting a large number of new HIV cases with minimal additional workload on staff of HIV testing centre. HIV testing of TB suspects aged 25–54 years demonstrated higher yield for a given effort, and should be considered by policy makers at least in settings with high HIV prevalence.     

Expanding HIV testing efforts in concentrated epidemic settings: a population-based survey from rural Vietnam

Background

To improve HIV prevention and care programs, it is important to understand the uptake of HIV testing and to identify population segments in need of increased HIV testing. This is particularly crucial in countries with concentrated HIV epidemics, where HIV prevalence continues to rise in the general population. This study analyzes determinants of HIV testing in a rural Vietnamese population in order to identify potential access barriers and areas for promoting HIV testing services.

Methods

A population-based cross-sectional survey of 1874 randomly sampled adults was linked to pregnancy, migration and economic cohort data from a demographic surveillance site (DSS). Multivariate logistic regression analysis was used to determine which factors were associated with having tested for HIV.

Results

The age-adjusted prevalence of ever-testing for HIV was 7.6%; however 79% of those who reported feeling at-risk of contracting HIV had never tested. In multivariate analysis, younger age (aOR 1.85, 95% CI 1.14–3.01), higher economic status (aOR 3.4, 95% CI 2.21–5.22), and semi-urban residence (aOR 2.37, 95% CI 1.53–3.66) were associated with having been tested for HIV. HIV testing rates did not differ between women of reproductive age who had recently been pregnant and those who had not.

Conclusions

We found low testing uptake (6%) among pregnant women despite an existing prevention of mother-to-child HIV testing policy, and lower-than-expected testing among persons who felt that they were at-risk of HIV. Poverty and residence in a more geographically remote location were associated with less HIV testing. In addition to current HIV testing strategies focusing on high-risk groups, we recommend targeting HIV testing in concentrated HIV epidemic settings to focus on a scaled-up provision of antenatal testing. Additional recommendations include removing financial and geographic access barriers to client-initiated testing, and encouraging provider-initiated testing of those who believe that they are at-risk of HIV.     

Studies of AIDS in Lithuania]

The seroepidemiological survey of 400,000 persons aged 20-40 years and belonging to different AIDS risk groups, as well as blood donors, for the presence of antibodies to HIV has been carried out on the territory of Lithuania. This investigation has been made with the use of the assay systems "Antigen", "Peptoscreen" and "Vector" manufactured in the USSR, as well as commercial assay systems from foreign manufacturers, such as Du Pont de Nemours Inc., Organon N. V., Abbott Laboratories, Serodia. The comparison of the results thus obtained has revealed that high frequency of false positive results is characteristic of all assay systems under study, including immunoblotting. These data indicate that test systems based on different acting principles should be used for the detection of anti-HIV antibodies. For the first time a HIV-infected resident of Lithuania has been detected. The investigation carried out in Lithuania has shown that HIV infection is not widely spread in this region, but due to some objective reasons this does not preclude the necessity of the constant epidemiological surveillance of this infection throughout this territory in order to bar the way to this infection.     

On the epidemiological situation in quarantine, natural focal and other infections on the territory of the Southern Federal District

The data on the sanitary and epidemiological situation in the Southern Federal District are presented. The analysis of morbidity in tuberculosis, measles, HIV infection, viral hepatitis A, typhoid fever, cholera and quarantine infections, Crimean hemorrhagic fever, West Nile fever, rabies, malaria has been carried out. Special attention has been given to "new and newly returning infections", and among them to the spread of SARS ("atypical pneumonia"). The role of regional epidemiological safety programs, in particular such program as "The prophylaxis of quarantine and natural focal infections and the sanitary protection of the territory of the Southern Federal District of the Russian Federation from the import and spread infectious diseases in 2003-2005", has been substantiated.     

Programmatic Cost Evaluation of Nontargeted Opt-Out Rapid HIV Screening in the Emergency Department

Background

The Centers for Disease Control and Prevention recommends nontargeted opt-out HIV screening in healthcare settings. Cost effectiveness is critical when considering potential screening methods. Our goal was to compare programmatic costs of nontargeted opt-out rapid HIV screening with physician-directed diagnostic rapid HIV testing in an urban emergency department (ED) as part of the Denver ED HIV Opt-Out Trial.

Methods

This was a prospective cohort study nested in a larger quasi-experiment. Over 16 months, nontargeted rapid HIV screening (intervention) and diagnostic rapid HIV testing (control) were alternated in 4-month time blocks. During the intervention phase, patients were offered HIV testing using an opt-out approach during registration; during the control phase, physicians used a diagnostic approach to offer HIV testing to patients. Each method was fully integrated into ED operations. Direct program costs were determined using the perspective of the ED. Time-motion methodology was used to estimate personnel activity costs. Costs per patient newly-diagnosed with HIV infection by intervention phase, and incremental cost effectiveness ratios were calculated.

Results

During the intervention phase, 28,043 eligible patients were included, 6,933 (25%) completed testing, and 15 (0.2%, 95% CI: 0.1%–0.4%) were newly-diagnosed with HIV infection. During the control phase, 29,925 eligible patients were included, 243 (0.8%) completed testing, and 4 (1.7%, 95% CI: 0.4%–4.2%) were newly-diagnosed with HIV infection. Total annualized costs for nontargeted screening were $148,997, whereas total annualized costs for diagnostic HIV testing were $31,355. The average costs per HIV diagnosis were $9,932 and $7,839, respectively. Nontargeted HIV screening identified 11 more HIV infections at an incremental cost of $10,693 per additional infection.

Conclusions

Compared to diagnostic testing, nontargeted HIV screening was more costly but identified more HIV infections. More effective and less costly testing strategies may be required to improve the identification of patients with undiagnosed HIV infection in the ED.     

HIV testing in patients with end stage renal disease.

One hundred and twenty eight British and Irish nephrologists were questioned about their policy for HIV testing of patients with end stage renal failure being considered for renal replacement therapy. A total of 101 (79%) replied. In the case of candidates for dialysis roughly one third of respondents tested only people they considered at risk of infection with HIV and nearly one fifth considered testing unnecessary. In the case of candidates for transplantation routine HIV testing was carried out by 68 of 100 nephrologists; 22 tested only patients "at risk" and 10 did not test. A positive HIV test result was considered by most but not all respondents (63/86) to exclude patients from transplantation. Twenty four of 88 nephrologists considered that HIV positivity should exclude patients from haemodialysis, but only seven of 87 would exclude such patients from peritoneal dialysis. Similar attitudes pertained for patients with end stage renal failure who refused HIV testing. Testing with the patient''s knowledge and consent was the policy of two thirds of nephrologists, but a patient''s signature was obtained by only 24 of 88. There should be a consensus on practice for HIV testing of patients with end stage renal failure.     

False Positive HIV Diagnoses in Resource Limited Settings: Operational Lessons Learned for HIV Programmes

Background

Access to HIV diagnosis is life-saving; however the use of rapid diagnostic tests in combination is vulnerable to wrongly diagnosing HIV infection when both screening tests give a false positive result. Misclassification of HIV patients can also occur due to poor quality control, administrative errors and lack of supervision and training of staff. Médecins Sans Frontières discovered in 2004 that HIV negative individuals were enrolled in some HIV programmes. This paper describes the result of an audit of three sites to review testing practices, implement improved testing algorithms and offer re-testing to clients enrolled in the HIV clinic.

Findings

In the Democratic Republic of Congo (DRC), Burundi and Ethiopia patients were identified for HIV retesting. In total, 44 false-positive patients were identified in HIV programmes in DRC, two in Burundi and seven in Ethiopia. Some of those identified had been abandoned by partners or started on anti-retroviral therapy or prophylaxis. Despite potential damage to programme reputations, no impact in terms of testing uptake occurred with mean monthly testing volumes stable after introduction of re-testing. In order to prevent the problem, training, supervision and quality control of testing procedures were strengthened. A simple and feasible confirmation test was added to the test algorithm. Prevalence of false positives after introducing the changes varied from zero percent (95% CI 0%–8.2%) to 10.3 percent (95% CI: 7.2%–14.1%) in Burundi and DRC respectively.

Conclusion

False HIV diagnoses were found in a variety of programme settings and had devastating individual consequences. We re-tested individuals in our programmes while instituting improved testing procedures without a negative impact on test uptake. Considering the importance of correct diagnosis to the individual, as well as the resources needed to care for someone with HIV, it is critical to ensure that all patients registered in HIV programmes are accurately diagnosed.     

Simplifying consent for HIV testing is associated with an increase in HIV testing and case detection in highest risk groups, San Francisco January 2003-June 2007

Background

Populations at highest risk for HIV infection face multiple barriers to HIV testing. To facilitate HIV testing procedures, the San Francisco General Hospital Medical Center eliminated required written patient consent for HIV testing in its medical settings in May 2006. To describe the change in HIV testing rates in different hospital settings and populations after the change in HIV testing policy in the SFDH medical center, we performed an observational study using interrupted time series analysis.

Methods

Data from all patients aged 18 years and older seen from January 2003 through June 2007 at the San Francisco Department of Public Health (SFDPH) medical care system were included in the analysis. The monthly HIV testing rate per 1000 hadpatient-visits was calculated for the overall population and stratified by hospital setting, age, sex, race/ethnicity, homelessness status, insurance status and primary language.

Results

By June 2007, the average monthly rate of HIV tests per 1000 patient-visits increased 4.38 (CI, 2.17–6.60, p<0.001) over the number predicted if the policy change had not occurred (representing a 44% increase). The monthly average number of new positive HIV tests increased from 8.9 (CI, 6.3–11.5) to 14.9 (CI, 10.6–19.2, p<0.001), representing a 67% increase. Although increases in HIV testing were seen in all populations, populations at highest risk for HIV infection, particularly men, the homeless, and the uninsured experienced the highest increases in monthly HIV testing rates after the policy change.

Conclusions

The elimination of the requirement for written consent in May 2006 was associated with a significant and sustained increase in HIV testing rates and HIV case detection in the SFDPH medical center. Populations facing the higher barriers to HIV testing had the highest increases in HIV testing rates and case detection in response to the policy change.     

HIV infection in Saint Petersburg: the changing face of the epidemic

The specific features of the epidemiological situation in St. Petersburg at the first stage (1987-1995) and the second stage (1986-1999) of the development of HIV infection are described. During this period morbidity in HIV infection, starting from the insignificant rate of growth, sharply increased. For the first time injecting drug users were noted to come out to the foreground in the structure of the contingent of persons affected by HIV infection (57.5% and 72.6% in 1998 and 1999 respectively). Such change on the epidemic situation requires corrections in the strategy and tactics of preventive measures and medical assistance. To control HIV infection among drug users, only the combination of medical assistance given by narcologists with the realization of all elements of the program "Harm Reduction" can be effective.     

Routine HIV Testing among Hospitalized Patients in Argentina. Is It Time for a Policy Change?

Introduction

The Argentinean AIDS Program estimates that 110,000 persons are living with HIV/AIDS in Argentina. Of those, approximately 40% are unaware of their status, and 30% are diagnosed in advanced stages of immunosuppression. Though studies show that universal HIV screening is cost-effective in settings with HIV prevalence greater than 0.1%, in Argentina, with the exception of antenatal care, HIV testing is always client-initiated.

Objective

We performed a pilot study to assess the acceptability of a universal HIV screening program among inpatients of an urban public hospital in Buenos Aires.

Methods

Over a six-month period, all eligible adult patients admitted to the internal medicine ward were offered HIV testing. Demographics, uptake rates, reasons for refusal and new HIV diagnoses were analyzed.

Results

Of the 350 admissions during this period, 249 were eligible and subsequently enrolled. The enrolled population was relatively old compared to the general population, was balanced on gender, and did not report traditional high risk factors for HIV infection. Only 88 (39%) reported prior HIV testing. One hundred and ninety (76%) patients accepted HIV testing. In multivariable analysis only younger age (OR 1.02; 95%CI 1.003-1.05) was independently associated with test uptake. Three new HIV diagnoses were made (undiagnosed HIV prevalence: 1.58%); none belonged to a most-at-risk population.

Conclusions

Our findings suggest that universal HIV screening in this setting is acceptable and potentially effective in identifying undiagnosed HIV-infected individuals. If confirmed in a larger study, our findings may inform changes in the Argentinean HIV testing policy.     

Prevalence of HIV among childbearing women and women having termination of pregnancy: multidisciplinary steering group study.

OBJECTIVE--To determine the prevalence of HIV among pregnant women, in particular those whose behaviour or that of their partners put them at "low risk" of infection. DESIGN--Voluntary named or anonymous HIV testing of pregnant women during 21 months (November 1988 to July 1990). SUBJECTS AND SETTING--All women who planned to continue their pregnancy and attended clinics serving the antenatal populations of Edinburgh and Dundee. All women admitted for termination of pregnancy to gynaecology wards serving the pregnant populations of Dundee and outlying rural areas. MAIN OUTCOME MEASURES--Period prevalence of HIV antibody positivity. RESULTS--91% of antenatal clinic attenders and 97% of women having termination of pregnancy agreed to HIV testing on a named or anonymous basis. HIV period prevalences for antenatal clinic attenders and women having termination of pregnancy tested in Dundee were 0.13% and 0.85% respectively, and for antenatal clinic attenders tested in Edinburgh 0.26%. For those at "low risk" rates for antenatal clinic attenders and women having termination of pregnancy in Dundee were 0.11% and 0.13%, and for antenatal clinic attenders in Edinburgh 0.02%. In Dundee HIV prevalence among women having a termination of pregnancy (0.85%) was significantly greater than that among antenatal clinic attenders (0.13%). CONCLUSIONS--HIV infection is undoubtedly occurring among women at "low risk," and it is clear that a policy of selective testing of those at only "high risk" is inadequate for pregnant women living in areas of high prevalence such as Edinburgh and Dundee. Moreover, when studying pregnant populations in such areas there is the need to include those having a termination of pregnancy.     

Prevention of Parent to Child Transmission (PPTCT) Program Data in India: An Emerging Data Set for Appraising the HIV Epidemic

Background

Evidence based resource allocation and decentralized planning of an effective HIV/AIDS response requires reliable information on levels and trends of HIV at national and sub-national geographic levels. HIV sentinel surveillance data from antenatal clinics (HSS-ANC) has been an important data source to assess the HIV/AIDS epidemic in India, but has a number of limitations. We assess the value of Prevention of Parent to Child Transmission (PPTCT) programme data to appraise the HIV epidemic in India.

Methods/Findings

HIV data from PPTCT sites were compared to HSS-ANC and general population level surveys at various geographic levels in the states of Karnataka, Maharashtra and Andhra Pradesh. Chi-square tests were used to ascertain statistical significance. PPTCT HIV prevalence was significantly lower than HSS-ANC HIV prevalence (0.92% vs. 1.22% in Andhra Pradesh, 0.65% vs. 0.89% in Karnataka, 0.52% vs. 0.60% in Maharashtra, p<0.001 for all three states). In all three states, HIV prevalence from PPTCT centres that were part of the sentinel surveillance was comparable to HSS-ANC prevalence but significantly higher than PPTCT centres that were not part of the sentinel surveillance. HIV prevalence from PPTCT data was comparable to that from general population surveys. In all three states, significant declines in HIV prevalence between 2007 and 2010 were observed with the PPTCT data set. District level analyses of HIV trends and sub-district level analysis of HIV prevalence were possible using the PPTCT and not the HSS-ANC data sets.

Conclusion

HIV prevalence from PPTCT may be a better proxy for general population prevalence than HSS-ANC. PPTCT data allow for analysis of HIV prevalence and trends at smaller geographic units, which is important for decentralized planning of HIV/AIDS programming. With further improvements to the system, India could replace its HSS-ANC with PPTCT programme data for surveillance.