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Reports conflict on how HIV infection influences the clinical course of COVID-19. The New York City (NYC) public hospital system provides care for over 14,000 people with HIV, was central in responding to the COVID-19 pandemic, and is therefore in a unique position to evaluate the intersection of these concurrent infections. Retrospective chart review of patients presenting to NYC Health and Hospitals (NYC H+H) diagnosed with COVID-19 infection from March 1, 2020, through April 28, 2020, compared people living with HIV (PLWH) and a propensity-matched (PM) control group of patients without HIV to evaluate associations between HIV status and COVID-19 outcomes. Two hundred thirty-four PLWH presented for COVID-19 testing and 110 (47%) were diagnosed with COVID-19. Among 17,413 patients with COVID-19 and without HIV, 1:n nearest neighbor propensity score matching identified 194 patients matched on age, sex, race, and any comorbidity. In the sample with COVID-19 ( N  = 304), PLWH (9.1%) had lower rates of mortality than controls [19.1%; PM odds ratio (PM-OR): 0.41, 95% confidence interval (CI): 0.19-0.86]. Among hospitalized COVID-19 patients ( N  = 179), HIV infection was associated with lower rates of mechanical ventilation (PM-OR: 0.31, 95% CI: 0.11-0.84) and mortality (PM-OR: 0.40, 95% CI: 0. 17-0.95). In the extended pandemic period through April 2021, aggregate data by HIV status suggested elevated hospitalization and mortality rates in PLWH versus people without HIV. These results suggest that the direct biological impacts of the HIV virus do not negatively influence COVID-19-related outcomes when controlling for comorbidity and demographic variables.

Background: Primary human papillomavirus (HPV) screening (PHS) utilizes oncogenic human papillomavirus (oncHPV) testing as the initial cervical cancer screening method and typically, if positive, additional reflex-triage (eg, HPV16/18-genotyping, Pap testing). While US guidelines support PHS usage in the general population, PHS has been little studied in women living with HIV (WLWH)., Methods: We enrolled n = 865 WLWH (323 from the Women's Interagency HIV Study [WIHS] and 542 from WIHS-affiliated colposcopy clinics). All participants underwent Pap and oncHPV testing, including HPV16/18-genotyping. WIHS WLWH who tested oncHPV[+] or had cytologic atypical squamous cells of undetermined significance or worse (ASC-US+) underwent colposcopy, as did a random 21% of WLWH who were oncHPV[-]/Pap[-] (controls). Most participants additionally underwent p16/Ki-67 immunocytochemistry., Results: Mean age was 46 years, median CD4 was 592 cells/µL, 95% used antiretroviral therapy. Seventy WLWH had histologically-determined cervical intraepithelial neoplasia grade 2 or greater (CIN-2+), of which 33 were defined as precancer (ie, [i] CIN-3+ or [ii] CIN-2 if concurrent with cytologic high grade squamous intraepithelial lesions [HSILs]). PHS had 87% sensitivity (Se) for precancer, 9% positive predictive value (PPV), and a 35% colposcopy referral rate (Colpo). "PHS with reflex HPV16/18-genotyping and Pap testing" had 84% Se, 16% PPV, 30% Colpo. PHS with only HPV16/18-genotyping had 24% Colpo. "Concurrent oncHPV and Pap Testing" (Co-Testing) had 91% Se, 12% PPV, 40% Colpo. p16/Ki-67 immunochemistry had the highest PPV, 20%, but 13% specimen inadequacy., Conclusions: PHS with reflex HPV16/18-genotyping had fewer unnecessary colposcopies and (if confirmed) could be a potential alternative to Co-Testing in WLWH., (© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Introduction: An estimated 25% of the 1.2 million individuals living with human immunodeficiency virus (HIV) in the U.S. are co-infected with hepatitis C (HCV). The Centers for Disease Control and Prevention recommends HCV testing for high-risk groups. Our goal was to measure the impact of bundled HIV and HCV testing vs. HIV testing alone on test acceptance and identification of HCV and HIV., Methods: We conducted a two-armed, randomized controlled trial on a convenience sample of 478 adult patients in the Jacobi Medical Center emergency department from December 2012 to May 2013. Participants were randomized to receive either an offer of bundled HIV/HCV testing or HIV testing alone. We compared the primary outcome, HIV test acceptance, between the two groups. Secondary outcomes included HIV and HCV prevalence, and HCV test acceptance, refusal, risk, and knowledge., Results: We found no significant difference in HIV test acceptance between the bundled HCV/HIV (91.8%) and HIV-only (90.6%) groups (p=0.642). There were also no significant differences in test acceptance based on gender, race, or ethnicity. A majority of participants (76.6%) reported at least one HCV risk factor. No participants tested positive for HIV, and one (0.5%) tested positive for HCV., Conclusion: Integrating bundled, rapid HCV/HIV testing into an established HIV testing program did not significantly impact HIV test acceptance. Future screening efforts for HCV could be integrated into current HIV testing models to target high-risk cohorts., Competing Interests: Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

Background/Aims HIV continues to be a major public health threat in the United States, and mathematical modeling has demonstrated that the universal effective use of antiretroviral therapy among all HIV-positive individuals (i.e. the "test and treat" approach) has the potential to control HIV. However, to accomplish this, all the steps that define the HIV care continuum must be achieved at high levels, including HIV testing and diagnosis, linkage to and retention in clinical care, antiretroviral medication initiation, and adherence to achieve and maintain viral suppression. The HPTN 065 (Test, Link-to-Care Plus Treat [TLC-Plus]) study was designed to determine the feasibility of the "test and treat" approach in the United States. Methods HPTN 065 was conducted in two intervention communities, Bronx, NY, and Washington, DC, along with four non-intervention communities, Chicago, IL; Houston, TX; Miami, FL; and Philadelphia, PA. The study consisted of five components: (1) exploring the feasibility of expanded HIV testing via social mobilization and the universal offer of testing in hospital settings, (2) evaluating the effectiveness of financial incentives to increase linkage to care, (3) evaluating the effectiveness of financial incentives to increase viral suppression, (4) evaluating the effectiveness of a computer-delivered intervention to decrease risk behavior in HIV-positive patients in healthcare settings, and (5) administering provider and patient surveys to assess knowledge and attitudes regarding the use of antiretroviral therapy for prevention and the use of financial incentives to improve health outcomes. The study used observational cohorts, cluster and individual randomization, and made novel use of the existing national HIV surveillance data infrastructure. All components were developed with input from a community advisory board, and pragmatic methods were used to implement and assess the outcomes for each study component. Results A total of 76 sites in Washington, DC, and the Bronx, NY, participated in the study: 37 HIV test sites, including 16 hospitals, and 39 HIV care sites. Between September 2010 and December 2014, all study components were successfully implemented at these sites and resulted in valid outcomes. Our pragmatic approach to the study design, implementation, and the assessment of study outcomes allowed the study to be conducted within established programmatic structures and processes. In addition, it was successfully layered on the ongoing standard of care and existing data infrastructure without disrupting health services. Conclusion The HPTN 065 study demonstrated the feasibility of implementing and evaluating a multi-component "test and treat" trial that included a large number of community sites and involved pragmatic approaches to study implementation and evaluation.

Importance: Achieving linkage to care and viral suppression in human immunodeficiency virus (HIV)-positive patients improves their well-being and prevents new infections. Current gaps in the HIV care continuum substantially limit such benefits., Objective: To evaluate the effectiveness of financial incentives on linkage to care and viral suppression in HIV-positive patients., Design, Setting, and Participants: A large community-based clinical trial that randomized 37 HIV test and 39 HIV care sites in the Bronx, New York, and Washington, DC, to financial incentives or standard of care., Interventions: Participants at financial incentive test sites who had positive test results for HIV received coupons redeemable for $125 cash-equivalent gift cards upon linkage to care. HIV-positive patients receiving antiretroviral therapy at financial incentive care sites received $70 gift cards quarterly, if virally suppressed., Main Outcomes and Measures: Linkage to care: proportion of HIV-positive persons at the test site who linked to care within 3 months, as indicated by CD4+ and/or viral load test results done at a care site. Viral suppression: proportion of established patients at HIV care sites with suppressed viral load (<400 copies/mL), assessed at each calendar quarter. Outcomes assessed through laboratory test results reported to the National HIV Surveillance System., Results: A total of 1061 coupons were dispensed for linkage to care at 18 financial incentive test sites and 39 359 gift cards were dispensed to 9641 HIV-positive patients eligible for gift cards at 17 financial incentive care sites. Financial incentives did not increase linkage to care (adjusted odds ratio, 1.10; 95% CI, 0.73-1.67; P = .65). However, financial incentives significantly increased viral suppression. The overall proportion of patients with viral suppression was 3.8% higher (95% CI, 0.7%-6.8%; P = .01) at financial incentive sites compared with standard of care sites. Among patients not previously consistently virally suppressed, the proportion virally suppressed was 4.9% higher (95% CI, 1.4%-8.5%; P = .007) at financial incentive sites. In addition, continuity in care was 8.7% higher (95% CI, 4.2%-13.2%; P < .001) at financial incentive sites., Conclusions and Relevance: Financial incentives, as used in this study (HPTN 065), significantly increased viral suppression and regular clinic attendance among HIV-positive patients in care. No effect was noted on linkage to care. Financial incentives offer promise for improving adherence to treatment and viral suppression among HIV-positive patients., Trial Registration: clinicaltrials.gov Identifier: NCT01152918.

Background: HPTN 065 (TLC-Plus) evaluated the feasibility and effectiveness of providing quarterly $70 gift card financial incentives to HIV-infected patients on antiretroviral therapy (ART) to encourage ART adherence and viral suppression, and represents the largest study to-date of a financial incentive intervention for HIV viral suppression. A post-trial qualitative substudy was undertaken to examine acceptability of the financial incentives among those receiving and implementing the intervention., Methods: Between July and October 2013, semi-structured interviews were conducted with 72 patients and 12 investigators from 14 sites; three focus groups were conducted with 12 staff from 10 sites. Qualitative data collection elicited experiences with and attitudes about the intervention, including philosophical viewpoints and implementation experiences. Transcripts were analyzed in NVivo 10. Memos and matrices were developed to explore themes from different participant group perspectives., Results: Patients, investigators, and staff found the intervention highly acceptable, primarily due to the emotional benefits gained through giving or receiving the incentive. Feeling rewarded or cared for was a main value perceived by patients; this was closely tied to the financial benefit for some. Other factors influencing acceptability for all included perceived effectiveness and health-related benefits, philosophical concerns about the use of incentives for health behavior change, and implementation issues. The termination of the incentive at the end of the study was disappointing to participants and unexpected by some, but generally accepted., Conclusion: Positive experiences with the financial incentive intervention and strategies used to facilitate implementation led to high acceptability of the intervention, despite some reluctance in principle to the use of incentives. The findings of this analysis provide encouraging evidence in support of the acceptability of a large-scale financial incentive intervention for HIV viral suppression in a clinical setting, and offer valuable lessons for future applications of similar interventions., Competing Interests: The authors have read the journal′s policy and have the following conflicts: BMB was an employee of the Centers for Disease Control and Prevention during the design and data collection for this study. Since his retirement in October 2014, BMB has been selfemployed as Scientific Affairs LLC and provided ad hoc consulting services funded by the study for work related to review and revision of this manuscript. BMB also served as a consultant to Gilead Sciences, received speaking honoraria from Siemens Healthcare Diagnostics, and served as an expert witness on HIV testing. These did not in any way affect the design, conduct or presentation of results for this study, and do not alter the authors’ adherence to PLOS ONE policies on sharing data and materials. Other coauthors declare no competing interests exist.

In 2012, immigrants constitute 63% of new cases of heterosexually transmitted HIV among individuals born outside Ireland. Current strategies to encourage testing can be ineffective if immigrants perceive them as culturally insensitive. We obtained qualitative data to explore challenges to voluntary HIV-testing for immigrants in Ireland. Content analysis was undertaken to identify and describe pertinent themes. Widespread beliefs that HIV is primarily a disease of African immigrants were identified as challenges that constrain access to testing and care. The organization and location of testing services, attitude of health workers, and beliefs regarding mandatory HIV-testing for immigrants seeking access to welfare benefits were also identified. Immigrants in Ireland encounter a variety of structural, cultural and personal constraints to HIV testing. Opportunities exist in the Irish Health system to increase testing among immigrants through greater acknowledgement of cultural sensitivities of immigrant groups.

One in 5 people living with HIV are unaware of their status; they account for an estimated 51% of new infections. HIV transmission can be reduced through a "Test and Treat" strategy, which can decrease both viral load and risk behaviors. However, linkage of newly diagnosed HIV-positive persons to care has proved challenging. We report quantitative and qualitative data on linkage to care from HIV testing sites that partnered with the New York City Department of Health and Mental Hygiene to implement "The Bronx Knows" (TBK), an initiative that tested 607,570 residents over 3 years. During TBK, partner agencies reported the aggregate number of HIV tests conducted, the number of confirmed positives (overall and new), and the number of confirmed positives linked to medical care. We conducted qualitative interviews with directors of 24 of 30 TBK HIV testing agencies to identify linkage barriers and selected 9 for case studies. Barriers to linkage fell into 3 domains: (1) health care system factors (long wait for provider appointments, requirement of a positive confirmatory test before scheduling an appointment, system navigation, and disrespect to patients); (2) social factors (HIV stigma); and (3) characteristics of risk populations (eg, mental illness, homelessness, substance use, and immigrant). Best practices for linkage included networking among community organizations, individualized care plans, team approach, comprehensive and coordinated care services, and patient peer navigation. Research and public health implications are discussed.

The purpose of this study was to examine the results of implementing a rapid counselor-based HIV testing program in community pharmacies. A prospective cross-sectional study was conducted on a convenience sample of clients at five community pharmacies in New York City (NYC). In 294 days of pharmacy testing, 2805 clients were eligible to receive testing, and 2030 individuals agreed to test. The average age was 33±15 years, 41% were male, 59% were Hispanic, 77% had been previously tested for HIV, and 34% were uninsured. HIV incidence was 0.3%, median CD4 cell count was 622.0, and the average age of the newly diagnosed positives was 36.0±13.9 years. Participants were satisfied with a counselor-based rapid HIV testing program in community-based pharmacies.

Background: The social environment in the Bronx, NY, has led to HIV infection rates among young people that are much higher than the national average., Methods: A prospective observational study on a convenience sample of medically stable emergency department (ED) patients was conducted from October 1, 2005, to August 31, 2012. Acceptability of the tested model was determined by assessing the number of patients tested and identified HIV infections. Data were compared with data from the rest of the ED that tested for HIV., Results: A total of 10,149 adolescents were approached during this period, of which 9.5% refused or were ineligible to test. Of those approached, 38.9% of patients were male, 59.7% were Hispanic, and 33.6% were black. The mean age was 19.4 ± 1.4 years, and 8.2% of patients were men who have sex with men. For risk behavior profiles, 24.3% never used condoms in the past 3 months. Incidence of HIV was less than 1%, and 92.6% of HIV-positive patients were linked to care. Of the patients who completed a postsatisfaction survey, 82.4% felt influenced to change their sexual practices. A smaller percentage of adolescent had tested previously for HIV compared with nonadolescents (67.7% vs. 80.6%). There was a slightly larger percentage of adolescents that accepted HIV testing compared with nonadolescents (95.4% vs. 90.8%). Adolescents who were positive for HIV were tested earlier in the progression of the disease, with higher median CD4 cell counts and lower viral loads compared with nonadolescents., Conclusions: Adolescents were highly receptive to a multimedia-integrated ED-based HIV testing program, as indicated by their high uptake of testing.

Purpose: To compare the effectiveness of a theory-based HIV educational video tool with in-person HIV counseling in promoting safer sex behaviors among adolescent patients of an urban Emergency Department (ED)., Methods: This was a randomized controlled trial taking place in the Emergency Department of Jacobi Medical Center in the Bronx, New York. A total of 203 stable, sexually active patients aged 15-21 years completed pre-intervention and postintervention measures. Participants were randomized to the intervention video series (102 participants), a theory-based, youth-friendly human immunodeficiency virus (HIV) educational video, or an in-person HIV counseling session with a trained HIV counselor (101 participants). Participants completed pre-intervention and postintervention measures on the primary outcomes: condom intention, outcome expectancy, and self-efficacy., Results: Participants in the video group improved condom use intention (adjusted differential mean improvement [ADMI] = .98 units; confidence interval [CI], .20-1.77; Holm adjusted p = .028), condom self-efficacy outcome (ADMI = .26 units; CI, .04-.48; Holm adjusted p = .019), and condom outcome expectancy scores (ADMI = .15 units; CI, .07-.23; Holm adjusted p < .001) significantly more than those in the counselor group, adjusting for stage of change. The intervention helped participants progress to the next level of readiness or maintain their positive behavior, and did not differ by age, gender, or race., Conclusions: A theory-based, youth-friendly video can be a valid means to provide posttest HIV education and prevention messages within an urban emergency department. The theory-based prevention messages can improve teenagers' condom intentions, condom self-efficacy, and condom outcome expectancies immediately after the intervention., (Copyright © 2013 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: The objective of this study was to explore emergency department (EDs) patients' knowledge, beliefs, attitudes, and acceptability toward revised human immunodeficiency virus (HIV) testing recommendations., Methods: Participants were recruited in proportion to the racial, sex, and ethnic makeup of the study ED. Interviewers presented participants with a stimulus followed by questions about opt-out consent, elimination of separate written consent, and curtailed counseling. Three investigators coded all transcripts using an iterative coding strategy until thematic saturation was achieved., Results: Thirty-four semistructured, in-depth, individual interviews were conducted, including five with patients ages 13 to 17 years and five with Spanish-speaking patients. Nineteen (56%) participants were women. The mean (± SD) age was 31 (± 12) years. Most were Hispanic (38%) or African American/black (44%). Only one (2.9%) participant knew about the revised testing recommendations. Participants believed that opt-out consent would result in increased testing, but this was confounded by misunderstanding of the consent process: "so the opt-out is, you basically don't have a choice." Participants thought eliminating separate written consent was a positive change but that it could result in people being tested without their knowledge. Attitudes diverged over curtailed counseling, but participants felt patients "should have options" for counseling because "everybody isn't the same.", Conclusions: Emergency department patients were unaware of revised HIV testing recommendations. Most felt that opt-out consent and elimination of separate written consent were positive changes but could result in a patient being tested without his or her knowledge. The response to curtailed counseling was polarized but participants agreed on the need to accommodate personal preferences. This information may be useful when designing ED-based HIV testing programs., (© 2013 by the Society for Academic Emergency Medicine.)

Despite the high prevalence of hepatitis C virus (HCV) infection among injection drug users also infected with human immunodeficiency virus (HIV), and the synergistic adverse effect of the two diseases on patients' health and survival, research on the clinical management of these patients and particularly the low uptake of HCV therapy is limited. We conducted qualitative interviews with 17 HIV providers from two urban public hospitals. We discovered that the limitations of the current state of medical knowledge, the severe side effects of HIV and HCV therapies, and the psychosocial vulnerability of HIV/HCV-coinfected patients combined with their resistance to becoming informed about HCV posed significant challenges for providers. To contend with these challenges, providers incorporated key dimensions of patient-centered medicine in their practice, such as considering their patients' psychosocial profiles and the meaning patients assign to being coinfected, and finding ways to engage their patients in a therapeutic alliance.

Background: UK guidance recommend all acute medical admissions be offered an HIV test. Our aim was to determine whether a dedicated staff member using a multimedia tool, a model found to be effective in the USA, is an acceptable, feasible, and cost-effective model when translated to a UK setting., Design: Between 14(th) Jan to 12(th) May 2010, a Health advisor (HA) approached 19-65 year olds at a central London acute medical admissions unit (AAU) and offered a rapid HIV point of care test (POCT) with the aid of an educational video. Patients with negative results had the option to watch a post-test video providing risk-reduction information. For reactive results the HA arranged a confirmatory test, and ensured linkage into HIV specialist care. Feasibility and acceptability were assessed through surveys and uptake rates. Costs per case of HIV identified were established., Results: Of the 606 eligible people admitted during the pilot period, 324 (53.5%) could not be approached or testing was deemed inappropriate. In total 23.0% of eligible admissions had an HIV POCT. Of the patients who watched the video and had not recently tested for HIV, 93.6% (131/140) agreed to an HIV test; four further patients had an HIV test but did not watch the video. Three tests (2.2%, 3/135) were reactive and all were confirmed HIV positive on laboratory testing. 97.5% felt HIV testing in this setting was appropriate, and 90.1% liked receiving the information via video. The cost per patient of the intervention was £21., Discussion: Universal POCT HIV testing in an acute medical setting, facilitated by an educational video and dedicated staff appears to be acceptable, feasible, effective, and low cost. These findings support the recommendation of HIV testing all admissions to AAU in high prevalence settings, although with the model used a significant proportion remained untested.

The realization that many persons with HIV/AIDS are subjected to multiple layers of stigmatization because they belong to socially deviant and disenfranchised groups (e.g., injection drug users, racial/ethnic and sexual minorities) accounts for an increasing interest in the phenomenon of stigma layering. The stigma associated with hepatitis C virus (HCV) has also been conceptualized as layered. However, researchers have overlooked the fact that HCV adds a layer to the HIV stigma and vice versa. Qualitative interviews with 132 HIV/HCV-coinfected patients were analyzed to explore how they experience the two layers of stigma. Most participants hierarchically ordered the stigmas associated with each disease and regarded HIV as the more stigmatizing of the two. A small number perceived HIV and HCV as equally stigmatizing. The impact of the hierarchical and nonhierarchical ordering of the two stigmas on coinfected patients' felt and enacted stigmatization is explored and implications for interventions are discussed.

Objective: The goal of this study was to compare the effectiveness of a youth-friendly HIV video with in-person counseling in conveying HIV knowledge and obtaining consent for HIV testing among adolescent patients of an urban emergency department., Methods: A 2-armed, randomized controlled trial was conducted on a convenience sample of 200 stable, sexually active people aged 15 to 21 years in an urban emergency department. Participants in both the in-person counseling group and the video intervention group completed preintervention and postintervention HIV knowledge measures. HIV knowledge was the primary outcome measure, and consent for HIV testing was the secondary outcome. Characteristics associated with voluntary HIV testing were identified., Results: Of 333 eligible people, 200 agreed to participate. There was no difference in preintervention HIV knowledge scores between groups. Mean postintervention knowledge scores differed significantly between the video (78.5% correct) and the counselor (66.3% correct) (P < 0.01) groups. Overall, 51% of the video group accepted HIV testing compared with 22% in the control group (P < .01). Watching the video (OR: 3.6 [95% CI: 1.8-7.2]), being female (OR: 2.1 [95% CI: 1.0-4.2]), engaging in oral sex (OR: 2.8 [95% CI: 1.4-5.9]), and being older than 18 years (OR: 3.8 [95% CI: 1.8-7.8]) were all positively associated with testing., Conclusions: A youth-friendly HIV educational video improved adolescents' HIV knowledge and increased their participation in HIV testing more than in-person counseling. video-based HIV counseling can perform as well or better than in-person counseling for adolescents in the ED.

Linking patients who test positive for HIV in an emergency department (ED) setting to HIV care can be challenging. The aim of this study was to assess whether a multimedia HIV testing model utilized in an inner-city ED can effectively link HIV-positive individuals into specialized medical care. A prospective cohort study was performed from October 2005 to January 2009 at an urban academic hospital with a Level 1 trauma center and in-house specialized HIV clinic. Patients were HIV tested in the ED using a multimedia video counseling program which included computer-assisted data collection. Patients who tested positive were linked to care by the same counselor who gave the test result. Linkage was immediate for discharged patients during clinic hours and patients tested during off-hours were scheduled a visit on the next business day. All follow-up was conducted through chart review. The public health advocates (PHAs) tested 24,495 patients over the course of the study, of whom 116 (0.47%) were HIV positive and 93 were newly diagnosed. A total of 83.6% (97/116) of HIV-positive individuals were linked into specialized care, defined here as an outpatient clinic visit within 30 days of diagnosis in the ED. The findings suggest that a multimedia testing model that includes a counselor who acts as tester and navigator can successfully link a high percentage of patients into specialized care.

Objective: To determine predictors of treatment failure and recurrence after surgical excisional procedures for CIN in HIV-infected women., Methods: A retrospective cohort study was conducted in which 136 eligible HIV-infected women treated for CIN between 1999 and 2005 were included. Data were abstracted from charts and computer databases. Treatment failures were defined as the presence of CIN 1+ at initial follow-up. Recurrences were defined as the presence of CIN 1+ subsequent to initial normal follow-up., Results: Treatment failure at initial follow-up was common, occurring in 51% of CIN 1 and 55% of CIN 2+. Most lesions detected at treatment failure were high grade (>70%), regardless of the grade of initial lesion. Significant risk factors for treatment failure were loop electrosurgical excision procedure (LEEP) compared to cold knife conization (RR=1.76; 95% CI: 1.15-2.64), and low CD4+ count (p=0.04). Among those with an initial normal clinical evaluation, 55% eventually recurred. As with treatment failure, most lesions detected at recurrence were high grade. Risk factors for recurrence included use of LEEP (hazard ratio [HR]=3.38; 95% CI: 1.55-7.39), higher HIV RNA level, and the presence of positive margins at treatment (HR=6.12; 95% CI: 1.90-19.73)., Conclusions: Most CIN treatment of HIV-infected women studied either failed or resulted in recurrence. Of particular concern, many of these subsequent lesions were high grade. Conization, however, was associated with significantly less failure/recurrence than LEEP. Clinicians treating CIN in HIV-infected women should avoid raising expectations of cure and instead focus on the achievable goal of cancer prevention until there are better therapies for this patient population., (Copyright © 2010 Elsevier Inc. All rights reserved.)

New Centers for Disease Control and Prevention (CDC) guidelines recommend routine HIV screening in locations including emergency departments. This study evaluates a novel approach to HIV counseling and testing (C&T) in a high-volume inner-city emergency department in terms of the number of patients who can be recruited, tested, test positive, and are linked to care. This prospective evaluation was conducted for 26 months. Noncritically ill or injured patients presenting to an inner-city emergency department were recruited. Patients used a multimedia program that facilitated data entry and viewed previously evaluated HIV counseling videos. Demographic characteristics, risk factors, and sexual history were collected. Data were collected on the number of patients tested, number of HIV-positive patients identified, and number linked to care. Demographic characteristics of the participants were as follows: 48.7% males, mean age 32.6 +/- 11.3, 34.6% Hispanic, and 37.9 % African American. Of the 7109 eligible patients approached, 6214 (87.4%) agreed to be HIV tested. There were 57 newly diagnosed or confirmed HIV-positive patients, representing a seroprevalence of 0.92%. Of those testing positive, 49 (84.2%) were linked to care and had a mean initial CD4 count of 238 cells/mm(3). In conclusion, a video-assisted rapid HIV program in a busy inner-city hospital emergency department can effectively test a high volume of patients and successfully link HIV-positive individuals to care, while providing high-quality education and prevention messages for all those who test.

Objective: Many of the individuals most at risk for HIV infection (i.e., minority populations, women, adolescents) are also the most marginalized by our health care system. Lacking primary care providers, they rely on the Emergency Department (ED) for their health care needs and education. In this prospective randomized controlled trial, we compared the educational effectiveness of a 15-minute posttest counseling video with the normal practice of a session with an HIV counselor. The study population was composed of ambulatory patients recruited for rapid HIV testing in the ED., Methods: The RAs (research assistants) recruited a convenience sample of stable patients presenting to the walk-in section of an inner-city adult ED for rapid HIV testing. Eligible patients for this study included patients who consented for the rapid HIV test and completed measures on condom intention and condom use self-efficacy. Before receiving their results, participants who consented to be in this study were randomized to either a 15-minute HIV posttest educational video available in English/Spanish or to a posttest educational session with an HIV counselor. Afterwards, both groups completed an assessment tool concerning HIV prevention and transmission., Results: Of the 128 participants, 61 and 67 patients were randomized to the video and counselor groups, respectively. The groups were similar with respect to gender, ethnicity and experience with prior HIV testing. Mean knowledge scores were higher in the video group (76.20% vs. 69.3%; 90% CI for the difference, 2.8, 11.2). As the lower bound of the CI for the difference was higher than the lower equivalence boundary (-5%), we infer that the video was at least as effective as the counselor educational session., Conclusions: The use of an educational counseling video is a valid alternative for providing posttest education and prevention information during the waiting period associated with the 20-minute HIV rapid test. Without disruption in clinical flow, both testing and education can be accomplished in a meaningful way in a busy ED.

Early diagnosis of persons infected with human immunodeficiency virus (HIV) through diagnostic testing and screening is a critical priority for individual and public health. Emergency departments (EDs) have an important role in this effort. As EDs gain experience in HIV testing, it is increasingly apparent that implementing testing is conceptually and operationally complex. A wide variety of HIV testing practice and research models have emerged, each reflecting adaptations to site-specific factors and the needs of local populations. The diversity and complexity inherent in nascent ED HIV testing practice and research are associated with the risk that findings will not be described according to a common lexicon. This article presents a comprehensive set of terms and definitions that can be used to describe ED-based HIV testing programs, developed by consensus opinion from the inaugural meeting of the National ED HIV Testing Consortium. These definitions are designed to facilitate discussion, increase comparability of future reports, and potentially accelerate wider implementation of ED HIV testing.

Objective: To test a model designed to increase willingness of patients presenting to the emergency department off hours to be tested for human immunodeficiency virus (HIV) by using a pretest counseling video as a substitute for face-to-face counseling., Methods: We conducted a randomized controlled trial comparing the rate of testing in patients randomized to receive video counseling with immediate testing (video group) versus standard care, which was referral to counseling and testing the next day (standard referral group)., Results: Fifty percent of 805 eligible patients consented to participate in the study, indicating willingness to be tested. The HIV testing rate was higher in the video group 92.6% (187 of 202) than in the standard referral group 4.5% (9 of 202) (difference = 88.1%, 95% confidence interval: 83.5%-92.7%). Thirty percent of 187 patients in the video group who were tested returned for their results; 8 of 9 patients in standard care returned to be tested and to get their results., Conclusion: Half of the patients who were solicited for HIV testing agreed to be tested. When testing was immediate the patient was more likely to have the test completed.

Study Objective: Multiple barriers to traditional pretest HIV counseling make HIV testing difficult to accomplish in the emergency department setting in off hours. This study compares the educational effectiveness of a 10-minute pretest counseling video with the usual practice of a session with an HIV counselor., Methods: This was a prospective randomized controlled trial of adult patients presenting to the urgent care area of a busy inner-city hospital. Patients either viewed an HIV educational video or spoke with an HIV counselor for pretest counseling. The video was developed by 2 of the investigators (YC, MH) and covered essential educational elements for HIV testing, as required by the New York State Department of Health. All participants completed a measure of HIV knowledge after their intervention. An equivalence analysis was performed to assess whether the video was at least as good as counseling in terms of overall mean knowledge score., Results: Of 129 patients recruited for the study, 65 patients were randomized to the intervention and 64 patients to the control group. Five patients were unable to complete the study. The final analysis was based on 124 patients. Mean knowledge scores were higher in the intervention (85.3% versus 79.7%; 90% confidence interval for the difference 2.6% to 8.7%)., Conclusion: We conclude that the use of an educational video with an inner-city adult population was at least as effective as in-person pretest counseling in conveying information related to HIV testing.

Background: Case reports and unblinded studies suggest that human immunodeficiency virus (HIV) disease is associated with QT prolongation and torsade de pointes ventricular tachycardia. Hepatitis C coinfection is common in patients with HIV disease, and cirrhosis is also associated with QT prolongation. We therefore undertook a systematic analysis of the role of liver injury, nutritional state, and coinfection with hepatitis C in the etiology of QT prolongation in HIV disease., Methods: We performed a blinded, controlled retrospective cohort study of 1648 patients over a 3-year period at a university-affiliated municipal hospital. All electrocardiograms were included if patients with HIV disease had measurements of CD4 count and viral load within 3 months and serum electrolytes within 30 days (n = 816). Control subjects were chosen randomly from the general medicine service (n = 832). QT interval was measured in lead II and corrected for heart rate by Bazett's formula (QTc)., Results: QTc was slightly but significantly longer in patients with HIV disease than in controls (443 +/- 37 vs 436 +/- 36 milliseconds, P < .001). Patients with hepatitis C had more pronounced QTc prolongation (452 +/- 41 vs 437 +/- 35 milliseconds, P < .001). CD4 count, HIV viral load, and HIV medications had no effect on QTc. When patients with hepatitis C were excluded from the analysis, there was no statistical difference between patients with HIV disease and controls (438 +/- 34 vs 436 +/- 36 milliseconds, P = .336). Multiple linear regression revealed that both HIV and hepatitis C infection predicted QTc prolongation, as did age, female sex, history of hypertension, use of opiates, low serum K+ and albumin, and high AST. Hepatitis C coinfection nearly doubled the risk of QTc of 470 milliseconds or greater in patients with HIV disease (29.6% vs 15.8%, P < .001)., Conclusions: Human immunodeficiency virus and hepatitis C infections both independently prolong QTc. Coinfection with hepatitis C greatly increases the likelihood of clinically significant QTc prolongation in patients with HIV disease.