Last data update: Oct 28, 2024. (Total: 48004 publications since 2009)
Records 1-30 (of 39 Records) |
Query Trace: Crepaz N[original query] |
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Identifying effective strategies for improving engagement in HIV prevention and care among transgender persons in the United States: A systematic review
Crepaz N , Peters O , Higa DH , Mullins MM , Collins CB . AIDS Behav 2024 This systematic review synthesized published literature (2000 - 2023) to identify HIV interventions specifically designed for transgender persons in the United States (PROSPERO registration number: CRD42021256460). The review also summarized strategies for improving outcomes related to the four pillars of the Ending the HIV Epidemic (EHE) initiative in the United States: Diagnose, Treat, Prevent, and Respond. A comprehensive search was conducted using the Centers for Disease Control and Prevention's HIV Prevention Research Synthesis Project database, which included over 120,000 citations from routine systematic searches in CINAHL, EMBASE, Global Health, MEDLINE, PsycInfo, and Sociological Abstracts. Of 23 interventions that met inclusion criteria, 94% focused on transgender women of color and 22% focused on young transgender persons aged 15-29 years old. Most interventions focused on Treat or Prevent, few focused on Diagnosis, and none focused on Respond. Twenty interventions (87%) showed improvement in at least one EHE related outcome and a quarter of these effective interventions were tested with randomized controlled trials. Common strategies observed in effective interventions include the following: engaging the community in intervention development; pilot-testing with the focus population to ensure appropriateness and acceptability; addressing social determinants of health (e.g. stigma, discrimination, violence) through empowerment and gender-affirming approaches; increasing access to care, prevention, and services through co-location and one-stop shop models; and utilizing peer-led counseling, education, support, and navigation. Continuous effort is needed in addressing gaps, including more research for transgender men and rural settings and for how best to adopt and adapt best practices for subgroups of transgender population. |
Identifying best practices for increasing HIV pre-exposure prophylaxis (PrEP) use and persistence in the United States: A systematic review
Kamitani E , Higa DH , Crepaz N , Wichser M , Mullins MM . AIDS Behav 2024 A qualitative systematic review was conducted to evaluate pre-exposure prophylaxis (PrEP) interventions, describe characteristics of best practices for increasing PrEP use and persistence, and explore research gaps based on current PrEP interventions. We searched CDC's Prevention Research Synthesis (PRS) Project's cumulative HIV database (includes CINAHL, EMBASE, Global Health, MEDLINE, PsycInfo, and Sociological Abstracts) to identify PrEP intervention studies conducted in the U.S., published between 2000 and 2022 (last searched January 2023). Eligibility criteria include studies that evaluated PrEP interventions for persons testing negative for HIV infection, or for healthcare providers who prescribed PrEP; included comparisons between groups or pre/post; and reported at least one relevant PrEP outcome. Each eligible intervention was evaluated on the quality of study design, implementation, analysis, and strength of evidence (PROSPERO registration number: CRD42021256460). Of the 26 eligible interventions, the majority were focused on men who have sex with men (n = 18) and reported PrEP adherence outcomes (n = 12). Nine interventions met the criteria for Best Practices (i.e., evidence-based interventions, evidence-informed interventions). Five were digital health interventions while two implemented individual counseling, one offered motivational interviewing, and one provided integrated medical care with a PrEP peer navigator. Longer intervention periods may provide more time for intervention exposure to facilitate behavioral change, and engaging the community when developing, designing and implementing interventions may be key for effectiveness. For digital health interventions, two-way messaging may help participants feel supported. Research gaps included a lack of Best Practices for several populations (e.g., Black persons, Hispanic/Latino persons, persons who inject drugs, and women of color) and evidence for various intervention strategies (e.g., interventions for promoting provider's PrEP prescription behavior, peer support). These findings call for more collaborative work with communities to develop interventions that work and implement and disseminate Best Practices for increasing PrEP use and persistence in communities. |
Systematic review of social determinants of health associated with HIV testing among Hispanic/Latino gay, bisexual, and other men who have sex with men in the United States
Crepaz N , Salabarría-Peña Y , Mullins MM , Gunn JKL , Higa DH . AIDS Educ Prev 2023 35 (1) 36-s6 This systematic review synthesized published literature (January 2008-October 2021) about the association between social determinants of health (SDOH) and HIV testing among Hispanic/Latino gay, bisexual, and other men who have sex with men (HLMSM), a group disproportionally affected by HIV. Having higher education than a high school diploma, health insurance and access to health care services, and visiting a health care provider in the past 12 months were some of the determinants associated with HIV testing, while limited English proficiency was associated with reduced odds of HIV-testing among HLMSM. More research is needed to understand the relationship of SDOH (especially neighborhood) and HIV testing, how SDOH may affect HIV testing among different HLMSM groups, and how to increase self-testing and use of e-health in this priority population. Additionally, culturally and linguistically appropriate multilevel interventions and health services for HLMSM are urgently needed to diagnose HIV as early as possible after infection. |
Estimated number of people who inject drugs in the United States
Bradley H , Hall E , Asher A , Furukawa N , Jones CM , Shealey J , Buchacz K , Handanagic S , Crepaz N , Rosenberg ES . Clin Infect Dis 2022 76 (1) 96-102 BACKGROUND: Public health data signal increases in the number of people who inject drugs (PWID) in the United States during the past decade. An updated PWID population size estimate is critical for informing interventions and policies aiming to reduce injection-associated infections and overdose, as well as to provide a baseline for assessments of pandemic-related changes in injection drug use. METHODS: We used a modified multiplier approach to estimate the number of adults who injected drugs in the United States in 2018. We deduced the estimated number of non-fatal overdose events among PWID from two of our previously published estimates: the number of injection-involved overdose deaths and the meta-analyzed ratio of non-fatal to fatal overdose. The number of non-fatal overdose events was divided by prevalence of non-fatal overdose among current PWID for a population size estimate. RESULTS: There were an estimated 3,694,500 (95% CI: 1,872,700-7,273,300) PWID in the U.S. in 2018, representing 1.46% (95% CI: 0.74% - 2.87%) of the adult population. The estimated prevalence of injection drug use was highest among male persons (2.1%; 95% CI: 1.1-4.2%), non-Hispanic White persons (1.8%; 95% CI: 0.9-3.6%), and adults aged 18-39 years (1.8%; 0.9-3.6%). CONCLUSIONS: Using transparent, replicable methods and largely publicly available data, we provide the first update to the number of people who inject drugs in the U.S. in nearly ten years. Findings suggest the population size of PWID has substantially grown in the past decade and that prevention services for PWID should be proportionally increased. |
HIV care outcomes in relation to racial redlining and structural factors affecting medical care access among black and white persons with diagnosed HIV-United States, 2017
Logan J , Crepaz N , Luo F , Dong X , Gant Z , Ertl A , Girod C , Patel N , Jin C , Balaji A , Sweeney P . AIDS Behav 2022 26 (9) 2941-2953 Black/African American (Black) versus White persons are unequally burdened by human immunodeficiency virus (HIV) in the United States. Structural factors can influence social determinants of health, key components in reducing HIV-related health inequality by race. This analysis examined HIV care outcomes among Black and White persons with diagnosed HIV (PWDH) in relation to three structural factors: racial redlining, Medicaid expansion, and Ryan White HIV/AIDS Program (RWHAP) use. Using National HIV Surveillance System, U.S. Census, and Home Mortgage Disclosure Act data, we examined linkage to HIV care and viral suppression (i.e., viral load < 200 copies/mL) in relation to the structural factors among 12,996 Black and White PWDH with HIV diagnosed in 2017/alive at year-end 2018, aged ≥ 18 years, and residing in 38 U.S. jurisdictions with complete laboratory data, geocoding, and census tract-level redlining indexes. Compared to White PWDH, a lower proportion of Black PWDH were linked to HIV care within 1 month after diagnosis and were virally suppressed in 2018. Redlining was not associated with the HIV care outcomes. A higher prevalence of PWDH residing (v. not residing) in states with Medicaid expansion were linked to HIV care ≤ 1 month after diagnosis. A higher prevalence of those residing (v. not residing) in states with > 50% of PWDH in RWHAP had viral suppression. Direct exposure to redlining was not associated with poor HIV care outcomes. Structural factors that reduce the financial burden of HIV care and improve care access like Medicaid expansion and RWHAP might improve HIV care outcomes of PWDH. |
Strategies to improve HIV care outcomes for people with HIV who are out of care: a meta-analysis
Higa DH , Crepaz N , Mullins MM , Adegbite-Johnson A , Gunn JKL , Denard C , Mizuno Y . AIDS 2022 36 (6) 853-862 OBJECTIVE: The aim of this study was to evaluate the effectiveness of five intervention strategies: patient navigation, appointment help/alerts, psychosocial support, transportation/appointment accompaniment, and data-to-care on HIV care outcomes among persons with HIV (PWH) who are out of care (OOC). DESIGN: A systematic review with meta-analysis. METHODS: We searched CDC's Prevention Research Synthesis (PRS) Project's cumulative HIV database to identify intervention studies conducted in the U.S., published between 2000 and 2020 that included comparisons between groups or prepost, and reported at least one relevant outcome (i.e., re-engagement and retention in HIV care, and viral suppression). Effect sizes were meta-analyzed using random-effect models to assess intervention effectiveness. RESULTS: Thirty-nine studies reporting on 42 unique interventions met the inclusion criteria. Overall, intervention strategies are effective in improving re-engagement in care [odds ratio (OR) = 1.79; 95% confidence interval (95% CI): 1.36-2.36, k = 14], retention in care (OR = 2.01; 95% CI: 1.64-2.64, k = 22), and viral suppression (OR = 2.50; 95% CI: 1.87-3.34, k = 27). Patient navigation, appointment help/alerts, psychosocial support, and transportation/appointment accompaniment improved all three HIV care outcomes. Data-to-care improved re-engagement and retention but had insufficient evidence for viral suppression. CONCLUSION: Several strategies are effective for improving HIV care outcomes among PWH who are OOC. More work is still needed for consistent definitions of OCC and HIV care outcomes, better reporting of intervention and cost data, and identifying how best to implement and scale-up effective strategies to engage and retain OOC PWH in care and reach the ending the HIV epidemic goals. |
Health care providers' views on clinic infrastructure and practice models that may facilitate HIV preexposure prophylaxis (PrEP) prescribing: A qualitative meta-synthesis
Mizuno Y , Gelaude DJ , Crepaz N , Kamitani E , DeLuca JB , Leighton CA , Wichser ME , Smith DK . Health Promot Pract 2021 23 (6) 999-1014 HIV (human immunodeficiency virus) preexposure prophylaxis (PrEP) is an effective biomedical HIV prevention tool. Increasing PrEP use among populations disproportionately affected by HIV is one of the key efforts in the United States' Ending the HIV Epidemic (EHE) initiative and the HIV National Strategic Plan for the United States. Given that PrEP is available only through prescription, it is important to explore structural, organizational, or environmental factors that could facilitate or impede health care provider's PrEP prescribing behavior. The purpose of this systematic review (PROSPERO [CRD: 42019138889]) is to identify qualitative studies that addressed this topic and conduct meta-synthesis using the thematic synthesis method to identify major themes on the characteristics of clinic infrastructure or clinic models that providers consider as facilitators of PrEP prescribing in the United States. Eighteen citations representing 15 studies were included in this review. Five overarching themes were identified: (1) routinized HIV risk assessment; (2) interdisciplinary/coordinated PrEP teams or services; (3) clinic capacity to provide essential PrEP-related services; (4) low out-of-pocket patient costs; and (5) access to the priority populations. Some of these themes are consistent with the recommendations of CDC's PrEP clinical guidelines and the EHE initiative. More recent studies that include perspectives of diverse providers, timely analysis of these studies, and implementation research to assess strategies to address the current practice gaps are needed to further promote PrEP prescribing among providers in the United States. |
A rapid review of disparities in HIV prevention and care outcomes among Hispanic/Latino men who have sex with men in the United States
Crepaz N , Mullins MM , Higa D , Gunn JKL , Salabarría-Peña Y . AIDS Educ Prev 2021 33 (4) 276-289 In the United States, Hispanic/Latino men who have sex with men (HLMSM) are disproportionally affected by HIV. We conducted a rapid review of national surveillance data to examine disparities in HIV prevention and care outcomes among HLMSM. Thirteen reports provided relevant data from 2011 to 2018. Compared to White MSM, a higher percentage of HIV-negative HLMSM reported not taking PrEP and engaging in condomless sex; a lower percentage of HIV-negative HLMSM at risk for HIV reported PrEP awareness and use; and a lower percentage of HIV-positive HLMSM were aware of their status, linked to HIV care, and virally suppressed. Viral suppression rates in HLMSM were better among Ryan White clients than the national rates, suggesting that access to comprehensive care/services reduces disparities. Findings also call for identifying individual, social, and structural factors contributing to condomless sex without PrEP use and HIV status unawareness and identifying best approaches for scaling up comprehensive care/services. |
Estimated time from HIV infection to diagnosis and diagnosis to first viral suppression during 2014-2018
Crepaz N , Song R , Lyss S , Hall HI . AIDS 2021 35 (13) 2181-2190 OBJECTIVE: To examine changes in the lengths of time from HIV infection to diagnosis (Infx-to-Dx) and from diagnosis to first viral suppression (Dx-to-VS), two periods during which HIV can be transmitted. DESIGN: Data from the National HIV Surveillance System (NHSS) for persons who were aged ≥13 years at the time of HIV diagnosis during 2014-2018 and resided in one of 33 U.S. jurisdictions with complete laboratory reporting. METHODS: The date of HIV infection was estimated based on a CD4-depletion model. Date of HIV diagnosis, and dates and results of first CD4 test and first viral suppression (<200 copies/mL) after diagnosis were reported to NHSS through December 2019. Trends for Infx-to-Dx and Dx-to-VS intervals were examined using estimated annual percentage change. RESULTS: During 2014-2018, among persons aged ≥13 years, 133,413 HIV diagnoses occurred. The median length of infx-to-Dx interval shortened from 43 months (2014) to 40 months (2018), a 1.5% annual decrease (7.0% relative change over the 5-year period). The median length of Dx-to-VS interval shortened from 7 months (2014) to 4 months (2018), an 11.4% annual decrease (42.9% relative change over the 5-year period). Infx-to-Dx intervals shortened in only some subgroups, while Dx-to-VS intervals shortened in all groups by sex, transmission category, race/ethnicity, age, and CD4 count at diagnosis. CONCLUSION: The shortened Infx-to-Dx and Dx-to-VS intervals suggest progress in promoting HIV testing and earlier treatment; however, diagnosis delays continue to be substantial. Further shortening both intervals and eliminating disparities are needed to achieve Ending the HIV Epidemic goals. |
Trends in time from HIV diagnosis to first viral suppression following revised U.S. HIV treatment guidelines, 2012-2017
Crepaz N , Song R , Lyss S , Hall HI . J Acquir Immune Defic Syndr 2020 85 (1) 46-50 BACKGROUND: Since 2012, treatment guidelines have recommended initiating antiretroviral therapy for all persons as soon as possible after HIV diagnosis, irrespective of CD4 count. If clinicians adopted the treatment guidelines, a shortened interval between diagnosis and first viral suppression (Dx-to-VS) would be expected, with greater declines among those with CD4 counts >/=500 cells/microL at diagnosis. METHODS: Using the National HIV Surveillance System data, we examined Dx-to-VS intervals among persons aged >/=13 years with HIV infection diagnosed during 2012-2017. Analyses were stratified by first CD4 count: CD4 >/=500, 200-499, <200, and no CD4 value within 3 months after diagnosis. RESULTS: During 2012-2017 in the 27 U.S. jurisdictions with complete laboratory reporting, 138,759 HIV diagnoses occurred. The median Dx-to-VS interval shortened overall for persons with HIV diagnosed in 2012 vs. 2017 from 9 to 5 months, a 12.3% annual decrease (P <0.001) and in all CD4 groups. In 2012, Dx-to-VS interval was longer for persons with CD4 >/=500 than 200-499 and <200 (median, 9, 7, and 6 months, respectively). By 2017, the median interval was 4 months for these groups, compared with 25 months for those without a CD4 value within 3 months after diagnosis. CONCLUSION: Decreases in Dx-to-VS intervals across all CD4 groups with a greater decrease among those with CD4 >/=500 is consistent with implementation of treatment recommendations. The Dx-to-VS interval was longest among persons not linked to care within 3 months after diagnosis, underscoring the importance of addressing barriers to linkage to care for ending the HIV epidemic. |
HIV prevention research on men who have sex with men: A scoping review of systematic reviews, 1988-2017
Higa DH , Crepaz N , McDonald CM , Adegbite-Johnson A , DeLuca JB , Kamitani E , Sipe TA . AIDS Educ Prev 2020 32 (1) 1-24 In the United States, men who have sex with men (MSM) are disproportionately affected by HIV. To identify research gaps and inform HIV prevention for MSM, we conducted a scoping review of systematic reviews using CDC's Prevention Research Synthesis database. Eligibility criteria comprised English-language systematic reviews focused on HIV prevention for MSM, published during 1988-2017, and included at least one U.S. primary study. We coded data type, subpopulations, topics, and key findings. To assess study quality, we used the Assessment of Multiple Systematic Reviews (AMSTAR). Among 129 relevant systematic reviews, study quality was high or moderate for 63%. Most common topics were sexual behavior and disease vulnerability. The most frequently mentioned MSM subgroups were HIV-positive, Black or African American, and young. Research gaps include Hispanic/Latino MSM, pre-exposure prophylaxis (PrEP), treatment as prevention, social determinants of health, health disparities, syndemics, and protective factors for sexual health. |
Racial and ethnic disparities in sustained viral suppression and transmission risk potential among persons aged 13-29 years living with diagnosed HIV infection, United States, 2016
Crepaz N , Dong X , Hess KL , Bosh K . J Acquir Immune Defic Syndr 2020 83 (4) 334-339 BACKGROUND: In 2016, persons aged 13-29 years represented 23.1% of the U.S. population, yet accounted for 41.7% of HIV diagnoses. Racial/ethnic minorities are disproportionally affected by HIV. Sustaining viral suppression helps persons living with diagnosed HIV infection (PLWDH) stay healthy and reduces the risk of transmitting HIV. We examined racial/ethnic disparities in sustained viral suppression and transmission risk potential among PLWDH aged 13-29 years. METHODS: We analyzed data from the National HIV Surveillance System reported through December 2018 from 42 jurisdictions with complete laboratory reporting. We included persons aged 13-29 years who received an HIV diagnosis by December 31, 2015, most recently resided in one of the 42 jurisdictions, and were alive at the end of 2016. Sustained viral suppression was defined as viral load <200 copies/mL for all tests in 2016. Transmission risk potential was estimated using the number of days with viral loads >1,500 copies/mL. RESULTS: Of the 90,812 PLWDH aged 13-29 years included in the analysis, 41.5% had sustained viral suppression in 2016. Across age, sex, and most transmission categories, blacks had the lowest prevalence of sustained viral suppression. Among the 28,154 who were in care but without sustained viral suppression, the average number of days with viral load >1,500 copies/mL was 206 days (56.4% of the 12-month period). CONCLUSION: Sustained viral suppression was suboptimal and transmission risk potential was high for PLWDH aged 13-29 years. Racial/ethnic disparities were apparent, calling for strengthening tailored interventions to improve care outcomes. |
Is co-location of services with HIV care associated with improved HIV care outcomes A systematic review
Mizuno Y , Higa DH , Leighton CA , Mullins M , Crepaz N . AIDS Care 2019 31 (11) 1-9 This systematic review identifies models of service co-location, a structural intervention strategy to remove barriers to HIV care and services, and examines their associations with HIV care outcomes. A cumulative database (e.g., MEDLINE, EMBASE) of HIV, AIDS, and STI literature was systematically searched and manual searches were conducted to identify relevant studies. Thirty-six studies were classified into six models of co-location: HIV care co-located with multiple ancillary services, tuberculosis (TB) care, non-HIV specific primary care, drug abuse treatment, prevention of mother to child transmission programs (PMTCT), and mental health care. More evidence of a positive association was seen for linkage to care and antiretroviral therapy (ART) uptake than for retention and viral suppression. Models of co-location that addressed HIV and non-HIV medical care issues (i.e., co-location with non-HIV specific primary care, PMTCT, and TB) had more positive associations, particularly for linkage to care and ART uptake, than other co-location models. While some findings are encouraging, more research with rigorous study designs is needed to strengthen the evaluation of, and evidence for, service co-location. |
Estimating national rates of HIV infection among men who have sex with men, persons who inject drugs and heterosexuals in the United States
Crepaz N , Hess KL , Purcell DW , Hall HI . AIDS 2018 33 (4) 701-708 BACKGROUND: Calculating national rates of HIV diagnosis, incidence, and prevalence can quantify disease burden and is important for planning and evaluating programs. We calculated HIV rates among men who have sex with men (MSM), persons who inject drugs (PWID), and heterosexuals in 2010 and 2015. METHODS: We used proportion estimates of the United States population classified as MSM, PWID, and heterosexuals along with census data to calculate the population sizes which were used as the denominators for calculating HIV rates. The numerators (HIV diagnosis, incidence, and prevalence) were based on data submitted to the National HIV Surveillance System through June 2017. RESULTS: The estimated HIV diagnosis and incidence rates in 2015 were 574.7 and 583.6 per 100,000 MSM; 34.3 and 32.7 per 100,000 PWID; and 4.1 and 3.8 per 100,000 heterosexuals. The estimated HIV prevalence in 2015 was 12,372.9 per 100,000 MSM; 1,937.2 per 100,000 PWID; and 126.7 per 100,000 heterosexuals. The HIV diagnosis rates decreased from 2010 to 2015 in all three transmission categories. Blacks had the highest HIV diagnosis rates at both time points. The HIV incidence rates decreased among white MSM, MSM aged 13-24 years, PWID overall, and male and female heterosexuals; however, it increased among MSM aged 25-34 years. CONCLUSIONS: The estimated HIV diagnosis and HIV infection rates decreased for several transmission categories as well as race/ethnicity and age subgroups. MSM continue to be disproportionately affected. Disparities remain and have widened for some groups. Efforts are needed to strengthen prevention, care, and supportive services for all persons with HIV infection. |
Racial and ethnic differences in viral suppression among HIV-positive women in care
Nwangwu-Ike N , Frazier EL , Crepaz N , Tie Y , Sutton MY . J Acquir Immune Defic Syndr 2018 79 (2) e56-e68 BACKGROUND: Women with HIV diagnoses are less likely to be virally suppressed than men. Women of different racial/ethnic groups may be differentially affected by sociodemographic factors. We examined differences in viral suppression among women by race/ethnicity and associated variables to inform prevention interventions. METHODS: We used data from the 2010-2014 cycles of the Medical Monitoring Project, a cross-sectional survey of HIV-positive adults in care. We limited analyses to black, Hispanic, and white women. We calculated weighted prevalences of recent viral suppression (undetectable or <200 copies/mL) and sustained viral suppression (consistent viral suppression during the past 12 months) among women by race/ethnicity. We computed adjusted prevalence differences (aPDs) and 95% confidence intervals (CIs) for viral suppression by racial/ethnic group, controlling for selected variables, including available social determinants of health variables. RESULTS: Among women, 62.9% were black, 19.8% Hispanic, and 17.3% white. Overall, 74.3% had recent viral suppression, and 62.3% had sustained viral suppression. Compared with white women (79.7%, CI: 77.2 to 82.2), black (72.5%, CI: 70.3 to 74.7; PD: 7.2) and Hispanic (75.4%, CI: 72.6 to 78.3; PD: 4.3) women were less likely to have recent viral suppression. In multivariable analyses, after adjusting for antiretroviral therapy adherence, HIV disease stage, age, homelessness, and education, black-white aPDs remained significant for recent (aPD: 4.8, CI: 1.6 to 8.1) and sustained (aPD: 5.0, CI: 1.1 to 9.0) viral suppression. CONCLUSION: Viral suppression was suboptimal for all women, but more for black and Hispanic women. Differences between black, Hispanic, and white women may be partially due to antiretroviral therapy adherence, HIV disease stage, and social determinants of health factors. |
Evaluation of a computer-based and counseling support intervention to improve HIV patients' viral loads
Marks G , O'Daniels C , Grossman C , Crepaz N , Rose CE , Patel U , Stirratt MJ , Gardner LI , Cachay ER , Mathews WC , Drainoni ML , Sullivan M , Bradley-Springer L , Corwin M , Gordon C , Rodriguez A , Dhanireddy S , Giordano TP . AIDS Care 2018 30 (12) 1-9 We sought to integrate a brief computer and counseling support intervention into the routine practices of HIV clinics and evaluate effects on patients' viral loads. The project targeted HIV patients in care whose viral loads exceeded 1000 copies/ml at the time of recruitment. Three HIV clinics initiated the intervention immediately, and three other HIV clinics delayed onset for 16 months and served as concurrent controls for evaluating outcomes. The intervention components included a brief computer-based intervention (CBI) focused on antiretroviral therapy adherence; health coaching from project counselors for participants whose viral loads did not improve after doing the CBI; and behavioral screening and palm cards with empowering messages available to all patients at intervention clinics regardless of viral load level. The analytic cohort included 982 patients at intervention clinics and 946 patients at control clinics. Viral loads were assessed at 270 days before recruitment, at time of recruitment, and +270 days later. Results indicated that both the control and intervention groups had significant reductions in viral load, ending with approximately the same viral level at +270 days. There was no evidence that the CBI or the targeted health coaching was responsible for the viral reduction in the intervention group. Results may stem partially from statistical regression to the mean in both groups. Also, clinical providers at control and intervention clinics may have taken action (e.g., conversations with patients, referrals to case managers, adherence counselors, mental health, substance use specialists) to help their patients reduce their viral loads. In conclusion, neither a brief computer-based nor targeted health coaching intervention reduced patients' viral loads beyond levels achieved with standard of care services available to patients at well-resourced HIV clinics. |
Racial and ethnic disparities in sustained viral suppression and transmission risk potential among persons receiving HIV care - United States, 2014
Crepaz N , Dong X , Wang X , Hernandez AL , Hall HI . MMWR Morb Mortal Wkly Rep 2018 67 (4) 113-118 Non-Hispanic blacks/African Americans (blacks) represent 12% of the U.S. POPULATION: * However, in 2014 an estimated 43% (471,500) of persons living with diagnosed and undiagnosed human immunodeficiency virus (HIV) infection were blacks (1). In 2016, blacks accounted for 44% of all new HIV diagnoses (2). Although antiretroviral therapy (ART) prescriptions among persons in HIV care increased overall from 89% in 2009 to 94% in 2013, fewer blacks than Hispanics or Latinos (Hispanics) and non-Hispanic whites (whites) were on ART and had a suppressed viral load (<200 HIV RNA copies/mL) in their most recent viral load test result (3). Blacks also might be less likely to have sustained viral suppression over time and to experience longer periods with viral loads >1,500 HIV RNA copies/mL, a level that increases the risk for transmitting HIV (4-7). National HIV Surveillance System (NHSS) data are among those used to monitor progress toward reaching the national goal of reducing health disparities. CDC analyzed NHSS data to describe sustained viral suppression and transmission risk potential by race/ethnicity. Among 651,811 persons with HIV infection diagnosed through 2013 and who were alive through 2014 in 38 jurisdictions with complete laboratory reporting, a lower percentage of blacks had sustained viral suppression (40.8%), than had Hispanics (50.1%) and whites (56.3%). Among persons who were in care (i.e., had at least one viral load test in 2014) and had not achieved sustained viral suppression in 2014, blacks experienced longer periods (52.1% of the 12-month period) with viral loads >1,500 copies/mL, than did Hispanics (47.2%) and white (40.8%). Blacks aged 13-24 years had the lowest prevalence of sustained viral suppression, a circumstance that might increase transmission risk potential. Strengthening interventions that improve access to ART, promote adherence, and address barriers to clinical care and supportive services for all persons with diagnosed HIV infection is important for achieving the national goal of reducing health disparities. |
Changes in viral suppression status among HIV patients receiving care: United States, 2014
Crepaz N , Tang T , Marks G , Hall HI . AIDS 2017 31 (17) 2421-2425 OBJECTIVE: To examine changes in viral suppression status among HIV patients receiving care in 2014 and the extent of viral suppression among persons with infrequent care visits. METHODS: Using data reported to the National HIV Surveillance System from 33 jurisdictions with complete reporting of CD4 and viral load tests, we created four viral suppression status groups based on their first and last viral loads in 2014: both suppressed, first unsuppressed and last suppressed (improved), first suppressed and last unsuppressed (worsened), and both unsuppressed. We also calculated the number and percentage of persons whose sole viral load in 2014 was suppressed and had a suppressed viral load at their last test in 2013. RESULTS: Among 339515 persons with at least two viral load tests in 2014, 72.6% had all viral loads suppressed (durably suppressed); 75.5% had the first and last tests suppressed, 10.5% improved, 4.2% worsened, and 9.9% had both unsuppressed. Among 92309 persons who had only one viral load test in 2014, 69960 (75.8%) were suppressed and, of those, 53834 (76.9%) also had a suppressed viral load at their last test in 2013. CONCLUSIONS: National surveillance data show that the majority of patients in HIV care during 2014 were durably suppressed. More showed improved compared to worsened viral suppression status. Some patients who have less frequent care visits have sustained viral suppression. Yet one in ten who were in regular care did not have a suppressed viral load in 2014, indicating missed opportunities for clinical interventions to help patients achieve and sustain viral suppression. |
Viral suppression patterns among persons in the United States with diagnosed HIV infection in 2014
Crepaz N , Tang T , Marks G , Hall HI . Ann Intern Med 2017 167 (6) 1-2 The most common measure of HIV suppression in clinical and surveillance studies is whether a patient’s most recent viral load was less than 200 copies/mL during the preceding 12 months. This single-value measure provides only a snapshot of suppression status and does not capture changes in viral load over time (1, 2). Persons who are suppressed according to their most recent viral load measurement may still transmit HIV if their suppression status changes. | Objective: | To determine the usefulness of a single measure of viral load for understanding long-term suppression and examine the extent of cumulative HIV burden for understanding the potential risk for transmission. |
Trends in sexual behavior among men who have sex with men (MSM) in high-income countries, 1990-2013: A systematic review
Hess KL , Crepaz N , Rose C , Purcell D , Paz-Bailey G . AIDS Behav 2017 21 (10) 2811-2834 HIV diagnoses among men who have sex with men (MSM) have been increasing in several high-income countries. A better understanding of the sexual behavior trends among MSM can be useful for informing HIV prevention. We conducted a systematic review of studies that examined behavioral trends (1990-2013) in any condomless anal sex, condomless anal sex with an HIV-discordant partner, and number of partners. Studies included come from the United States, Europe, and Australia. We found increasing trends in condomless anal sex and condomless anal sex with an HIV-discordant partner, and a decreasing trend in number of partners. The increase in condomless anal sex may help to explain the increase in HIV infections. More explanatory research is needed to provide insight into factors that contribute to these behavior trends. Continuous monitoring of HIV, risk behaviors, and use of prevention and treatment is needed to evaluate prevention efforts and monitor HIV transmission risk. |
Examination of HIV infection through heterosexual contact with partners who are known to be HIV infected in the United States, 2010-2015
Crepaz N , Dong B , Chen M , Hall I . AIDS 2017 31 (11) 1641-1644 Using data from the National HIV Surveillance System, we examined HIV infections diagnosed between 2010 and 2015 attributed to heterosexual contact with partners previously known to be HIV infected. More than 4 in 10 HIV infections among heterosexual males and 5 in 10 HIV infections among heterosexual females were attributed to this group. Findings may inform the prioritization of prevention and care efforts and resource allocation modeling for reducing new HIV infection among discordant partnerships. |
Diagnosed HIV infection in transgender adults and adolescents: Results from the National HIV Surveillance System, 2009-2014
Clark H , Babu AS , Wiewel EW , Opoku J , Crepaz N . AIDS Behav 2016 21 (9) 2774-2783 Publications on diagnosed HIV infection among transgender people have been limited to state- or local-level data. We analyzed data from the National HIV Surveillance System and present results from the first national-level analysis of transgender people with diagnosed HIV infection. From 2009 to 2014, HIV surveillance jurisdictions from 45 states plus the District of Columbia identified and reported at least one case of newly diagnosed HIV infection for transgender people; jurisdictions from 5 states reported no cases for transgender people. Of 2351 transgender people with newly diagnosed HIV infection during 2009-2014, 84.0% were transgender women (male-to-female), 15.4% were transgender men (female-to-male), and 0.7% were additional gender identity (e.g., gender queer, bi-gender). Over half of both transgender women (50.8%; 1002/1974) and men (58.4%; 211/361) with newly diagnosed HIV infection were non-Hispanic black/African American. Improvements in data collection methods and quality are needed to gain a better understanding of HIV burden among transgender people. |
Durable viral suppression and transmission risk potential among persons with diagnosed HIV infection: United States, 2012-2013
Crepaz N , Tang T , Marks G , Mugavero MJ , Espinoza L , Hall HI . Clin Infect Dis 2016 63 (7) 976-83 BACKGROUND: To examine durable viral suppression, cumulative viral load (VL) burden, and transmission risk potential among HIV-diagnosed persons in care. METHODS: Using data from the National HIV Surveillance System from 17 jurisdictions with complete reporting of VL test results, we determined the percentage of persons in HIV care who achieved durable viral suppression (all VL results <200 copies/mL) and examined viremia copy-years and time spent above VL levels that increase the risk of HIV transmission during 2012-2013. RESULTS: Of 265,264 persons in HIV care in 2011, 238,641 had at least two VLs in 2012-2013. The median number of VLs per individual during the 2-year period was five. Approximately 62% had durable viral suppression. The remaining 38% had high VL burden (geometric mean of viremia copy-years: 7,261) and spent an average of 438 days, 316 days, and 215 days (60%, 43.2%, and 29.5% of the 2-year time) above 200, 1,500, and 10,000 copies/mL. Women, blacks/African Americans, Hispanics/Latinos, persons with HIV infection attributed to transmission other than male-to-male sexual contact, younger age groups, and persons with gaps in care had higher viral burden and transmission risk potential. CONCLUSIONS: Two-thirds of persons in HIV care had durable viral suppression during a 2-year period. One-third had high VL burden and spent substantial time above VL levels with increased risk of onward transmission. More intervention efforts are needed to improve retention in care and medication adherence so that more persons in HIV care achieve durable viral suppression. |
Single Viral Load Measurements Overestimate Stable Viral Suppression among HIV Patients in Care: Clinical and Public Health Implications
Marks G , Patel U , Stirratt MJ , Mugavero MJ , Mathews WC , Giordano TP , Crepaz N , Gardner LI , Grossman C , Davila J , Sullivan M , Rose CE , O'Daniels C , Rodriguez A , Wawrzyniak AJ , Golden MR , Dhanireddy S , Ellison J , Drainoni ML , Metsch LR , Cachay ER . J Acquir Immune Defic Syndr 2016 73 (2) 205-12 BACKGROUND: The HIV continuum of care paradigm uses a single viral load test per patient to estimate the prevalence of viral suppression. We compared this single-value approach with approaches that used multiple viral load tests to examine stability of suppression. METHODS: The retrospective analysis included HIV patients who had at least two viral load tests during a 12-month observation period. We assessed (1) percent with suppressed viral load (<200 copies/ml) based on a single test during observation; (2) percent with suppressed viral loads on all tests during observation; (3) percent who maintained viral suppression among patients whose first observed viral load was suppressed; and (4) change in viral suppression status comparing first with last measurement occasions. Prevalence ratios compared demographic and clinical subgroups. RESULTS: Of 10,942 patients, 78.5% had a suppressed viral load based on a single test, whereas 65.9% were virally suppressed on all tests during observation. Of patients whose first observed viral load was suppressed, 87.5% were suppressed on all subsequent tests in next 12 months. More patients exhibited improving status (13.3% went from unsuppressed to suppressed) than worsening status (5.6% went from suppressed to unsuppressed). Stable suppression was less likely among women, younger patients, black patients, those recently diagnosed with HIV, and patients who missed ≥1 scheduled clinic visits. CONCLUSIONS: Using single viral load measurements overestimated the percent of HIV patients with stable suppressed viral load by 16% (relative difference). Targeted clinical interventions are needed to increase the percent of patients with stable suppression. |
Are couple-based interventions more effective than interventions delivered to individuals in promoting HIV protective behaviors? a meta-analysis
Crepaz N , Tungol-Ashmon MV , Vosburgh HW , Baack BN , Mullins MM . AIDS Care 2015 27 (11) 1-6 Despite several advantages to bringing couples together to learn how to protect themselves and new-born children from the risk of HIV infection, most interventions are designed for individuals or groups, not for dyads. This meta-analysis provides a direct test of whether couple-based interventions are more effective in promoting HIV protective behaviors than interventions delivered to individuals. We conducted systematic searches of five electronic databases and 60 journals. Eligible studies were controlled trials or prospective cohort designs; evaluated a couple-based intervention compared to an individual-level intervention; assessed at least one HIV prevention outcome (e.g., protective sex, drug use, HIV testing, medication adherence, and sexually transmitted infections [STI]); and were published between 1988 and 2014. Fifteen interventions, including 21,882 participants from China, Kenya, Rwanda, Tanzania, Trinidad, Zambia, and the USA, were evaluated. The results of random-effects models showed statistically significant intervention effects for protective sex (OR = 1.60, 95% CI = 1.21, 2.11), HIV testing (OR = 1.79, 95% CI = 1.31, 2.45), and Nevirapine uptake (OR = 1.51, 95% CI = 1.02, 2.24). The evidence demonstrates the usefulness of couple-based interventions in protecting individuals, partners, and new-born children from the risk of HIV transmission and infection. |
Identifying best practices for increasing linkage to, retention, and re-engagement in HIV medical care: findings from a systematic review, 1996-2014
Higa DH , Crepaz N , Mullins MM . AIDS Behav 2015 20 (5) 951-66 A systematic review was conducted to identify best practices for increasing linkage, retention and re-engagement in HIV care (LRC) for persons living with HIV (PLWH). Our search strategy consisted of automated searches of electronic databases and hand searches of journals, reference lists and listservs. We developed two sets of criteria: evidence-based to identify evidence-based interventions (EBIs) tested with a comparison group and evidence-informed to identify evidence-informed interventions (EIs) tested with a one-group design. Eligible interventions included being published between 1996 and 2014, U.S.-based studies with a comparison or one-group designs with pre-post data, international randomized controlled trials, and having objective measures of LRC-relevant outcomes. We identified 10 best practices: 5 EBIs and 5 EIs. None focused on re-engagement. Providers and prevention planners can use the review findings to identify best practices suitable for their clinics, agencies, or communities to increase engagement in care for PLWH, ultimately leading to viral suppression. |
Effects of integrated interventions on transmission risk and care continuum outcomes in persons living with HIV: meta-analysis, 1996-2014
Crepaz N , Baack BN , Higa DH , Mullins MM . AIDS 2015 29 (18) 2371-83 BACKGROUND: Reducing HIV infection and improving outcomes along the continuum of HIV care are high priorities of the US National HIV/AIDS strategy. Interventions that target multiple problem behaviors simultaneously in an integrated approach (referred to as integrated interventions) may improve prevention and care outcomes of persons living with HIV (PLWH). This systematic review and meta-analysis examines the effects of integrated interventions. METHODS: A systematic review, including both electronic and hand searches, was conducted to identify randomized controlled trials (RCTs) published between 1996 and 2014 that were designed to target at least two of the following behaviors among PLWH: HIV transmission risk behaviors, HIV care engagement, and medication adherence. Effect sizes were meta-analyzed using random-effects models. RESULTS: Fifteen RCTs met the inclusion criteria. Integrated interventions significantly reduced sex without condoms [odds ratio (OR) = 0.74, 95% confidence interval (CI) = 0.59, 0.94, P = 0.013, 13 effect sizes] and had marginally significant effects on improving medication adherence behaviors (OR = 1.35, 95% CI = 0.98, 1.85, P = 0.063, 12 effect sizes) and undetectable viral load (OR = 1.46, 95% CI = 0.93, 2.27, P = 0.098, seven effect sizes). Significant intervention effects on at least two outcomes were seen in RCTs tailored to individual needs, delivered one on one, or in settings wherein PLWH received services or care. CONCLUSION: Integrated interventions produced some favorable prevention and care continuum outcomes in PLWH. How to incorporate integrated interventions with other combination HIV prevention strategies to reach the optimal impact requires further research. |
Estimating the number of heterosexual persons in the United States to calculate national rates of HIV infection
Lansky A , Johnson C , Oraka E , Sionean C , Joyce MP , DiNenno E , Crepaz N . PLoS One 2015 10 (7) e0133543 BACKGROUND: This study estimated the proportions and numbers of heterosexuals in the United States (U.S.) to calculate rates of heterosexually acquired human immunodeficiency virus (HIV) infection. Quantifying the burden of disease can inform effective prevention planning and resource allocation. METHODS: Heterosexuals were defined as males and females who ever had sex with an opposite-sex partner and excluded those with other HIV risks: persons who ever injected drugs and males who ever had sex with another man. We conducted meta-analysis using data from 3 national probability surveys that measured lifetime (ever) sexual activity and injection drug use among persons aged 15 years and older to estimate the proportion of heterosexuals in the United States population. We then applied the proportion of heterosexual persons to census data to produce population size estimates. National HIV infection rates among heterosexuals were calculated using surveillance data (cases attributable to heterosexual contact) in the numerators and the heterosexual population size estimates in the denominators. RESULTS: Adult and adolescent heterosexuals comprised an estimated 86.7% (95% confidence interval: 84.1%-89.3%) of the U.S. population. The estimate for males was 84.1% (CI: 81.2%-86.9%) and for females was 89.4% (95% CI: 86.9%-91.8%). The HIV diagnosis rate for 2013 was 5.2 per 100,000 heterosexuals and the rate of persons living with diagnosed HIV infection in 2012 was 104 per 100,000 heterosexuals aged 13 years or older. Rates of HIV infection were >20 times as high among black heterosexuals compared to white heterosexuals, indicating considerable disparity. Rates among heterosexual men demonstrated higher disparities than overall population rates for men. CONCLUSIONS: The best available data must be used to guide decision-making for HIV prevention. HIV rates among heterosexuals in the U.S. are important additions to cost effectiveness and other data used to make critical decisions about resources for prevention of HIV infection. |
Estimating the number of persons who inject drugs in the United States by meta-analysis to calculate national rates of HIV and hepatitis C virus infections
Lansky A , Finlayson T , Johnson C , Holtzman D , Wejnert C , Mitsch A , Gust D , Chen R , Mizuno Y , Crepaz N . PLoS One 2014 9 (5) e97596 BACKGROUND: Injection drug use provides an efficient mechanism for transmitting bloodborne viruses, including human immunodeficiency virus (HIV) and hepatitis C virus (HCV). Effective targeting of resources for prevention of HIV and HCV infection among persons who inject drugs (PWID) is based on knowledge of the population size and disparity in disease burden among PWID. This study estimated the number of PWID in the United States to calculate rates of HIV and HCV infection. METHODS: We conducted meta-analysis using data from 4 national probability surveys that measured lifetime (3 surveys) or past-year (3 surveys) injection drug use to estimate the proportion of the United States population that has injected drugs. We then applied these proportions to census data to produce population size estimates. To estimate the disease burden among PWID by calculating rates of disease we used lifetime population size estimates of PWID as denominators and estimates of HIV and HCV infection from national HIV surveillance and survey data, respectively, as numerators. We calculated rates of HIV among PWID by gender-, age-, and race/ethnicity. RESULTS: Lifetime PWID comprised 2.6% (95% confidence interval: 1.8%-3.3%) of the U.S. population aged 13 years or older, representing approximately 6,612,488 PWID (range: 4,583,188-8,641,788) in 2011. The population estimate of past-year PWID was 0.30% (95% confidence interval: 0.19 %-0.41%) or 774,434 PWID (range: 494,605-1,054,263). Among lifetime PWID, the 2011 HIV diagnosis rate was 55 per 100,000 PWID; the rate of persons living with a diagnosis of HIV infection in 2010 was 2,147 per 100,000 PWID; and the 2011 HCV infection rate was 43,126 per 100,000 PWID. CONCLUSION: Estimates of the number of PWID and disease rates among PWID are important for program planning and addressing health inequities. |
A systematic review of interventions for reducing HIV risk behaviors among people living with HIV in the United States, 1988-2012
Crepaz N , Tungol-Ashmon MV , Higa DH , Vosburgh W , Mullins MM , Barham T , Adegbite A , DeLuca JB , Sipe TA , White CM , Baack BN , Lyles CM . AIDS 2014 28 (5) 633-656 OBJECTIVE: To conduct a systematic review to examine interventions for reducing HIV risk behaviors among people living with HIV (PLWH) in the United States. METHODS: Systematic searches included electronic databases from 1988 to 2012, hand searches of journals, reference lists of articles, and HIV/AIDS Internet listservs. Each eligible study was evaluated against the established criteria on study design, implementation, analysis, and strength of findings to assess the risk of bias and intervention effects. RESULTS: Forty-eight studies were evaluated. Fourteen studies (29%) with both low risk of bias and significant positive intervention effects in reducing HIV transmission risk behaviors were classified as evidence-based interventions (EBIs). Thirty-four studies were classified as non-EBIs due to high risk of bias or nonsignificant positive intervention effects. EBIs varied in delivery from brief prevention messages to intensive multisession interventions. The key components of EBIs included addressing HIV risk reduction behaviors, motivation for behavioral change, misconception about HIV, and issues related to mental health, medication adherence, and HIV transmission risk behavior. CONCLUSION: Moving evidence-based prevention for PLWH into practice is an important step in making a greater impact on the HIV epidemic. Efficacious EBIs can serve as model programs for providers in healthcare and nonhealthcare settings looking to implement evidence-based HIV prevention. Clinics and public health agencies at the state, local, and federal levels can use the results of this review as a resource when making decisions that meet the needs of PLWH to achieve the greatest impact on the HIV epidemic. |
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