1. Using HIV Incidence Surveillance Data
to Examine Racial/Ethnic Disparities in
HIV Testing Behaviors Among YMSM
in Los Angeles County
S Nakelsky, V Hu, E Kahn, Z Sheng, L Taylor, T Bingham
HIV Epidemiology Program
Los Angeles County Department of Public Health

2. Overview
• Background
• Study population
• Methods
– Core HIV Surveillance System
– HIV Incidence Surveillance System
• Results
– New HIV cases diagnosed
– HIV testing behaviors and frequency by race/ethnicity
– HIV incidence estimates for all MSM
• Conclusions and recommendations

3. Background
• CDC testing recommendations:
– At least annual HIV testing for those at high risk
• MSM in LAC are not adhering to guidelines:
– Concurrent HIV and AIDS diagnoses (13%)
– 24% diagnosed with AIDS within 6 months of HIV
– 2008 NHBS-MSM2 data (mean= 12.1 months)
– New indicator: testing and treatment history data
collected for HIV Incidence Surveillance

4. Why young MSM?
• The majority (~84%) of people diagnosed with
HIV annually in LAC are MSM.
• In 2008, MSM aged 13-29 years were the
group most frequently diagnosed with HIV.
• Identifying strategies to increase HIV
diagnosis and to decrease transmission in
YMSM will have a large impact on LAC’s
epidemic.

5. Methods
• Data were obtained from existing HIV
surveillance systems
• Eligibility for analysis:
– 13-29 years of age
– Diagnosed in 2008
– Resided in LAC at the time of diagnosis
– Reported sex with males as a risk factor
• Denominators for rates assumed 4% of males
aged 13-29 years were MSM

6. Data Sources (1)
• Enhanced HIV/AIDS Reporting System
(EHARS)
– Age
– Race/ethnicity
– Mode of transmission
– HIV diagnosis date
– Proportion of cases diagnosed with AIDS within 6
months of HIV diagnosis (late detection)

7. Data Sources (2)
• HIV Incidence Surveillance
– Uses statistical methods to estimate # of new
infections among those who do and don’t test
– Serologic Testing Algorithm for Recent HIV
Seroconversion (STARHS)
• Remnant sera of new HIV diagnoses tested with BED
assay to estimate # of cases acquiring HIV in 12 months
– HIV testing and treatment history
• History of previous negative test results
• Date of most recent negative test result
• Time between last negative and first positive test

8. Results from EHARS

9. Results: Overview of YMSM in LAC, 2008
• 563 MSM aged 13-29 years were newly
diagnosed with HIV
• Latinos represented the largest number of new
diagnoses among YMSM
• Rates of new HIV diagnoses:
– 31 per 1,000 for Blacks
– 10 per 1,000 for Whites
– 9 per 1,000 for Latinos

10. Proportion of YMSM in
Los Angeles County by Race, 2008
Total Population New HIV Diagnoses
Black, Other
Other,
9.0% 7.8%
12.0%
Black
White, White 26.3%
23.1% 21.0%
Latino,
55.9% Latino
44.9%

11. Late Detection
% diagnosed with AIDS within 6 months of HIV Diagnosis
20%
15% 18.3% 17.4%
15.3%
10%
5%
0%
Black (n=148) Latino (n=253) White (n=118)

12. Results from HIS data

13. STARHS Results by Race
70%
Recent
60% 63%
63% Longterm
50%
50% 50%
40%
37% 37%
30%
20%
10%
0%
Black (n=78) Latino (n=116) White (n=50)

14. First Time versus Repeat Testers by Race
100%
80%
60% 74%
87% 89%
40% Repeat Tester
New Tester
20%
26%
13% 11%
0%
Black (n=82) Latino White(n=64)
(n=151)
Latino vs. Black p=0.02; Latino vs. White p=0.01

15. Months between Last Negative and
First Positive Test by Race
16
Mean Number of Months
14
12 14
10 13
8
6
9
4
2
0
Black (n=70) Latino (n=106) White (n=56)
White vs. Latino p=0.02; white vs. black p=0.04

16. Months since Last HIV Test by Race,
YMSM enrolled in 2008 NHBS
15
Mean Number of Months
13
11
9 12.8 12.6
10.8
7
5
3
1
Black Latino White

17. Estimated HIV Incidence Rates
for all MSM in LAC, 2008
18 16
16
14
11
12
10 9
Rate per 1,000
10
8
8 7
6
4
2
0 Black Latino
13-29 30-39 40-49 White
Age Race
17

18. Summary
• STARHS results indicate <50% of YMSM
adhere to annual HIV testing recommendations
• Frequency of HIV testing varies by race/eth.
– Latino YMSM reported highest:
• Average months between last negative and first positive
• Proportion of new HIV diagnoses at first test
– Black YMSM reported lower testing frequency
compared with White YMSM
• Black YMSM are disproportionately impacted
– Findings observed in both surveillance systems
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19. Limitations
• Establishing HIS within LAC has proven
challenging
• HIS data for 2008 are marginally complete
– Of the men diagnosed with non-AIDS HIV, 244
(51%) had a STARHS result available
– 435 cases (71%) had some but not all testing
history data elements available

20. Conclusions
• HIS provides additional insight for monitoring
HIV testing behaviors and rate of new
infections
• In LAC, all YMSM—but especially Blacks
and Latinos—would benefit from increased
HIV testing to detect new infections

21. Moving Forward
• Future research should focus on identifying
specific barriers (e.g., stigma, access,
acceptable modes) to HIV testing among
YMSM
• Revised testing recommendations, social
marketing campaigns, and other approaches
must consider racial/ethnic differences in
testing norms and HIV incidence rates to
support more appropriate testing intervals

22. Thank You!
For more information contact:
Shoshanna Nakelsky
HIV Incidence Surveillance Coordinator
snakelsky@ph.lacounty.gov
213.351.8154
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