HIV counseling procedures, which are delivered during HIV testing, provide information about HIV risk behaviors.1 The information provided during HIV counseling has been found to reduce risk behaviors in many recipients.2–6 However, evidence suggests that certain risk groups will continue risk behaviors after HIV diagnosis, despite the messages delivered during HIV counseling.7 Previous studies have noted that sexually transmitted disease (STD) infection following an HIV diagnosis, or “STD coinfection,” can serve as a surrogate indicator of continued sexual risk behaviors.8
This study was a retrospective cohort study of data extracted from the STD-MIS system of the Baltimore City Health Department (BCHD) Bureau of STD/HIV Prevention. The public health records from STD-MIS were examined for the period 2004–2008. Individuals were eligible for inclusion in this study if they were reported to the BCHD as having tested HIV-positive by Western Blot analysis for the first time in 2004. The records of this cohort were examined through 2008 for evidence of coinfection with an STD.
Laboratory data were reported to BCHD from private medical providers and public clinics in Baltimore City and entered into the STD-MIS system. Incident cases of disease were identified from positive Western Blot tests (for HIV) and Nucleic Acid Amplification tests (for gonorrhea and chlamydia). Early syphilis was defined as primary, secondary, or early latent syphilis. Incident cases of primary and secondary syphilis were diagnosed clinically, while early latent syphilis was diagnosed as: (a) a negative syphilis test in the previous year or a 4-fold increase in Rapid Plasma Reagin titer over the previous year; (b) symptoms of primary or secondary syphilis in the previous year; or (c) exposure to a partner with primary, secondary or confirmed early latent syphilis in the past year. STD coinfection was defined as a case of gonorrhea, chlamydia, or early syphilis occurring 30 days or more after HIV diagnosis, a time period that would exclude undiagnosed STDs that were already present at the time of HIV diagnosis. (A limitation to this definition of coinfection is that early latent syphilis may have existed for a period of up to 1 year before diagnosis. However, since early latent syphilis may have been a new infection during the study period, it was included in this analysis). Evidence of coinfection was examined through the end of 2008. STD reinfection was defined as a unique occurrence of STD infection following a previous STD infection.
Risk behavior information was collected through interviews conducted by BCHD staff during clinical visits and field investigations associated with each patient's HIV diagnosis and/or STD diagnoses. Patients were asked about risk behaviors that took place during the 12 months before their HIV or STD diagnosis.
Risk groups that were examined included men who have sex with men (MSM), commercial sex work (CSW), intravenous drug use (IDU), nonintravenous drug use, and high risk heterosexual behavior. The CSW risk group included individuals who received drugs, money, or property for sex, as well as those who gave drugs, money or property for sex. Included in the nonintravenous drug use group were individuals who reported using alcohol, noninjection cocaine, crack, ecstasy, marijuana, methamphetamines, or nitrates. The high risk heterosexual risk group included heterosexual individuals who reported never having used condoms, having used condoms on an infrequent basis, having sex with a person known to be HIV-positive, or having sex with a person known to be an intravenous drug user. These risk groups were not mutually exclusive, so each patient could be a member of more than 1 risk group (for example, an individual reporting MSM and CSW would be recorded in each category). Finally, mean age was calculated based on the age recorded at the time of HIV diagnosis.
Risk data were not available for all individuals in this cohort. Coinfected individuals tended to have more risk information than noncoinfected individuals because their additional STD diagnosis provided an additional opportunity to collect these data. Risk information was available for 88.7% of coinfected individuals, and 71.7% of noncoinfected individuals.
Logistic regression models were constructed using risk factors of interest (Table 1) and “age under 25 years” as predictor variables. The odds ratios were adjusted for age, except for the variable “age under 25 years.” Statistical significance was judged using α = 0.05, and association between predictor variables was evaluated using a χ2 test. All statistical analyses were conducted using Stata Version 10 (published by StataCorp, College Station, TX).
There were 424 incident cases of HIV in 2004. Of these, 53 individuals (12.5%) had an STD coinfection following their HIV diagnoses (Table 1). Of the coinfected individuals, 84.9% received post-test counseling, 92.5% were black, and 67.9% were tested for HIV in a public STD clinic. Of all coinfections, 31 (58.5%) were gonorrhea, 14 (26.4%) were syphilis, and 8 (15.1%) were chlamydia. The predictor variables that were statistically significantly associated with coinfection were (1) MSM, (2) CSW, and (3) age under 25 years (Table 1).
It was found that many coinfected individuals were becoming “reinfected” over the 5-year follow-up period. These individuals were infected more than once with an STD following their HIV diagnosis. Of the 53 coinfected individuals, 22 had more than 1 occurrence of STD infection during follow-up. These reinfected individuals had a mean age of 26.0 years, 40.9% reported MSM risk behavior, 27.3% reported high-risk heterosexual behavior, 100% were black, and 82.2% tested for HIV at public STD clinics. The mean time between STD infections among reinfected individuals was 16 months. The 22 reinfected individuals had a total of 62 unique diagnoses of STD infection, including 32 occurrences of gonorrhea, 18 of chlamydia, and 12 of early syphilis. The burden of STD coinfection was so concentrated in these reinfected individuals that they accounted for 66.7% of STD coinfection among this cohort. Of note, 1 person had 7 STD reinfections during follow-up, and 2 people had 5 STD reinfections each during follow-up.
The STD coinfection that was identified in this study suggests that sexual risk behaviors continued after HIV diagnosis in individuals who reported MSM and CSW risk behaviors. STD reinfection data suggest that African-American MSM under age 25 continued risk behaviors after HIV diagnosis and after a subsequent STD diagnosis. Thus, the continued sexual risk behaviors that lead to the spread of HIV and STDs were concentrated in a small group of individuals who were primarily young African-American MSM. Behavior change messages that were delivered during HIV counseling and testing did not prevent young African-American MSM from continuing sexual risk behaviors. Future studies should examine novel approaches to changing risk behaviors in this subgroup.
Current Baltimore City interventions to prevent STD coinfection among HIV-positive individuals (and thereby prevent the further spread of HIV) include condom distribution, social marketing of HIV prevention messages, and a variety of educational programs. This study reflects the need for continued STD testing and prevention counseling among HIV-positive individuals, particularly in public STD clinics which serve a generally higher-risk population.
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