J Community Health DOI 10.1007/s10900-014-9933-8
ORIGINAL PAPER
Evaluation of the National HIV Behavioral Surveillance System Among Men Who Have Sex with Men in Denver, Colorado Kathryn H. DeYoung • Alia Al-Tayyib Mark Thrun
•
Ó Springer Science+Business Media New York 2014
Abstract Denver Public Health implements the National HIV Behavioral Surveillance System (NHBS), a cyclical survey of populations at increased risk for HIV. We evaluated the implementation of NHBS among Denver men who have sex with men (MSM), considering the system’s simplicity, data quality, representativeness, and sensitivity to trends. We found that the time required for implementation and the complexity of data management and analysis are barriers to disseminating local findings. Data quality has improved in each cycle of the study but must be protected by continually checking for errors and training field staff to be attentive to detail. Compared with the US census and other convenience samples of Denver MSM, the overall demographic representativeness of NHBS has improved over time. However, there is concern that the underlying population included in the study may be changing. NHBS survey data show evidence of two suspected trends in the local MSM population at risk for HIV: increasing sexual risk-taking and the transition away from bars as a dominant partner-finding location. It is unclear whether the increasing reports of sexual risk-taking reflect a real trend or simply a change in the population sampled, since most NHBS participants are recruited at gay bars and
K. H. DeYoung A. Al-Tayyib (&) M. Thrun Denver Public Health, 605 Bannock St, Denver, CO 80204, USA e-mail: [email protected] A. Al-Tayyib Department of Epidemiology, Colorado School of Public Health, Denver, CO, USA M. Thrun Division of Infectious Diseases, Department of Medicine, University of Colorado Denver School of Medicine, Denver, CO, USA
other venues. To ensure that the sample continues to represent the underlying population at risk and accurately identify trends, it is necessary to closely monitor MSM sample characteristics during implementation and incorporate weighted data provided by the Centers for Disease Control and Prevention into analyses. Keywords evaluation
NHBS MSM Surveillance system
Introduction In Denver and throughout Colorado, HIV prevalence is highest among gay, bisexual, and other men who have sex with men (collectively, MSM) [1, 2]. From 2008–2012, the majority of new cases in Denver were among individuals whose risk was male–male sex (71 %) and/or were male (90 %), non-Hispanic white (51 %) or Hispanic/Latino (31 %), or 20–29 or 30–39 years of age (31 % each) [2]. The Colorado Department of Public Health and Environment ranks urban MSM as the second highest priority for HIV prevention in Colorado (after people living with HIV/ AIDS), particularly youth aged 13–24 years and Caucasians, black/African Americans, and Hispanic/Latinos aged 25–49 years [3].
Program Being Evaluated The National HIV Behavioral Surveillance (NHBS) system is an anonymous multisite cyclical survey of populations at increased HIV risk [4–6]. Cycles focus in turn on MSM, injecting drug users (IDU), and heterosexuals at increased risk for HIV (HET). Health departments serving
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metropolitan statistical areas (MSAs) or MSA divisions with the highest AIDS prevalence are eligible to participate in NHBS. The primary objective of NHBS is to monitor HIV prevalence and trends in HIV risk behaviors, HIV testing history, and interaction with HIV preventive services among the risk populations [4]. Local data are intended for use in developing and monitoring local HIV prevention efforts and progress toward National HIV/AIDS Strategy goals [6, 7]. The National HIV Behavioral Surveillance MSM cycle methods have been described elsewhere [6, 8–10]. Briefly, these cycles employ venue-based time–space sampling to create an approximate sampling frame of the local MSM population at risk for HIV. NHBS sites conduct formative research to describe the target population and potentially underrepresented sub-groups. Input is obtained from people who are knowledgeable about the local MSM population via focus groups, key informant interviews, brief street interviews, and meetings with community stakeholders. Next, venues in the MSA with a high ratio of MSM attendees (including bars, bathhouses, restaurants, and street locations) and best dates and times for recruiting are compiled into a ‘‘venue universe.’’ In MSM1 and MSM2, venues were included if at least 75 % of attendees selfidentified as MSM during a venue observation; in MSM3 this criterion changed to 50 % [5, 9]. At recruiting events, every person entering the venue who appears male and 18 or older is counted and men who walk through a predefined sampling area are recruited [6, 11]. In MSM2 and MSM3, HIV testing was offered using oral specimens for rapid (OraQuick ADVANCEÒ Rapid HIV1/2 Antibody Test) and Western blot (BioRad GS HIV-1 Western Blot Human Immunodeficiency Virus Type 1) testing.
Purpose Before now, NHBS implementation had not been systematically evaluated in Denver. With HIV prevalence highest among Denver MSM, we decided to evaluate NHBS sampling and study methods in this population and focus on simplicity, data quality, representativeness, and sensitivity to trends. The Centers for Disease Control and Prevention (CDC)’s guide for evaluating public health surveillance systems informed this evaluation [12].
Clinic (DMHC), Denver Public Health (DPH) HIV Outreach, and the Denver Health Emergency Department (DH ED) HIV testing program. The 2010 US Census provided information on the underlying male population in Denver. Denver Metro Health Clinic is an urban STD clinic located within DPH. DPH also conducts outreach testing for HIV and STDs at various locations in the community including gay bathhouses and an outreach location primarily serving gay men in central Denver. Data from DMHC and outreach testing encounters are collected in HealthDoc, an electronic medical record system. MSM attending DMHC represent men who are actively seeking healthcare and screening related to their potential risk of HIV and other STDs; outreach testing records represent MSM who may or may not have been at the venue to seek screening related to their sexual risk factors. From January 2011 through September 2012, the DH ED used an instrument to calculate patients’ HIV risk score for targeted HIV screening [13, 14]. Data from this instrument provide a sample of MSM seeking healthcare for urgent medical needs. Data sources were sampled to reflect NHBS selection criteria and timing as closely as possible. The US census data were restricted to Denver men 18 years of age and older. All other samples were restricted to English/Spanishspeaking males (not transgender) who were 18–89 years of age and lived, received services, and/or attended venues in the Denver–Aurora MSA. Individuals in the NHBS, DMHC, HIV Outreach samples were included if they reported sex with at least one man within the prior 12 months. The ED Risk score did not ask about past-year sex, so that sample included men who reported ever having had sex with a man. NHBS MSM cycles took place in 2004–2005 (MSM1), 2008 (MSM2), and 2011 (MSM3). Other data sources were not available for all 3 years and were restricted to 2010 or 2011 for comparison with MSM3. To assess qualitative attributes, we interviewed local NHBS staff and community stakeholders and reviewed NHBS process indicators, protocols, and data correction logs. Data were analyzed using SAS Enterprise Guide. Chi square tests were used to detect differences in NHBS across two or more cycles; the Cochran–Armitage trend test was used to detect trends in variables collected in all three cycles. The study was determined by the Colorado Multiple Institutional Review Board (COMIRB) to be a program evaluation and not human subject research; results are not generalizable outside of the immediate context of the study.
Methods
Evaluation Criteria
Data Sources
Simplicity
NHBS–MSM participants were compared to three local data sources on MSM at risk for HIV: the Denver Metro Health
In a public health surveillance system, simplicity includes the ease of data collection, cleaning, analysis, and use. We
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examined local implementation requirements and the complexities of data analysis. Data Quality A questionnaire-based system with high data quality has few missing or invalid responses. This attribute can be impacted by interviewer skill, technology, and participant engagement. We reviewed data correction logs for MSM2 and MSM3 to determine number and types of errors detected and examined test results among self-reported HIV positive participants to review performance of the confirmatory HIV test.
Representativeness This attribute describes the accuracy of the system’s depiction of health trends, including time, geography, and participant sub-groups; it depends on selecting a representative sample from the target population and obtaining true responses from participants. Assessing this attribute requires data from alternative sources for the same population and time period. It is preferred to make comparisons with a ‘‘gold standard’’ representation of the population. While general estimates of the MSM population have been developed using figures from the National Survey of Family Growth (NSFG) and the American Community Survey’s estimates of same-sex couples, there is no detailed gold standard measure of MSM populations at risk for HIV, and we did not have access to comparable local data from other national studies such as NSFG [11, 15, 16]. We therefore compared Denver males and MSM as represented by the 2010 US Census, NHBS–MSM, DMHC, HIV Outreach, and the ED HIV testing program. Sensitivity to Trends Sensitivity can refer to the ability to accurately detect disease, health events, or relevant trends over time. Detecting trends requires consecutive observations and, optimally, another data source for comparison. We compared HIV status and sexual risk, partner-finding, and testing behaviors in the three NHBS MSM cycles.
Results Simplicity National HIV Behavioral Surveillance System is complex. Study preparation and data collection require substantial
time and effort (Fig. 1). Preparation for implementation has grown more efficient each cycle, with CDC delivering the protocol earlier in the year, materials moving more quickly through COMIRB, and formative research building on previous cycles. Still, the two periods of NHBS activities occupy essentially the full year, limiting time for analyzing and disseminating results. Until 2009, CDC acted as the data management center. CDC took 23 months in MSM1 and 19 months in MSM2 to return final corrected datasets to the sites. Recognizing this limitation, CDC contracted with a Data Coordinating Center (DCC), which returned final MSM3 datasets to sites in 3 months. Once returned, final datasets require substantial data management before analysis can occur. This is for three main reasons. Datasets retain the structure of the questionnaire software; no one source documents all of the information needed for accurate data analysis; and questions have changed slightly from cycle to cycle. Final datasets include variables calculated by the questionnaire software for use in skip patterns and edit checks (e.g., the date 12 months prior to the interview) as well as variables for questions that were asked in the IDU or HET cycles but not in the MSM cycle: MSM3 had nearly 300 unnecessary variables. Additionally, datasets do not include composite variables for questions where ‘‘check all that apply’’ answer options were recorded separately or where similar or identical questions were asked of different groups due to skip patterns. Questions about respondents’ sex practices like condom use during insertive or receptive anal intercourse were separated by whether the respondent had one male partner in the past 12 months or more than one. Calculating the number of reported anal sex partners in the past 12 months requires compilation of 4–6 different variables, depending on the cycle. Although datasets are returned with a data dictionary, there is no one guide documenting questions, answer options and associated keys (e.g., 1 = Male, 2 = Female), skip patterns, and unnecessary variables. This information must be compiled from several resources which do not always agree. A thorough knowledge of the questionnaires is necessary because one topic may be covered in several questions. For example, known HIV status was addressed in one variable in MSM1, two in MSM2, and three in MSM3. Slight changes to questions or answer options can complicate longitudinal analyses. For instance, a question about where the participant received his most recent HIV test had 18 response options in MSM1, 15 in MSM2, and 12 in MSM3. This topic was covered in two questions in MSM1 (one for location of recent negative/unknown result in the past 12 months and one for location of positive
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Fig. 1 Current schema of local NHBS tasks for MSM cycle
participants’ first positive result); in one question of all respondents with a prior HIV test in MSM2; and in MSM3, in one question of all with a test in the past 5 years. Comparing these questions requires reconciliation of the answer options and acceptance that the question was asked of slightly different groups each time. Data Quality HIV testing was offered during MSM2 and MSM3, with test and survey consent documented separately. In MSM2, 95 participants did not have documented HIV consent. Of those 95, 31 (33 %) had a Western blot (confirmatory HIV testing) performed. It is likely that these participants verbally consented but their consent was not recorded. In MSM3, the number of participants without documented consent decreased to 39 and only 2 (5 %) of these received a confirmatory test. Test results without documented consent cannot be included in analyses.
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Data corrections logs for MSM2 and MSM3 reveal common interviewer errors, including incorrect survey ID, venue ID, and event number. In MSM2, an interviewer was found to be unreliable and their interviews were deleted. MSM3 saw an increase in technological errors; occasionally the calendar and clock on the handheld devices would reset and assign incorrect dates and times to interviews unless the interviewer noticed and corrected the problem. A key component of NHBS is the ability to connect participants’ risk and preventive behaviors with their HIV status. Among self-reported HIV positive participants who consented to testing, 22 (31 %) in MSM2 and 18 (23 %) in MSM3 had an indeterminate or negative Western blot result (Table 1). In both cycles, the Denver site tested oral fluid, which is known to have a higher false-negative rate than blood [17, 18]. After MSM3, Denver began drawing blood for HIV testing and the Western blot was replaced by a fourth generation enzyme immunoassay. These changes are expected to improve HIV test performance.
J Community Health Table 1 Performance of NHBS confirmatory HIV test (Western blot on oral specimen) among self-reported HIV-positive MSM who consented to testing Western blot
MSM2
%
MSM3
%
Overall
%
Positive
47
67.1
60
75.9
107
71.8
Indeterminate
15
21.4
13
16.5
28
18.8
7 1
10.0 1.4
5 1
6.3 1.3
12 2
8.1 1.3
Negative Missing Total
70
79
149
Representativeness Some field staff and community stakeholders voiced questions about the representativeness achieved by the NHBS venue-based sampling method. One staff member suggested that the Denver MSM population might be represented differently by respondent driven sampling, which is used in the NHBS IDU and HET cycles. Community members commented that non-gay identified (NGI) and minority MSM may more regularly attend venues with a lower percent of MSM than the NHBS venue criteria permit. Minority MSM tend not to live in Denver’s historically gay neighborhoods and may attend venues that reflect their race/ ethnicity rather than their sexual identity. Finally, there was concern that increasing use of the internet for partnerfinding may decrease the frequency that some MSM visit physical venues and their likelihood of being sampled. The demographic makeup of NHBS–MSM participants has changed significantly across the three cycles, with the proportion of MSM who are younger, black/African American, or Hispanic/Latino increasing over time and becoming generally more representative of the Denver MSM population at risk (Tables 2, 3). Educational attainment also changed, perhaps due to the shifting age and race/ethnicity of participants. Denver NHBS–MSM samples were compared to several other data sources of the underlying male and MSM population at risk in the Denver metro area (Table 3). Sources were restricted to 2010 or 2011 to examine a similar point in time. NHBS had a greater proportion of males aged 18–24 compared to the US Census but a lower proportion than the other samples and the greatest proportion of 30–49 year-olds of any source. American Indians and black/African Americans made up a greater proportion of the NHBS sample than the other sources. The NHBS sample had the highest percent of men who self-reported as HIV positive and the lowest percent who reported never having been tested. Compared to electronic testing records in the DMHC, HIV Outreach, and ED samples, NHBS participants self-reported a greater mean number of years since most recent HIV test (among those ever tested) and a
greater mean number of tests in the last 2 years (among those tested in the last 2 years). These seemingly contradictory findings may indicate that NHBS represents a greater diversity of MSM than the other samples. Finally, NHBS had the lowest rate of previously undiagnosed HIV positive participants, likely because the other settings have less reason to test known positive patients. Sensitivity to Trends Community members and stakeholders were concerned that sexual risk behaviors may be increasing among Denver MSM. They also raised the possibility that increasing use of the internet and mobile applications for partner-finding and the declining significance of predominantly gay venues and neighborhoods could cause venue-based sampling to become less representative. There is evidence that these trends exist and extend past Denver. CDC has reported that MSM NHBS participants are reporting more sexual risk than in past cycles [19]. The decline of gay neighborhoods and venues, rise of internetbased socialization, and differences between MSM sampled online versus at physical venues have been described in other US cities and internationally [20–23]. We tested the ability of NHBS to confirm these trends in Denver (Table 4). The proportion of participants who met their last casual or exchange male partner in a bar or club decreased from 49.8 % in MSM1 to 29.5 % in MSM3, while those who met that partner on the internet doubled between MSM1 and MSM3. Participants reporting condomless anal intercourse (CAI) with at least one male in the past 12 months increased significantly from 49.5 % in MSM1 to 65.7 % in MSM3. HIV testing behaviors, known status, and new HIV diagnoses remained stable over time.
Lessons Learned Denver’s NHBS MSM cycles have yielded good quality data that appear representative of the population of MSM at risk and able to detect local trends. However, these attributes require attention to ensure that NHBS remains a source of trustworthy, usable local data. Additionally, the time required for implementation of each cycle and the complexity of data management and analysis are significant barriers to disseminating findings at the local level. Maintaining robust documentation of the questionnaires and datasets will make the analysis process more efficient. Access to DMHC, HIV Outreach, and ED data allowed us to evaluate representativeness in comparison with several local data sources on MSM at risk of HIV infection. At the same time, these were convenience samples, each with their own sampling biases. We were also unable to
123
123 102 280 244 118
25–29
30–39
40–49
50?
833 17 151 267 398
Education
\High school
High school diploma/GED
Some college/tech. degree
College degree/postgrad ed.
a
761 66 4
Homosexual/gay
Bisexual
Other
0.5
7.9
91.4 (0.0, 1.0)
(6.1, 9.8)
(89.4, 93.3)
0
62
481
1
Cochran–Armitage trend test was performed on variables collected in all three cycles
2
Heterosexual/straight
108 544
84
$75,000? Orientation
219
$50,000–74,999
544
213
177
123
31
544
35
336
149
22
2
37.52 544
98
126
153
82
85
544
$20,000–$49,999
–
(44.4, 51.2)
(28.9, 35.2)
(15.5, 20.7)
(1.1, 3.0)
(5.6, 9.2)
(63.0, 69.5)
(16.9, 22.4)
(4.0, 7.1)
(0.5, 2.0)
(37.55, 39.01)
(11.8, 16.5)
(26.2, 32.4)
(30.4, 36.8)
(10.0, 14.5)
(8.6, 12.8)
133
0.2
47.8
32.1
18.1
2.0
7.4
66.3
19.6
5.5
1.2
14.2
29.3
33.6
12.2
10.7
0–$19,999
833
60
Other
Household income
160 540
White
45
Black/African American
Hispanic/Latino
10
American Indian
38.28 815
89
Mean age Race/ethnicity
833
18–24
0.0
11.4
88.4
0.2
19.9
15.4
40.3
24.4
39.2
32.5
22.6
5.7
6.4
61.8
27.4
4.0
0.4
18.0
23.2
28.1
15.1
15.6
%
N
95 % CI
N
%
MSM2 (2008)
MSM1 (2004–2005)
Age groups
Variable
Table 2 Demographic characteristics of NHBS participants (2005–2011)
–
–
–
(8.7, 14.1)
(85.7, 91.1)
(16.5, 23.2)
(12.4, 18.5)
(36.1, 44.4)
(20.8, 28.1)
(35.0, 43.3)
(28.6, 36.5)
(19.1, 26.1)
(3.7, 7.6)
(4.4, 8.5)
(57.7, 65.9)
(23.6, 31.1)
(2.4, 5.7)
(36.50, 38.53)
(14.8, 21.2)
(19.6, 26.7)
(24.3, 31.9)
(12.1, 18.1)
(12.6, 18.7)
95 % CI
0
62
479
1
84 542
89
207
163
543
207
195
125
16
543
30
297
145
59
12
36.82 543
84
118
146
108
87
543
N
0.0
11.4
88.4
0.2
15.5
16.4
38.1
30.0
38.1
35.9
23.0
2.9
5.4
54.7
26.7
10.9
2.2
15.5
21.7
26.9
19.9
16.0
%
MSM3 (2011)
–
(8.8, 14.1)
(85.7, 91.1)
–
(12.4, 18.5)
(13.3, 19.5)
(34.0, 42.2)
(26.2, 33.9)
(34.0, 42.2)
(31.9, 40.0)
(19.5, 26.6)
(1.5, 4.4)
(3.5, 7.2)
(50.6, 59.0)
(23.0, 30.5)
(8.3, 13.5)
(1.0, 3.5)
(35.78, 37.87)
(12.4, 18.5)
(18.3, 25.2)
(23.2, 30.6)
(16.5, 23.3)
(12.9, 19.1)
95 % CI
(–)
(0.0228)
(0.0581)
(0.8131)
0.0552
0.0888
(0.0002)
(0.1540)
(0.0207)
(0.1859)
\0.0001
(0.1411)
(\0.0001)
(0.0012)
(0.0004)
(0.1790)
0.07 \0.0001
(0.3933)
(0.0010)
(0.0055)
(0.0001)
(0.0028)
\.0001
Chi square p (Cochran–Armitage pa)
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J Community Health Table 3 Demographics, HIV testing, and new diagnoses of MSM by data source (2010–2011)
US Census (Males 18? 2010) Age groups
1,183
1,064
87 (16.0)
284 (24.0)
198 (18.6)
77 (21.1)
25–29
33,027 (14.1)
108 (19.9)
270 (22.8)
198 (18.6)
58 (15.9)
30–39
55,727 (23.7)
146 (26.9)
286 (24.2)
248 (23.3)
92 (25.2)
40–49
41,052 (17.5)
118 (21.7)
211 (17.8)
223 (21.0)
73 (20.0)
50?
74,257 (31.6)
84 (15.5)
132 (11.2)
197 (18.5)
65 (17.8)
234,704
36.82 ± 1.05 543
34.34 ± 0.67 1,183
37.56 ± 0.80 1,064
364
12 (2.2)
4 (0.3)
13 (1.2)
1,294 (0.6) 21,665 (9.2)
59 (10.9)
86 (7.3)
53 (5.0)
39 (10.7)
Hispanic/Latino
63,824 (27.2)
145 (26.7)
303 (25.6)
170 (16.0)
94 (25.8)
136,423 (58.1)
297 (54.7)
719 (60.8)
725 (68.1)
208 (57.1)
30 (5.4)
71 (6.0)
103 (9.7)
11,498 (4.9)
d
Gave any answer indicating known positive status
543
23 (6.3) 365
Men only
265 (48.8)
183 (50.1)
Men and woman
278 (51.2)
182 (49.9)
Orientation
Excludes 2 who denied ever testing but elsewhere indicated a known positive status
a
Black/African American
Ever had sex with
Self-report
365
543
Other/Multiple
c
ED (2011)
30,641 (13.1)
White
b
Outreach (2011)
234,704
American Indian
Not an option in ED risk assessment tool
DMHC (2011)
18–24
Mean age Race/ethnicity
a
NHBS (2011)
542
1,183
Heterosexual/straight
1 (0.2)
86 (7.3)
16 (1.5)
Homosexual/gay
479 (88.4)
893 (75.5)
862 (81.0)
Bisexual
62 (11.4)
117 (15.0)
166 (15.6)
Other
0 (0.0)
27 (2.3)
20 (1.9)
543 32c (5.9)
1,183 139 (11.8)
1,064 74 (7.0)
Yes
511 (94.1)
1,044 (88.3)
990 (93.1)
288 (78.9)
Unsure
0
0
0
4 (1.1)
543
1,183
1,064
288
431c (79.4)
966 (81.7)
948 (89.1)
283 (98.3)
Ever testedb No
Self-reported HIV status Negative
d
1,064
365 73 (20.0)
Positive
80 (14.7)
102 (8.6)
47 (4.4)
0 (0)
Unknowne
32 (5.9)
115 (9.7)
69 (6.5)
5 (1.7)
Mean # years since latest test (among ever tested)
2.12 ± 0.35b
1.78 ± 0.21f
1.49 ± 0.22f
g
Mean # tests in last 2 years (among tested 2 years)
3.25 ± 0.32b
1.84 ± 0.11f
1.98 ± 0.11f
1.9 ± 1.1g
h
Previously undiagnosed HIV
11 (15.5)
37 (88.1)
23 (95.8)
13 (100.0)
71h
42
24
13i
e
Includes never tested, results not known, and indeterminate
f
HealthDoc records
Emergency department records Consented to HIV testing, tested, positive Western blot test through NHBS
i
Preliminary rapid test result
Total persons testing positive for HIV
compare NHBS trends in partner-finding and sexual risk with consecutive observations from another source. Representativeness and sensitivity to trends are interdependent; changes over time could represent sampling changes (intentional and unintentional), emerging trends, or both. One notable concern is that venue-based sampling may select individuals whose risk behaviors differ from the overall local at-risk MSM population [10, 20, 21]. This difference could be growing due to the increased use of the internet for partner-finding and decreased attendance at gay bars and other venues. If
MSM who regularly attend venues meeting NHBS criteria are engaging in more risk behaviors than those who do not, the increase in the percent of MSM reporting CAI could reflect a sampling bias that is emerging as other MSM decrease attendance at these venues. Similarly, new HIV diagnoses in Denver are known to have steadily declined in recent years, so the lack of a significant decrease in new HIV diagnoses between MSM2 and MSM3 could indicate that this method is increasingly sampling higher-risk MSM [1, 2]. On the other hand, there is some evidence that MSM who meet via the
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J Community Health Table 4 Trends in Sexual behaviors, HIV testing history, and HIV status Variable
Where met last non-main male partnerb Bar/club Internet/chat room Other Condomless anal intercourse with male past 12 months
MSM1 (2004–2005)
MSM2 (2008)
MSM3 (2011)
N
N
N
%
95 % CI
576
%
95 % CI
288
%
95 % CI
\0.0001
308
287
49.8
(45.7, 53.9)
117
40.6
(34.9, 46.3)
91
29.5
(24.4, 34.7)
(\0.0001)
83
14.4
(11.5, 17.3)
62
21.5
(16.8, 26.3)
88
28.6
(23.5, 33.6)
(\0.0001)
206
35.8
(31.8, 39.7)
109
37.8
(32.2, 43.5)
129
41.9
(36.4, 47.4)
833
544
Yes
412
49.5
(46.1, 52.9)
309
56.8
(52.6, 61.0)
357
65.7
(61.7, 69.7)
421
50.5
(47.1, 53.9)
235
43.2
(39.0, 47.4)
183
34.3
(30.3, 38.3)
No Yes Unknown
833
544
38
4.6
795 0
95.4
(3.1, 6.0) (94.0, 96.9)
HIV testing past 12 months
833
No (includes never tested, unknown if tested)
328
39.4
(36.1, 42.7)
505
60.6
(57.3, 63.9)
Yes Self-reported HIV status
543 5.9
93.6 (91.9, 95.9) 0.4 –
511 0
94.1
220
40.4
(36.3, 44.6)
236
43.5
(39.3, 47.6)
324
59.6
(55.4, 63.7)
307
56.5
(52.4, 60.7)
509 2
6.1
(4.1, 8.1)
544
833
(4.2, 8.3) (91.7, 95.8)
0.3134
543
(0.1409)
0.5266
Positived
119
14.3
(11.9, 16.7)
92
16.9
(13.8, 20.1)
80
14.7
(11.7, 17.7)
(0.7051)
Negative
671
80.6
(77.9, 83.2)
417
76.7
(73.1, 80.2)
431
79.4
(76.0, 82.8)
(0.4763)
43
5.2
35
6.4
(4.4, 8.5)
32
5.9
(3.9, 7.9)
(0.5080)
Positive
60
13.5
(10.3, 16.6)
71
14.2
Negative
367
82.3
(78.7, 85.8)
416
83.0
19
4.3
14
2.8
(1.3, 4.2)
15.5
(6.9–24.0)
Unknown (never tested/results not known/indeterminate)
(3.7, 6.7)
Result of NHBS Western blot
Indeterminate Total (consented and tested) Previously undiagnosed HIV Total persons testing positive for HIV)e a
(0.1526)
–
543
544
(\0.0001) 0.3033
32c
33
(0.0779) \0.0001
543
No Ever tested for HIV
Chi square p (Cochran–Armitage pa)
0.4587
(2.4, 6.1)
446 13
(11.1, 17.2) (79.7, 86.3)
501 21.7
(11.1–32.3)
60
11
0.3628
71
Cochran–Armitage trend test was performed on variables collected in all three cycles
b
MSM1–MSM3: restricted to where met last casual/exchange male partner; in MSM3 this question was only asked of men who had been in the relationship \3 years
c
Excludes 2 who denied ever testing but elsewhere indicated a known positive status (counted here as ‘‘yes’’ despite denying ever testing)
d
Gave any answer indicating known positive status
e
Consented, tested, positive Western blot in NHBS
internet have higher rates of sexual risk behaviors than those who met elsewhere [20]. In MSM3, CDC began providing locally weighted data to account for bias arising from venue selection, day/time of venue visits, and venue size. Additional venue information will be collected in MSM4 to improve the weighting process. To ensure that the sample continues to represent the underlying population at risk and accurately identify trends, it will be necessary to closely monitor the
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MSM sample characteristics during implementation and incorporate weighted data into analyses. Acknowledgments This report was supported in part by an appointment to the Applied Epidemiology Fellowship Program administered by the Council of State and Territorial Epidemiologists (CSTE) and funded by the Centers for Disease Control and Prevention (CDC) Cooperative Agreement Number 5U38HM000414-5. The authors gratefully acknowledge Jason Haukoos, Emily Caruso, and Christie Mettenbrink for their assistance in obtaining additional data sources for comparison. The authors thank Charles Chen, Toby
J Community Health LeRoux, Theresa Mickiewicz, and the Denver NHBS interviewers for their tireless efforts in collecting this important data. We also thank the community members and stakeholders who so generously gave of their time to provide their insights to inform this evaluation.
10.
References 1. Colorado Department of Public Health and Environment, Disease Control and Environmental Epidemiology Department, Sexually Transmitted Infections/HIV Surveillance Section. (2013). Colorado HIV surveillance report: 4th quarter 2013. Retrieved from http://www.colorado.gov/cs/Satellite?blobcol=urldata&blobhead ername1=Content-Disposition&blobheadername2=Content-Type &blobheadervalue1=inline%3B?filename%3D%22HIV?4Q? 2013.pdf%22&blobheadervalue2=application%2Fpdf&blobkey= id&blobtable=MungoBlobs&blobwhere=1251936194638&ssbin ary=true. 2. Colorado Department of Public Health and Environment, Disease Control and Environmental Epidemiology Department, STI/HIV Surveillance Program. (2013). Five-year trend table for new HIV diagnoses (2008–2012), Denver County, Colorado. Retrieved from http://www.colorado.gov/cs/Satellite?blobcol=urldata&blob headername1=Content-Disposition&blobheadername2=ContentType&blobheadervalue1=inline%3B?filename%3D%22Den ver.pdf%22&blobheadervalue2=application%2Fpdf&blobkey=id &blobtable=MungoBlobs&blobwhere=1251879890319&ssbinary =true. 3. Colorado Department of Public Health and Environment, Disease Control and Environmental Epidemiology Department, STI/HIV Surveillance Program. (2009). STI/HIV Reports and References: Priority Population Profiles. Retrieved from https://stage.color ado.gov/cs/Satellite?blobcol=urldata&blobheadername1=ContentDisposition&blobheadername2=Content-Type&blobheadervalue1 =inline%3B?filename%3D%22Priority?Population?Profiles.pdf% 22&blobheadervalue2=application%2Fpdf&blobkey=id&blobt able=MungoBlobs&blobwhere=1251609842920&ssbinary=true. 4. Gallagher, K. M., Sullivan, P.S., Lansky, A., and Onorato I.M. (2007). Behavioral surveillance among people at risk for HIV infection in the U.S.: The National HIV Behavioral Surveillance System. Public Health Reports, 122(Suppl 1), 32–38. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1804113/ pdf/phr122S10032.pdf. 5. Wejnert, C., Le, B., Rose, C., et al. (2013). HIV infection and awareness among men who have sex with men-20 cities, United States, 2008 and 2011. PLoS One, 8(10), e76878. doi:10.1371/ journal.pone.0076878. 6. Finlayson, T. J., Le, B., Smith A., et al. (2011). HIV risk, prevention, and testing behaviors among men who have sex with men–National HIV Behavioral Surveillance System, 21 U.S. cities, United States, 2008. Morbidity And Mortality Weekly Report Surveillance Summaries, 60(14), 1–34. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6014a1.htm. 7. White House Office of National AIDS Policy. (2010). National HIV/AIDS strategy for the United States. Retrieved from http:// www.whitehouse.gov/sites/default/files/uploads/NHAS.pdf. 8. Allen, D. R., Finlayson, T., Abdul-Quader, A., & Lansky, A. (2009). The role of formative research in the National HIV Behavioral Surveillance System. Public Health Reports, 124(1), 26–33. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/arti cles/PMC2602928/pdf/phr124000026.pdf. 9. MacKellar, D. A., Gallagher, K. M., Finlayson, T., Sanchez, T., Lansky, A., & Sullivan, P. S. (2007). Surveillance of HIV risk and prevention behaviors of men who have sex with men–a national application of venue-based, time-space sampling. Public
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Health Reports, 122(Suppl 1), 39–47. Retrieved from http:// www.ncbi.nlm.nih.gov/pmc/articles/PMC1804106/pdf/phr122S10 039.pdf. Jenness, S., Neaigus, A., Murrill, C., Gelpi-Acosta, C., Wendel, T., & Hagan, H. (2011). Recruitment-adjusted estimates of HIV prevalence and risk among men who have sex with men: effects of weighting venue-based sampling data. Public Health Reports, 126(5), 635–642. Retrieved from http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC3151180/pdf/phr126000635.pdf. Burt, R., Oster, A., Golden, M., & Thiede, H. (2014). Comparing study populations of men who have sex with men: Evaluating consistency within repeat studies and across studies in the Seattle area using different recruitment methodologies. AIDS and Behavior, 18(Suppl 3), 370–381. doi:10.1007/s10461-013-0568-z. German, R. R., Lee, L. M., Horan, J. M., Milstein, R. L., Pertowski, C. A., & Waller, M. N. (2001). Updated guidelines for evaluating public health surveillance systems: Recommendations from the Guidelines Working Group. MMWR. Recommendations and Reports: Morbidity and Mortality Weekly Report, 50(RR-13), l1–35. Retrieved from http://www.cdc.gov/mmwr/preview/ mmwrhtml/rr5013a1.htm. Haukoos, J., Hopkins, E., Conroy, A., et al. (2010). Routine optout rapid HIV screening and detection of HIV infection in emergency department patients. JAMA, 304(3), 284–292. doi:10. 1001/jama.2010.953. Haukoos, J., Lyons, M., Lindsell, C., et al. (2012). Derivation and validation of the Denver Human Immunodeficiency Virus (HIV) risk score for targeted HIV screening. American Journal of Epidemiology, 175(8), 838–846. doi:10.1093/aje/kwr389. Mosher, W. D., Chandra, & A., Jones, J. (2005). Sexual Behavior and Selected Health Measures: Men and Women 15–44 Years of Age, United States, 2002. Advance Data, (362), 1–55. Retrieved from http://www.cdc.gov/nchs/data/ad/ad362.pdf. Lieb, S., Fallon, S. J., Friedman, S. R., et al. (2011). Statewide estimation of racial/ethnic populations of men who have sex with men in the U.S. Public Health Reports, 126(1), 60–72. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3001824/ pdf/phr12600060.pdf. Wesolowski, L. G., Sanchez, T., MacKellar, D. A., et al. (2009). Evaluation of oral fluid enzyme immunoassay for confirmation of a positive rapid human immunodeficiency virus test result. Clinical and Vaccine Immunology, 16(7), 1091–1092. doi:10. 1128/CVI.00083-09. American Public Health Association. (2013). Testing oral fluid for the presence of HIV antibodies. APHL Public Health Laboratory Issues in Brief. Retrieved from http://www.aphl. org/AboutAPHL/publications/Documents/ID_Feb2013_Testingof-Oral-Fluid-for-the-Presence-of-HIV-Antibodies-Brief.pdf. Paz-Bailey, G., Hall, H., Wolitski, R., et al. (2013). HIV testing and risk behaviors among gay, bisexual, and other men who have sex with men—United States. MMWR Morbidity Mortality Weekly Report, 62(47), 958–962. Retrieved from http://www.cdc. gov/mmwr/preview/mmwrhtml/mm6247a4.htm. Sanchez, T., Smith, A., Denson, D., DiNenno, E., & Lansky, A. (2012). Internet-based methods may reach higher-risk men who have sex with men not reached through venue-based sampling. The Open AIDS Journal, 6, 83–89. doi:10.2174/ 1874613601206010083. Raymond, H., Rebchook, G., Curotto, A., et al. (2010). Comparing internet-based and venue-based methods to sample MSM in the San Francisco Bay Area. AIDS and Behavior, 14(1), 218–224. doi:10.1007/s10461-009-9521-6. Kelly, B., Carpiano, R., Easterbrook, A., & Parsons, J. (2014). Exploring the Gay Community Question: Neighborhood and Network Influences on the Experience of Community among
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doi:10.1080/
ORIGINAL PAPER
Evaluation of the National HIV Behavioral Surveillance System Among Men Who Have Sex with Men in Denver, Colorado Kathryn H. DeYoung • Alia Al-Tayyib Mark Thrun
•
Ó Springer Science+Business Media New York 2014
Abstract Denver Public Health implements the National HIV Behavioral Surveillance System (NHBS), a cyclical survey of populations at increased risk for HIV. We evaluated the implementation of NHBS among Denver men who have sex with men (MSM), considering the system’s simplicity, data quality, representativeness, and sensitivity to trends. We found that the time required for implementation and the complexity of data management and analysis are barriers to disseminating local findings. Data quality has improved in each cycle of the study but must be protected by continually checking for errors and training field staff to be attentive to detail. Compared with the US census and other convenience samples of Denver MSM, the overall demographic representativeness of NHBS has improved over time. However, there is concern that the underlying population included in the study may be changing. NHBS survey data show evidence of two suspected trends in the local MSM population at risk for HIV: increasing sexual risk-taking and the transition away from bars as a dominant partner-finding location. It is unclear whether the increasing reports of sexual risk-taking reflect a real trend or simply a change in the population sampled, since most NHBS participants are recruited at gay bars and
K. H. DeYoung A. Al-Tayyib (&) M. Thrun Denver Public Health, 605 Bannock St, Denver, CO 80204, USA e-mail: [email protected] A. Al-Tayyib Department of Epidemiology, Colorado School of Public Health, Denver, CO, USA M. Thrun Division of Infectious Diseases, Department of Medicine, University of Colorado Denver School of Medicine, Denver, CO, USA
other venues. To ensure that the sample continues to represent the underlying population at risk and accurately identify trends, it is necessary to closely monitor MSM sample characteristics during implementation and incorporate weighted data provided by the Centers for Disease Control and Prevention into analyses. Keywords evaluation
NHBS MSM Surveillance system
Introduction In Denver and throughout Colorado, HIV prevalence is highest among gay, bisexual, and other men who have sex with men (collectively, MSM) [1, 2]. From 2008–2012, the majority of new cases in Denver were among individuals whose risk was male–male sex (71 %) and/or were male (90 %), non-Hispanic white (51 %) or Hispanic/Latino (31 %), or 20–29 or 30–39 years of age (31 % each) [2]. The Colorado Department of Public Health and Environment ranks urban MSM as the second highest priority for HIV prevention in Colorado (after people living with HIV/ AIDS), particularly youth aged 13–24 years and Caucasians, black/African Americans, and Hispanic/Latinos aged 25–49 years [3].
Program Being Evaluated The National HIV Behavioral Surveillance (NHBS) system is an anonymous multisite cyclical survey of populations at increased HIV risk [4–6]. Cycles focus in turn on MSM, injecting drug users (IDU), and heterosexuals at increased risk for HIV (HET). Health departments serving
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metropolitan statistical areas (MSAs) or MSA divisions with the highest AIDS prevalence are eligible to participate in NHBS. The primary objective of NHBS is to monitor HIV prevalence and trends in HIV risk behaviors, HIV testing history, and interaction with HIV preventive services among the risk populations [4]. Local data are intended for use in developing and monitoring local HIV prevention efforts and progress toward National HIV/AIDS Strategy goals [6, 7]. The National HIV Behavioral Surveillance MSM cycle methods have been described elsewhere [6, 8–10]. Briefly, these cycles employ venue-based time–space sampling to create an approximate sampling frame of the local MSM population at risk for HIV. NHBS sites conduct formative research to describe the target population and potentially underrepresented sub-groups. Input is obtained from people who are knowledgeable about the local MSM population via focus groups, key informant interviews, brief street interviews, and meetings with community stakeholders. Next, venues in the MSA with a high ratio of MSM attendees (including bars, bathhouses, restaurants, and street locations) and best dates and times for recruiting are compiled into a ‘‘venue universe.’’ In MSM1 and MSM2, venues were included if at least 75 % of attendees selfidentified as MSM during a venue observation; in MSM3 this criterion changed to 50 % [5, 9]. At recruiting events, every person entering the venue who appears male and 18 or older is counted and men who walk through a predefined sampling area are recruited [6, 11]. In MSM2 and MSM3, HIV testing was offered using oral specimens for rapid (OraQuick ADVANCEÒ Rapid HIV1/2 Antibody Test) and Western blot (BioRad GS HIV-1 Western Blot Human Immunodeficiency Virus Type 1) testing.
Purpose Before now, NHBS implementation had not been systematically evaluated in Denver. With HIV prevalence highest among Denver MSM, we decided to evaluate NHBS sampling and study methods in this population and focus on simplicity, data quality, representativeness, and sensitivity to trends. The Centers for Disease Control and Prevention (CDC)’s guide for evaluating public health surveillance systems informed this evaluation [12].
Clinic (DMHC), Denver Public Health (DPH) HIV Outreach, and the Denver Health Emergency Department (DH ED) HIV testing program. The 2010 US Census provided information on the underlying male population in Denver. Denver Metro Health Clinic is an urban STD clinic located within DPH. DPH also conducts outreach testing for HIV and STDs at various locations in the community including gay bathhouses and an outreach location primarily serving gay men in central Denver. Data from DMHC and outreach testing encounters are collected in HealthDoc, an electronic medical record system. MSM attending DMHC represent men who are actively seeking healthcare and screening related to their potential risk of HIV and other STDs; outreach testing records represent MSM who may or may not have been at the venue to seek screening related to their sexual risk factors. From January 2011 through September 2012, the DH ED used an instrument to calculate patients’ HIV risk score for targeted HIV screening [13, 14]. Data from this instrument provide a sample of MSM seeking healthcare for urgent medical needs. Data sources were sampled to reflect NHBS selection criteria and timing as closely as possible. The US census data were restricted to Denver men 18 years of age and older. All other samples were restricted to English/Spanishspeaking males (not transgender) who were 18–89 years of age and lived, received services, and/or attended venues in the Denver–Aurora MSA. Individuals in the NHBS, DMHC, HIV Outreach samples were included if they reported sex with at least one man within the prior 12 months. The ED Risk score did not ask about past-year sex, so that sample included men who reported ever having had sex with a man. NHBS MSM cycles took place in 2004–2005 (MSM1), 2008 (MSM2), and 2011 (MSM3). Other data sources were not available for all 3 years and were restricted to 2010 or 2011 for comparison with MSM3. To assess qualitative attributes, we interviewed local NHBS staff and community stakeholders and reviewed NHBS process indicators, protocols, and data correction logs. Data were analyzed using SAS Enterprise Guide. Chi square tests were used to detect differences in NHBS across two or more cycles; the Cochran–Armitage trend test was used to detect trends in variables collected in all three cycles. The study was determined by the Colorado Multiple Institutional Review Board (COMIRB) to be a program evaluation and not human subject research; results are not generalizable outside of the immediate context of the study.
Methods
Evaluation Criteria
Data Sources
Simplicity
NHBS–MSM participants were compared to three local data sources on MSM at risk for HIV: the Denver Metro Health
In a public health surveillance system, simplicity includes the ease of data collection, cleaning, analysis, and use. We
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examined local implementation requirements and the complexities of data analysis. Data Quality A questionnaire-based system with high data quality has few missing or invalid responses. This attribute can be impacted by interviewer skill, technology, and participant engagement. We reviewed data correction logs for MSM2 and MSM3 to determine number and types of errors detected and examined test results among self-reported HIV positive participants to review performance of the confirmatory HIV test.
Representativeness This attribute describes the accuracy of the system’s depiction of health trends, including time, geography, and participant sub-groups; it depends on selecting a representative sample from the target population and obtaining true responses from participants. Assessing this attribute requires data from alternative sources for the same population and time period. It is preferred to make comparisons with a ‘‘gold standard’’ representation of the population. While general estimates of the MSM population have been developed using figures from the National Survey of Family Growth (NSFG) and the American Community Survey’s estimates of same-sex couples, there is no detailed gold standard measure of MSM populations at risk for HIV, and we did not have access to comparable local data from other national studies such as NSFG [11, 15, 16]. We therefore compared Denver males and MSM as represented by the 2010 US Census, NHBS–MSM, DMHC, HIV Outreach, and the ED HIV testing program. Sensitivity to Trends Sensitivity can refer to the ability to accurately detect disease, health events, or relevant trends over time. Detecting trends requires consecutive observations and, optimally, another data source for comparison. We compared HIV status and sexual risk, partner-finding, and testing behaviors in the three NHBS MSM cycles.
Results Simplicity National HIV Behavioral Surveillance System is complex. Study preparation and data collection require substantial
time and effort (Fig. 1). Preparation for implementation has grown more efficient each cycle, with CDC delivering the protocol earlier in the year, materials moving more quickly through COMIRB, and formative research building on previous cycles. Still, the two periods of NHBS activities occupy essentially the full year, limiting time for analyzing and disseminating results. Until 2009, CDC acted as the data management center. CDC took 23 months in MSM1 and 19 months in MSM2 to return final corrected datasets to the sites. Recognizing this limitation, CDC contracted with a Data Coordinating Center (DCC), which returned final MSM3 datasets to sites in 3 months. Once returned, final datasets require substantial data management before analysis can occur. This is for three main reasons. Datasets retain the structure of the questionnaire software; no one source documents all of the information needed for accurate data analysis; and questions have changed slightly from cycle to cycle. Final datasets include variables calculated by the questionnaire software for use in skip patterns and edit checks (e.g., the date 12 months prior to the interview) as well as variables for questions that were asked in the IDU or HET cycles but not in the MSM cycle: MSM3 had nearly 300 unnecessary variables. Additionally, datasets do not include composite variables for questions where ‘‘check all that apply’’ answer options were recorded separately or where similar or identical questions were asked of different groups due to skip patterns. Questions about respondents’ sex practices like condom use during insertive or receptive anal intercourse were separated by whether the respondent had one male partner in the past 12 months or more than one. Calculating the number of reported anal sex partners in the past 12 months requires compilation of 4–6 different variables, depending on the cycle. Although datasets are returned with a data dictionary, there is no one guide documenting questions, answer options and associated keys (e.g., 1 = Male, 2 = Female), skip patterns, and unnecessary variables. This information must be compiled from several resources which do not always agree. A thorough knowledge of the questionnaires is necessary because one topic may be covered in several questions. For example, known HIV status was addressed in one variable in MSM1, two in MSM2, and three in MSM3. Slight changes to questions or answer options can complicate longitudinal analyses. For instance, a question about where the participant received his most recent HIV test had 18 response options in MSM1, 15 in MSM2, and 12 in MSM3. This topic was covered in two questions in MSM1 (one for location of recent negative/unknown result in the past 12 months and one for location of positive
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Fig. 1 Current schema of local NHBS tasks for MSM cycle
participants’ first positive result); in one question of all respondents with a prior HIV test in MSM2; and in MSM3, in one question of all with a test in the past 5 years. Comparing these questions requires reconciliation of the answer options and acceptance that the question was asked of slightly different groups each time. Data Quality HIV testing was offered during MSM2 and MSM3, with test and survey consent documented separately. In MSM2, 95 participants did not have documented HIV consent. Of those 95, 31 (33 %) had a Western blot (confirmatory HIV testing) performed. It is likely that these participants verbally consented but their consent was not recorded. In MSM3, the number of participants without documented consent decreased to 39 and only 2 (5 %) of these received a confirmatory test. Test results without documented consent cannot be included in analyses.
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Data corrections logs for MSM2 and MSM3 reveal common interviewer errors, including incorrect survey ID, venue ID, and event number. In MSM2, an interviewer was found to be unreliable and their interviews were deleted. MSM3 saw an increase in technological errors; occasionally the calendar and clock on the handheld devices would reset and assign incorrect dates and times to interviews unless the interviewer noticed and corrected the problem. A key component of NHBS is the ability to connect participants’ risk and preventive behaviors with their HIV status. Among self-reported HIV positive participants who consented to testing, 22 (31 %) in MSM2 and 18 (23 %) in MSM3 had an indeterminate or negative Western blot result (Table 1). In both cycles, the Denver site tested oral fluid, which is known to have a higher false-negative rate than blood [17, 18]. After MSM3, Denver began drawing blood for HIV testing and the Western blot was replaced by a fourth generation enzyme immunoassay. These changes are expected to improve HIV test performance.
J Community Health Table 1 Performance of NHBS confirmatory HIV test (Western blot on oral specimen) among self-reported HIV-positive MSM who consented to testing Western blot
MSM2
%
MSM3
%
Overall
%
Positive
47
67.1
60
75.9
107
71.8
Indeterminate
15
21.4
13
16.5
28
18.8
7 1
10.0 1.4
5 1
6.3 1.3
12 2
8.1 1.3
Negative Missing Total
70
79
149
Representativeness Some field staff and community stakeholders voiced questions about the representativeness achieved by the NHBS venue-based sampling method. One staff member suggested that the Denver MSM population might be represented differently by respondent driven sampling, which is used in the NHBS IDU and HET cycles. Community members commented that non-gay identified (NGI) and minority MSM may more regularly attend venues with a lower percent of MSM than the NHBS venue criteria permit. Minority MSM tend not to live in Denver’s historically gay neighborhoods and may attend venues that reflect their race/ ethnicity rather than their sexual identity. Finally, there was concern that increasing use of the internet for partnerfinding may decrease the frequency that some MSM visit physical venues and their likelihood of being sampled. The demographic makeup of NHBS–MSM participants has changed significantly across the three cycles, with the proportion of MSM who are younger, black/African American, or Hispanic/Latino increasing over time and becoming generally more representative of the Denver MSM population at risk (Tables 2, 3). Educational attainment also changed, perhaps due to the shifting age and race/ethnicity of participants. Denver NHBS–MSM samples were compared to several other data sources of the underlying male and MSM population at risk in the Denver metro area (Table 3). Sources were restricted to 2010 or 2011 to examine a similar point in time. NHBS had a greater proportion of males aged 18–24 compared to the US Census but a lower proportion than the other samples and the greatest proportion of 30–49 year-olds of any source. American Indians and black/African Americans made up a greater proportion of the NHBS sample than the other sources. The NHBS sample had the highest percent of men who self-reported as HIV positive and the lowest percent who reported never having been tested. Compared to electronic testing records in the DMHC, HIV Outreach, and ED samples, NHBS participants self-reported a greater mean number of years since most recent HIV test (among those ever tested) and a
greater mean number of tests in the last 2 years (among those tested in the last 2 years). These seemingly contradictory findings may indicate that NHBS represents a greater diversity of MSM than the other samples. Finally, NHBS had the lowest rate of previously undiagnosed HIV positive participants, likely because the other settings have less reason to test known positive patients. Sensitivity to Trends Community members and stakeholders were concerned that sexual risk behaviors may be increasing among Denver MSM. They also raised the possibility that increasing use of the internet and mobile applications for partner-finding and the declining significance of predominantly gay venues and neighborhoods could cause venue-based sampling to become less representative. There is evidence that these trends exist and extend past Denver. CDC has reported that MSM NHBS participants are reporting more sexual risk than in past cycles [19]. The decline of gay neighborhoods and venues, rise of internetbased socialization, and differences between MSM sampled online versus at physical venues have been described in other US cities and internationally [20–23]. We tested the ability of NHBS to confirm these trends in Denver (Table 4). The proportion of participants who met their last casual or exchange male partner in a bar or club decreased from 49.8 % in MSM1 to 29.5 % in MSM3, while those who met that partner on the internet doubled between MSM1 and MSM3. Participants reporting condomless anal intercourse (CAI) with at least one male in the past 12 months increased significantly from 49.5 % in MSM1 to 65.7 % in MSM3. HIV testing behaviors, known status, and new HIV diagnoses remained stable over time.
Lessons Learned Denver’s NHBS MSM cycles have yielded good quality data that appear representative of the population of MSM at risk and able to detect local trends. However, these attributes require attention to ensure that NHBS remains a source of trustworthy, usable local data. Additionally, the time required for implementation of each cycle and the complexity of data management and analysis are significant barriers to disseminating findings at the local level. Maintaining robust documentation of the questionnaires and datasets will make the analysis process more efficient. Access to DMHC, HIV Outreach, and ED data allowed us to evaluate representativeness in comparison with several local data sources on MSM at risk of HIV infection. At the same time, these were convenience samples, each with their own sampling biases. We were also unable to
123
123 102 280 244 118
25–29
30–39
40–49
50?
833 17 151 267 398
Education
\High school
High school diploma/GED
Some college/tech. degree
College degree/postgrad ed.
a
761 66 4
Homosexual/gay
Bisexual
Other
0.5
7.9
91.4 (0.0, 1.0)
(6.1, 9.8)
(89.4, 93.3)
0
62
481
1
Cochran–Armitage trend test was performed on variables collected in all three cycles
2
Heterosexual/straight
108 544
84
$75,000? Orientation
219
$50,000–74,999
544
213
177
123
31
544
35
336
149
22
2
37.52 544
98
126
153
82
85
544
$20,000–$49,999
–
(44.4, 51.2)
(28.9, 35.2)
(15.5, 20.7)
(1.1, 3.0)
(5.6, 9.2)
(63.0, 69.5)
(16.9, 22.4)
(4.0, 7.1)
(0.5, 2.0)
(37.55, 39.01)
(11.8, 16.5)
(26.2, 32.4)
(30.4, 36.8)
(10.0, 14.5)
(8.6, 12.8)
133
0.2
47.8
32.1
18.1
2.0
7.4
66.3
19.6
5.5
1.2
14.2
29.3
33.6
12.2
10.7
0–$19,999
833
60
Other
Household income
160 540
White
45
Black/African American
Hispanic/Latino
10
American Indian
38.28 815
89
Mean age Race/ethnicity
833
18–24
0.0
11.4
88.4
0.2
19.9
15.4
40.3
24.4
39.2
32.5
22.6
5.7
6.4
61.8
27.4
4.0
0.4
18.0
23.2
28.1
15.1
15.6
%
N
95 % CI
N
%
MSM2 (2008)
MSM1 (2004–2005)
Age groups
Variable
Table 2 Demographic characteristics of NHBS participants (2005–2011)
–
–
–
(8.7, 14.1)
(85.7, 91.1)
(16.5, 23.2)
(12.4, 18.5)
(36.1, 44.4)
(20.8, 28.1)
(35.0, 43.3)
(28.6, 36.5)
(19.1, 26.1)
(3.7, 7.6)
(4.4, 8.5)
(57.7, 65.9)
(23.6, 31.1)
(2.4, 5.7)
(36.50, 38.53)
(14.8, 21.2)
(19.6, 26.7)
(24.3, 31.9)
(12.1, 18.1)
(12.6, 18.7)
95 % CI
0
62
479
1
84 542
89
207
163
543
207
195
125
16
543
30
297
145
59
12
36.82 543
84
118
146
108
87
543
N
0.0
11.4
88.4
0.2
15.5
16.4
38.1
30.0
38.1
35.9
23.0
2.9
5.4
54.7
26.7
10.9
2.2
15.5
21.7
26.9
19.9
16.0
%
MSM3 (2011)
–
(8.8, 14.1)
(85.7, 91.1)
–
(12.4, 18.5)
(13.3, 19.5)
(34.0, 42.2)
(26.2, 33.9)
(34.0, 42.2)
(31.9, 40.0)
(19.5, 26.6)
(1.5, 4.4)
(3.5, 7.2)
(50.6, 59.0)
(23.0, 30.5)
(8.3, 13.5)
(1.0, 3.5)
(35.78, 37.87)
(12.4, 18.5)
(18.3, 25.2)
(23.2, 30.6)
(16.5, 23.3)
(12.9, 19.1)
95 % CI
(–)
(0.0228)
(0.0581)
(0.8131)
0.0552
0.0888
(0.0002)
(0.1540)
(0.0207)
(0.1859)
\0.0001
(0.1411)
(\0.0001)
(0.0012)
(0.0004)
(0.1790)
0.07 \0.0001
(0.3933)
(0.0010)
(0.0055)
(0.0001)
(0.0028)
\.0001
Chi square p (Cochran–Armitage pa)
J Community Health
J Community Health Table 3 Demographics, HIV testing, and new diagnoses of MSM by data source (2010–2011)
US Census (Males 18? 2010) Age groups
1,183
1,064
87 (16.0)
284 (24.0)
198 (18.6)
77 (21.1)
25–29
33,027 (14.1)
108 (19.9)
270 (22.8)
198 (18.6)
58 (15.9)
30–39
55,727 (23.7)
146 (26.9)
286 (24.2)
248 (23.3)
92 (25.2)
40–49
41,052 (17.5)
118 (21.7)
211 (17.8)
223 (21.0)
73 (20.0)
50?
74,257 (31.6)
84 (15.5)
132 (11.2)
197 (18.5)
65 (17.8)
234,704
36.82 ± 1.05 543
34.34 ± 0.67 1,183
37.56 ± 0.80 1,064
364
12 (2.2)
4 (0.3)
13 (1.2)
1,294 (0.6) 21,665 (9.2)
59 (10.9)
86 (7.3)
53 (5.0)
39 (10.7)
Hispanic/Latino
63,824 (27.2)
145 (26.7)
303 (25.6)
170 (16.0)
94 (25.8)
136,423 (58.1)
297 (54.7)
719 (60.8)
725 (68.1)
208 (57.1)
30 (5.4)
71 (6.0)
103 (9.7)
11,498 (4.9)
d
Gave any answer indicating known positive status
543
23 (6.3) 365
Men only
265 (48.8)
183 (50.1)
Men and woman
278 (51.2)
182 (49.9)
Orientation
Excludes 2 who denied ever testing but elsewhere indicated a known positive status
a
Black/African American
Ever had sex with
Self-report
365
543
Other/Multiple
c
ED (2011)
30,641 (13.1)
White
b
Outreach (2011)
234,704
American Indian
Not an option in ED risk assessment tool
DMHC (2011)
18–24
Mean age Race/ethnicity
a
NHBS (2011)
542
1,183
Heterosexual/straight
1 (0.2)
86 (7.3)
16 (1.5)
Homosexual/gay
479 (88.4)
893 (75.5)
862 (81.0)
Bisexual
62 (11.4)
117 (15.0)
166 (15.6)
Other
0 (0.0)
27 (2.3)
20 (1.9)
543 32c (5.9)
1,183 139 (11.8)
1,064 74 (7.0)
Yes
511 (94.1)
1,044 (88.3)
990 (93.1)
288 (78.9)
Unsure
0
0
0
4 (1.1)
543
1,183
1,064
288
431c (79.4)
966 (81.7)
948 (89.1)
283 (98.3)
Ever testedb No
Self-reported HIV status Negative
d
1,064
365 73 (20.0)
Positive
80 (14.7)
102 (8.6)
47 (4.4)
0 (0)
Unknowne
32 (5.9)
115 (9.7)
69 (6.5)
5 (1.7)
Mean # years since latest test (among ever tested)
2.12 ± 0.35b
1.78 ± 0.21f
1.49 ± 0.22f
g
Mean # tests in last 2 years (among tested 2 years)
3.25 ± 0.32b
1.84 ± 0.11f
1.98 ± 0.11f
1.9 ± 1.1g
h
Previously undiagnosed HIV
11 (15.5)
37 (88.1)
23 (95.8)
13 (100.0)
71h
42
24
13i
e
Includes never tested, results not known, and indeterminate
f
HealthDoc records
Emergency department records Consented to HIV testing, tested, positive Western blot test through NHBS
i
Preliminary rapid test result
Total persons testing positive for HIV
compare NHBS trends in partner-finding and sexual risk with consecutive observations from another source. Representativeness and sensitivity to trends are interdependent; changes over time could represent sampling changes (intentional and unintentional), emerging trends, or both. One notable concern is that venue-based sampling may select individuals whose risk behaviors differ from the overall local at-risk MSM population [10, 20, 21]. This difference could be growing due to the increased use of the internet for partner-finding and decreased attendance at gay bars and other venues. If
MSM who regularly attend venues meeting NHBS criteria are engaging in more risk behaviors than those who do not, the increase in the percent of MSM reporting CAI could reflect a sampling bias that is emerging as other MSM decrease attendance at these venues. Similarly, new HIV diagnoses in Denver are known to have steadily declined in recent years, so the lack of a significant decrease in new HIV diagnoses between MSM2 and MSM3 could indicate that this method is increasingly sampling higher-risk MSM [1, 2]. On the other hand, there is some evidence that MSM who meet via the
123
J Community Health Table 4 Trends in Sexual behaviors, HIV testing history, and HIV status Variable
Where met last non-main male partnerb Bar/club Internet/chat room Other Condomless anal intercourse with male past 12 months
MSM1 (2004–2005)
MSM2 (2008)
MSM3 (2011)
N
N
N
%
95 % CI
576
%
95 % CI
288
%
95 % CI
\0.0001
308
287
49.8
(45.7, 53.9)
117
40.6
(34.9, 46.3)
91
29.5
(24.4, 34.7)
(\0.0001)
83
14.4
(11.5, 17.3)
62
21.5
(16.8, 26.3)
88
28.6
(23.5, 33.6)
(\0.0001)
206
35.8
(31.8, 39.7)
109
37.8
(32.2, 43.5)
129
41.9
(36.4, 47.4)
833
544
Yes
412
49.5
(46.1, 52.9)
309
56.8
(52.6, 61.0)
357
65.7
(61.7, 69.7)
421
50.5
(47.1, 53.9)
235
43.2
(39.0, 47.4)
183
34.3
(30.3, 38.3)
No Yes Unknown
833
544
38
4.6
795 0
95.4
(3.1, 6.0) (94.0, 96.9)
HIV testing past 12 months
833
No (includes never tested, unknown if tested)
328
39.4
(36.1, 42.7)
505
60.6
(57.3, 63.9)
Yes Self-reported HIV status
543 5.9
93.6 (91.9, 95.9) 0.4 –
511 0
94.1
220
40.4
(36.3, 44.6)
236
43.5
(39.3, 47.6)
324
59.6
(55.4, 63.7)
307
56.5
(52.4, 60.7)
509 2
6.1
(4.1, 8.1)
544
833
(4.2, 8.3) (91.7, 95.8)
0.3134
543
(0.1409)
0.5266
Positived
119
14.3
(11.9, 16.7)
92
16.9
(13.8, 20.1)
80
14.7
(11.7, 17.7)
(0.7051)
Negative
671
80.6
(77.9, 83.2)
417
76.7
(73.1, 80.2)
431
79.4
(76.0, 82.8)
(0.4763)
43
5.2
35
6.4
(4.4, 8.5)
32
5.9
(3.9, 7.9)
(0.5080)
Positive
60
13.5
(10.3, 16.6)
71
14.2
Negative
367
82.3
(78.7, 85.8)
416
83.0
19
4.3
14
2.8
(1.3, 4.2)
15.5
(6.9–24.0)
Unknown (never tested/results not known/indeterminate)
(3.7, 6.7)
Result of NHBS Western blot
Indeterminate Total (consented and tested) Previously undiagnosed HIV Total persons testing positive for HIV)e a
(0.1526)
–
543
544
(\0.0001) 0.3033
32c
33
(0.0779) \0.0001
543
No Ever tested for HIV
Chi square p (Cochran–Armitage pa)
0.4587
(2.4, 6.1)
446 13
(11.1, 17.2) (79.7, 86.3)
501 21.7
(11.1–32.3)
60
11
0.3628
71
Cochran–Armitage trend test was performed on variables collected in all three cycles
b
MSM1–MSM3: restricted to where met last casual/exchange male partner; in MSM3 this question was only asked of men who had been in the relationship \3 years
c
Excludes 2 who denied ever testing but elsewhere indicated a known positive status (counted here as ‘‘yes’’ despite denying ever testing)
d
Gave any answer indicating known positive status
e
Consented, tested, positive Western blot in NHBS
internet have higher rates of sexual risk behaviors than those who met elsewhere [20]. In MSM3, CDC began providing locally weighted data to account for bias arising from venue selection, day/time of venue visits, and venue size. Additional venue information will be collected in MSM4 to improve the weighting process. To ensure that the sample continues to represent the underlying population at risk and accurately identify trends, it will be necessary to closely monitor the
123
MSM sample characteristics during implementation and incorporate weighted data into analyses. Acknowledgments This report was supported in part by an appointment to the Applied Epidemiology Fellowship Program administered by the Council of State and Territorial Epidemiologists (CSTE) and funded by the Centers for Disease Control and Prevention (CDC) Cooperative Agreement Number 5U38HM000414-5. The authors gratefully acknowledge Jason Haukoos, Emily Caruso, and Christie Mettenbrink for their assistance in obtaining additional data sources for comparison. The authors thank Charles Chen, Toby
J Community Health LeRoux, Theresa Mickiewicz, and the Denver NHBS interviewers for their tireless efforts in collecting this important data. We also thank the community members and stakeholders who so generously gave of their time to provide their insights to inform this evaluation.
10.
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