Multicampus outbreak of HIV in North Carolina spurs quick state action

Prevention, testing program targets black colleges

An HIV RNA screening program in North Carolina has uncovered the beginning of an outbreak of HIV infection among college students and has led state health officials to speculate that the outbreak could have an impact on youth across the Southeast.

Investigators from the Centers for Disease Control and Prevention (CDC) are studying an outbreak of HIV among North Carolina college students, focusing primarily on young black men.

Specifically, CDC investigators are surveying both HIV-positive and HIV-negative young black men to evaluate differences and better determine effective intervention strategies, says Lisa Fitzpatrick, MD, MPH, CDC medical epidemiologist. "Another reason this investigation is important is because it will highlight the critical need of health resources in the South," she says. "Rates of HIV are continuing to increase in the South despite dropping everywhere else in the country, or at least leveling off."

That trend is evident in North Carolina where between 2001 and 2002, there was a 9.6% increase in HIV infection; and from 2002 and through the end of September 2003, there was a 5% increase in HIV infection, says Evelyn Foust, MPH, branch head of HIV/STD Prevention and Care for the North Carolina Department of Health and Human Services in Raleigh.

In November 2002, North Carolina officials and investigators began screening all HIV-negative blood samples for HIV RNA to detect acute infections.

The Screening Tracing Active Transmission program for HIV RNA screening that North Carolina now conducts on 120,000 samples per year is the only state program of its kind in the country, Foust says.

While RNA screening is expensive per sample, researchers have discovered a way to make it cost-effective through a multistage pooling process that was launched as a pilot project in North Carolina two years ago.1

RNA testing is done on blood samples from the people who visit STD and HIV clinics, counseling, and testing programs, Foust says. The screening program’s success at identifying newly infected individuals and trends proves that screening for acute infection is an important state mission, she says.

"We found that we are able to find people who may have been infected two-to-three weeks ago," Foust explains. "Had we not been doing testing for acute HIV infection then, we might not have discovered [the outbreak] for a year or two."

Within three months of starting the screening program, they found five acute cases of HIV, two of which were among male college students who were attending different colleges within the same county, says Lisa Hightow, MD, MPH, infectious diseases fellow at the University of North Carolina in Chapel Hill. The study was presented at the 41st annual meeting of the Alexandria, VA-based Infectious Diseases Society of America recently held in San Diego.

Hightow and co-investigators found that 25 of 146 newly infected men in central North Carolina attended 11 colleges, and a sexual network linked seven of the campuses. Also, 88% of these men were African-American, and the same percentage were men who have sex with men.2

"So we were concerned that something was going on in the college population," Hightow says. "Then we did a retrospective review of state HIV surveillance records."

After examining the files, which included demographics, risk factors, and places of employment, from January 2002 to March 2003, investigators found 29 cases of HIV-positive college students of which 28 were men, Hightow explains. "And the cases were increasing when you plotted the epidemic curve," she says.

The newly diagnosed HIV cases involved students at 12 different colleges, Foust says.

When investigators compared HIV-positive college men with noncollege men, they found that the newly diagnosed college men were more likely to be African-American, to have sex partners who were either only male or both male and female, to use club drugs, and to meet their sex partners over the Internet and through bars and clubs, Hightow explains. By creating a chart linking sexual partners, researchers discovered that while the cases were spread out among colleges, the colleges could be linked on the chart, she adds.

Investigators also found that between 40% and 50% of all new infections of HIV in the state occurred among people younger than 25, Foust says. A significant percentage of these new infections also were among college students.

"About 14% of new diagnoses in the 18-25 age group were among college students," Hightow points out. "We found 56 cases of newly diagnosed HIV among college men in that age group, compared with 367 newly diagnosed men in that age group who were not in college."

Investigators notified the universities where HIV cases were found before they presented their data for the first time at the 2003 National HIV Prevention Conference held July 2003, in Atlanta.

Then in August, the CDC team arrived. Its investigation should conclude by the end of 2003, Fitzpatrick says.

"Now that we’ve discovered the problem, we’re moving to the point where we have to do something about it," Foust says. "It’s of concern and depressing to me that here we are in 2003, and we have identified a new generation that has apparently not heard or has heard and not embraced the prevention messages that will keep their generation safe from HIV infection."

This outbreak is a wake-up call for North Carolina and other southern states where there are problems with access to health care, cultural taboos regarding discussions of sex and HIV, and continued discrimination and stigma attached to homosexuality, she states. "We have to work with communities to identify those barriers and to create safer places for people to seek voluntary counseling and testing," Foust says.

Sexual education and HIV prevention messages also need to reach young people, and this also has been lacking, she continues.

"For the most part, in North Carolina and the South, the schools do not take the lead in providing health education around transmission of disease through sex, so there’s a huge gap there," Foust says. "I think that’s one of the things that is contributing to the lack of awareness in our young people who have sex."

North Carolina and the state’s long-standing minority colleges are collaborating in a program called Project Commit to Prevent, which provides peer education training for HIV counseling and testing.

Close to 40,000 students are enrolled at the 12 institutions, which are participating in Project Commit to Prevent, says Phyllis Gray, MPH, project manager for the North Carolina Division of Public Health in Raleigh. Gray is in charge of the project. North Carolina has more historically minority colleges and universities — most of which date back more than 100 years — than any other state, she says.

HIV and STD data show that these institutions typically are located in counties in which there are high rates of HIV and STDs, Gray explains. "When you look at who these communities are, you see they are communities of color; and when you look at the data in general and see who is disproportionately affected by this disease, you see they are communities of color. It only makes sense to go to these universities and ask them to use the strength they have to not only focus on student populations, but in time, to work with us in reaching the larger populations around their campus," she says.

North Carolina public health officials contacted the 11 black colleges and the one Native American college in the state and began to work with them to enhance on-campus counseling and testing options and prevention education.

While public health officials anticipate that this program will have a positive impact on the HIV epidemic’s spread among college students, they also plan to implement changes suggested by the CDC after the investigators have completed their research and report.

References

1. Pilcher C, McPherson JT, Leone PA, et al. Real-time, universal screening for acute and early HIV infection in a routine HIV counseling and testing population using multistage pooling and RNA PCR: Cost-effective, specific, and feasible. Presented at the 9th Conference on Retroviruses and Opportunistic Infections. Seattle; February 2002. Poster 359-M.

2. Hightow LB, Leone PA, MacDonald P, et al. Are colleges high transmission areas in the rural Southeast? Insights from acute HIV surveillance. Presented at the 41st annual meeting of the Infectious Diseases Society of America. San Diego; Oct. 9-12, 2003. Abstract 608.