# Presentation: 425767

## HIV Transmission on Campus:

***Peter Leone, MD***
***June 19, 2006***

## Case 1

- 21 yo AA male college student presenting to a student health urgent care clinic
- 5 days sweats, heartburn, sore throat, fatigue
- PE: Afebrile.  Thrush, non-exudative pharyngitis and tender cervical lymphadenopathy
- WBC 2.3 ALC 0.6 LUC 4% Hgb 18 Plt 90
- AST 205 ALT 93 AP 79 LDH 1050 GGT 122

## Case 1

- HIV ELISA/WB: negative (no bands)
- HIV-1 RNA 6,012,322 copies/ml
- p24 Ag: positive
- HIV DNA: positive
- Treatment: sx, lab abnormalities normalized

## Mode of Transmission

## Detection of Outbreak

**November 2002: ****NC’s Screening & Tracing Active Transmission (STAT) Program:**
**HIV RNA screening to all public VCT for detection of Ab-negative, acute HIV Infections**
**Robotic Pooling**
**Rapid notification/confirmatory testing**
**Rapid tracing/prospective screening of partners**
**Of 5 acute infections detected in <3 months, 2 were male students attending college in the same city. **

- Hightow, et al JAIDS 2005

## Study Design

**Retrospective review of state HIV surveillance records**
**Men age 18-30**
**January 1,2000-April 30, 2005**
**All 100 NC counties **
**Includes**
**Counseling and testing site data**
**DIS interview records**

- Hightow, et al JAIDS 2005

## 1403 Men Aged 18-30 Newly Diagnosed with HIV 

**1403 Men Aged 18-30 Newly Diagnosed with HIV **
**in North Carolina, January 2000- April 2005**

**1197 Cases **
**(85%) **

**157 College Students**
**13%**

**1040 Non College Students**
**87%**

**206 Cases previous positives **
**or not available **
**for review**

- Hightow, et al JAIDS 2005

## College vs Non-CollegeJanuary 2000-April 2005

- Hightow, et al JAIDS 2005

## College casesJanuary 2000-April 2005

- Hightow, et al JAIDS 2005

## Increasing Percentage of College Cases by Year of Diagnosis

## College cases by Stage of Diagnosis

- Hightow, et al JAIDS 2005

## 157 College Students

**133 African American**
**(84.7%)**

**6 Female sex partners**
**(4.5%)**

**79 Male sex partners**
**(59.4%)**

**44 Male and female **
**sex partners**
**(33.1%)**

- Hightow, et al JAIDS 2005

## Factors Associated with College

**College students more likely......**
- 				_**OR**_**	****	**_**95%CI**_
**African American****	****	****	****3.19****	****	****1.99-5.15**
**Diagnosed with recent infection ****	****	****3.17****	****	****1.84-5.44**
**Both male and female sex partners****	****3.03****	****	****2.01-4.57**
**Report anonymous sex****	****	****	****1.52****	****	****1.06-2.19**
**Meet sex partners in:**
**	****	****Gay bars/clubs****	****	****	****2.01****	****	****1.37-2.96**
**	****	****Internet****	****	****	****	****5.76****	****	****3.81-8.70**
**	****	****College****	****campus****	****	****	****16.79****	****	****7.39-38.90**

- Hightow, et al JAIDS 2005

## Factors Associated with College

**College students less likely......**
- 			**	**_**OR**_**	**_**95%CI**_
**Diagnosed with AIDS****	****	****	****0.39****	****0.19-0.78**
**Report only female sex partners****	****0.13****	****0.06-0.29**
**Partner with known HIV/AIDS****	****	****0.54****	****0.32-0.90**
**Exchange sex for drugs/$****	****	****0.17****	****0.04-0.45**
**History of incarceration****	****	****0.22****	****0.10-0.45**
**	****	**

- Hightow, et al JAIDS 2005

## Slide 15

## Network Analysis

- Network analysis has been used to study disease transmission in gonorrhea, chlamydia, syphilis and tuberculosis
- A network approach facilitates identification of persons in an infected individual’s social group who may benefit from HIV/STI screening and prevention activities.
- Socio-sexual network analysis may have potential applications for future HIV interventions targeted at high-risk groups.

## Network Diagram: College Cases (n=140)

- Created by Irene Doherty, PhD using UCINET V6 and Netdraw

## University in NC System

**University in NC System**

**Community/**
**Tech College**

**Private College**

**Out of State**

**Schools ego-centric networks****separate components**

- Created by Irene Doherty, PhD using UCINET V6 and Netdraw

## Network Diagram: College Cases Associated with Local Bar (n=24)

**Network Diagram: College Cases Associated with Local Bar (n=24)**

## Network Diagram: College Cases Associated with Internet Site (n=21)

## Acute cases ego-centric network

- Created by Irene Doherty, PhD using UCINET V6 and Netdraw

## Acute cases’ networks, k-core in blue

- All k-cores are part of one component

- Created by Irene Doherty, PhD using UCINET V6 and Netdraw

## The Role of MSMW

## 
“... I think a lot of these young men only have wives or girlfriends to cover up their homosexuality.  In the meantime, they are denying who they are...” 
	Posted by Brandip  8/3/03 NY Times Magazine Web Forum 
Are they?

*“... **I think a lot of these young men only have wives or girlfriends to cover up their homosexuality.  In the meantime, they are denying who they are...” *
*	**Posted by Brandip  8/3/03 NY Times Magazine Web Forum** *
*Are they?*

- _Sexual orientation_: to whom you are attracted (men, women, both)
- _Sexual identity_: how you describe yourself (to yourself and others)
- _Sexual behavior_: with whom you have sex
- 							(Purcell et al., 1996)

- Sexual Identity and Behavior

**Notes:**
The DL debate is replete with references to men who deny their ‘true’ sexual desire and in the process endanger the lives of Black women.
But sexuality is not that simple.
Let’s review 3 key concepts....

(after reading concepts and defn)

In the least complicated of all worlds a man attracted only to men would have a homosexual orientation, a gay identity, and sleep only with men.
But we don’t live in that world and there are innumerable incongruent combinations including men who’s sexual orientation is homosexual, identify as straight, and sleep with women and men.

## College Students: MSM/W

**33/103 (32%) college students reported MSM/W in previous 12 months**
**32/33 (97%) were Black**
**College MSM/W, were more likely than non-college MSM/W to:**
**frequent bars/clubs (OR 2.38 95% CI 1.00-5.70) **
**meet sex partners on college campuses (OR 24.79, 95% CI 2.91-211.50) than the MSM/W who were not college students **
**One-third**** of the college students who identified themselves as MSM/W reported the names of male partners only**

## Gender of Sex PartnersN=103

**Gender of Sex Partners****N=103**

|  | Black
N=89 (86%) | White
N=14 (14%) |
| --- | --- | --- |
| M | 49 (55%) | 12 (86%) |
| M/W | 32 (36%) | 1 (7%) |
| W | 3 (3%) | 1 (7%) |
| Unknown | 5 (6%) | 0 (0%) |

## MSM/W in North Carolina

**In multivariable analysis, compared to HIV-infected MSM, HIV-infected MSM/W were more likely **
**to be college students (OR 1.96, 95% 1.02-3.76)**
**to meet sex partners on college campuses (OR 4.19, 95% CI 1.06-16.58) **
**to report >10 sex partners in the year prior to their HIV diagnosis (OR 2.90, 95% CI 1.14-7.41)**

## 6 Separate Networks

**6 Separate Networks**
**17 schools**
**58 students**
**2 contacts**

- Hightow, et al STD 2006

## 1 Connected Network

**1 Connected Network**
**26 schools**
**95 students**
**8 contacts**

- Hightow, et al STD 2006

## Prevention for Bisexual Men

**Some bisexual men may be in transition to a homosexual identity. **
**Interventions need to encourage a positive gay identification and exposure to role models who emphasize avoiding sexual activity, avoiding anal sex, and/or using condoms consistently**
**Research is need to explore the relationship of bisexual activity/identity and race**
**Other bisexual men will never identify as gay, and may not even identify as bisexual.**** **
**These men likely have relatively high levels of self-homophobia and low levels of perceived acceptance of same-sex activity **
**For them, prevention messages and materials that are not gay-oriented will be most successful**

## Percent of HIV-Infected Students Meeting Sex Partners via the Internet

## All web sites together – Kcores in black

- Created by Irene Doherty, PhD using UCINET V6 and Netdraw

## Bar #2 Ego-centric network with k-cores in blue

**Bar #2 Ego-centric network with k-cores in blue**

- Created by Irene Doherty, PhD using UCINET V6 and Netdraw

## All cases, schools, bars, web sites

**All cases, schools, bars, web sites**

## Hightow, et al 13th CROI 2006

**30’s**
**W**

**30’s**
**W**

**27**
**W**

**30’s**
**W**

**30’s**
**W**

**30’s**
**W**

- 20+ Partners

**30’s**
**W**

**25**
**B**

**27**
**W**

**9 Partners: E-mail addresses/screen **
**names only, **

**30’s**
**W**

**26**
**W**

**23**
**H**

**31**
**B**

**29**
**W**

**21**
**W**

- 15 male
- partners

**21**
**W**

- Acute HIV

- HIV and/or
- Syphilis negative

- Not tested/
- Unknown
- HIV status

- Syphilis

- Chronic HIV

- Gay.com

- Manhunt

- Crystal Meth
- Use

- AOL

- HIV/Syphilis
- coinfection

**Age**
**race**

- 30
- W

- College Student

**30’s**
**W**

- Non-Internet
- sex partner

- Hightow, et al 13th CROI 2006

## Lessons Learned

**Outbreak recognized because real-time surveillance method linked with PCR and traditional outbreak investigation**

## Lessons Learned

- Outbreak recognized because real-time surveillance method linked with PCR and traditional outbreak investigation
**Network approach allowed linkage of geographically scattered cases through a group of young African American MSM and MSM/W attending college**

## Lessons Learned

- Outbreak recognized because real-time surveillance method linked with PCR and traditional outbreak investigation
- Network approach allowed linkage of geographically scattered cases through a group of young African American MSM and MSM/W attending college
- Bars and the internet may act as accelerants for transmission

## Lessons Learned

- Outbreak recognized because real-time surveillance method linked with PCR and traditional outbreak investigation
- Network approach allowed linkage of geographically scattered cases through a group of young African American MSM and MSM/W attending college
- Bars and the internet may act as accelerants for transmission
**College students represent at risk, population for ongoing HIV prevention interventions**