To describe the epidemiology of people coinfected with hepatitis B virus (HBV) or hepatitis C virus (HCV) and HIV in San Francisco, the San Francisco Department of Public Health's Communicable Disease Control and Prevention Section and the HIV Epidemiology Section collaborated to link their registries.
In this article, we describe the San Francisco Department of Public Health's (SFDPH's) framework for developing evidence-based screening and vaccination recommendations. We first reviewed our local data using surveillance and syndemic data. We then compiled and compared existing federal, state, and local recommendations. Then we identified differences as compared with our local evidence; where more evidence was required to make a recommendation, we culled from additional data sources and conducted additional analyses. Lastly, we developed our guidelines by confirming existing recommendations or making new recommendations based on this process. In the end, we successfully developed evidence-based clinical screening and prevention guidelines that have been adopted by the SFDPH Health Commission. We encourage the use of this framework in other public health settings at the local level.
The San Francisco Department of Public Health (SFDPH) has the goal of offering HIV partner services (PS) to all individuals newly diagnosed with HIV in San Francisco. However, measuring the potential impact of these services is challenging. Building on an existing syphilis partner notification program, we developed a framework for expanding and monitoring HIV PS in San Francisco.
In 2010, the San Francisco Department of Public Health offered antiretroviral therapy (ART) to all its patients with human immunodeficiency virus (HIV) regardless of CD4 count. We assessed trends in time from diagnosis to ART initiation and factors associated with ART initiation among San Francisco residents living with HIV between 2007 and 2011. Time to ART initiation decreased among those diagnosed with higher CD4 count. ART initiation rate was significantly higher in recent years and lower among African Americans, men who have sex with men who also inject drugs, and persons aged ?50 years. We found a trend toward early treatment. However, racial and social disparities persist.
We use HIV testing history of persons newly diagnosed with HIV through HIV partner services to identify persons who might not otherwise have tested. Seventeen percent had never been tested, 44% had not been tested in the previous 2 years, and none had been tested routinely. These data demonstrate that HIV partner services were successful in reaching persons who may not have initiated testing without this service.
Accurate estimates of HIV incidence are crucial for prioritizing, targeting, and evaluating HIV prevention efforts. Using the methodology the CDC used to estimate national HIV incidence, we estimated HIV incidence in Los Angeles County (LAC), San Francisco (SF), and Californias remaining counties.
In San Francisco, men who have sex with men (MSM) have historically comprised 90% of the HIV epidemic. It has been suggested that given the ongoing HIV transmission among this population, there is the possibility of a high-level endemic of HIV into the future. We report on the possibility of another phase in the HIV epidemic among MSM in San Francisco.
People aged 50 and older are an increasing proportion of the population of persons living with AIDS (PLWA) in the USA. We used San Franciscos population-based HIV/AIDS surveillance registry to examine trends in the age distribution of people diagnosed and living with AIDS in San Francisco, California. AIDS case reporting is highly complete. Death ascertainment is complete through 2009 and 95% complete for 2010. At the end of 2010, 9796 persons were living with AIDS in San Francisco. Of these, more than half (5112 or 52%) were 50-years old or older. This proportion has steadily increased since 1990 in San Francisco. Our data also indicate that age at AIDS diagnosis has increased in San Francisco during the years 1990-2010. The proportion of PLWA who are aged 50 years or older is now a majority among PLWA in San Francisco. We believe that San Francisco is the first local jurisdiction in the USA to reach this milestone. The growing population of older persons with AIDS presents new challenges for research, medical care and support services.
We used data from HIV/AIDS surveillance case registry to assess the timing of entry into medical care, level of care received after HIV diagnosis, and to identify characteristics associated with delayed and insufficient care among persons diagnosed with HIV/AIDS between 2006 and 2007 in San Francisco. Laboratory reports of HIV viral load and CD4 test results were used as a marker for receipt of medical care. The time from HIV diagnosis to entry into care was estimated using Kaplan-Meier product limit method and independent predictors of delayed entry into care were determined using the proportional hazards model. Insufficient care was defined as less than an average of two viral load/CD4 tests per person-year of follow-up. Predictors of insufficient care were evaluated using a logistic regression model. An estimated 85% of persons diagnosed with HIV/AIDS entered care within three months after HIV diagnosis; the proportion increased to 95% within 12 months after diagnosis. Persons who were born outside of the USA and those tested at the public counseling and testing sites were more likely to delay care. Nineteen percent of persons were determined to have received insufficient care. Younger persons and those diagnosed at a hospital were more likely to receive insufficient care. A high proportion of persons diagnosed with HIV/AIDS in San Francisco established timely and adequate care after HIV diagnosis. However, delays for some individuals in entry into care and markers of insufficient care suggest that there remains a need to improve access to and sustainability of HIV-specific medical care.
At the individual level, higher HIV viral load predicts sexual transmission risk. We evaluated San Franciscos community viral load (CVL) as a population level marker of HIV transmission risk. We hypothesized that the decrease in CVL in San Francisco from 2004-2008, corresponding with increased rates of HIV testing, antiretroviral therapy (ART) coverage and effectiveness, and population-level virologic suppression, would be associated with a reduction in new HIV infections.
The Centers for Disease Control and Prevention recently released the first direct national estimate of HIV incidence. Local jurisdictions have begun to apply this methodology. The national and local estimates have been higher than assumed. When applied to San Francisco, there were 935 new HIV infections [95% confidence interval (CI) 658-1212] during 2006. We compared this incidence estimate to an estimate produced in San Francisco in 2006 by a panel of HIV researchers using an iterative Delphi method. Results were similar. Further corroboration of the new method in local areas would strengthen interpretation and identify HIV risk variations.
Linkage to care after HIV diagnosis is associated with both clinical and public health benefits. However, ensuring and monitoring linkage to care by public health departments has proved to be a difficult task. Here, we report the usefulness of routine monitoring of CD4 T cell counts and plasma HIV viral load as measures of entry into care after HIV diagnosis.
The Medical Monitoring Project (MMP) is a national, multi-site population-based supplemental HIV/AIDS surveillance project of persons receiving HIV/AIDS care. We compared California MMP data by region. Demographic characteristics, medical care experiences, HIV treatment, clinical care outcomes, and need for support services are described.
The increased life expectancy and well-being of HIV-infected persons presents the need for effective prevention methods in this population. Personalized cognitive counseling (PCC) has been shown to reduce unprotected anal intercourse (UAI) with a partner of unknown or different serostatus among HIV-uninfected men who have sex with men (MSM). We adapted PCC for use among HIV-infected MSM and tested its efficacy against standard risk-reduction counseling in a randomized clinical trial in San Francisco. Between November 2006 and April 2010, a total of 374 HIV-infected MSM who reported UAI with two or more men of negative or unknown HIV serostatus in the previous 6 months were randomized to two sessions of PCC or standard counseling 6 months apart. The primary outcome was the number of episodes of UAI with a non-primary male partner of different or unknown serostatus in the past 90 days, measured at baseline, 6, and 12 months. Surveys assessed participant satisfaction with the counseling. The mean number of episodes of UAI at baseline did not differ between PCC and control groups (2.97 and 3.14, respectively; p=0.82). The mean number of UAI episodes declined in both groups at 6 months, declined further in the PCC group at 12 months, while increasing to baseline levels among controls; these differences were not statistically significant. Episode mean ratios were 0.76 (95% confidence interval [CI] 0.25-2.19, p=0.71) at 6 months and 0.48 (95% CI 0.12-1.84, p=0.34) at 12 months. Participants in both groups reported a high degree of satisfaction with the counseling. The findings from this randomized trial do not support the efficacy of a two-session PCC intervention at reducing UAI among HIV-infected MSM and indicate the continued need to identify and implement effective prevention methods in this population.
AIDS-related primary central nervous system lymphoma (AR-PCNSL) has a poor prognosis. Improved understanding of specific patient, infectious, diagnostic, and treatment-related factors that affect overall survival (OS) are required to improve outcomes.
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