Sounding Board
Applying Public Health Principles to the HIV Epidemic
N Engl J Med 2005; 353:2397-2402December 1, 2005
- Article
Although human immunodeficiency virus (HIV) infection has killed more than half a million people in the United States, a comprehensive public health approach that has stopped other epidemics has not been used to address this one. When HIV infection first emerged among stigmatized populations (homosexual men, injection-drug users, and immigrants from developing countries), the discriminatory responses ranged from descriptions of AIDS as “retribution” to violence and proposals for quarantine, universal mandatory testing, and even tattooing of infected persons. This response led to HIV exceptionalism, an approach that advocated both for special resources and increased funding and against the application of standard methods of disease control.1 The need for extra resources remains essential, but the failure to apply standard disease-control methods undermines society's ability and responsibility to control the epidemic.
Now, given the availability of drugs that can effectively treat HIV infection and progress on antidiscrimination initiatives, perhaps society is ready to adopt traditional disease-control principles and proven interventions that can identify infected persons, interrupt transmission, ensure treatment and case management, and monitor infection and control efforts throughout the population (Table 1Table 1
Comparison of Public Health Approach to HIV Infection and Other Infectious Diseases.). Doing so will have political and economic costs. The political costs include offending both sides of the political establishment: conservatives who oppose the implementation of effective prevention programs, including syringe exchange and the widespread availability of condoms, and some HIV activists who oppose expansion of testing, notification of the partners of infected persons (also known as partner counseling and referral services), and what some see as inappropriate “medicalization” of the response to the epidemic. The economic costs, particularly to improve population-wide case management and notification of partners, would be substantial. But the human and economic costs of failing to adopt a comprehensive public health approach are much higher.We have identified and elucidated the biology of the virus, established and improved diagnostic tests, and created effective drugs and care systems that have reduced the number of deaths from AIDS in the United States by 70 percent since 1995.2 However, 25 years into the epidemic, progress is stalled. The number of deaths among people with AIDS has not declined since 1998, and the number of newly diagnosed cases is rising slightly.2 Disease transmission continues at the same or, possibly, a slightly higher rate.3 High-risk behavior remains common and is increasing in some groups. Late diagnosis of infection is common.3 Notification of the partners of infected persons is rare.4 Black and Latino patients are less likely than white patients to receive optimal care.5 Few patients in care receive counseling about preventing transmission of the virus.6 All these trends are apparent in New York City, which is home to one in six of all U.S. patients with AIDS.
Case Finding and Surveillance
When HIV testing became available 20 years ago in the absence of treatment and in the context of discrimination, the use of prescriptive regulations mandating counseling and separate written consent, based largely on the genetic-counseling model of testing for untreatable conditions, was reasonable. Today, the existence of these regulations and the separation of counseling and testing from routine medical care result in missed opportunities to diagnose, treat, and stop the spread of HIV infection. Nearly half of black men tested in public venues where men who have sex with men congregate (e.g., bars, bathhouses, and parks) in 2004 and 2005 were HIV-positive, and two thirds of those who were positive were unaware of their status.7 Our outdated approach to HIV screening means that we not only fail to identify infected patients promptly and thus allow the epidemic to continue to spread, but we may also perpetuate HIV-related stigma by targeting screening only to those perceived to be at risk. Routine, voluntary HIV testing in health care settings, although advocated by the Centers for Disease Control and Prevention (CDC) for more than a decade,8 widely recommended,9 and cost-effective,10 has not occurred. In New York City in 2002, only one third of adults who had had three or more sex partners in the preceding year — and only half of men who had sex with men who had had three or more partners — had been tested for HIV in the previous 18 months.
Early diagnosis is essential both to link patients to effective care and to prevent the spread of infection. The CDC estimates that more than half of new HIV infections are spread by HIV-positive people who are unaware they are infected.11 In nearly 40 percent of persons who received a diagnosis of HIV infection, AIDS either was concurrently diagnosed or developed within a year.3 They had been infected with HIV for about a decade; health care and other institutions missed many opportunities to diagnose their infection. As a result of delayed diagnosis, such patients are sicker when they begin to receive care and will thus die sooner than those whose infection is diagnosed promptly. Many unwittingly spread HIV to their spouses, partners, and others. Once they know their diagnosis, people infected with HIV reduce their practice of high-risk sex by about half,12 and the risk of heterosexual transmission, at least, is further reduced by treatment that decreases the viral load to below 1500 copies of HIV type 1 RNA per milliliter.13 Voluntary HIV screening and linkage to care should become a normal part of medical practice, similar to screening for other treatable conditions, such as high cholesterol levels, hypertension, diabetes, and breast cancer. Screening and linkage to care are especially important in communities with a high prevalence of HIV infection.
The partners of more than two thirds of people with newly diagnosed HIV infection do not receive organized partner notification, and when contact is attempted, the rate of success varies greatly.4 The notification of partners by public health counselors is more effective than notification by individual patients,14 but this approach is rare in most areas. As a result, most partners are not notified of their exposure or offered testing, contributing to late diagnosis and continued spread of HIV. Of 4312 persons with newly diagnosed HIV infection in New York City in 2003, information on these persons' partners was available for less than a fifth and testing results were confirmed for fewer than 200 partners. In addition, the policy of offering partner notification only at the time of diagnosis ignores the continuing high-risk sexual behavior of many HIV-positive persons. Systematic notification of partners by public health personnel and the use of newer antibody or nucleic acid–amplification tests in addition to traditional methods could identify social networks and acute or early HIV infections and could potentially stop clusters of transmission.
Interrupting Transmission
The application of the public health principles of near-universal screening and treatment has all but eliminated transfusion-related and perinatal transmission of HIV.3 Among injection-drug users, syringe-exchange programs and widespread voluntary screening for the virus reduced the rate of transmission by 50 to 80 percent.15 Further progress in preventing HIV infection is possible — interventions to change behavior work16-19 — but reducing sexual transmission is challenging. Evidence-based ways to reduce high-risk behavior include promoting the use of condoms and making free condoms widely available,16,19 including in schools20; making clean needles readily available to people who inject illicit drugs21; and community interventions.19
Condoms, which can substantially reduce transmission,16,22 are not widely available nor is their use strongly promoted, and they are still used infrequently in high-risk sexual encounters.23 Most injection-drug users in the United States continue to use nonsterile needles.24 Until recently in New York City, condom-distribution programs were limited, even in high-risk settings, and several neighborhoods in need of syringe-exchange services were not served by these programs.
Systematic Treatment and Case Management
Standard public health approaches that have either not been applied or been applied inconsistently to HIV prevention and control efforts include public health monitoring to ensure that all HIV-infected patients receive quality care, providing public health support through referrals and outreach for patients who are not receiving effective treatment, monitoring of CD4 cell counts and viral loads to identify patients who may be candidates for treatment or who are lost to care, and assisting clinicians with outreach and partner notification. Although HIV infection remains incurable, AIDS is now a chronic disease for those fortunate enough to receive effective treatment. The use of effective treatment that incorporates risk-reduction counseling,25 including distribution of condoms, promotion of the use of condoms and clean needles, and treatment for substance abuse and mental health conditions, would improve individual treatment outcomes and reduce disease transmission, but it is uncommon.6
Case management is prominent in the HIV service delivery system, yet few if any jurisdictions ensure that every patient is offered effective treatment and prevention services. Public health interventions to monitor and improve HIV case management can be effective26 but are rare.
Population-Based Monitoring and Evaluation
It took nearly two decades to make HIV reportable throughout the United States, and named reporting is still not universal. Although information on CD4 cell counts and viral loads is collected in most jurisdictions, monitoring these data to determine patients' progress is rare. Surveillance for drug-resistant strains of virus in patients who have never been treated is generally not conducted. Information on viral loads, CD4 cell counts, and drug resistance recently became reportable in New York State, thus making it possible to identify patients who are not receiving effective care, monitor trends in drug resistance, potentially identify clusters of disease, and potentially provide physicians and their patients who are not receiving care with more intensive services. Publicly funded case management, treatment, and service systems are not effectively coordinated to ensure a continuum of care. Effective population-based monitoring and evaluation would track not only the incidence, prevalence, and mortality of HIV infection, but also indicators of the interruption of transmission, such as the use of voluntary testing, proportion of partners notified, linkage to care of those who test positive, and success at reducing viral load when treatment is clinically indicated.
The spread of HIV could be reduced substantially if newly infected people promptly learned of their status, reduced high-risk behaviors, and when clinically indicated, began and continued treatment that suppresses viral replication. But few if any jurisdictions even attempt to monitor whether all HIV-infected people receive effective treatment, let alone intervene to provide additional support when patients do not start, discontinue, or do not respond well to treatment. New York City, which has one of the nation's strongest case-management infrastructures, has no systematic citywide information available on whether patients have begun, are continuing, or have a virologic response to treatment.
Conclusions
Proven interventions, such as the use of condoms, clean needles, and expanded voluntary screening, and linkage to care, could prevent most HIV infections.27 Improving community-based efforts and counseling of individual patients to prevent transmission, supporting patients to facilitate their return to care, and improving the availability of effective treatment could further reduce transmission. But 25 years into the epidemic, we do not consistently apply these proven strategies.
Cost-effective programs include mass-media education campaigns, efforts to make condoms widely available, and interventions to change high-risk behavior in groups with a high prevalence of HIV infection.19 Routine, voluntary screening for HIV is indicated on the basis of clinical efficacy and cost-effectiveness,10 and the cost is moderate, as compared with that of many other health interventions. Notification of an infected person's partners after counseling and testing prevents infections and probably saves money.28
Using the current CDC estimate of 40,000 new HIV infections per year, the potential to prevent half to two thirds of these infections, and the current average lifetime cost of care for a patient with HIV infection of $200,000,29 more effective epidemic control would save between $4 billion and $5.4 billion per year. Widespread availability of condoms, syringe-exchange programs, public health notification of the partners of infected persons, and improvement of case management and monitoring systems would be unlikely to cost more than an additional $1 billion to $2 billion per year nationally — two to three times the current CDC funding for HIV prevention.
Controlling epidemics is a fundamental responsibility of the government, working in concert with physicians, patients, and communities. There is a delicate balance between protecting the public and the individual right to privacy. Until we implement prevention programs with proven efficacy more widely, make voluntary screening and linkage to care a normal part of medical care and expand screening in community settings, and improve treatment, risk reduction, monitoring, and partner notification, we will continue to miss opportunities to reduce the spread of HIV infection.
Some religious and political groups oppose the use of effective prevention measures. Some advocacy groups oppose expansion of screening and funding of government programs for prevention and control of HIV infection. Some doctors, health care facilities, and organizations will oppose increased monitoring of treatment efficacy; moreover, this cannot be accomplished without additional resources. There are few models for this approach, although Malawi has begun to apply public health principles to testing, treatment, and monitoring.30 Although stigma and discrimination on the basis of sexual orientation continue, advocacy has resulted in substantial progress, including antidiscrimination statutes in many states and increasing numbers of jurisdictions that recognize the rights of domestic partners. The world has changed in the past 25 years, and approaches to HIV prevention must also change. If we fully apply public health principles to the HIV epidemic, we can improve the health of people living with HIV infection and prevent tens of thousands of people in this country from becoming infected with HIV in the next decade.
We are indebted to Drew Blakeman for assistance in the preparation of the manuscript and to Colin McCord and Mark Barnes for helpful comments.
Source Information
From the New York City Department of Health and Mental Hygiene, New York.
- References
References
1
Bayer R . Public health policy and the AIDS epidemic: an end to HIV exceptionalism? N Engl J Med 1991;324:1500-1504
Full Text | Web of Science | Medline2
Advancing HIV prevention: new strategies for a changing epidemic -- United States, 2003. MMWR Morb Mortal Wkly Rep 2003;52:329-332
Medline3
Cases of HIV infection and AIDS in the United States, 2003. HIV/AIDS surveillance report. Vol. 15. Atlanta: Centers for Disease Control and Prevention, 2004.
4
Golden MR ,Hogben M ,Potterat JJ ,Handsfield HH . HIV partner notification in the United States: a national survey of program coverage and outcomes. Sex Transm Dis 2004;31:709-712
CrossRef | Web of Science | Medline5
Palacio H ,Kahn JG ,Richards TA ,Morin SF . Effect of race and/or ethnicity in use of antiretrovirals and prophylaxis for opportunistic infection: a review of the literature. Public Health Rep 2002;117:233-251
Web of Science | Medline6
Morin SF ,Koester KA ,Steward WT , et al. Missed opportunities: prevention with HIV-infected patients in clinical care settings. J Acquir Immune Defic Syndr 2004;36:960-966
CrossRef | Web of Science | Medline7
HIV prevalence, unrecognized infection, and HIV testing among men who have sex with men -- five U.S. cities, June 2004-April 2005. MMWR Morb Mortal Wkly Rep 2005;54:597-601
Medline8
Recommendations for HIV testing services for inpatients and outpatients in acute-care hospital settings. MMWR Recomm Rep 1993;42:1-6
9
Beckwith CG ,Flanigan TP ,del Rio C , et al. It is time to implement routine, not risk-based, HIV testing. Clin Infect Dis 2005;40:1037-1040
CrossRef | Web of Science | Medline10
Paltiel AD ,Weinstein MC ,Kimmel AD , et al. Expanded screening for HIV in the United States -- an analysis of cost-effectiveness. N Engl J Med 2005;352:586-595
Full Text | Web of Science | Medline11
Advancing HIV prevention: the four strategies. Atlanta: Centers for Disease Control and Prevention. July 23, 2003. (Accessed October 27, 2005, at http://www.cdc.gov/hiv/partners/ahp_program.htm.)
12
Marks G ,Crepaz N ,Senterfitt JW ,Janssen RS . Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. J Acquir Immune Defic Syndr 2005;39:446-453
CrossRef | Web of Science | Medline13
Quinn TC ,Wawer MJ ,Sewankambo N , et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. N Engl J Med 2000;342:921-929
Full Text | Web of Science | Medline14
Landis SE ,Schoenbach VJ ,Weber DJ , et al. Results of a randomized trial of partner notification in cases of HIV infection in North Carolina. N Engl J Med 1992;326:101-106
Full Text | Web of Science | Medline15
Des Jarlais DC ,Perlis T ,Arasteh K , et al. HIV incidence among injection drug users in New York City, 1990 to 2002: use of serologic test algorithm to assess expansion of HIV prevention services. Am J Public Health 2005;95:1439-1444
CrossRef | Web of Science | Medline16
Nelson KE ,Celentano DD ,Eiumtrakol S , et al. Changes in sexual behavior and a decline in HIV infection among young men in Thailand. N Engl J Med 1996;335:297-303
Full Text | Web of Science | Medline17
Martin JL . The impact of AIDS on gay male sexual behavior patterns in New York City. Am J Public Health 1987;77:578-581
CrossRef | Web of Science | Medline18
Diffusion of Effective Behavioral Interventions Project. Fact sheet. Atlanta: Centers for Disease Control and Prevention, July 21, 2005. (Accessed October 27, 2005, at http://www.effectiveinterventions.org/interventions/fact_sheets/DEBI.pdf.)
19
Cohen DA ,Wu S-Y ,Farley TA . Comparing the cost-effectiveness of HIV prevention interventions. J Acquir Immune Defic Syndr 2004;37:1404-1414
CrossRef | Web of Science | Medline20
Blake SM ,Ledsky R ,Goodenow C ,Sawyer R ,Lohrmann D ,Windsor R . Condom availability programs in Massachusetts high schools: relationships with condom use and sexual behavior. Am J Public Health 2003;93:955-962
CrossRef | Web of Science | Medline21
Shalala D. Evidence-based findings on the efficacy of syringe exchange programs: an analysis for the Assistant Secretary for Health and Surgeon General of the scientific research completed since April 1988. Washington, D.C.: Department of Health and Human Services, May 2000.
22
Weller S ,Davis K . Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Database Syst Rev 2002;1:CD003255-CD003255
Medline23
Shlay JC ,McClung MW ,Patnaik JL ,Douglas JM Jr . Comparison of sexually transmitted disease prevalence by reported level of condom use among patients attending an urban sexually transmitted disease clinic. Sex Transm Dis 2004;31:154-160
CrossRef | Web of Science | Medline24
Injection drug use update: 2002 and 2003. The NSDUH report. Rockville, Md.: Substance Abuse and Mental Health Services Administration, April 8, 2005.
25
Schriebman T ,Friedland G . Human immunodeficiency virus infection prevention: strategies for clinicians. Clin Infect Dis 2003;36:1171-1176
CrossRef | Web of Science | Medline26
Remafedi G . Linking HIV-seropositive youth with health care: evaluation of an intervention. AIDS Patient Care STDS 2001;15:147-151
CrossRef | Web of Science | Medline27
Stover J ,Walker N ,Garnett GP , et al. Can we reverse the HIV/AIDS pandemic with an expanded response? Lancet 2002;360:73-77
CrossRef | Web of Science | Medline28
Varghese B ,Peterman TA ,Holtgrave DR . Cost-effectiveness of counseling and testing and partner notification: a decision analysis. AIDS 1999;13:1745-1751
CrossRef | Web of Science | Medline29
Holtgrave DR, Curran JW. What works, and what remains to be done, in HIV prevention in the United States. Annu Rev Public Health (in press).
30
Libamba E ,Makombe S ,Harries AD , et al. Scaling up antiretroviral therapy in Africa: learning from tuberculosis control programmes -- the case of Malawi. Int J Tuberc Lung Dis 2005;9:1062-1071
Web of Science | Medline
- Citing Articles (41)
Citing Articles
1
Hsin-Ya Lee, Yi-Hsin Yang, Wen-Jing Yu, Lien-Wen Su, Tsang-Yaw Lin, Hsien-Jane Chiu, Hsin-Pei Tang, Chien-Yang Lin, Ryh-Nan Pan, Jih-Heng Li. (2012) Essentiality of HIV testing and education for effective HIV control in the national pilot harm reduction program: The Taiwan experience. The Kaohsiung Journal of Medical Sciences
CrossRef2
Jessika Deblonde, Herman Meulemans, Steven Callens, Stanley Luchters, Marleen Temmerman, Françoise F. Hamers. (2011) HIV testing in Europe: Mapping policies. Health Policy 103:2-3, 101-110
CrossRef3
David B. Hanna, Richard M. Selik, Tian Tang, Stephen J. Gange. (2011) Disparities among states in hiv-related mortality in persons with hiv infection, 37 U.S. STATES, 2001–2007. AIDS1
CrossRef4
Rosanna F. DeMarco, Donna Gallagher, Lucy Bradley-Springer, Sande Gracia Jones, Julie Visk. (2011) Recommendations and reality: Perceived patient, provider, and policy barriers to implementing routine HIV screening and proposed solutions. Nursing Outlook
CrossRef5
Reinhard H. Dennin, Michael Lafrenz, Arndt Sinn, Lan-juan Li. (2011) Dilemma of concepts and strategies for the prevention of spread of HIV in relation to human behavior, law and human rights. Journal of Zhejiang University SCIENCE B 12:7, 591-610
CrossRef6
Aleksandar Kecojevic, Christopher J. Lindsell, Michael S. Lyons, David Holtgrave, Gretchen Torres, James Heffelfinger, Jeremy Brown, Eileen Couture, Julianna Jung, Samantha Connell, Richard E. Rothman. (2011) Public Health and Clinical Impact of Increasing Emergency Department–Based HIV Testing: Perspectives From the 2007 Conference of the National Emergency Department HIV Testing Consortium. Annals of Emergency Medicine 58:1, S151-S159.e1
CrossRef7
M. Teresa Celada, Roland C. Merchant, Michael J. Waxman, Angela M. Sherwin. (2011) An Ethical Evaluation of the 2006 Centers for Disease Control and Prevention Recommendations for HIV Testing in Health Care Settings. The American Journal of Bioethics 11:4, 31-40
CrossRef8
Charulata J. Sabharwal, Kent Sepkowitz, Reshma Mehta, Colin Shepard, Sara Bodach, Lucia Torian, Elizabeth M. Begier. (2011) Impact of Accelerated Progression to AIDS on Public Health Monitoring of Late HIV Diagnosis. AIDS Patient Care and STDs110216122532031
CrossRef9
Kipton Jensen, Joseph BR Gaie. (2010) African communalism and public health policies: the relevance ofindigenous concepts of personal identity to HIV/AIDS policies in Botswana. African Journal of AIDS Research 9:3, 297-305
CrossRef10
Jennifer Uhrig, Doğan Eroğlu, Carla Bann, Jill L. Wasserman, Carolyn Guenther-Grey. (2010) Systematic Formative Research to Develop HIV Prevention Messages for People Living With HIV. Social Marketing Quarterly 16:3, 23-59
CrossRef11
Jennifer D. Uhrig, Carla M. Bann, Jill Wasserman, Carolyn Guenther-Grey, Doğan Eroğlu. (2010) Audience Reactions and Receptivity to HIV Prevention Message Concepts for People Living With HIV. AIDS Education and Prevention 22:2, 110-125
CrossRef12
Chi-Chi N. Udeagu, Angelica Bocour, Ilona Gale, Elizabeth M. Begier. (2010) Provider and Client Acceptance of a Health Department Enhanced Approach to Improve HIV Partner Notification in New York City. Sexually Transmitted Diseases1
CrossRef13
William A. Fisher, Taylor Kohut, Jeffrey D. Fisher. (2009) AIDS Exceptionalism: On the Social Psychology of HIV Prevention Research. Social Issues and Policy Review 3:1, 45-77
CrossRef14
(2009) Mortality of HIV-infected patients starting potent antiretroviral therapy: comparison with the general population in nine industrialized countries. International Journal of Epidemiology 38:6, 1624-1633
CrossRef15
JOHN J. CHIN. (2009) THE LIMITS AND POTENTIAL OF NONPROFIT ORGANIZATIONS IN PARTICIPATORY PLANNING: A CASE STUDY OF THE NEW YORK HIV PLANNING COUNCIL. Journal of Urban Affairs 31:4, 431-460
CrossRef16
Amy S.B. Bohnert, Carl A. Latkin. (2009) HIV Testing and Conspiracy Beliefs Regarding the Origins of HIV among African Americans. AIDS Patient Care and STDs 23:9, 759-763
CrossRef17
David B Hanna, Benjamin W Tsoi, Elizabeth M Begier. (2009) Most Positive HIV Western Blot Tests Do Not Diagnose New Cases in New York City: Implications for HIV Testing Programs. JAIDS Journal of Acquired Immune Deficiency Syndromes 51:5, 609-614
CrossRef18
Peter D. Ehrenkranz, José A. Pagán, Elizabeth M. Begier, Benjamin P. Linas, Kristin Madison, Katrina Armstrong. (2009) Written Informed-Consent Statutes and HIV Testing. American Journal of Preventive Medicine 37:1, 57-63
CrossRef19
Alexis Palmer, Jocelyn Tomkinson, Charlene Phung, Nathan Ford, Michel Joffres, Kimberly A Fernandes, Leilei Zeng, Viviane Lima, Julio SG Montaner, Gordon H Guyatt, Edward J Mills. (2009) Does ratification of human-rights treaties have effects on population health?. The Lancet 373:9679, 1987-1992
CrossRef20
L. Gable, L. Gostin, J.G. Hodge. (2009) A global assessment of the role of law in the HIV/AIDS pandemic. Public Health 123:3, 260-264
CrossRef21
L.O. Gostin, K.G. Gostin. (2009) A broader liberty: J.S. Mill, paternalism and the public's health. Public Health 123:3, 214-221
CrossRef22
Maureen C. Malave, Dipal Shah, Judith E. Sackoff, Steve Rubin, Elizabeth M. Begier. (2008) Human Immunodeficiency Virus Partner Elicitation and Notification in New York City: Public Health Does It Better. Sexually Transmitted Diseases 35:10, 869-876
CrossRef23
Kyle T Bernstein, Elizabeth Begier, Ryan Burke, Adam Karpati, Matthew Hogben. (2008) HIV Screening Among U.S. Physicians, 1999–2000. AIDS Patient Care and STDs 22:8, 649-656
CrossRef24
M. Das-Douglas, N. M. Zetola, J. D. Klausner, G. N. Colfax. (2008) WRITTEN INFORMED CONSENT AND HIV TESTING RATES: THE SAN FRANCISCO EXPERIENCE. American Journal of Public Health 98:9, 1544-1545
CrossRef25
Evan Wood, Thomas Kerr, Mark W Tyndall, Julio SG Montaner. (2008) A review of barriers and facilitators of HIV treatment among injection drug users. AIDS 22:11, 1247-1256
CrossRef26
T. R Frieden, M. T Bassett, L. E Thorpe, T. A Farley. (2008) Public health in New York City, 2002-2007: confronting epidemics of the modern era. International Journal of Epidemiology 37:5, 966-977
CrossRef27
Trang Quyen Nguyen, R Charon Gwynn, Scott E Kellerman, Elizabeth Begier, Renu K Garg, Melissa R Pfeiffer, Kevin J Konty, Lucia Torian, Thomas R Frieden, Lorna E Thorpe. (2008) Population prevalence of reported and unreported HIV and related behaviors among the household adult population in New York City, 2004. AIDS 22:2, 281-287
CrossRef28
David B. Hanna, Melissa R. Pfeiffer, Lucia V. Torian, Judith E. Sackoff. (2008) Concurrent HIV/AIDS Diagnosis Increases the Risk of Short-Term HIV-Related Death among Persons Newly Diagnosed with AIDS, 2002–2005. AIDS Patient Care and STDs 22:1, 17-28
CrossRef29
CHARLES B. SMITH, MARGARET P. BATTIN, LESLIE P. FRANCIS, JAY A. JACOBSON. (2007) SHOULD RAPID TESTS FOR HIV INFECTION NOW BE MANDATORY DURING PREGNANCY? GLOBAL DIFFERENCES IN SCARCITY AND A DILEMMA OF TECHNOLOGICAL ADVANCE. Developing World Bioethics 7:2, 86-103
CrossRef30
Jerome Amir Singh, Michelle Govender, Edward J Mills. (2007) Do human rights matter to health?. The Lancet 370:9586, 521-527
CrossRef31
Richard Rothenberg. (2007) The Relevance of Social Epidemiology in HIV/AIDS and Drug Abuse Research. American Journal of Preventive Medicine 32:6, S147-S153
CrossRef32
(2007) Prognosis of HIV-1-infected patients up to 5 years after initiation of HAART: collaborative analysis of prospective studies. AIDS 21:9, 1185-1197
CrossRef33
Richard E. Rothman, Roland C. Merchant. (2007) Commentary. Annals of Emergency Medicine 49:5, 577-579
CrossRef34
Sheryl B Lyss, Bernard M Branson, Karen A Kroc, Eileen F Couture, Daniel R Newman, Robert A Weinstein. (2007) Detecting Unsuspected HIV Infection With a Rapid Whole-Blood HIV Test in an Urban Emergency Department. JAIDS Journal of Acquired Immune Deficiency Syndromes 44:4, 435-442
CrossRef35
Reinhard H. Dennin, D. Doese, W. Theobald, M. Lafrenz. (2007) HIV-Infektion – Grenzen der Präventionskonzepte. Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz 50:4, 458-464
CrossRef36
D. B. Hanna, L. S. Gupta, L. E. Jones, D. M. Thompson, S. E. Kellerman, J. E. Sackoff. (2007) AIDS-defining opportunistic illnesses in the HAART era in New York City. AIDS Care 19:2, 264-272
CrossRef37
Lindsey L. Wolf, Rochelle P. Walensky. (2007) Testing for HIV infection in the United States. Current Infectious Disease Reports 9:1, 76-82
CrossRef38
Michael D. Grossman, Stanislaw P. Stawicki. (2006) The impact of human immunodeficiency virus (HIV) on outcome and practice in trauma: Past, present and future. Injury 37:12, 1117-1124
CrossRef39
(2006) Public Health Principles for the HIV Epidemic. New England Journal of Medicine 354:8, 877-878
Full Text40
D. J. Koo. (2006) HIV Counseling and Testing: Less Targeting, More Testing. American Journal of Public Health 96:6, 962-964
CrossRef41
Elizabeth A. McCarthy, Megan E. O'Brien, William R. Rodriguez. (2006) Training and HIV-Treatment Scale-Up: Establishing an Implementation Research Agenda. PLoS Medicine 3:7, e304
CrossRef
- Letters
