Undiagnosed Human Immunodeficiency Virus Infection Research Articles

Assisted Partner Notification Services in Namibia: Comparison of Case-Finding in Persons With New and Previously Diagnosed Human Immunodeficiency Virus, and Success as a Platform for PrEP Referral.

Assisted partner notification services (APS) are widely implemented throughout sub-Saharan Africa. The effectiveness of APS among persons with previously diagnosed human immunodeficiency virus (HIV) infection is uncertain, and there are few published data on the success of integrating referrals for HIV preexposure prophylaxis (PrEP) into APS. Staff in 22 Namibian Ministry of Health and Social Service clinics offered APS to patients newly and previously diagnosed with HIV (index cases [ICs]) between October 2019 and June 2021. Counselors used a structured interview guide to elicit ICs' sex partners and biological children and assisted ICs to arrange testing of contacts. Contacts testing HIV-positive were linked to HIV services and those 14 years or older testing negative were offered PrEP. The primary outcome was the case-finding index (contacts testing HIV-positive ÷ ICs receiving APS). Staff provided APS to 1222 (78%) of 1557 newly diagnosed ICs eliciting 1155 sex partners and 649 biological children. Among 280 previously diagnosed ICs, 279 sex partners and 158 biological children were elicited. The case-finding index was higher among ICs with newly diagnosed HIV compared with previously diagnosed HIV (0.14 vs 0.09, P = 0.46), though this difference was not statistically significant. Most sex partners testing HIV-negative were initiated on PrEP (67% in sex partners from newly diagnosed ICs; 74% in sex partners from previously diagnosed ICs). Assisted partner notification services successfully identified sex partners and biological children with undiagnosed HIV infection when provided to both newly and previously diagnosed ICs. Integration of referral to PrEP resulted in many HIV-negative partners initiating PrEP.

HIV incidence before and during the COVID-19 pandemic in Japan.

At the end of 2022, a total of 20,003 diagnoses of human immunodeficiency virus (HIV) infection and 8,983 cases of acquired immunodeficiency syndrome (AIDS) among Japanese nationals, and 3,860 HIV diagnoses and 1,575 AIDS cases among foreign residents, had been notified to the government in Japan. This study updates the estimate of HIV incidence, including during the COVID-19 pandemic. It aimed to reconstruct the incidence of HIV and understand how the disruption caused by COVID-19 affected the epidemiology of HIV. Using a median incubation period of 10.0 years, the number of undiagnosed HIV infections was estimated to be 3,209 (95% confidence interval (CI): 2,642, 3,710) at the end of 2022. This figure has declined steadily over the past 10 years. Assuming that the median incubation period was 10.0 years, the proportion of diagnosed HIV infections, including surviving AIDS cases, was 89.3% (95% CI: 87.8%, 91.0%). When AIDS cases were excluded, the proportion was 86.2% (95% CI: 84.3%, 88.3%). During the COVID-19 pandemic, the estimated annual diagnosis rate was slightly lower than during earlier time intervals, at around 16.5% (95% CI: 14.9%, 18.1%). Japan may already have achieved diagnostic coverage of 90%, given its 9% increment in the diagnosed proportion during the past 5 years. The incidence of HIV infection continued to decrease even during the COVID-19 pandemic from 2020 to 2022, and the annual rate of diagnosis decreased slightly to 16.5%. Monitoring the recovery of diagnosis along with the effective reproduction number is vital in the future.

Leveraging CD4 Cell Count at Entry Into Care to Monitor Success of Human Immunodeficiency Virus Prevention, Treatment, and Public Health Programming in the Greater St Louis Area Between 2017 and 2020.

CD4 cell count at entry into human immunodeficiency virus (HIV) care is a useful indicator of success of multiple steps in HIV public health programming. We demonstrate that CD4 cell count at care initiation was stable in St Louis between 2017 and 2019 but declined in 2020. Missouri efforts in the Ending the HIV Epidemic plan should focus on rapidly identifying individuals with undiagnosed HIV infection.

Factors Associated With Partner Notification, Testing, and Positivity in HIV Partner Services Programs in the United States, 2013 to 2017.

Human immunodeficiency virus (HIV) partner services are an essential component of comprehensive HIV prevention and care. We examined factors associated with partner notification, HIV testing, and HIV positivity among partners of HIV-diagnosed persons (index persons) contacted by Centers for Disease Control and Prevention (CDC)-funded state and local health departments. We analyzed partner service data submitted to the CDC by 61 state and local health departments from 2013 to 2017. Using multivariate Poisson regression-adjusted for clustering effects among partners reported by a common index person-we assessed associations between 3 outcomes of interest (partner notification, HIV testing, and HIV positivity) and the demographic characteristics, risk behaviors, geographic region, and service year of index persons and their partners. A total of 51,368 sexual and/or needle-sharing partners were matched with 33,524 index persons. Of notifiable partners, 97.2% were notified of their potential HIV exposure, and 52.3% were tested for HIV. Among 21,842 notified and tested partners, 23.8% were newly diagnosed with an HIV infection. Partner notification, HIV testing, and HIV positivity were associated with both partner and index person characteristics (individually and interactively), geographic region, and year of service. Partner service programs provided through CDC-funded health departments were effective in both partner notification and identification of undiagnosed HIV infection among partners. However, HIV testing rate among notified partners remained low. Implementing strategies to address gaps in HIV testing can contribute toward ending the HIV epidemic in the United States.

Estimating HIV incidence, prevalence, and percent of undiagnosed infections in Taiwan using CD4 data

Estimation of the human immunodeficiency virus (HIV) epidemic trend and percent of undiagnosed infections is an important measure for the assessment of HIV control programs. In this study, we aimed to investigate and estimate the HIV incidence, HIV prevalence, and percent of undiagnosed HIV infections in Taiwan using the CD4 depletion model. Data on newly reported HIV diagnoses during 2012-2019 were obtained from the National HIV/AIDS reporting and case management system. We used an Asian-adjusted CD4 depletion model to determine diagnosis delays and then used this distribution and HIV case surveillance data to estimate the incidence, prevalence and percent of undiagnosed infections. The estimated HIV incidence rate decreased after 2012, from 9.4 per 100,000 people (95% confidence interval [CI]: 8.7 to 10.2) to 7.1 per 100,000 people (95% CI: 5.7 to 8.5) in 2019. The prevalence rate increased from 111 per 100,000 people (95% CI: 107 to 116) in 2012 to 158 per 100,000 people (95% CI: 146 to 169) in 2019, whereas the undiagnosed rate decreased from 21.5% (95% CI: 18.2%-24.8%) in 2012 to 12.1% (95% CI: 8.9%-15.2%) in 2019. In addition, the undiagnosed percentage in the population of men who have sex with men (MSM) also decreased from 28.8% to 13.6% during this period. We found decreases in the HIV incidence and undiagnosed percentage from 2012 to 2019 in Taiwan. These findings highlight the importance of intensified HIV testing efforts to achieve the global 95-95-95 goals by 2030.

Peer Mobilization and Human Immunodeficiency Virus (HIV) Partner Notification Services Among Gay, Bisexual, and Other Men Who Have Sex With Men and Transgender Women in Coastal Kenya Identified a High Number of Undiagnosed HIV Infections.

BackgroundHuman immunodeficiency virus (HIV) partner notification services (HPN), peer mobilization with HIV self-testing, and acute and early HIV infection (AEHI) screening among gay, bisexual, and other men who have sex with men (GBMSM) and transgender women (TGW) were assessed for acceptability, feasibility, and linkage to antiretroviral therapy (ART) and preexposure prophylaxis (PrEP) services.MethodsBetween April and August 2019, peer mobilizers mobilized clients by offering HIV oral self-tests and immediate clinic referral for clients with AEHI symptoms. Mobilized participants received clinic-based rapid antibody testing and point-of-care HIV RNA testing. Newly diagnosed participants including those derived from HIV testing services were offered immediate ART and HPN. Partners were recruited through HPN.ResultsOf 772 mobilized clients, 452 (58.5%) enrolled in the study as mobilized participants. Of these, 16 (3.5%) were HIV newly diagnosed, including 2 (0.4%) with AEHI. All but 2 (14/16 [87.5%]) initiated ART. Thirty-five GBMSM and TGW were offered HPN and 27 (77.1%) accepted it. Provider referral identified a higher proportion of partners tested (39/64 [60.9%] vs 5/14 [35.7%]) and partners with HIV (27/39 [69.2%] vs 2/5 [40.0%]) than index referral. Of 44 enrolled partners, 10 (22.7%) were newly diagnosed, including 3 (6.8%) with AEHI. All 10 (100%) initiated ART. PrEP was initiated among 24.0% (103/429) mobilized participants and 28.6% (4/14) partners without HIV.ConclusionsHPN, combined with a peer mobilization–led self-testing strategy and AEHI screening for GBMSM and TGW, appears to be acceptable and feasible. These strategies, especially HPN provider referral, effectively identified undiagnosed HIV infections and linked individuals to ART and PrEP services.

Conjunctival Kaposi’s sarcoma in Acquired Immunodeficiency Syndrome (AIDS) patient: a case report

Background: Kaposi’s sarcoma (KS) is malignant neoplasm of the vascular endothelium, caused by Human Herpes Virus 8 (HHV 8). Clinical variants consist of classic KS, iatrogenic KS, and AIDS KS. The manifestation of KS in the eye may occur in the eyelids, the lacrimal sac or gland, the orbit and bulbar or palpebral conjunctiva. This case study aims to demonstrate the incidental finding of conjunctival Kaposi sarcoma (KS) leading to acquired immunodeficiency syndrome (AIDS) diagnosis.Case Presentation: A 34-years old male patient presented with a three-month history of progressively growing reddish mass in bulbar conjunctiva of the left eye. A mass with notable aggressive tumor characteristics heightened the suspicion for KS and comprehensive assessments were done accordingly. The patient was found to suffer from human immunodeficiency virus (HIV)/AIDS. Multistep approach treatment was commenced to treat AIDS-related KS and prevent recurrence in this case.Conclusion: Patients with undiagnosed HIV infection would benefit from early diagnosis initiated by AIDS-defining illnesses such as KS. Given early identification and comprehensive management, KS abridged the time to diagnosis of HIV infection.

Importance of early identification of PrEP breakthrough infections in a generalized HIV epidemic: a case report from a PrEP demonstration project in South Africa

BackgroundThe World Health Organisation recommends the use of tenofovir-containing pre-exposure prophylaxis (PrEP) as an additional Human Immunodeficiency Virus (HIV) prevention choice for men and women at substantial risk of HIV infection. PrEP could fill an important HIV prevention gap, especially for sexually active young women who are limited in their ability to negotiate mutual monogamy or condom use.As PrEP is scaled up in high HIV incidence settings, it is crucial to consider the importance of early identification of HIV infection during PrEP use, to allow for rapid discontinuation of PrEP to reduce the risk of antiretroviral (ARV) resistance. The purpose of this case study is to provide this critical evidence.Case presentationThis report describes a 20-year-old woman in a HIV sero-discordant relationship who initiated oral PrEP (tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC)) through a demonstration project (CAPRISA 084) in October 2017. Despite good adherence throughout her PrEP use, she tested HIV antibody positive at month nine of study participation.Retrospective testing showed increasing HIV viral load over time, and retrospective use of fourth-generation rapid HIV tests showed HIV detection (positive antigen/antibody) at month one. Sequencing confirmed a dominant wild type at month one with dual therapy resistance patterns emerging by month three (M184V and K65R mutations), which is suggestive of protracted PrEP use during an undetected HIV infection.The participant was referred to infectious diseases for further management of her HIV infection and was initiated on a first line, tenofovir-sparing regimen. At the time of this report (January 2020), the participant had been on ARV- therapy (ART) for 13 months and had no signs of either clinical, immunologic or virologic failure.ConclusionsThis case report highlights the importance of appropriate HIV screening during wider oral PrEP scale-up in high HIV incidence settings to circumvent the consequences of prolonged dual therapy in an undiagnosed HIV infection and in turn prevent ARV resistance.

Missed opportunities for HIV testing persist despite a single educational intervention: how can we close this evidence-practice gap?

In Australia, one-third of human immunodeficiency virus (HIV) diagnoses occur late, with an estimated 11% of people with HIV unaware of their diagnosis. Undiagnosed and untreated HIV infection increases morbidity in the HIV positive person and allows onward transmission of HIV. To determine the rate of HIV testing in acute general medicine patients with HIV indicator conditions (IC) and evaluate the effectiveness of an educational intervention in improving testing rates. Single-centre, tertiary hospital, before-after study of general medicine inpatients with IC for 12 weeks prior and 10 weeks post an educational intervention focusing on recommendations for HIV testing including IC. The REASON Cohort Discovery Tool was used to search for the IC using ICD-10 codes and laboratory data. The presence of IC was estimated, and HIV testing rates before and after the intervention were compared. Regression analysis was utilised to identify characteristics associated with HIV testing. Of 1414 admissions in the baseline period and 946 in the post-period, 161 (11.4%) and 132 (14.0%) had at least one IC present respectively. There were 18 (11.2%) HIV tests performed for admissions with IC in the pre-period which increased to 27 (20.5%) (P = 0.028) in the post-period. Younger patients were more likely to be tested and regression analysis identified the educational intervention (adjusted odds ratio) 2.2 (1.1, 4.4) to be significantly associated with testing. Although HIV testing rates for IC doubled following the intervention, they remained unacceptably low. The recently introduced electronic medical record presents opportunities to prompt HIV testing.

A rare case of progressive multifocal leukoencephalopathy – As a presenting manifestation of AIDS

Progressive multifocal leukoencephalopathy (PML) is a fatal demyelinating central nervous system (CNS) infection disease that exclusively affects immunocompromised individuals. John Cunningham virus, the etiologic agent for PML, is ubiquitous in the general population but rarely causes disease in immunocompetent hosts. Here, we present a 35-year-old male with left hemiparesis and loss of vision, diagnosed as PML as the first AIDS-defining event, with previously undiagnosed human immunodeficiency virus (HIV) infection. PML is an underinvestigated CNS infection seen in HIV patients usually with advanced disease. We present an unusual case report, where PML occurred as the first AIDS-defining event in a patient with previously undiagnosed HIV infection. This case is presented to enlighten the physicians regarding the clinical entity of PML to be suspected in HIV-infected patients who present with focal neurologic deficits even in undiagnosed infection.

Clinical manifestations leading to a diagnosis of human immunodeficiency virus infection: a case report

Background In the United States, of the approximately 1.1 million people age 13 years and older living with human immunodeficiency virus (HIV) infection, an estimated 162,500 remain undiagnosed. Numerous clinical manifestations of HIV infection have been reported, but these have declined in prevalence since the advent of highly active antiretroviral therapy. Here, we present a case of a previously undiagnosed patient presenting with multiple supportive clinical manifestations that led to a confirmed diagnosis of HIV infection. Case Summary A 22-year-old male was referred to the Missouri School of Dentistry & Oral Health, A.T. Still University, with the chief complaint of a 6-month history of painful gingivae. Intraoral examination revealed ulcerated, hemorrhagic, and necrotic gingivae, with blunted papillae, associated bone loss, and fetid odor consistent with necrotizing ulcerative periodontitis (NUP). Extraoral examination revealed fingernail hyperpigmentation, cervical lymphadenopathy, and multiple smooth-surfaced, sessile, umbilicated papules of the mid-face area, suggestive of molluscum contagiosum. Biopsy of the skin lesions and histopathology confirmed the clinical impression. Despite the patient's denial of high-risk behaviors, undiagnosed HIV infection was suspected, given the combination of extra- and intraoral manifestations. The patient was prescribed chlorhexidine, metronidazole, and penicillin for NUP and advised to present to his physician the same day for HIV testing. At follow-up, intraoral examination revealed pseudomembranous candidiasis and resolving NUP lesions. When presented with the suggestive clinical findings and upon further questioning regarding his sexual history, the patient reported unprotected sexual intercourse with an HIV-positive partner 2 years earlier. Consequently, the patient was referred for rapid HIV testing at a local infectious diseases clinic, and the results came back positive for HIV infection. Conclusions This case demonstrates some of the various intraoral and extraoral presentations of HIV infection, including NUP, fingernail hyperpigmentation, cervical lymphadenopathy, molluscum contagiosum, and pseudomembranous candidiasis. Although the patient's chief complaint was painful gingivae, the presence of other lesions led to a suspected, and later confirmed, diagnosis of HIV infection. Therefore, it is important that clinicians know the various manifestations of HIV infection, especially in patients who are undiagnosed. The possibility of undiagnosed HIV infection should be suspected, and a referral for appropriate testing should be made.

Epidemiological Impact of Expedited Partner Therapy for Men Who Have Sex With Men: A Modeling Study.

Expedited partner therapy (EPT) is an intervention for patients with gonorrhea or chlamydia, providing index patients with prescriptions or medication to give to their partners. Expedited partner therapy is recommended for heterosexuals but not for men who have sex with men (MSM), partially due to concerns about overtreatment of uninfected partners and missed opportunities for human immunodeficiency virus (HIV) diagnosis. We extended our stochastic network-based mathematical model of HIV, gonorrhea, and chlamydia among MSM to include EPT. The EPT implementation was simulated for 10 years. Counterfactual scenarios varied EPT coverage, provision, uptake, and partnership window duration. We estimated sexually transmitted infection (STI) incidence, proportion of infections averted, and process outcomes under each scenario. Delivery of EPT to 20% of eligible MSM index patients (coverage) reduced cumulative STI incidence by 27% (interquartile range, 13%-39%) over 10 years compared with current estimated STI screening levels. A 20% increase in providing medication to non-index partners (provision) averted 32% (interquartile range, 20%-41%) of STI infections compared with estimated STI screening levels. When targeted by partnership type, EPT solely to casual partners maximized the population-level infections averted. The proportion of partners given medication who had no current STI varied from 52% to 63%, depending on coverage level. The proportion of partners given medication with undiagnosed HIV infection was 4% across scenarios. Expedited partner therapy could reduce bacterial STI incidence for MSM. However, this intervention could result in missed opportunities for HIV/STI prevention and a substantial increase in use of antimicrobials by STI-uninfected MSM, raising concerns about cost and antimicrobial resistance.

Prevalence and route of transmission of undiagnosed human immunodeficiency virus infection among children using provider-initiated testing and counselling strategy in Ido-Ekiti, Nigeria: a cross-sectional study.

IntroductionNinety-one percent of global Human Immunodeficiency Virus (HIV) infection in children occurs in sub-Saharan Africa. Provider Initiated Testing and Counselling (PITC) Strategy is a means of reducing missed opportunities for HIV exposed or infected children. The present study determined the prevalence of HIV infection using PITC Strategy among children seen at the Paediatric Emergency Unit of Federal Medical Centre (FMC), Ido-Ekiti, and the possible route of transmission.MethodsCross-sectional study on prevalence of HIV infection using PITC model. 530 new patients whose HIV serostatus were unknown and aged 15 years or below were recruited consecutively and offered HIV testing. Serial algorithm testing for HIV infection using Determine HIV-1/2 and Uni-Gold rapid test kits was adopted. Seropositive patients younger than eighteen months had HIV Deoxyribonucleic Acid Polymerase Chain Reaction (HIV DNA PCR) test for confirmation.ResultsTwenty-four (4.5%) of the 530 patients were confirmed to have HIV infection; of whom 19 (79.2%) were less than 18 months of old; with age range of 5 to 156 months. Fifteen (62.5%) of the infected children were females; likewise, the gender specific infection rate was higher (%) among the females compared with (%) among the males. Two of the HIV infected children’s mothers were late, while the remaining 22 mothers (%) were HIV seropositive. Mother-to-child-transmission was the most likely route of transmission in the children.ConclusionPITC strategy is vital to the early diagnosis and effective control of HIV infection in children. However, this cannot be totally effective if PMTCT is not optimized.

Drug Resistance During HIV Pre-Exposure Prophylaxis.

Clinical studies have demonstrated that use of tenofovir disoproxil fumarate with or without emtricitabine as antiretroviral pre-exposure prophylaxis (PrEP) can decrease the risk of human immunodeficiency virus (HIV) acquisition when medication adherence is high. However, the potential for PrEP to promote antiretroviral resistance remains an important public health consideration. We performed a search of the medical literature to identify studies that address HIV drug resistance during PrEP use. In this review, we summarize findings about emergent drug resistance during clinical trials of PrEP, case reports of seroconversions in patients adherent to PrEP, and animal studies of PrEP effectiveness against drug-resistant viral strains. We also discuss the potential utility of novel PrEP formulations for protection against drug-resistant HIV, the impact of drug resistance on HIV treatment options, and mathematical models that estimate the potential contribution of PrEP to population-level drug resistance. Evidence suggests that selection for HIV drug resistance with PrEP use is infrequent and most likely to occur when PrEP is used during undiagnosed acute HIV infection. Breakthrough infections during PrEP use with high adherence are possible, but appear to be rare. The prevalence of drug-resistant HIV strains needs to be monitored as PrEP is scaled up. However, the benefit of a decreased HIV incidence with wider PrEP use is likely to outweigh the risk of harms from possible increases in the prevalence of HIV drug resistance.

181 Clinical Knowledge of Human Immunodeficiency Virus Among Emergency Providers at Two Level 1 Trauma Centers in Cleveland, Ohio

Emergency departments (ED) are targeted areas for prevention and diagnosis of early human immunodeficiency virus (HIV) and sexually transmitted infections (STI) given increased prevalence in this setting. Clinical knowledge and recognition of these diseases is required for identifying those at risk. Previous studies show that STI knowledge is sup-optimal among general practitioners, and acute HIV infection is frequently misdiagnosed in the ED. The purpose of this study was to assess the correlation between self-reported STI knowledge and HIV test ordering practices among emergency medicine providers in a survey study of simulated scenarios. We modified 2 surveys previously published in the literature that assess knowledge of acute HIV infection and STIs. The survey was divided into 2 sections: a 29-point score for STIs and a 10-point score for HIV. This modified survey was administered to all emergency physicians, residents, and advanced practice providers affiliated with 2 level 1 trauma centers in Cleveland, Ohio. The primary outcome of ordering an HIV test was analyzed using Spearman’s correlation coefficient (SC) to assess strength of correlation with STI knowledge. Subgroup analyses were conducted using SC and ANOVA. This study was powered to estimate the SC using an effect size of 0.3 at an alpha of 0.05 for 90% power requiring a sample size of 90 respondents. A total of 75 providers (31.3%) completed the survey. Respondents were primarily physicians (54.6%), male (56%), white (83.7%), with a median of 8 years in practice (IQR: 2,16). The majority of respondents (57%) report formal HIV training as part of their professional education. Spearman’s correlation of HIV and STIs showed a monotonic relationship with a weak positive correlation (r = 0.3513, p = 0.002). A similar analysis comparing length of time as an emergency medicine provider with HIV and STI scores was monotonic with a weak negative correlation that was not statistically significant. There was no association between HIV scores and provider type (p=0.67) or provider sex (p=0.89); however, those with formal HIV training scored higher than those without formal HIV training (p=0.003). There was no association between STI scores and provider type (p=0.10) or provider sex (p=0.79). The movement in emergency medicine to screen patients at risk of undiagnosed HIV focuses on universal or targeted screening. The results of our study reveal that when presented with a patient at high-risk for undiagnosed HIV or with undiagnosed symptomatic HIV infection, most providers either do not screen or do not have HIV in the differential diagnosis. Similarly, knowledge of STIs is only weakly correlated with knowledge of HIV risk factors and symptomatic HIV infection. Further research and screening efforts may benefit by focusing on HIV education among EM providers.

Weight loss might be an early clinical feature of undiagnosed human immunodeficiency virus infection in Taiwan.

Background/Objective: Little research is available on the relationship between weight loss and human immunodeficiency virus (HIV) infection in Taiwan. We hope to evaluate whether weight loss could be an early clinical feature of undiagnosed HIV infection in Taiwan.Methods: We conducted a retrospective population-based cohort study using the database of the Taiwan National Health Insurance (NHI) Program. There were 4748 male subjects aged 1-84 with newly diagnosed weight loss as the weight loss group from 1998-2012 and 18982 age-matched male subjects without weight loss as the non-weight loss group. The incidence of HIV infection at the end of 2013 was measured in both groups. The multivariable Cox proportional hazards regression model was used to measure the hazard ratio (HR) and 95% confidence interval (CI) for HIV risk associated with weight loss.Results: The overall incidence of HIV infection was 3.79-fold higher in the weight loss group than in the non-weight loss group (6.83 vs. 1.80 per 10000 person-years, 95% CI 3.41, 4.21). The incidence was the highest during the first 6 months of follow-up in the weight loss group (39.0 per 10000 person-years). After adjusting for confounding factors, the adjusted HR of HIV infection was 3.63 (95% CI 1.77, 7.44) for the weight loss group, compared with the non-weight loss group.Conclusion: Weight loss might be an early clinical feature of undiagnosed HIV infection in Taiwan. Male patients with weight loss who have risk factors for HIV infection should be recommended to regularly be tested for HIV infection.

Expanding Hospital Human Immunodeficiency Virus Testing in the Bronx, New York and Washington, District of Columbia: Results From the HPTN 065 Study.

Human immunodeficiency virus (HIV) testing is critical for both HIV treatment and prevention. Expanding testing in hospital settings can identify undiagnosed HIV infections. To evaluate the feasibility of universally offering HIV testing during emergency department (ED) visits and inpatient admissions, 9 hospitals in the Bronx, New York and 7 in Washington, District of Columbia (DC) undertook efforts to offer HIV testing routinely. Outcomes included the percentage of encounters with an HIV test, the change from year 1 to year 3, and the percentages of tests that were HIV-positive and new diagnoses. From 1 February 2011 to 31 January 2014, HIV tests were conducted during 6.5% of 1621016 ED visits and 13.0% of 361745 inpatient admissions in Bronx hospitals and 13.8% of 729172 ED visits and 22.0% of 150655 inpatient admissions in DC. From year 1 to year 3, testing was stable in the Bronx (ED visits: 6.6% to 6.9%; inpatient admissions: 13.0% to 13.6%), but increased in DC (ED visits: 11.9% to 15.8%; inpatient admissions: 19.0% to 23.9%). In the Bronx, 0.4% (408) of ED HIV tests were positive and 0.3% (277) were new diagnoses; 1.8% (828) of inpatient tests were positive and 0.5% (244) were new diagnoses. In DC, 0.6% (618) of ED tests were positive and 0.4% (404) were new diagnoses; 4.9% (1349) of inpatient tests were positive and 0.7% (189) were new diagnoses. Hospitals consistently identified previously undiagnosed HIV infections, but universal offer of HIV testing proved elusive.

HIV Testing and Positivity Patterns of Partners of HIV-Diagnosed People in Partner Services Programs, United States, 2013-2014.

Human immunodeficiency virus (HIV) partner services are an integral part of comprehensive HIV prevention programs. We examined the patterns of HIV testing and positivity among partners of HIV-diagnosed people who participated in partner services programs in CDC-funded state and local health departments. We analyzed data on 21 484 partners submitted in 2013-2014 by 55 health departments. We conducted descriptive and multivariate analyses to examine patterns of HIV testing and positivity by demographic characteristics and geographic region. Of 21 484 partners, 16 275 (75.8%) were tested for HIV; 4503 of 12 886 (34.9%) partners with test results were identified as newly HIV-positive. Compared with partners aged 13-24, partners aged 35-44 were less likely to be tested for HIV (adjusted odds ratio [aOR] = 0.86; 95% confidence interval [CI], 0.78-0.95) and more likely to be HIV-positive (aOR = 1.35; 95% CI, 1.20-1.52). Partners who were male (aOR = 0.89; 95% CI, 0.81-0.97) and non-Hispanic black (aOR = 0.68; 95% CI, 0.63-0.74) were less likely to be tested but more likely to be HIV-positive (male aOR = 1.81; 95% CI, 1.64-2.01; non-Hispanic black aOR = 1.52; 95% CI, 1.38-1.66) than partners who were female and non-Hispanic white, respectively. Partners in the South were more likely than partners in the Midwest to be tested for HIV (aOR = 1.56; 95% CI, 1.35-1.80) and to be HIV-positive (aOR = 2.18; 95% CI, 1.81-2.65). Partner services programs implemented by CDC-funded health departments are successful in providing HIV testing services and identifying previously undiagnosed HIV infections among partners of HIV-diagnosed people. Demographic and regional differences suggest the need to tailor these programs to address unique needs of the target populations.

Rapid Decline in HIV Incidence Among Persons Who Inject Drugs During a Fast-Track Combination Prevention Program After an HIV Outbreak in Athens.

A "seek-test-treat" intervention (ARISTOTLE) was implemented in response to an outbreak of human immunodeficiency virus (HIV) infection among persons who inject drugs (PWID) in Athens. We assess trends in HIV incidence, prevalence, risk behaviors and access to prevention/treatment. Methods included behavioral data collection, provision of injection equipment, HIV testing, linkage to opioid substitution treatment (OST) programs and HIV care during 5 rounds of respondent-driven sampling (2012-2013). HIV incidence was estimated from observed seroconversions. Estimated coverage of the target population was 88% (71%-100%; 7113 questionnaires/blood samples from 3320 PWID). The prevalence of HIV infection was 16.5%. The incidence per 100 person-years decreased from 7.8 (95% confidence interval, 4.6-13.1) (2012) to 1.7 (0.55-5.31) (2013; P for trend = .001). Risk factors for seroconversion were frequency of injection, homelessness, and history of imprisonment. Injection at least once daily declined from 45.2% to 18.8% (P < .001) and from 36.8% to 26.0% (P = .007) for sharing syringes, and the proportion of undiagnosed HIV infection declined from 84.3% to 15.0% (P < .001). Current OST increased from 12.2% to 27.7% (P < .001), and 48.4% of unlinked seropositive participants were linked to HIV care through 2013. Repeat participants reported higher rates of adequate syringe coverage, linkage to HIV care and OST. Multiple evidence-based interventions delivered through rapid recruitment in a large proportion of the population of PWID are likely to have helped mitigate this HIV outbreak.

How Underestimates of Need Contribute to Biased Conclusions.

How Underestimates of Need Contribute to Biased Conclusions.