In the context of adolescent health disparities prevention, this approach may be especially useful for identifying and/or implementing asset-based and youth-led interventions.For example, researchers could directly partner with teachers, service providers, parents, and transgender adolescents of color to gather insights based on survey data and in-depth interviews or focus groups into the individual, interpersonal, and contextual factors that influence adolescent vaping. Indeed, research has found that supportive school, community-based, and family contexts may buffer against substance use and support well-being among transgender adolescents– MM-CBPR is well-suited to examine these influences and identify multiple levers for intervention. There is also a need to examine gender identity disparities in adolescent vaping and co-use of tobacco products, such as combustible cigarettes. While explorations of vaping alone are important given recent increases in vaping prevalence, examinations of co-use and the health effects of co-use relative to vaping alone should be prioritized for prevention planning. Universal HIV testing is a cornerstone in efforts to achieve epidemic control as HIV-infected and unaware people are associated with the majority of HIV transmission events. In particular, during acute and early HIV infection , people who are unaware of their HIV status represent a subgroup with a disproportionate risk of HIV transmission due to high HIV viral loads, ongoing sexual risk behaviors and greater per-contact infectivity. The CDC recommends provision of confidential partner services to provide HIV risk reduction education and HIV testing to the recent sex or needle-sharing partners of newly HIV diagnosed people. By linking recently exposed persons to testing and treatment, this public health intervention has been used to limit the spread of sexually transmitted infections ,dry rack cannabis such as syphilis and gonorrhea, since the early 20th century. In the setting of HIV, however, partner services has had its limitations.
In 2006, Katz et al.estimated that fewer than half of newly HIV-diagnosed persons received partner services at public health departments across the United States. Reasons include that partner services is not mandated by law for HIV infection and more importantly that HIV remains a highly stigmatizing condition with significant implications for direct or indirect disclosure. Not only is partner services underutilized, but it can be limited in finding HIV unawares in the setting of newly diagnosed chronic HIV infection in which persons are often required to recall partners from several years prior. In 2007, the Task Force on Community Preventive Services, in reviewing the efficacy of partner services, showed that 20% of all referred partners were newly diagnosed with HIV. Persons with AEH likely represent a group particularly appropriate for partner services, as recall of recent sexual or needle-sharing partners may be more likely to identify putative transmission partners . Studies of partner services in the setting of recent HIV infection are limited, but demonstrate a greater yield of new HIV diagnoses in the setting of newly diagnosed acute HIV infection as compared with partner services provided to chronically HIV-infected persons. We examined the yield of HIV partner services provided to persons newly diagnosed with AEH in San Diego for identification of HIV-unaware persons, individuals with AEH, genetically linked partners and HIV-uninfected individuals at high risk for acquiring HIV infection.Adults and adolescents were offered confidential and free-of-charge screening for acute, early and established HIV infection at multiple community-based sites in San Diego as part of the San Diego Primary Infection Resource Consortium from 1996 to 2014. Before 2007, a quantitative HIV RNA was performed in HIV antibody–negative persons presenting with signs or symptoms of AEH and behavioral risks for HIV infection . Beginning in 2007, HIV nucleic acid testing was provided to all HIV antibody–negative persons regardless of symptoms and exposures. AHI was defined by a negative or indeterminate HIV antibody test in the presence of detectable HIV-1 RNA, corresponding to Fiebig stages I–II. Consenting antiretroviral -naive individuals with AEH were offered enrollment and longitudinal follow-up in the observational SD PIRC study.Routine clinical laboratories and HIV drug resistance testing were performed at baseline; demographic and behavioral risk data were collected for all individuals.
Longitudinal follow-up included visits at weeks 2, 4, 8, 12 and every 24 weeks thereafter. HIV partner services were offered to all AEH clients and included education and counseling to elicit information about recent sex or needle-sharing partners. Index cases were offered ‘self-disclosure’ , ‘dual-disclosure’ and ‘third-party notification’ for recruiting their recent sex or needle-sharing contacts. Study staff providing partner services received structured partner services training by the California Department of Public Health or Centers for Disease Control and Prevention. These structured trainings were repeated by our study staff every 5 years. The trainings included how to elicit partners from index cases, including prompts and reinterviews, and delivering exposure notifications to partners. Privacy concerns were taken very seriously, in particular when an index case chose third-party notification . Partners successfully contacted were offered free-of-charge HIV testing and counseling through SD PIRC or a testing facility of their choice and linkage to prevention and treatment services. Those with positive HIV test results who reported unknown or negative HIV serostatus before HIV testing were defined as newly HIV diagnosed, whereas those who reported positive serostatus or found to have been diagnosed previously were defined as previously diagnosed. All recruited partners who underwent HIV testing and counseling with the SD PIRC provided behavioral risk information, and recruited partners identified with AEH were also offered enrollment into SD PIRC as index clients . Partnerships were characterized as genetically linked if the HIV population sequence from an index case and their recruited partner were less than or equal to 1.5% genetically different using the Tamura-Nei model. The study focused on sex or needle sharing partners recruited within 6 months of diagnosis of the index case. Statistical analysis was performed using SPSS version 22 and SAS 9.3 . The efficacy of partner services provided to AEH clients was assessed by the number of index cases needed to interview to identify recruited partners: for HIV/STI testing, newly diagnosed with HIV infection, AEH infection and genetically linked index and recruited partners. We compared demographic and behavioral characteristics between HIV-infected and HIV uninfected recruited partners by using two-tailed t tests and two-tailed x2 analyses.
Because both index and recruited partners were occasionally represented in multiple different partnerships, mixed-effects logistic modeling was performed for genetic linkage and new HIV diagnoses. The UCSD Human Research Protections Program approved the study protocol, consent and all study related procedures. All study participants provided voluntary,roll bench written informed consent before any study procedures were undertaken.A total of 574 ART-naive individuals were newly diagnosed with AEH and offered partner services between 1996 and 2014. Among those index clients, 107 provided contact information sufficient to successfully identify and test partner.These 107 index cases identified 119 recruited partners and 128 distinct partnerships . Only for two recruited partners, needle sharing was identified as the most likely mode of HIV transmission . There were nine individuals who served as both index case and recruited partner in distinct partnerships . Index case and recruited partner demographics were not significantly different. The majority of both, index cases and recruited partners were non-Hispanic white men , MSM . The median age of index cases and recruited partners was not significantly different . Behavioral risks were also not significantly different between AEH index cases and recruited partners . In addition, there were no significant demographic or behavioral risk differences between HIV infected and HIV-uninfected recruited partners except for age . Of the 128 distinct partnerships identified, were HIV serodiscordant, and the remaining 76 were HIV seroconcordant. Paired HIV resistance test sequences were available in 62 of 76 seroconcordant partnerships and demonstrated genetic linkage in 38 of these partnerships. Genetic linkage between the index case and recruited partner was used to identify putative transmission pairs and was observed in 50% of recruited partners with AEH and 50% of recruited partners with chronic HIV infection. Behavioral risks were not significantly different between index cases who were part of a genetic cluster and those who were not . Evaluation of the time between identification of the index case and recruited partners showed that those recruited partners enrolled within 30 days of their index were significantly more likely to be newly diagnosed with HIV and genetically linked to their index than partners identified later. The results were robust to whether partnerships were treated as independent or were corrected for belonging to multiple partnerships in the mixed-effects framework.We found that partner services for persons with AEH represents an effective tool to find HIV-unaware persons, particularly when partner services is performed within 30 days of diagnosis. Importantly, more than a third of the newly HIV-diagnosed recruited partners were still in the acute and early phases of HIV infection, that is the phase with the greatest risk of HIV transmission. Partner services also identified putative transmission partners, with genetically linked partners representing 61% of the seroconcordant partnerships. Finally, partner services identified a high-risk HIV-uninfected cohort, whose risk behaviors did not differ from those newly diagnosed with HIV infection. The HIV epidemic is propagated by HIV unawares, particularly during the phase of AEH. We demonstrated that HIV screening within the sexual contact network of persons diagnosed with AEH is an effective strategy to identify HIVunawares in early stages of HIV infection. In this study, one out of three recruited partners was newly diagnosed with HIV infection and one out of seven with AEH.
This was 12 times higher than the overall yield of voluntary community-based HIV screening of MSM with the SD PIRC , the HIV-screening program used to identify the index participants in this study. Also, the recruited partners identified in this study represented a more high-yield cohort than previously documented. In two prior studies of partner services in AHI,7–10% of all recruited partners identified were newly diagnosed with HIV, as compared with 33% in this study. Partner services might contribute to broader public health goals to end the epidemic. Although we found a decrease over time in the number of recruited partners , which may be explained in part by the success of anonymous, internet-based sexual networks, partner services continued to be high yield in terms of identifying HIV-positive individuals . Another key finding was that the immediacy of partner services was essential. Partners identified in the first 30 days of a new AEH diagnosis were more likely to yield a new HIV diagnosis and a putative transmission link to the index case . In addition, 29% of genetic linkages occurred in partnerships in which the recruited partner also had AEH, showing that partner services coupled with phylogenetic analysis could potentially be an effective tool in identifying and targeting real-time transmission outbreaks among AEH persons. The HIV-uninfected recruited partners in this study reported behavioral risks that were comparable with AEH-infected index cases. Because they belonged to the sexual network of an individual with high infectivity, and because their risk behaviors did not differ from HIV-infected recruited partners, this group may represent ideal candidates for focused HIV-prevention services, including preexposure prophylaxis . Limitations of this study included the observational study design and the convenience sampling used to identify the study cohort. Further, this study was performed among MSM and in San Diego, among whom the HIVepidemic may differ from other areas of the world. Despite the fact that new HIV diagnoses within this studies were based on laboratory findings, self-report , and also checked against local HIV clinical and research databases, we can’t rule out that a proportion of recruited partners classified as newly diagnosed may, in fact, have been diagnosed with HIV before. Also, our study participants identified fewer recruited partners when compared with two prior studies of partner services . This is most likely because field-services were not provided in this study, as compared with the two prior studies in which partner services was performed by the local public health departments. In conclusion, our study indicates that provision of partner services to persons with AEH within the first 30 days of diagnosis represents an effective tool for finding HIV-unaware persons, including those with AEH who are at greatest risk of HIV transmission. In addition, partner services in this setting identifies HIV-uninfected partners who may greatly benefit from targeted prevention services, such as PrEP.