HIV-infected Clients Research Articles

Client-provider interactions in provider-initiated and voluntary HIV counseling and testing services in Uganda

BackgroundProvider-initiated HIV testing and counselling (PITC) is based on information-giving while voluntary counselling and testing (VCT) includes individualised client-centered counseling. It is not known if the provider-client experiences, perceptions and client satisfaction with the information provided differs in the two approaches.MethodsIn 2008, we conducted structured interviews with 627 individuals in Uganda; 301 tested through PITC and 326 through voluntary counselling and testing (VCT). We compared client experiences and perceptions based on the essential elements of consent, confidentiality, counseling, and referral for follow-up care. We conducted multivariate analysis for predictors of reporting information or counselling as sufficient.ResultsIn VCT, 96.6% (282) said they were asked for consent compared to 91.3% (198) in PITC (P = 0.01). About the information provided, 92.0% (286) in VCT found it sufficient compared to 78.7% (221) in PITC (P = <0.01). In VCT 79.9% (246) thought their results were kept confidential compared to 71.7% (200) in PITC (P = 0.02). Eighty percent (64) of HIV infected VCT clients said they were referred for follow-up care versus 87.3% (48) in PITC (p = 0.2). Predictors of perceived adequacy of information in PITC included an opportunity to ask questions (adj.RR 1.76, CI 1.41, 2.18) and expecting the test results received (adj.RR 1.18, CI 1.06, 1.33). For VCT significant factors included being given an opportunity to ask questions (adj.RR 1.62, CI 1.00, 2.60) and 3+ prior times tested, (adj.RR 1.05, CI 1.00, 1.09).ConclusionsThis study demonstrates good practices in the essential elements of HIV testing for both VCT and PITC. However, further quality enhancement is required in both testing approaches in relation to referral to HIV care post-test, client confidence in relation to confidentiality, and providing an opportunity to ask questions to address client-specific information needs.

IMB Model in Practice: Social Workers’ Intentions to Change Their Practice Following HIV Mental Health Training

We identified predictors of social workers’ intentions to integrate HIV and mental health care following Information, Motivation, Behavior Change (IMB) model trainings. We used multiple logistic regression analysis to understand applicability of the IMB model in promoting practice change. Significantly greater intentions to integrate care were found among participants who perceived an increase in knowledge (twofold) or who felt more comfortable (nearly fourfold) or capable (nearly fivefold) working with HIV-infected clients. Training that enhances knowledge and motivation enhanced social workers’ intentions to change clinical practice. IMB-based training builds social worker capacity to deliver integrated care. The results support utility of the IMB model in enhancing HIV care.

Low Rates of Repeat HIV Testing Despite Increased Availability of Antiretroviral Therapy in Rural Tanzania: Findings from 2003–2010

BackgroundHIV counselling and testing (HCT) services can play an important role in HIV prevention by encouraging safe sexual behaviours and linking HIV-infected clients to antiretroviral therapy (ART). However, regular repeat testing by high-risk HIV-negative individuals is important for timely initiation of ART as part of the ‘treatment as prevention’ approach.AimTo investigate HCT use during a round of HIV serological surveillance in northwest Tanzania in 2010, and to explore rates of repeat testing between 2003 and 2010.MethodsHCT services were provided during the fourth, fifth and sixth rounds of serological surveillance in 2003–2004 (Sero-4), 2006–2007 (Sero-5) and 2010 (Sero-6). HCT services have also been available at a government-run health centre and at other clinics in the study area since 2005. Questionnaires administered during sero-surveys collected information on socio-demographic characteristics, sexual behaviour and reported previous use of HCT services.ResultsThe proportion of participants using HCT increased from 9.4% at Sero-4 to 16.6% at Sero-5 and 25.5% at Sero-6. Among participants attending all three sero-survey rounds (n = 2,010), the proportions using HCT twice or more were low, with 11.1% using the HCT service offered at sero-surveys twice or more, and 25.3% having tested twice or more if reported use of HCT outside of sero-surveys was taken into account. In multivariable analyses, individuals testing HIV-positive were less likely to repeat test than individuals testing HIV-negative (aOR 0.17, 95% CI 0.006–0.52).Discussion/ConclusionsAlthough HCT service use increased over time, it was disappointing that the proportions ever testing and ever repeat-testing were not even larger, considering the increasing availability of HCT and ART in the study area. There was some evidence that HIV-negative people with higher risk sexual behaviours were most likely to repeat test, which was encouraging in terms of the potential to pick-up those at greatest risk of HIV-infection.

Factors Associated With Mortality of HIV-Positive Clients Receiving Methadone Maintenance Treatment in China

Little is known about mortality of opiate users attending methadone maintenance treatment (MMT) clinics. We sought to investigate mortality and its predictors among human immunodeficiency virus (HIV)-positive MMT clients. Records of 306 786 clients enrolled in China's MMT program from 24 March 2004 to 30 April 2011 were abstracted. Mortality rates were calculated for all HIV-positive antiretroviral treatment (ART)-naive and ART-experienced clients. Risk factors were examined using stratified proportional hazard ratios (HRs). The observed mortality rate for all clients was 11.8/1000 person-years (PY, 95% confidence interval [CI], 11.5-12.1) and 57.2/1000 PY (CI, 54.9-59.4) for HIV-positive clients (n = 18 193). An increase in average methadone doses to >75 mg/day was associated with a 24% reduction in mortality (HR = 0.76, CI, .70-.82), a 48% reduction for ART-naive HIV-positive clients (HR = 0.52, CI, .42-.65), and a 47% reduction for ART-experienced HIV-positive clients (HR = 0.53, CI, .46-.62). Among ART-experienced clients, initiation of ART when the CD4(+) T-cell count was >300 cells/mm(3) (HR = 0.64, CI, .43-.94) was also associated with decreased risk of death. We found high mortality rates among HIV-positive MMT clients, yet decreased risk of death, with earlier ART initiation and higher methadone doses. A higher daily methadone dose was associated with reduced mortality in both HIV-infected and HIV-uninfected clients, independent of ART.

Diagnosis of latent tuberculosis infection among HIV-infected clients in Far North Queensland: use of an interferon-gamma release assay

Latent Mycobacterium tuberculosis infection is a significant risk for those infected with HIV. We examined the use of an interferon-gamma release assay for the diagnosis of latent tuberculosis among HIV-infected clients attending two sexual health services in Far North Queensland. Of 240 clients tested, 19 returned a positive result (7.9%, 95% confidence interval (CI): 4.5-11.3%) and three were indeterminate (1.3%, 95% CI: -0.2%-2.7%). Low CD4 count was found to be significantly associated with an indeterminate test result (P=0.004). However, we found no significant association between test results and client demographics, self-reported prior tuberculosis infection, Bacille Calmette-Guérin vaccine status or selected tuberculosis risk factors (P-values=0.2-0.9).

Prevalence and Correlates of Non-Disclosure of HIV Serostatus to Sex partners among HIV-Infected Female Sex Workers and HIV-infected Male Clients of Female Sex Workers in India

This study examines non-disclosure of HIV serostatus to sex partners among HIV-infected adults involved with transactional sex in Mumbai, India. Surveys were conducted with HIV-infected female sex workers (n = 211) and infected male clients (n = 205) regarding HIV knowledge, awareness of sex partners' HIV serostatus, alcohol use, transactional sex involvement post-HIV diagnosis and non-disclosure of HIV serostatus. Gender-stratified multiple logistic regression models were used for analysis. Non-disclosure of one's serostatus to all sex partners was reported by almost three-fifths of females and two-fifths of males. Predictors of non-disclosure included lack of correct knowledge about HIV and no knowledge of sex partners' HIV serostatus. Among females, recent alcohol consumption also predicted non-disclosure. Among males, 10 + paid sexual partners in the year following HIV diagnosis predicted non-disclosure. Secondary HIV prevention efforts in India require greater focus on HIV disclosure communication and integrated alcohol and sexual risk reduction.

“The Anticipation Alone could Kill You”: Past and Potential Clients' Perspectives on HIV Testing in Non-Health Care Settings

HIV testing in non-health care settings is an effective strategy for increasing the proportion of persons aware of their infection. We conducted 21 focus groups with 186 past and potential clients in five U.S. cities to explore attitudes and experiences related to HIV counseling and testing in non-health care settings. Qualitative analysis yielded several key themes. HIV-related stigma and fear emerged as a main theme throughout the discussions. Knowing one's HIV status quickly and accurately was of primary importance; HIV prevention counseling was secondary. Participants prioritized a supportive, nonjudgmental environment with adequate privacy and confidentiality. Provision of immediate emotional support, medical information, and linkage services to HIV-infected clients were considered essential. Staff with HIV-specific skills to address clients' emotional and informational needs was considered a strength of non-health care testing programs. Frequently, however, participants compared non-health care settings unfavorably to health care settings regarding privacy, competency, confidentiality, and test accuracy. Recommendations for enhancing counseling and testing services in non-health care settings are discussed.

Lack of pre-antiretroviral care and competition from traditional healers, crucial risk factors for very late initiation of antiretroviral therapy for HIV - A case-control study from eastern Uganda

Although WHO recommends starting antiretroviral treatment at a CD4 count of 350 cells/[µ]L, many Ugandan districts still struggle with large proportions of clients initiating ART very late at CD4<50 cells/[µ]L. This study seeks to establish crucial risk factors for very late ART initiation in eastern Uganda. All adult HIV-infected clients on ART in Iganga who enrolled between 2005 and 2009 were eligible for this case-control study. Clients who started ART at CD4 cell count of <50 cells/[µ]L (very late initiators) were classified as cases and 50-200 cells/[µ]L (late initiators) as control subjects. A total of 152 cases and 202 controls were interviewed. Multivariate analyses were performed to calculate adjusted odds ratios and 95% confidence intervals. Reported health system-related factors associated with very late ART initiation were stock-outs of antiretroviral drugs stock-outs (affecting 70% of the cases and none of the controls), competition from traditional/spiritual healers (AOR 7.8, 95 CI% 3.7-16.4), and lack of pre-ARV care (AOR 4.6, 95% CI: 2.3-9.3). Men were 60% more likely and subsistence farmers six times more likely (AOR 6.3, 95% CI: 3.1-13.0) to initiate ART very late. Lack of family support tripled the risk of initiating ART very late (AOR 3.3, 95% CI: 1.6-6.6). Policy makers should prevent ARV stock-outs though effective ARV procurement and supply chain management. New HIV clients should seek pre-ARV care for routine monitoring and determination of ART eligibility. ART services should be more affordable, accessible and user-friendly to make them more attractive than traditional healers.

Feasibility and Efficacy of Isoniazid Prophylaxis for Latent Tuberculosis in HIV-Infected Clients Patients in Thailand

A prospective study was conducted in 4339 HIV-positive clients at the Thai Red Cross AIDS Research Centre (TRC-ARC) Anonymous clinic, Bangkok, Thailand between January 2003 and April 2008. A tuberculin skin test (TST) was done for all patients without a previous history of tuberculosis (TB). Nine months of isoniazid (INH) was given for all positive TST/no active TB. TST-negative clients were asked to repeat the TST annually. The study aim was to evaluate the feasibility and efficacy of INH prophylaxis for preventing TB in HIV-positive Thai patients. Of those patients, 4111 (94.7%) had a TST done; 1157 (28.1%) were TST positive and 799 patients started INH prophylaxis. In all, 551 (69%) and 633 (79.2%) patients completed 9 months and 6 months of INH, respectively; 176 (20.2%) patients had a negative TST at baseline and subsequently converted to positive. Only patients with a baseline CD4 >200 cells/μL (p=0.000) and currently on antiretroviral (ARV) treatment (p=0.000) were related to having a positive TST. This baseline CD4 level was also significantly related to higher INH completion rates at 6 months (p=0.000). Interestingly, none of INH completion patients developed active TB. The feasibility of INH prophylaxis in TST-positive patients in this setting is possible. However, the long-term advantage of INH prophylaxis in terms of TB prevention, especially in HIV-1-infected patients on highly active antiretroviral therapy (HAART), is still an issue that needs more research.

Outcomes of HIV Partner Services for People With HIV and STD Coinfection Versus New HIV Diagnosis: Implications for HIV Prevention Strategies

To the Editor: In the April issue of STD, Hague et al.1 reported a disturbingly high incidence of STDs in the 5 years following HIV diagnosis among young black men who have sex with men (MSM) in Baltimore in 2004. In New York City (NYC), we have also observed high rates of new STDs in HIV-infected clients.2 Although we agree with the authors' conclusion that prevention counseling regarding STD needs to continue for years following HIV diagnosis, identification of an effective and affordable prevention strategy for this high-risk group poses a number of challenges. The NYC Health Department's HIV Field Services Unit (FSU) provides HIV partner services (PS) at 19 high-volume HIV clinics in NYC neighborhoods most affected by the HIV epidemic. From February 2009 to June 2010, we expanded the range of clients offered PS to include HIV-positive persons with newly reported gonorrhea (GC) or chlamydia (CT). We matched cases from NYC's STD surveillance registry newly diagnosed with GC or CT at these facilities to the NYC HIV Surveillance Registry, then selected for PS cases with an HIV diagnosis date at least 2 years prior. In 2009, FSU partner facilities had approximately 14,000 active HIV-infected patients and reported ∼1000 new HIV diagnoses. Over these 14 months, 171 GC- or CT-coinfected patients met our criteria and were offered PS, 20 (12%) of whom were reinfected at least twice. We compared PS outcomes of the STD coinfected to 1237 newly HIV-diagnosed patients without coinfection receiving PS during the same period (Table 1). Coinfected patients were more likely to be under 25 years old (33% versus 19%) or MSM (72% versus 58%). Interview rates among both groups were comparable (82% coinfected versus 87% newly diagnosed); however, significantly fewer coinfected (49%) than newly diagnosed (68%) named partners, and partners elicited per index patient interviewed was also lower (0.89 versus 1.12). Median days from case assignment to interview was longer for coinfected than newly diagnosed patients (13 versus 6; P < 0.05). Proportions of partners according to HIV status category (positive, negative, or unknown) were similar. Of the notified partners with negative or unknown serostatus, those named by the newly diagnosed were more likely to accept HIV testing, and 14% were newly diagnosed with HIV as a result of PS. None of the 28 partners of the coinfected tested through PS was positive.TABLE 1: Demographics, Risk Behaviors, and Partner Services Outcomes for HIV-Positive Patients Coinfected and Newly DiagnosedProviding PS to coinfected patients with long-standing HIV diagnoses required far more resources compared to the newly diagnosed, which we attribute to the lack of accurate and current locating information, and lag time caused by the need to match registries. PS outcomes among the coinfected were more modest, stemming from coinfected clients' frequent refusal to name partners, on the basis that their partners “were already aware” of their serostatus or had received STD treatment. Unable to justify the resources required, we no longer prioritize this group for PS, but instead have focused on obtaining provider referrals for HIV/GC- or HIV/CT-infected clients deemed most likely to benefit from PS. Although continued prevention efforts are needed with this group, the crucial question is how they can be provided efficiently and effectively. Chi-Chi N. Udeagu, MPH Adey Tsega, MPH Bureau of HIV/AIDS Prevention and Control New York City Department of Health and Mental Hygiene New York, NY Ellen J Klingler, MPH Bureau of Sexually Transmitted Diseases Control New York City Department of Health and Mental Hygiene New York, NY Angelica Bocour, MPH Charulata J. Sabharwal, MD, MPH Colin W. Shepard, MD Bureau of HIV/AIDS Prevention and Control New York City Department of Health and Mental Hygiene New York, NY

Transactional sex risk and STI among HIV-infected female sex workers and HIV-infected male clients of FSWs in India

To describe sex risk behaviors of HIV-infected female sex workers (FSWs) and HIV-infected male clients of FSWs, to evaluate associations between risky transactional sex and number of unprotected transactional sex episodes, and to assess the association between unprotected transactional sex and self-reported sexually transmitted infection (STI). Adult HIV-infected FSWs (n=211) and HIV-infected male clients (n=205) were surveyed in Mumbai about demographics, STI, and past 90-day and past year sex and substance use histories. Gender-stratified Poisson regression models were used to evaluate associations between four risky transactional sex behaviors (number of transactional sex partners; alcohol use before transactional sex; anal transactional sex; and transactional sex with a known HIV-infected partner) and number of unprotected transactional sex episodes; logistic regression was used to assess the association between unprotected transactional sex and self-reported STI. Twenty-nine percent of females and 7% of males reported any unprotected transactional sex episodes in the past 90 days. Thirty-nine percent of females and 12% of males reported past year STI. Among males, a greater number of transactional sex partners was associated with more unprotected transactional sex episodes (adjusted incidence rate ratio [IRR] = ;8.2, 95% confidence interval [CI] ;= ;1.8–38.4 highest vs. lowest tertile), and any unprotected transactional sex was associated with a higher odds of self-reported STI in the past year (adjusted odds ratio [AOR] ;= ;5.6, 95% CI ;= ;1.4–22.4). For women, risky transactional sex behaviors were not associated with condom non-use, and unprotected sex was negatively associated with STI (AOR ;= ;0.4, 95% CI ;= ;0.2–0.9). Reports of condom use during transactional sex were high for these samples. However, standard predictors of unprotected transactional sex (i.e., greater number of partners) and STI (i.e., unprotected sex) only held true for males. Further research is needed to guide an understanding of sex risk and STI among HIV-infected FSWs in India.

Clinical predictors of low CD4 count among HIV infected pulmonary tuberculosis clients: A health facility-based survey

The study aimed to determine the clinical and laboratory predictors of a low CD4+ cell count (<200 cells/microl) in HIV-infected patients with pulmonary tuberculosis (PTB). A prospective cohort study on HIV-positive patients with smear-positive PTB attending an outpatient clinic in Zimbabwe. Consecutively consenting HIV-positive adults, aged 18 years and over, who had positive sputum smears for acid-fast bacilli and were naïve to both antituberculosis drugs and ART. Baseline CD4+ cell count, full blood count, functional status using the Karnofsky Performance Status (KPS) score and body mass index (BMI, kg/m2) were determined for all participants. Univariate and multiple logistic regression analyses of the data were done. Of the 97 participants recruited, 59 (61%) were females. The overall mean age was 34 years (standard deviation (SD) 8). The median CD4+ cell count was 104.5 cells/microl (intraquartile range (IQR) 41-213 cells/microl). Patients with pleuritic chest pain were less likely to have a low CD4+ cell count than patients who did not (odds ratio (OR) 0.2; confidence interval (CI) 0.03-0.8). The following were statistically significant predictors of a CD4+ cell count of <200 cells /microl: BMI<18 kg/m2 (OR 3.8; CI 1.2-12), KPS<54.4 (OR 3; CI 1.1-12) and haemoglobin concentration<8 g/dl (OR 13; CI 1.8 - 533). HIV-infected sputum-positive PTB patients presenting with a BMI<18, KPS<54.4% and haemoglobin concentration<8 g/dl should have early initiation of ART since they are more likely to have a low CD4+ cell count, whereas those presenting with pleuritic pain are less likely to have a low CD4+ cell count.

Referral and Referral Facilitation Behavior of Family Planning Providers for Women with HIV Infection in the Southern United States

Many women receive family planning (FP) services from federally supported FP providers. These FP services include testing for sexually transmitted infections (STD), including the human immunodeficiency virus (HIV). FP providers are expected to refer patients with non-FP conditions, including HIV, to other providers for treatment. Prompt HIV treatment improves outcomes and survival, yet many women face barriers to accessing treatment. Facilitation of referrals improves referral follow-up. However, little is known about the referral practices and facilitation activities of FP providers for their clients testing positive for HIV. To fill this gap, this article reports the findings of a study that used a mail survey of FP providers (n = 456) to document referral practices and facilitation activities when providers see HIV-positive patients. The study found that nearly all FP providers report referring HIV-infected clients to another provider rather than providing treatment themselves. Factors associated with significantly more facilitation of referrals included perception of less competent patients, perception of more referral resources, personal relationships with referral providers, rural locality, and information support staff. Some factors associated with low facilitation (such as perception of few referral resources and no personal relationships with referral providers) are amenable to change. Interventions targeting these factors should be designed and tested to increase facilitation of referrals and the follow-up with referrals for HIV treatment.

Alcohol use and sex risk behaviors among HIV-infected female sex workers (FSWs) and HIV-infected male clients of FSWs in India.

Unprotected heterosexual transactional sex plays a central role in the spread of HIV in India. Given alcohol's association with risky sex in other populations and alcohol's role in HIV disease progression, we investigated patterns of alcohol use in HIV-infected female sex workers (FSWs) and HIV-infected male clients of FSWs in Mumbai. Analyses identified factors associated with heavy alcohol use and evaluated the relationship between alcohol use and risky sex. We surveyed 211 female and 205 male individuals; 80/211 FSWs (38%) and 127/205 male clients (62%) drank alcohol in the last 30 days. Among females, 32 and 11% drank heavily and were alcohol-dependent, respectively; among males the respective proportions were 44 and 29%. Men's heavy alcohol use was significantly associated with inconsistent condom use over the last year (AOR 2.40, 95% CI 1.21-4.77, P = 0.01); a comparable association was not seen in women. These findings suggest a need to address alcohol use both to avoid the medical complications of its heavy use in this population and to mitigate inconsistent condom use, the latter issue possibly requiring gender specific approaches. Such efforts to reduce drinking will be an important dimension to secondary HIV prevention in India.

Provider Challenges in Implementing Antenatal Provider-Initiated HIV Testing and Counseling Programs in Uganda

While provider-initiated HIV testing and counseling (PITC) programs are being increasingly implemented in antenatal care settings, there is scant information about the specific challenges providers face when offering these services. Through qualitative interviews with 30 HIV antenatal care providers from 10 clinics in central Uganda, we sought to understand specific challenges Ugandan providers face in implementing antenatal PITC programs, including how these challenges impact prevention of mother-to-child HIV transmission programs. Counseling-specific challenges included counseling discordant couples, incomplete follow-up of HIV-infected clients, low rates of both male involvement and HIV serostatus discourse, and inadequate training and support to carry out counseling duties. Health system challenges included lack of adequate space for counseling, frequent "stock-outs" of supplies, shortages of both counselors and lab personnel, and inadequate referral services. These challenges must be addressed in order to optimize the success of PITC programs at providing universal access to HIV testing and counseling services.

Associations among Violence Exposure, Mental Disorder, Substance Use Disorder, and HIV

This study's primary aim was to provide co-occurring mental and substance use disorders (COD) prevalence data as well as additional epidemiologic data needed to more firmly establish violence exposure and COD as principally associated with HIV infection. Participants were clients assessed for alcohol and other drug treatment through the network of providers overseen by the Alcohol and Drug Addiction Services Board of Cuyahoga County (Ohio) from December 12, 2001 through July 18, 2007. Study design was a matched comparison of two groups of equal number (N = 638): HIV-infected and HIV-uninfected clients. The prevalence of COD with HIV infection was determined to be 26.3%. Through logistic regression modeling, both violence exposure and COD were found to be associated with HIV infection.

Hematologic Abnormalities in Treatment-naïve HIV Patients

Objectives Hematologic abnormalities, indicated by a deranged full blood count, are common manifestations and important prognostic tools for human immunodeficiency virus (HIV) infection and AIDS. This study aimed to determine the prevalence of cytopenia and its relationship to the degree of immunosupression in HIV treatment-naïve patients. Methods This was a cross-sectional study of treatment-naïve HIV-infected clients who enrolled at the HIV clinic of Lagos State University Teaching Hospital (LASUTH) between December 2009 and June 2010. Participants had samples taken for full blood count and CD4 counts, which are free routine pre-requisite and pre-treatment evaluations done for all registered HIV patients at LASUTH. They were asked to fill the structured questionnaires to obtain demographic data, with assistance if necessary. Results A total of 205 cases were reviewed: 24.2% had anemia (PCV &lt; 30%), 26.8% had leucopenia (white blood cell &lt;4,000/L) and 16.1% had thrombocytopenia (platelet count &lt;150,000/L) at enrollment. The degree of cytopenia was directly related to the degree of immunosupression. Conclusion About one-fifth of HIV treatment-naïve patients were cytopenic at enrollment and the degree of cytopenia was directly related to the degree of immunosupression. It is necessary to investigate various causes of cytopenia in these patients so as to administer a specific intervention.

HIV Testing Rates and Outcomes in a South African Community, 2001-2006: Implications for Expanded Screening Policies

Revised World Health Organization recommendations seek to increase HIV testing. We assessed the need for expanded testing in South Africa by examining current testing and treatment trends among a high prevalence population. We determined the numbers of adults receiving HIV testing and antiretroviral treatment (ART) during 2001-2006 using testing registers linked to patient records from 2 health care facilities believed responsible for virtually all HIV services available to the population. We evaluated annual population testing rates using census population counts; proportions of clients testing seropositive (yield); CD4 counts and World Health Organization stage at diagnosis; and ART initiation rates. HIV testing rates rose from 4% in 2001 to 20% in 2006 (P < 0.001) and were highest among pregnant females receiving provider-initiated testing. Yield for first-time testers decreased from 47% in 2001 to 28% in 2006; annual incidence of seroconversion among initially HIV-negative retesters was 1.9%. Median CD4 counts and World Health Organization stage distributions for newly diagnosed clients remained stable. HIV-infected clients receiving ART within 6 months of eligibility increased from 0% in 2001 to 68% in 2006 (P < 0.001). Population testing and ART initiation rates rose dramatically during 2001-2006. Yet, yield remained high, and HIV-infected persons continued to receive late diagnoses. These findings highlight the continuing need for expanded testing and linkage to care.

Exposure to HIV Partner Counseling and Referral Services and Notification of Sexual Partners among Persons Recently Diagnosed with HIV

Among HIV-infected persons, we evaluated use of client partner notification (CPN) and health-department partner notification strategies to inform sex partners of possible HIV exposure, and prior exposure to partner counseling and referral services. We conducted a cross-sectional, observational study of 590 persons diagnosed with HIV in the prior 6 months at 51 HIV test, medical, and research providers in Chicago and Los Angeles in 2003 and 2004. Logistic regression was used to identify independent correlates of using CPN to notify all locatable partners. Participants reported a total of 5091 sex partners in the 6 months preceding HIV diagnosis; 1253 (24.6%) partners were locatable and not known to be HIV-positive. Of 439 participants with ≥1 locatable partners, 332 (75.6%) reported notifying 696 (55.5%) partners by CPN (585, 84.1%), health-department partner notification (94, 13.5%), or other means (17, 2.4%); 208 (47.4%) used CPN to notify all locatable partners. Independent correlates of CPN included having fewer locatable partners and discussing the need to notify partners with an HIV medical-care provider (black and Hispanic participants only). Many participants reported that their HIV test or medical-care provider did not discuss the need to notify partners (48.8%, 33.7%, respectively) and did not offer health-department partner-notification services (60.8%, 52.8%). Many locatable sex partners who might benefit from being notified of potential HIV exposure are not notified. In accordance with national policies, HIV test and medical-care providers should routinely provide partner counseling and referral services to HIV-infected clients so that all locatable partners are notified and provided an opportunity to learn their HIV status.

Assessing Quality of Primary Care Provided to the HIV-Infected Ryan White Population in the Baltimore Eligible Metropolitan Area

The Baltimore Eligible Metropolitan Area (EMA) receives Ryan White (RW) funds each year because of its high AIDS case rate. This study assessed the quality of primary care services provided to HIV-infected clients in the Baltimore EMA. Medical charts of 384 randomly selected clients served in 2004 were reviewed. A survey instrument was designed to assess the minimum requirements satisfied for CD4 and viral load count, highly active antiretroviral treatment, pneumocystitis carinii pneumonia and mycobacterium avium complex prophylaxis, tuberculosis, syphilis, hepatitis B and C screening and safe sex education. A numeric index of quality was developed for each client in the form of a total score. The clients were categorized into high, medium and low quality groups depending on their total scores. Only 32% of clients were in the high-quality category. Number of primary care visits per year (P <or= .0001) was found to be significantly associated with quality of care. Proactive efforts are needed at the provider level to keep or reengage HIV clients in care.