Comparative Mortality Among People Diagnosed with HIV Infection or AIDS in the U.S., 2001–2010

ObjectiveThe comparative mortality figure (CMF) is the expected number of deaths in the standard population compared with those observed. We assessed state-based CMFs for people with HIV infection to allow standardized assessment of mortality in all states.MethodsWe used National HIV Surveillance System data to compute CMFs for people diagnosed with HIV and AIDS from 2001 to 2010 who met the CDC HIV case definition; were alive on December 31, 2009; and died during 2010.ResultsIn 33 U.S. states with name-based HIV reporting since 2001, the 2010 CMF for people with an HIV diagnosis was 2.8 compared with 4.5 for those with an AIDS diagnosis. CMFs for males were higher than for females (3.4 vs. 3.1) and black people had higher CMFs than white people for HIV (3.2 vs. 2.2) and AIDS (4.7 vs. 4.3). CMFs by state ranged from 0.9 to 4.2 for HIV and 1.9 to 9.7 for AIDS. In 50 states and the District of Columbia with AIDS reporting, CMFs for males and females were similar (4.5 and 4.6, respectively), CMFs for black people remained higher than for white people (5.0 and 3.9, respectively), and the range for states remained broad (1.2–9.4).ConclusionState mortality figures varied based on population composition and disease stage at diagnosis, possibly indicating a need for state-specific testing, linkage to care, and viral suppression strategies to reduce mortality.State mortality rates for people infected with human immunodeficiency virus (HIV) vary greatly, and comparability among states will benefit from enhanced standardization. The 2010 death rate of HIV-infected people aged ≥13 years in the United States was 7.5 per 100,000 population, with state rates ranging broadly from 0.4 per 100,000 population in Maine to 38.8 per 100,000 population in the District of Columbia (DC).¹ Similarly, in the same age group of people diagnosed with HIV infection, those with stage 3 infection (i.e., acquired immunodeficiency syndrome [AIDS])² had a death rate of 6.1 per 100,000 population in 2010, with state rates also ranging broadly from 0.3 per 100,000 population in Maine to 33.7 per 100,000 population in DC. The large disparity among state death rates for people with HIV infection, and the disproportionate impact on some racial/ethnic, risk factor, and age groups,³ indicates a need for standardization of each state rate to a fixed population to enhance comparability. This study provides those results.Testing for HIV infection is recommended by the U.S. Preventive Services Task Force for all adolescents and adults aged 15–65 years and for all pregnant women⁴ to increase early detection, facilitate treatment, reduce transmission, and reduce mortality.^5,6 While testing with rapid tests, in-home, and at other nonmedical facilities has increased the number of people with HIV infection who know their status, it is estimated that in 2010, one in six people with HIV infection did not know they were infected.⁷In addition, despite implementation of a variety of prevention strategies,⁸ increased testing, linkage-to-care activities, and improved HIV infection treatments aimed at viral load suppression have resulted in increased prevalence of people living with HIV infection. The 2013 Presidential Continuum of Care Initiative recommends further enhancements to identify and address gaps in care along the continuum, beginning with diagnosis and moving though sequential stages for linkage to care, retention in care, and antiretroviral treatment (ART) utilization, resulting in viral suppression.⁹Comparisons of state mortality, the ultimate indicator of success along the continuum of care, can inform HIV infection testing and care initiatives, and evaluate the impact of linkage to and retention-in-care activities. However, the method selected for analysis can significantly affect the results.¹⁰ Standardized methods for presenting state death rates are necessary to ensure comparability of state mortality.Numerous methodologies for assessing standardized mortality rates have been documented.^10,11 The standardized mortality ratio for indirect standardization is commonly reported, although the comparative mortality figure (CMF) (or comparative mortality ratio [CMR] derived from CMFs) for direct standardization is recommended for geographic comparisons among heterogeneous populations.^12–14 While the CMF has been used for mortality studies of chronic disease and disability,^15–19 it has not previously been used to compare state-level CMFs for people diagnosed with HIV infection using data from a national HIV surveillance system.     

Sex and Racial/Ethnic Differences in Premature Mortality Due to HIV: Florida, 2000–2009

Objective

This study aimed to characterize premature mortality among people diagnosed with HIV infection from 2000 to 2009 in Florida, by sex and race/ethnicity, to estimate differences in premature mortality that could be prevented by linkage to HIV care and treatment.

Methods

Florida surveillance data for HIV diagnoses (excluding concurrent AIDS diagnoses) were linked with vital records data to ascertain deaths through 2011. Years of potential life lost (YPLL) were obtained from the expected number of remaining years of life at a given age from the U.S. sex-specific period life tables.

Results

Among 41,565 people diagnosed with HIV infection during the study period, 5,249 died, and 2,563 (48.8%) deaths were due to HIV/AIDS. Age-standardized YPLL (aYPLL) due to HIV/AIDS per 1,000 person-years was significantly higher for females than males (372.6, 95% confidence interval [CI] 349.8, 396.2 vs. 295.2, 95% CI 278.4, 312.5); for non-Hispanic black (NHB) females than non-Hispanic white (NHW) and Hispanic females (388.2, 95% CI 360.7, 416.9; 294.3, 95% CI 239.8, 354.9; and 295.0, 95% CI 242.9, 352.5, respectively); and for NHB males compared with NHW and Hispanic males (378.7, 95% CI 353.7, 404.7; 210.6, 95% CI 174.3, 250.8; and 240.9, 95% CI 204.8, 280.2, respectively). In multilevel modeling controlling for individual factors, NHB race was associated with YPLL due to HIV/AIDS for women (p=0.04) and men (p<0.001).

Conclusion

Among people diagnosed with HIV infection, females and NHB people had a disproportionately high premature mortality from HIV/AIDS, suggesting the need for enhanced efforts to improve linkage to and retention in care and medication adherence for these groups.Minority groups in the United States are disproportionately affected by human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). In 2009, the estimated annual HIV incidence rate was 7.7 times higher for non-Hispanic black (NHB) people and 2.6 times higher for Hispanic people than for non-Hispanic white (NHW) people (69.9, 26.4, and 9.1 per 100,000 population, respectively).¹ These racial/ethnic disparities persist in HIV mortality rates. In 2010, the age-adjusted HIV mortality rate among NHB people was 7.2 times greater for men (16.5 vs. 2.3 per 100,000 population) and 15.0 times greater for women (7.5 vs. 0.5 per 100,000 population) than among NHW people.²In the era of antiretroviral therapy (ART), the life span among people living with HIV who are appropriately treated is approaching that of underlying populations.^3,4 As people living with HIV live longer, they are more likely to die from non-HIV causes such as heart disease, liver disease, and cancer.^5–7 Numerous studies have documented a declining proportion of deaths due to AIDS, particularly for those in care.^8–10 However, the benefits of ART have not been fully realized for the majority of people living with HIV. To benefit from these treatment advances, individuals must be diagnosed early in the course of their illness, be linked to care, be offered treatment, and adhere to treatment. Nationally, people are being lost at each step of this continuum. It is estimated that in 2009, 66% of people diagnosed with HIV were linked to care, 37% were retained in care, 33% were prescribed ART, and 25% had a suppressed viral load. Relative to NHW people, NHB people (and, to a lesser extent, Hispanic people) had lower percentages at each step of the care continuum. In 2009, an estimated 79% of NHB, 74% of Hispanic, and 70% of NHW people with HIV infection had no viral load suppression.¹¹HIV is a burden for communities because it tends to cause death at younger ages than more common causes of death (e.g., cancer and heart disease). Comparing the impact of HIV using mortality rates alone does not capture the impact of premature mortality. However, years of potential life lost (YPLL), which measures premature mortality, tallies the number of years a person would have been expected to live had he/she not died early.¹² The objective of this study was to characterize premature mortality among people diagnosed with HIV from 2000 to 2009 in Florida, by sex and racial/ethnic group, to estimate differences in premature mortality that could be prevented by linkage to HIV care and treatment.     

Evaluation of a Community Health Worker Intervention to Reduce HIV/AIDS Stigma and Increase HIV Testing Among Underserved Latinos in the Southwestern U.S.

Objectives

Latinos are at an elevated risk for HIV infection. Continued HIV/AIDS stigma presents barriers to HIV testing and affects the quality of life of HIV-positive individuals, yet few interventions addressing HIV/AIDS stigma have been developed for Latinos.

Methods

An intervention led by community health workers (promotores de salud, or promotores) targeting underserved Latinos in three southwestern U.S. communities was developed to decrease HIV/AIDS stigma and increase HIV knowledge and perception of risk. The intervention was led by HIV-positive and HIV-affected (i.e., those who have, or have had, a close family member or friend with HIV/AIDS) promotores, who delivered interactive group-based educational sessions to groups of Latinos in Spanish and English. To decrease stigma and motivate behavioral and attitudinal change, the educational sessions emphasized positive Latino cultural values and community assets. The participant pool comprised 579 Latino adults recruited in El Paso, Texas (n=204); San Ysidro, California (n=175); and Los Angeles, California (n=200).

Results

From pretest to posttest, HIV/AIDS stigma scores decreased significantly (p<0.001). Significant increases were observed in HIV/AIDS knowledge (p<0.001), willingness to discuss HIV/AIDS with one''s sexual partner (p<0.001), and HIV risk perception (p=0.006). Willingness to test for HIV in the three months following the intervention did not increase. Women demonstrated a greater reduction in HIV/AIDS stigma scores when compared with their male counterparts, which may have been related to a greater increase in HIV/AIDS knowledge scores (p=0.016 and p=0.007, respectively).

Conclusion

Promotores interventions to reduce HIV/AIDS stigma and increase HIV-related knowledge, perception of risk, and willingness to discuss sexual risk with partners show promise in reaching underserved Latino communities.Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) has disproportionately affected U.S. Latinos during the last 25 years. Although Latinos constitute 16% of the U.S. population, they account for 19% of those living with HIV and 21% of new HIV infections.¹ Since 2006, the Centers for Disease Control and Prevention (CDC) has recommended HIV testing for all people aged 13–64 years.² However, nearly half (46%) of Latino adults aged 18–64 years have never been tested, compared with 23% of black and 50% of white adults.³ Additionally, HIV testing often occurs at a late stage among HIV-positive Latinos. More than one-third (36%) of HIV-positive Latinos were diagnosed with AIDS within one year of learning their HIV status, compared with 32% of white people and 31% of black people.³ Late HIV testing hinders treatment options and may contribute to unknowing HIV transmission.Factors contributing to low HIV testing rates among Latinos include poverty, lack of health-care access, and limited availability of culturally and linguistically responsive services.^1,4–6 HIV/AIDS stigma is another factor.^7,8 UNAIDS (Joint United Nations Programme on AIDS) defines HIV stigma as the “devaluation of people either living with or associated with HIV/AIDS.”⁹ Stigma often results from fears about HIV as well as the associations of HIV with stigmatized groups such as homosexuals, sex workers, and injection drug users.^9,10HIV/AIDS stigma has negative consequences both at a population level and for individuals who are its targets, including people living with HIV/AIDS. Stigmatizing attitudes toward people living with HIV/AIDS are associated with decreased HIV testing, limited utilization of HIV prevention services, and high-risk sexual behaviors.^7,10,11 Additionally, for people living with HIV/AIDS, the stigma associated with HIV/AIDS contributes to unwillingness to disclose HIV status, unsafe sexual behaviors, delays in care seeking, reduced treatment adherence, mental health issues, and difficulties obtaining social support.^9,11–14Despite significant implications, few interventions have been developed to reduce HIV/AIDS stigma.^10,11,15 Existing interventions have often focused on specific populations (e.g., university students and health-care providers), with few interventions focused on Latinos,^11,15,16 who have high levels of stigmatizing attitudes toward people living with HIV/AIDS^1,17,18 that contribute to negative outcomes.^7,19Among Latinos, research indicates that community health workers (promotores de salud, hereinafter “promotores”) are an effective and culturally acceptable means of reaching the population with health information and motivating health behaviors.^20,21 Promotores are well positioned to promote changes in their communities because they share language and cultural values, are held in high esteem, and are perceived as role models.²¹ Promotores have been used to address health conditions ranging from chronic diseases to preventive screenings.^20–22 Several interventions have incorporated promotores into HIV prevention, finding significant changes in HIV risk behaviors, HIV counseling and testing, and other psychosocial constructs important to prevention.^16,23–29 To date, few studies have used promotores in interventions to reduce HIV stigma among Latinos.¹⁶We describe and report findings of an intervention using promotores to reduce HIV/AIDS stigma and increase willingness to seek HIV testing among Latinos in three communities in the southwestern United States: Los Angeles, California; San Ysidro, California; and El Paso, Texas.     

Persistent Racial/Ethnic Disparities in AIDS Diagnosis Rates Among People Who Inject Drugs in U.S. Metropolitan Areas, 1993–2007

Objectives

We estimated race/ethnicity-specific incident AIDS diagnosis rates (IARs) among people who inject drugs (PWID) in U.S. metropolitan statistical areas (MSAs) over time to assess the change in disparities after highly active antiretroviral therapy (HAART) dissemination.

Methods

We compared IARs and 95% confidence intervals (CIs) for black/African American and Hispanic/Latino PWID with those of white PWID in 93 of the most populous MSAs. We selected two three-year periods from the years immediately preceding HAART (1993–1995) and the years with the most recent available data (2005–2007). To maximize stability, we aggregated data across three-year periods, and we aggregated data for black/African American and Hispanic/Latino PWID for most comparisons with data for white PWID. We assessed disparities by comparing IAR 95% CIs for overlap.

Results

IARs were significantly higher for black/African American and Hispanic/Latino PWID than for white PWID in 81% of MSAs in 1993–1995 and 77% of MSAs in 2005–2007. MSAs where disparities became non-significant over time were concentrated in the West. Significant differences were more frequent in comparisons between black/African American and white PWID (85% of MSAs in 1993–1995, 79% of MSAs in 2005–2007) than in comparisons between Hispanic/Latino and white PWID (53% of MSAs in 1993–1995, 56% of MSAs in 2005–2007). IARs declined modestly across racial/ethnic groups in most MSAs.

Conclusions

AIDS diagnosis rates continue to be substantially higher for black/African American and Hispanic/Latino PWID than for white PWID in most large MSAs. This finding suggests a need for increased targeting of prevention and treatment programs, as well as research on MSA-level conditions that may serve to maintain the disparities.Together, non-Hispanic black people/African Americans (hereafter, black people) and Hispanic or Latino people (hereafter, Hispanic people) are estimated to comprise about half of the population of people who inject drugs (PWID) in the U.S.,¹ but they comprise about three-quarters of PWID who have been diagnosed with acquired immunodeficiency syndrome (AIDS).² Harm-reduction programs are believed to have been partly responsible for reducing human immunodeficiency virus (HIV) transmission among PWID since the 1980s,³ and highly active antiretroviral therapy (HAART) has greatly reduced rates of progression to AIDS.⁴ These benefits, however, may not have spread evenly across racial/ethnic groups and localities. Racial/ethnic disparities in AIDS diagnosis rates may reflect disparities in HIV incidence, progression to AIDS among people who are HIV-positive, and time to diagnosis among people living with AIDS.⁵From a fundamental cause perspective, racial/ethnic AIDS incidence disparities reflect underlying differences in social conditions and access to resources, including HIV prevention and treatment.⁶ These disparities can include proximal factors, such as access to harm-reduction programs and high-quality health care, and more distal factors, such as risk of incarceration and potential exposure to HIV from living in neighborhoods with high HIV prevalence.⁷ The social conditions that link race/ethnicity to HIV/AIDS risk act through multiple mechanisms, so that attempts to reduce disparities by eliminating one mechanism may fail because other mechanisms remain. The fundamental cause perspective suggests that improvements in treatment and prevention are likely to benefit white people more than black or Hispanic people, potentially maintaining or amplifying disparities over time.^6,8,9Nationally, there is evidence of decline in racial/ethnic disparities in HIV or AIDS diagnosis in the U.S. across risk groups. The magnitude of black-white and Hispanic-white AIDS diagnosis disparities declined significantly from 2000 to 2009, except for adolescent and young adult males (aged 13–24 years).⁵ From 2001 to 2004, the rate of HIV diagnosis declined by 6.8% annually among black people and by 4.7% among Hispanic people, but increased by 1.4% annually among white people.¹⁰ In an analysis of 2007 HIV surveillance data, black-white and Hispanic-white disparities in large urban areas were greatest in the Northeast, South, and Midwest.¹¹ Results of that study suggest that changing HIV disparities may be related to changing trends in HIV incidence by risk category regardless of race/ethnicity, and contacts among risk groups and racial/ethnic groups over time.Assessing disparities in AIDS diagnoses in specific geographic areas can help us study the fundamental causes of the disparities. Some of the mechanisms linking race/ethnicity to AIDS act outside of the direct control of individuals. For example, living in an area where HIV treatment is unavailable or is of poor quality can impact everyone in the area who is HIV-positive and is difficult to contend with individually, short of moving to an area with better treatment options. Area-specific AIDS prevalence rates reflect the accumulation of individual risk behaviors, the concentration of HIV in sex and injection networks, the social conditions in the area that affect risk behaviors, and HIV and drug use treatment and prevention programs.^11,12 By comparing racial/ethnic differences in area-specific AIDS incidence rates across time, we can indirectly assess the system of mechanisms linking race/ethnicity and AIDS risk and identify where conditions are improving or worsening. Concurrently, data on changes in area-level racial/ethnic disparities can be used to more completely identify and understand those mechanisms.To assess changes in racial/ethnic disparities, we compared new (incident) AIDS diagnosis rates (IARs) for black and Hispanic PWID with those of non-Hispanic white (hereafter, white) PWID in U.S. metropolitan areas over time.     

Who Are California's Late HIV Testers? An Analysis of State AIDS Surveillance Data, 2000–2006

Objectives

Late HIV testing leads to preventable, severe clinical and public health outcomes. California, lacking a mature HIV surveillance system, has been excluded from documented analyses of late HIV testers in the United States. We identified factors associated with late HIV testing in the California AIDS surveillance data to inform programs of HIV testing and access to treatment.

Methods

We analyzed data from California AIDS cases diagnosed between 2000 and 2006 and reported through November 1, 2007. Late testers were people diagnosed with HIV within 12 months before their AIDS diagnosis. We identified factors significantly associated with late HIV testing using multivariable logistic regression.

Results

Among 28,382 AIDS cases, 61.2% were late HIV testers. Late testing was significantly associated with those ≥35 years of age, heterosexual contact or unknown/other reported transmission risk, and being born outside of the U.S. When further classified by country of birth, people born in Mexico were most likely to be HIV late testers who progressed to AIDS.

Conclusions

Our findings support wider implementation of opt-out HIV testing and HIV testing based in emergency departments. Services for HIV testing and treatment should be inclusive of all populations, but especially targeted to populations that may have more limited access.Among the more than one million people in the United States estimated to be infected with human immunodeficiency virus (HIV), nearly one-quarter remain undiagnosed.¹ Increasing evidence suggests that earlier antiretroviral therapy (ART) for HIV improves survival compared with deferred therapy.^2,3 The benefits of HIV diagnosis well before acquired immunodeficiency syndrome (AIDS) diagnosis are clearly documented and include survival benefit for asymptomatic HIV-infected people with early initiation as compared with deferred initiation of ART,² decreased viral transmission due to lower-serum HIV-1 ribonucleic acid levels⁴ as well as risk modification in people who know their HIV serostatus,⁵ and decreased health expenditures.⁶ In Canada, the estimated annual medical cost of a late presenter, after adjusting for patient characteristics, was more than twice that of a non-late presenter, with a difference of more than $8,000 per person. This discrepancy is mostly due to hospital care costs, which are 15 times higher for those diagnosed late.⁷Given that the period from primary HIV infection to AIDS is estimated at seven to eight years⁸ and the Centers for Disease Control and Prevention (CDC) guidelines advocate routine HIV testing for all U.S. adults,⁹ late HIV testing (defined as the first diagnosis of HIV within one year of an AIDS diagnosis)¹⁰ should be an unusual clinical outcome. However, national estimates from CDC reported that 45% of people with AIDS at 16 sites in the U.S. were late testers.¹⁰ Among AIDS surveillance cases in San Francisco and South Carolina, 39% and 41%, respectively, were late testers.^11,12 In the U.S., AIDS diagnoses can be arguably regarded as a measure of diagnostic or treatment failure.In California, approximately 85% of adult HIV cases are male, 28% are Hispanic, 20% are African American, and 50% are white. Men who have sex with men (MSM) comprise the main risk exposure for men (77%). For women, heterosexual contact is the main risk exposure (52%), followed by injection drug use (23%).¹³ California is home to about 4.4 million Mexican immigrants, about 40% of the total immigrant population in the U.S., and is a key destination for Mexican migrants.^11,14 Both the U.S. and Mexico have concentrated HIV epidemics, where prevention and testing campaigns prioritize traditionally high-risk groups such as MSM and injection drug users (IDUs).The role of migration on the vulnerability of immigrants in California, historically considered a low-risk group, is complex and poorly understood but may have a significant impact on the likelihood of becoming infected with HIV while in the U.S.¹⁵ The denominator of Mexican immigrants in California likely varies by structural factors such as agricultural season. The effect and extent of this varying denominator on HIV/AIDS estimates is not well characterized. In this analysis of California AIDS surveillance data, we identified factors that are significantly associated with late HIV testing in the state.     

The Association Between Neighborhood Poverty and HIV Diagnoses Among Males and Females in New York City, 2010–2011

Objective

We assessed the association of neighborhood poverty with HIV diagnosis rates for males and females in New York City.

Methods

We calculated annual HIV diagnosis rates by ZIP Code, sex, and neighborhood poverty level using 2010–2011 New York City (NYC) HIV surveillance data and data from the U.S. Census 2010 and American Community Survey 2007–2011. Neighborhood poverty levels were percentage of residents in a ZIP Code with incomes below the federal poverty threshold, categorized as 0%–<10% (low poverty), 10%–<20% (medium poverty), 20%–<30% (high poverty), and 30%–100% (very high poverty). We used sex-stratified negative binomial regression models to measure the association between neighborhood-level poverty and HIV diagnosis rates, controlling for neighborhood-level education, race/ethnicity, age, and percentage of men who have sex with men.

Results

In 2010–2011, 6,184 people were newly diagnosed with HIV. Median diagnosis rates per 100,000 population increased by neighborhood poverty level overall (13.7, 34.3, 50.6, and 75.6 for low-, medium-, high-, and very high-poverty ZIP Codes, respectively), for males, and for females. In regression models, higher neighborhood poverty remained associated with higher diagnosis rates among males (adjusted rate ratio [ARR] = 1.63, 95% confidence interval [CI] 1.34, 1.97) and females (ARR=2.14, 95% CI 1.46, 3.14) for very high- vs. low-poverty ZIP Codes.

Conclusion

Living in very high- vs. low-poverty urban neighborhoods was associated with increased HIV diagnosis rates. After controlling for other factors, the association between poverty and diagnosis rates was stronger among females than among males. Alleviating poverty may help decrease HIV-related disparities.More than 40,000 people in the United States are newly diagnosed with human immunodeficiency virus (HIV) every year.¹ The National HIV/AIDS Strategy called for a 20% drop in this figure by 2015, and emphasis at the federal level on high-impact prevention is attempting to shift the focus of HIV prevention activities from individuals to entire communities or populations.^2,3 Yet, most investigations of the determinants of HIV infection have focused on individual traits, typically identifying people as high risk based on factors such as race/ethnicity or sexual or drug use behaviors. For example, black and Hispanic people have HIV diagnosis rates more than twice that of white people and account for more than two-thirds of HIV diagnoses in the United States. Men who have sex with men (MSM) also account for more than two-thirds of HIV diagnoses.^1,4Area-based social conditions such as neighborhood poverty are increasingly being recognized as important determinants of health inequities, including HIV infection.^4–9 In the United States, areas with relatively high poverty (where ≥20% of the population live in households with incomes below the federal poverty threshold) have the highest HIV diagnosis rates and account for about half of all new HIV diagnoses.⁴ County-level poverty has been shown to be significantly associated with HIV diagnosis rates in the United States, overall, by sex, and by race/ethnicity.⁸ However, this association has not been explored by ZIP Code within a U.S. city. Cities concentrate health risks, and disaggregating their health information (e.g., by neighborhood poverty level) uncovers disparities.¹⁰ Furthermore, it is not known if differences in HIV diagnosis rates by ZIP Code-level poverty can be explained by area-based differences in age and racial/ethnic distribution (e.g., people living in poorer neighborhoods are younger and more likely to be black or Hispanic, which are populations with higher HIV incidence) or area-based poverty is independently associated with HIV diagnosis rates, and whether or not this relationship differs between males and females.The distribution of people with HIV in New York City (NYC) has been described by neighborhood and area-based poverty level.¹¹ Because local governance is a key force in improving social conditions and reducing health inequalities,¹⁰ local demand for expanded analyses that more thoroughly assess the connection between poverty and health exists. The NYC Department of Health and Mental Hygiene (DOHMH) formed the Center for Health Equity in 2014. Its goals are to examine and develop policy that addresses health disparities and their causes, a chief one of which is poverty. To advance these goals, we investigated health disparities related to HIV and poverty among males and females, controlling for other factors.We conducted an ecological analysis¹² using NYC HIV surveillance data to examine if area-based poverty at the ZIP Code level is independently associated with HIV diagnosis rates among males and females.     

Connecting Discovery and Delivery: The Need For More Evidence on Effective Smoking Cessation Strategies for People Living With HIV/AIDS

Smoking prevalence among the 1.1 million Americans living with HIV/AIDS is 2 to 3 times higher than the 19.8% rate among the general population. Since 1990, scientists have worked toward the discovery of health risks related to smoking in people living with HIV/AIDS; however, few studies have evaluated the delivery of smoking cessation interventions for this population. Increasing linkages between discovery science and delivery science may facilitate a faster transition to delivery of smoking cessation interventions for people living with HIV/AIDS.Health research often focuses on the discovery of risk factors associated with disease and death.¹ Although discovery of health risks is necessary to protect health, the delivery of interventions to improve health is equally important.^1–5 Information regarding how science moves from discovery to delivery points to substantial time lag and little cross-talk between discovery and delivery research.^1,6 This may be especially problematic in areas such as HIV/AIDS and smoking, where delay between discovery of smoking-related health outcomes in people living with HIV/AIDS and the delivery of interventions to reduce smoking among this population has serious consequences.Smoking prevalence in people living with HIV/AIDS is 2 to 3 times higher than is the 19.8% rate among the general population.^7–16 Discovery research has concluded that smokers with HIV/AIDS are more likely to be nonadherent to treatment, have a greater chance of being diagnosed with an AIDS-defining condition or dying, and report lower quality of life than do nonsmoking persons with HIV/AIDS.^13,17–21 Smokers living with HIV/AIDS have a higher risk of disease and opportunistic infection than do smokers who do not have HIV/AIDS.^9,22–34Delivery research indicates that population-specific smoking cessation interventions can be effective.^35–52 Although few studies have examined such strategies for persons living with HIV/AIDS,³⁵ a recent study found that 86% of smokers with HIV/AIDS would not benefit from standard cessation programs.⁵³ I used citation network analysis^54–56 to examine the characteristics of—and possible relationships between—discovery research relating health outcomes to smoking in persons living with HIV/AIDS and delivery research on interventions to reduce smoking among this population.     

Timely HIV Diagnosis and HIV/TB Comanagement Among California Patients in 2008

Objective

National guidelines highlight the roles of early HIV diagnosis and effective comanagement for HIV and tuberculosis (TB) to prevent mortality and morbidity from HIV-related TB. We assessed HIV diagnosis timing and HIV/TB comanagement for California HIV/TB patients.

Methods

We reviewed and analyzed public health charts for California HIV/TB patients reported during 2008. HIV diagnoses fewer than three months before TB diagnosis were considered new HIV diagnoses. We determined the proportion of patients with new HIV diagnoses, risk factors for new HIV diagnoses, and proportion of patients receiving recommended CD4 cell count measurements, supervised TB therapy, and antiretroviral therapy (ART).

Results

Of 130 HIV/TB patients, 51% had new HIV diagnoses. Foreign-born patients were more likely than U.S.-born patients to have new HIV diagnoses. Supervised TB therapy and CD4 cell count measurements followed national recommendations for 91% and 74% of patients, respectively. At least 73% of patients started ART before completing TB therapy. Compared with patients who had previous HIV diagnoses, patients with new HIV diagnoses started ART later and had lower CD4 cell counts and higher viral loads at TB diagnosis.

Conclusions

Although most HIV/TB patients received the recommended treatment, half had new HIV diagnoses. Compared with patients who had previous HIV diagnoses, patients with new HIV diagnoses had greater immunosuppression at TB diagnosis. A new diagnosis indicates that HIV could have been diagnosed earlier and ART or treatment for latent TB infection could have been initiated to prevent TB development.Human immunodeficiency virus (HIV) infection is a potent risk factor for death among tuberculosis (TB) patients.^1–5 In the United States during 2006, HIV-infected patients comprised 12% of TB patients with known HIV status but 30% of patients who died during TB therapy.¹ Among all states, California reported the largest number of TB patients and the second-largest number of patients diagnosed with HIV infection in 2009.^6,7 A field assessment in California found that 132 TB patients had HIV in 2008,⁸ accounting for 14% of all TB patients with HIV in the U.S.⁹Timely HIV diagnosis is an important step in preventing TB disease and HIV/TB mortality. Early HIV diagnosis informs patients of their risk for developing TB disease and triggers opportunities to prevent TB through isoniazid prophylaxis and antiretroviral therapy (ART).¹⁰ Isoniazid prophylaxis effectively reduces the risk of progression to TB disease among HIV-infected patients with latent TB infection (LTBI).¹¹ ART restores immune function and is estimated to reduce the risk of TB in HIV-infected patients by 65%.¹² ART even reduces the TB risk in people without a positive tuberculin skin test, suggesting a possible protective effect against establishment of infection by Mycobacterium tuberculosis.^13,14Even when LTBI progresses to TB disease in patients unaware of their HIV infection, HIV diagnosis is still critical because providers are alerted to patients'' need for ART, which can reduce the risk of death.⁴ Providers can also make referrals to HIV services and coordinate HIV/TB comanagement. Therefore, HIV status determination is recommended for all TB patients.²Once TB patients with HIV infection are identified, effective HIV/TB comanagement is needed to optimize patient outcomes. Recommendations from the Office of AIDS Research Advisory Council (OARAC) help TB clinicians ensure effective comanagement.¹⁵ TB clinicians should obtain cluster of differentiation 4 (CD4) cell counts to monitor HIV progression and determine the timing of ART. Clinicians should also ensure supervision of TB therapy to enhance adherence and prevent acquired TB drug resistance. At the time of the 2008 OARAC recommendations, there was insufficient evidence to determine the optimal timing of ART initiation during TB therapy. Although the 2008 guidelines did not make formal recommendations, they suggested that ART be started two weeks after TB treatment initiation for patients with <100 CD4 cells/millimeter cubed (mm³), eight weeks after TB treatment initiation for patients with 100–200 CD4 cells/mm³, and based on clinical judgment for patients with >200 CD4 cells/mm³.U.S. guidelines highlight the need for early HIV identification and effective HIV/TB comanagement, but little is known about the actual timing of HIV identification or strength of elements of HIV/TB comanagement practices for patients in California. Therefore, we conducted a review of TB patients with HIV (henceforth referred to as HIV/TB patients) reported in California during 2008 to assess the timing of HIV diagnosis and adherence to the 2008 OARAC HIV/TB comanagement recommendations.     

Hospitalization Rates of People Living with HIV in the United States, 2009

Objectives

We determined hospitalization rates and disparities among people with HIV, which may have been underestimated in previous studies, as only those in medical care were included.

Methods

We estimated the hospitalization rate of people with diagnosed HIV infection in the U.S. in 2009 using two nationally representative datasets. We took the number of hospitalizations from the Nationwide Inpatient Sample and searched each discharge for International Classification of Diseases, Ninth Revision codes for HIV infection and opportunistic infections (OIs). We divided the number of hospitalizations by the number of prevalent diagnosed HIV cases estimated by CDC to produce hospitalization rates, and then compared those rates using Z-tests.

Results

The estimated nationwide hospitalization rate was 26.6 per 100 population. Women had a 51% higher rate than men (35.5 vs. 23.5 per 100 population, p=0.002). Black people (31.2 per 100 population, p=0.01) had a 42% higher rate, and Hispanic people (18.2 per 100 population, p=0.23) had an 18% lower rate than white people (22.1 per 100 population) of hospitalization for any illness. Of hospitalizations with an OI, females with HIV had a 50% higher rate than males with HIV (5.0 vs. 3.4 per 100 population, p=0.003). Black people with HIV (4.7 per 100 population, p<0.001) had a 72% higher rate and Hispanic people with HIV (2.9 per 100 population, p=0.78) had a similar rate of hospitalization with an OI compared with white people with HIV (2.7 per 100 population).

Conclusions

Hospitalization rates among people living with HIV in the U.S. are higher than have been previously estimated. Substantial gender and racial/ethnic disparities in hospitalization rates exist, suggesting that the benefits of antiretroviral therapy have not been realized across all groups equally.Hospitalization rates among people with human immunodeficiency virus (HIV) have fallen in recent years with the widespread use of highly active antiretroviral therapy.^1–6 However, recent studies examining hospitalizations of people living with HIV in the United States have been limited to those in medical care, and it is unclear if results are generalizable to the total U.S. population with HIV. To produce more generalizable estimates, we conducted a cross-sectional analysis of hospitalization rates among people living with HIV using nationally representative data.The outcome of hospitalization among people with HIV merits continued study. As antiretroviral therapy (ART) has been associated with a substantial reduction in hospitalization rates among people living with HIV,^1–6 measuring population-based hospitalization rates may serve as a marker for access to and success of care on a population level. Changes in hospitalization rates may be more sensitive indicators of treatment failures or toxicity than changes in mortality. In addition, hospitalizations represent a substantial portion of the cost of HIV care, especially for those with advanced disease,⁷ and decreases in hospitalizations may allow for the redistribution of resources to other aspects of HIV care.Recent studies examining hospitalization rates among people living with HIV included only patients engaged in HIV care, possibly underestimating the true hospitalization rates. Population-based studies have estimated that approximately one-quarter of people with newly diagnosed HIV infection do not receive care within one year.^8–10 In addition, previous studies have shown that in any given year, up to one-half of people living with HIV are not in HIV care.^8,11–13 Populations not in HIV care do not benefit from ART, and, therefore, may have significantly higher hospitalization rates, particularly for diseases associated with untreated HIV, such as opportunistic infections (OIs). Therefore, by only including those engaged in HIV care, cohort studies may underestimate true hospitalization rates.Women and those in racial/ethnic minority groups are less likely to be engaged and retained in HIV care.^11,14,15 Therefore, previous studies may also have preferentially underestimated hospitalization rates in these groups by only including those engaged in care, thus underestimating gender and racial/ethnic disparities in hospitalization rates. To determine unbiased estimates of outcomes disparities by gender and race/ethnicity, we aimed to estimate hospitalization rates for these groups while including patients not in care.The goals of this study were to (1) estimate the nationwide rate of all-cause hospitalizations, hospitalizations for OIs, and in-hospital deaths among people living with HIV; and (2) determine if significant gender and racial/ethnic disparities exist in these outcomes for all people living with HIV in the U.S. We hypothesized that hospitalization rates among people living with HIV would be higher than has previously been reported, and that black people, Hispanic people, and women would have higher rates of overall hospitalization, more hospitalizations related to OIs, and a higher rate of in-hospital death.     

Effectiveness of the U.S. National HIV Testing Day Campaigns in Promoting HIV Testing: Evidence from CDC-Funded HIV Testing Sites, 2010

Objectives

We assessed if HIV testing and diagnoses increased during the week of National HIV Testing Day (NHTD) and if characteristics of people who were tested varied compared with control weeks.

Methods

We analyzed HIV testing data from the 2010 National HIV Prevention Program Monitoring and Evaluation system to compare NHTD week (June 24–30, 2010) with two control weeks (January 7–13, 2010, and August 12–18, 2010) for the number of HIV testing events and new HIV-positive diagnoses, by demographics and other HIV-related variables. Characteristics associated with testing during NHTD week compared with control weeks were identified using Chi-square analyses.

Results

In 2010, an average of 15,000 more testing events were conducted and 100 more new HIV-positive diagnoses were identified during NHTD week than during the control weeks (p<0.001). Compared with control weeks, people tested during NHTD week were significantly less likely to be aged 20–29 years and non-Hispanic white and significantly more likely to be (1) aged ≥50 years, (2) non-Hispanic black or African American, (3) men who have sex with men, (4) low-risk heterosexuals, (5) tested with a rapid HIV test, or (6) tested in a non-health-care setting.

Conclusion

In 2010, CDC-funded HIV testing events and new HIV-positive diagnoses increased during NHTD week compared with control weeks. HIV testing programs increased the use of rapid tests and returned a high percentage of test results. NHTD campaigns reached populations disproportionately affected by HIV and further expanded testing to people traditionally less likely to be tested. Incorporating strategies used during NHTD in programs conducted throughout the year may assist in increasing HIV testing and the number of HIV-positive diagnoses.Human immunodeficiency virus (HIV) continues to be a major public health problem in the United States. In 2009, the Centers for Disease Control and Prevention (CDC) estimated that 1.2 million people were living with HIV in the U.S. However, 18% are unaware they are infected and 32% of people diagnosed with HIV were also diagnosed with acquired immunodeficiency syndrome (AIDS) within 12 months of their diagnosis, which indicates they may have been infected with HIV for years before being diagnosed.¹ HIV testing identifies infected people and is the entry point to a continuum of HIV medical care and prevention services that improve health outcomes, including survival, and reduce the risk of HIV transmission. CDC recommends routine HIV testing in health-care settings for all people aged 13–64 years, annual HIV testing for those at high risk of infection, and routine testing as a part of prenatal care for all pregnant women.²CDC supports these HIV testing recommendations with a number of initiatives^3,4 designed to expand HIV testing to populations disproportionately affected by HIV, especially non-Hispanic black or African American people (hereafter, non-Hispanic black people), Hispanic or Latino people, and men who have sex with men (MSM).⁴ CDC-funded HIV testing events are an important part of national HIV prevention efforts.⁵ In 2010, 3.2 million CDC-funded HIV testing events were conducted, diagnosing 13,000 newly identified people living with HIV.⁶June 27 of each year is designated as National HIV Testing Day (NHTD). NHTD was founded in 1995 by the National Association of People with AIDS (NAPWA), an advocacy group for people living with HIV/AIDS. The objectives of NHTD are to encourage people to (1) get tested for HIV; (2) become aware of their HIV status; (3) get linked to prevention, care, and treatment services; and (4) work to reduce the stigma associated with HIV.^5,7 These objectives are in line with the major goals of the National HIV/AIDS Strategy, released by the White House in 2010.⁸ Through 2012, NAPWA organized and promoted NHTD activities with the support of CDC and other public and private partners, such as state and local health departments and community-based organizations. While the theme of each year''s NHTD remains the promotion of HIV testing, local organizations determine the specific activities they conduct during NHTD. Most NHTD events offer free HIV testing and include mass media and social marketing campaigns to improve knowledge about HIV testing, care, and prevention services; address barriers to getting tested; and encourage testing.⁷Because NHTD is a nationally recognized day to encourage HIV testing, it is important to document the effect this type of public health campaign has on increasing HIV testing and new HIV-positive diagnoses. Mass media campaigns can promote behavioral change for a wide range of HIV/AIDS preventive actions, including testing. A Cochrane review of 14 mass media interventions for promoting HIV testing found that these interventions have immediate and overall effects on promoting HIV testing in the targeted populations.⁹ However, most of these mass media interventions were designed and tested for specific populations or in limited geographical areas. In comparison, NHTD campaign activities are not predetermined at a national level, vary from place to place, and may incorporate a broad range of mass media campaigns. Therefore, the effectiveness of NHTD campaigns on increasing HIV testing nationally is unclear.Two previous reports have assessed HIV testing before and after NHTD.^5,10 In 2000, CDC compared the number of HIV tests and HIV-positive tests the week before and the week of NHTD from 1995 through 1998 among 43 CDC-funded health departments. CDC found that 4,266 more HIV tests were conducted and 57 more HIV-positive tests were identified during the week of NHTD compared with the week before NHTD.⁵ Similar results were found in a 2013 study by the HIV/AIDS and Hepatitis Program of the Florida State Bureau of Communicable Diseases. From 2003 through 2012, greater numbers of HIV tests and HIV-positive tests were documented, annually, during the week of NHTD compared with the week before NHTD.¹⁰We sought to update and expand the scope of the previous analyses. We assessed the effect national public health campaigns, such as NHTD, have on increasing the number of CDC-funded HIV testing events and the number of new HIV-positive diagnoses in the U.S. by asking two questions: (1) During the week of NHTD, how many additional CDC-funded HIV testing events were conducted and new HIV-positive diagnoses identified compared with the control weeks? and (2) Do characteristics of people tested during the week of NHTD differ from people tested during the control weeks? Specifically, do populations (e.g., MSM, non-Hispanic black people, and Hispanic or Latino people) disproportionately affected by HIV experience higher testing during the week of NHTD than during other times of the year?The previous studies documented the importance of NHTD campaigns in increasing the uptake of HIV testing and diagnosis of people living with HIV.^5,10 However, the CDC study was conducted more than a decade ago and did not examine the characteristics of people tested. While the Florida study was more recent, it reflected data from only one state and did not provide comparisons to examine the potential differences in the populations served the week before and the week of NHTD. In contrast with the previous studies, we selected control weeks throughout the year rather than the week before NHTD to reduce the risk of missing a true difference in HIV testing (Type II error) due to implementation of NHTD activities in the weeks leading up to NHTD.     

Electronic matching of HIV/AIDS and hepatitis C surveillance registries in three states

Objectives

Both HIV and hepatitis C virus (HCV) can be transmitted through percutaneous exposure to blood in similar high-risk populations. HCV and HIV/AIDS surveillance databases were matched in Colorado, Connecticut, and Oregon to measure the frequency of co-infection and to characterize co-infected people.

Methods

We defined a case of HCV infection as a person with a reactive antibody for hepatitis C, medical diagnosis, positive viral-load test result, or positive genotype reported to any of three state health departments from the start of each state’s hepatitis C registry through June 30, 2008. We defined a case of HIV/AIDS as a person diagnosed and living with HIV/AIDS at the start of each state’s respective hepatitis C registry through June 30, 2008. HIV/AIDS and hepatitis C datasets were matched using Link King, public domain record linkage and consolidation software, and all potential matches were manually reviewed before acceptance as a match.

Results

The proportion of reported hepatitis C cases co-infected with HIV/AIDS was 1.8% in Oregon, 1.9% in Colorado, and 4.9% in Connecticut. Conversely, the proportion of HIV/AIDS cases co-infected with hepatitis C was consistently higher in the three states: 4.4% in Oregon, 9.7% in Colorado, and 23.6% in Connecticut.

Conclusions

Electronic matching of registries is a potentially useful and efficient way to transfer information from one registry to another. In addition, it can provide a measure of the public health burden of HIV/AIDS and hepatitis C co-infection and provide insight into prevention and medical care needs for respective states.In the United States, an estimated 3.2 million people have chronic hepatitis C virus (HCV) infection¹ and an estimated 1.1 million people are living with human immunodeficiency virus (HIV).² Co-infection of HIV and HCV results in more rapid progression of both infections^3,4 and complicates treatment.⁵ Because both HIV and HCV viruses can be transmitted through percutaneous exposure to blood, similar at-risk populations are affected, notably injection drug users (IDUs), and estimating the number of co-infected people can help steer public health initiatives.At the local level, assessing the number and characteristics of co-infected individuals is an important public health endeavor. Prevention and care planning groups can use these data to target and evaluate their activities. The objectives of this study were to use surveillance data to measure HIV/acquired immunodeficiency syndrome (AIDS) and HCV co-infections; to characterize the co-infected populations; and to compare similarities and differences of the co-infected populations in Colorado, Connecticut, and Oregon.     

High Risk for HIV Following Syphilis Diagnosis Among Men in Florida, 2000–2011

Objective

Multiple interventions have been shown to reduce the risk of HIV acquisition, including preexposure prophylaxis with antiretroviral medications, but high costs require targeting interventions to people at the highest risk. We identified the risk of HIV following a syphilis diagnosis for men in Florida.

Methods

We analyzed surveillance records of 13- to 59-year-old men in Florida who were reported as having syphilis from January 1, 2000, to December 31, 2009. We excluded men who had HIV infection reported before their syphilis diagnosis (and within 60 days after), then searched the database to see if the remaining men were reported as having HIV infection by December 31, 2011.

Results

Of the 9,512 men with syphilis we followed, 1,323 were subsequently diagnosed as having HIV infection 60–3,753 days after their syphilis diagnosis. The risk of a subsequent diagnosis of HIV infection was 3.6% in the first year after syphilis was diagnosed and reached 17.5% 10 years after a syphilis diagnosis. The risk of HIV was higher for non-Hispanic white men (3.4% per year) than for non-Hispanic black men (1.8% per year). The likelihood of developing HIV was slightly lower for men diagnosed with syphilis in 2000 and 2001 compared with subsequent years. Of men diagnosed with syphilis in 2003, 21.5% were reported as having a new HIV diagnosis by December 31, 2011.

Conclusion

Men who acquire syphilis are at very high risk of HIV infection.Antiretroviral medications have reduced acquired immunodeficiency syndrome mortality in the United States from 50,260 adults in 1995 to 17,770 adults in 2009.^1,2 However, the risk of acquiring human immunodeficiency virus (HIV) infection remains high, particularly for men who have sex with men (MSM). An estimated 30,000 MSM have acquired HIV in each of the past several years.^3,4 The White House''s National HIV/AIDS Strategy states that to reduce HIV incidence, we must (1) intensify HIV prevention efforts in communities where HIV is most heavily concentrated and (2) expand targeted efforts to prevent HIV infection using a combination of effective, evidence-based approaches.⁵ By estimating the percentage of men in the population who are MSM, researchers have estimated the HIV incidence for all MSM as 0.66% per year in Florida (in 2006)⁶ and 0.67% per year in 37 states (in 2008).⁷ This risk might be reduced by a variety of interventions, including antiretroviral preexposure prophylaxis (PrEP), which reduced the incidence of HIV by 44% among MSM in a blinded randomized controlled trial.⁸ If PrEP could be widely implemented with high-use effectiveness, it could have an impact on HIV incidence; however, the high cost of PrEP will require targeting MSM at highest risk.⁹ Some groups of high-risk MSM have been identified. For example, MSM recruited into HIV vaccine efficacy studies have had incidence rates as high as 2.7% per year.¹⁰People diagnosed with other sexually transmitted infections (STIs) have long been known to be at increased risk for having HIV coinfection.¹¹ Among 212 men with early syphilis in Los Angeles, California, in 2002–2004, 35% had HIV coinfection, and HIV incidence was estimated to be 17% in the preceding year.¹² Among 363 MSM with early syphilis in Atlanta, Georgia; San Francisco, California; or Los Angeles in 2004–2005, 47% had HIV coinfection, and 10 of these coinfections were recently diagnosed, suggesting an incidence of 12%.¹³ However, preventing infection requires identifying high-risk people before they acquire HIV. A recent study in San Francisco''s City Clinic retrospectively followed MSM for two years after they were diagnosed with rectal gonorrhea or chlamydia and found that 27 acquired HIV, for an incidence of 2.3% per year.¹⁴In Florida, all syphilis, gonorrhea, and chlamydia infections are reportable to the state health department, and the reports are maintained in a common database. This database is routinely cross-matched with the HIV surveillance database to determine if any of the people with other STIs have been reported as having HIV. Gender of sex partners is not available for all reported cases of STI, but since the early 2000s, syphilis cases have been increasingly concentrated among MSM.¹⁵ We used this database to study all men in Florida who were reported as having early syphilis and to determine their risk of subsequent diagnosis and report of HIV infection.     

Correlates of HIV Risk Behaviors Among Homeless and Unstably Housed Young Adults

Objectives

Homeless young adults are exposed to multiple risk factors for HIV infection. We identified HIV risk behaviors and their correlates among homeless young adults in Portland, Oregon.

Methods

We conducted a community-based, cross-sectional survey of HIV risk behaviors among homeless young adults aged 18–25 years in 2010. Participants completed three study components: (1) an interviewer-administered survey of HIV risk behaviors; (2) a brief, client-centered HIV risk-based counseling session; and (3) rapid HIV testing.

Results

Among 208 participants, 45.8% identified as racial/ethnic minority groups, 63.8% were male, and 35.7% self-identified as nonheterosexual. Six participants, all from sexual minority groups, had positive HIV screening results (two newly identified, four previously known) for a seropositivity rate of 2.9%. Female sex, belonging to a sexual minority group, frequent traveling between cities, depression, and alcohol use to intoxication were significantly associated with unprotected sex in univariate analysis. Female sex and high perceived risk of HIV were significantly associated with unprotected sex in multivariate analysis.

Conclusions

Our findings support the need for enhanced HIV prevention interventions for homeless young adults.In the Portland, Oregon, metropolitan area, an estimated 1,500–2,000 homeless young people are living on the street (Personal communication, Caitlin Campbell, Homeless Youth Continuum Coordinator, Multnomah County, Oregon, July 2009). Young adults and adolescents are at particularly high risk of human immunodeficiency virus (HIV) infection. In 2008, the Centers for Disease Control and Prevention (CDC) reported that 13% of all new HIV infections in the U.S. occur among people aged 13–24 years.¹ Statistical modeling estimates that approximately half of HIV infections in the U.S. occur before 25 years of age.² The young adult years are accompanied by escalating risk due to sexual contact and initiation of drug use in certain populations.Homeless young people live at the intersection of multiple risk factors and are especially at risk for HIV infection. Up to 35% of homeless young people identify as gay, lesbian, bisexual, or transgender.^3–6 Homeless populations frequently exchange sex for money, drugs, or a place to stay;⁷ have high rates of substance use;⁸ and experience substantial unmet needs for multiple types of health care,⁹ further increasing their risk for HIV infection. Mental illness, such as depression, has been shown to be associated with infrequent condom usage among homeless adolescents in the U.S. Pacific Northwest.¹⁰ In 1994, Allen et al. reported findings from a 16-city CDC-sponsored seroprevalence study that showed an HIV prevalence of 2.3% among runaway young people aged 15–24 years and 3.4% among homeless adults.¹¹ More recent studies demonstrate HIV prevalence proportions of 5%–16% among homeless adolescents and young adults.^12,13An updated account of HIV prevalence among homeless young adults is essential to inform HIV prevention programs, reduce HIV transmission by educating about behaviors that put people at risk for infection, and connect affected people with resources. Additionally, little is known about current risk-taking behaviors among homeless young adults. The purpose of this study was to identify HIV risk behaviors and their correlates among homeless young adults in the Portland, Oregon, metropolitan area.     

Estimating the Cost to U.S. Health Departments to Conduct HIV Surveillance

Objectives

HIV case surveillance is a primary source of information for monitoring HIV burden in the United States and guiding the allocation of prevention and treatment funds. While the number of people living with HIV and the need for surveillance data have increased, little is known about the cost of surveillance. We estimated the economic cost to health departments of conducting high-quality HIV case surveillance.

Methods

We collected primary data on the unit cost and quantity of resources used to operate the HIV case surveillance program in Michigan, where HIV burden (i.e., the number of HIV cases) is moderate to high (n=14,864 cases). Based on Michigan''s data, we projected the expected annual HIV surveillance cost for U.S., state, local, and territorial health departments. We based our cost projection on the variation in the number of new and established cases, area-specific wages, and potential economies of scale.

Results

We estimated the annual total HIV surveillance cost to the Michigan health department to be $1,286,524 ($87/case), the annual total cost of new cases to be $108,657 ($133/case), and the annual total cost of established cases to be $1,177,867 ($84/case). Our projected median annual HIV surveillance cost per health department ranged from $210,600 in low-HIV burden sites to $1,835,000 in high-HIV burden sites.

Conclusions

Our analysis shows that a systematic approach to costing HIV surveillance at the health department level is feasible. For HIV surveillance, a substantial portion of total surveillance costs is attributable to maintaining established cases.An estimated 1.2 million people aged 13 years and older are living with human immunodeficiency virus (HIV) in the United States, and about 47,500 people are infected with the virus each year.^1,2 A recent HIV surveillance report shows that the number of people living with HIV increased by 8% from 2006 through 2009.³ The U.S. Centers for Disease Control and Prevention (CDC) has developed an HIV surveillance system for collecting, analyzing, and disseminating accurate information on the number of people with new HIV diagnoses (new cases) and those living with HIV infection (established cases).^4,5 Access to timely and high-quality surveillance data is essential to detect trends in the HIV burden and develop appropriate prevention and control measures.^4,6,7 The U.S. Department of Health and Human Services has closely aligned the $16 billion it spent in 2010 on HIV care, treatment, and prevention with the number of reported HIV cases in each state.⁸ HIV case surveillance additionally guides the implementation of test-and-treat prevention strategies that require data on timing of diagnosis, entry into and retention in care, and viral load (VL) suppression.^8–10 The Institute of Medicine recently identified HIV case surveillance as one of the data collection systems that could be used to monitor progress in achieving National HIV/AIDS Strategy goals.^11,12The purpose of this analysis was to estimate the economic cost to health departments to conduct high-quality HIV case surveillance, where high quality is defined as meeting or exceeding CDC data quality standards regarding the completeness and timeliness of reporting diagnosed HIV cases and ascertaining duplicate cases and deaths.^6,7 We examined potential variation in costs across health departments based on differences in the number of new vs. established HIV cases, area-specific wages, and potential economies of scale. Results from the analysis could help inform surveillance funding allocation across health departments and enable health departments to more accurately assess their own costs attributable to new and established HIV cases.     

HIV Testing Among Men at Risk for Acquiring HIV Infection Before and After the 2006 CDC Recommendations

Objectives

Testing for human immunodeficiency virus (HIV) is the key first step in HIV treatment and prevention. In 2006, the Centers for Disease Control and Prevention (CDC) recommended annual HIV testing for people at high risk for HIV infection. We evaluated HIV testing among men with high-risk heterosexual (HRH) contact and sexually active men who have sex with men (MSM) before and after the CDC recommendations.

Methods

We used data from the National Survey of Family Growth, 2002 and 2006–2010, to assess proportions of HRH respondents and MSM reporting HIV testing in the prior 12 months, compare rates of testing before and after release of the 2006 CDC HIV testing guidelines, and examine demographic variables and receipt of health-care services as correlates of HIV testing.

Results

Among MSM, the proportion tested was 37.2% (95% confidence interval [CI] 28.2, 47.2) in 2002, 38.2% (95% CI 25.9, 52.2) in 2006–2008, and 41.7% (95% CI 29.2, 55.3) in 2008–2010; among HRH respondents, the proportion was 23.7% (95% CI 20.5, 27.3) in 2002, 24.5% (95% CI 20.9, 28.7) in 2006–2008, and 23.9% (95% CI 20.2, 28.1) in 2008–2010. HIV testing was more likely among MSM and HRH respondents who received testing or treatment for sexually transmitted disease in the prior 12 months, received a physical examination in the prior 12 months (MSM only), or were incarcerated in the prior 12 months.

Conclusions

The rate of annual HIV testing was low for men with sexual risk for HIV infection, and little improvement took place from 2002 to 2006–2010. Interventions aimed at men at risk, especially MSM, in both nonmedical and health-care settings, likely could increase HIV testing.New infections of human immunodeficiency virus (HIV) occur in the United States at a rate of approximately 50,000 per year, driven mostly by sexual transmission, particularly among men who have sex with men (MSM).¹ In 2010, male-to-male sexual contact accounted for 63% of new HIV infections (78% among males), and heterosexual contact accounted for 25% of new HIV infections (11% among males).^1,2 Although overall incidence has been relatively stable since 2006, among young MSM, particularly young black MSM, new infections continue to increase.^1,3An estimated 14% of adults and adolescents living with HIV infection in the United States are undiagnosed, of whom 11% are males with high-risk heterosexual (HRH) contact and 62% are MSM.⁴ To increase the proportion of HIV-infected people who are aware of their status and link them to treatment and prevention services, the Centers for Disease Control and Prevention (CDC) recommended in 2006 that all people aged 13–64 years be tested at least once for HIV infection and that people at high risk for HIV infection, including men with HRH contact and sexually active MSM,⁵ be tested annually.Using data from multiple waves of a nationally representative survey, we examined the percentage of HRH and MSM respondents who reported having been tested for HIV in the prior 12 months. We compared rates of testing before and after the revised HIV testing guidelines⁵ were released by CDC in 2006. Additionally, because the 2006 CDC guidelines recommended that HIV screening be conducted as part of routine clinical care in all health-care settings,⁵ we examined HIV testing among men stratified by their reported use of health-care services in the prior 12 months and by several sociodemographic variables.     

Rapid HIV Testing at Gay Pride Events to Reach Previously Untested MSM: U.S., 2009–2010

We offered rapid HIV testing at social events frequented by young men who have sex with men (MSM), a group disproportionately affected by the HIV epidemic. We tested 1,312 MSM; of those MSM, 1,072 (81.7%) reported HIV testing history. Of those reporting HIV testing history, 550 (51.3%) were non-Hispanic black and 404 (37.7%) were aged <25 years. One hundred twenty-eight (11.9%) had never tested for HIV; 77 (7.2%) were preliminarily positive, with 15 (19.5%) being first-time testers. Factors associated with no previous HIV test included young age (13–24 years) (adjusted odds ratio [AOR] = 3.5, 95% confidence interval [CI] 1.9, 6.5) and non-Hispanic black (AOR=3.2, 95% CI 1.6, 6.4) or Hispanic (AOR=2.8, 95% CI 1.2, 6.3) race/ethnicity. HIV testing at Gay Pride events reaches young, previously untested MSM. This venue-based HIV testing approach at nonclinical sociocultural events is an additional strategy for HIV prevention goals to increase the number of people aware of their HIV infection with subsequent linkage to HIV care.An estimated 20% of 1.2 million people living with human immunodeficiency virus (HIV) infection in the United States are unaware of their HIV infection.¹ Among people living with HIV, young non-Hispanic black men who have sex with men (MSM) are the only group with significant increases in incident HIV cases in recent years.² Although young non-Hispanic black and Hispanic MSM are more likely to report being tested, they are also more likely to be unaware of an HIV infection than their white counterparts.³ A recent analysis reported that 44% of MSM in 21 cities were unaware of their infection; non-Hispanic black MSM comprised 59% of that group.⁴ People unaware of their HIV infection transmit approximately half of incident HIV infections.⁵Although young non-Hispanic black MSM do not engage in risky behaviors more than young non-Hispanic white or Hispanic men,⁶ they are more vulnerable to becoming HIV-infected than MSM from other racial/ethnic groups. Reasons for this disproportionate impact on young MSM of color are unclear, but include high community prevalence of HIV, social and structural barriers to routine screening and treatment (e.g., less health insurance, higher unemployment, and higher rate of incarceration), and stigma and homophobia.⁷ MSM with increased risk of HIV exposure may benefit from increased access to HIV screening in nontraditional/clinical settings.Early diagnosis and effective treatment with antiretroviral therapy are important components of reducing HIV transmission risk and incident HIV infections.³ Current recommendations support routine HIV screenings in health-care settings for people aged 13–64 years to provide opportunities for early diagnosis and linkage to care.⁸ Gaps in the implementation of these recommendations remain, however, and data suggest that opportunities to diagnose HIV infections in health-care settings, particularly among young MSM of color, may frequently be missed.⁹ Young MSM at increased risk of HIV exposure may benefit from more frequent testing intervals (i.e., every 3–6 months).^6,10HIV testing in nonclinical community settings is an additional prevention strategy to reach young minority MSM who disproportionately lack health-care access.^10,11 Nonclinical social events where large numbers of at-risk people may gather at locations perceived to be culturally sensitive, such as Gay Pride festivals, offer expanded opportunities for HIV testing. In addition, from the provider perspective, analyses have shown that community-based efforts for HIV testing cost less than testing in clinical settings.¹² These efforts are crucial as we work toward goals of the National HIV/AIDS Strategy.¹³Previous reports of HIV testing outreach have supported the feasibility of this approach with racial/ethnic minority MSM.^14,15 However, factors associated with having not been previously tested among MSM reached at these events are poorly understood.¹⁴ In this article, we summarize findings from the Behavioral Assessment and Rapid Testing (BART) project,¹⁶ a community-based HIV testing project that was implemented in multiple U.S. cities. Our objectives were to (1) describe characteristics of MSM who accepted HIV testing, (2) examine differences in time since previous HIV test for participants, and (3) describe factors associated with not having been previously tested for HIV.     

Trends in HIV Testing Among U.S. Older Adults Prior to and Since Release of CDC's Routine HIV Testing Recommendations: National Findings from the BRFSS

Objective

This study examined temporal trends in HIV testing among U.S. older adults (50–64 years of age) before and after the release of CDC''s routine HIV testing recommendations in 2006.

Methods

The sample (n=872,797; 51.4% female) comprised 2003–2010 Behavioral Risk Factor Surveillance System respondents in the oldest categories to which the recommendations apply: 50–54 years (34.5%, n=301,519), 55–59 years (34.1%, n=297,865), and 60–64 years (31.3%, n=273,413). We calculated (1) four-year pooled prevalences of past-year HIV testing before and after 2006, when the recommendations were released; and (2) annual prevalences of HIV testing overall and by age category from 2003–2010. Using weighted, multivariable logistic regression analyses, we examined binary (pre- vs. post-recommendations) and annual changes in testing, controlling for covariates. We stratified the data by recent doctor visits, examined racial/ethnic differences, and tested for linear and quadratic temporal trends.

Results

Overall and within age categories, the pooled prevalence of past-year HIV testing decreased following release of the recommendations (p<0.001). The annual prevalence decreased monotonically from 2003 (5.5%) to 2006 (3.6%) (b=–0.16, p<0.001) and then increased immediately after release of the recommendations, but decreased to 3.7% after 2009 (b=0.01, p<0.001). By race/ethnicity, testing increased over time among non-Hispanic black people only. Annual prevalence also increased among respondents with recent doctor visits.

Conclusion

CDC''s HIV testing recommendations were associated with a reversal in the downward trend in past-year HIV testing among older adults; however, the gains were neither universal nor sustained over time.In 2006, the Centers for Disease Control and Prevention (CDC) began recommending routine opt-out human immunodeficiency virus (HIV) testing of all adults <65 years of age seeking health care in any setting where HIV prevalence is ≥0.1%.¹ Routine testing is an efficient, cost-effective strategy for early detection of HIV infection.² It involves screening every patient (except those who decline testing) regardless of any reported risk behaviors; therefore, it can facilitate detection of undiagnosed HIV infection among people unlikely to seek an HIV test, including those presumed to have little or no HIV risk.³Routine testing may be particularly important for older adults (i.e., those aged ≥50 years), among whom 11% of U.S. HIV infections occur. Of concern, HIV-infected older adults are disproportionately diagnosed late in the course of HIV disease.^4,5 Late diagnosis is associated with rapid progression to acquired immunodeficiency syndrome (AIDS), and it exacerbates the management of both HIV disease and the non-HIV conditions that are prevalent among older adults (e.g., hypertension).^6–9 Rates of HIV testing generally decrease with age;^10–13 however, it is unclear if the release and implementation of the recommendations have helped to improve HIV testing levels in this age group.^14,15To understand the recommendations'' potential influence on HIV testing among older adults, we examined trends in HIV testing from January 1, 2003, to December 31, 2010, among Behavioral Risk Factor Surveillance System (BRFSS) respondents in the three categories of older adulthood (50–54, 55–59, and 60–64 years of age) to which the routine HIV testing recommendations apply. The study period began four years prior to CDC''s publication of the recommendations and concluded four years thereafter, enabling us to compare HIV testing levels before and after their release. Full implementation should produce a sustained increase in testing that begins in 2007 and is most apparent among people with a recent doctor visit. This study sought to determine if:

1. The annual prevalence of past-year HIV testing increased among older adults since release of the routine HIV testing recommendations,
2. Racial/ethnic differences in past-year HIV testing exist over time among older adults,
3. The odds of testing increased more for those with vs. without a recent doctor visit since release of the recommendations, and
4. The characteristics of older testers changed over time.

     

Barriers to routine HIV testing among Massachusetts community health center personnel

Objectives

We assessed the extent to which Centers for Disease Control and Prevention (CDC) recommendations have influenced routine HIV testing among Massachusetts community health center (CHC) personnel, and identified specific barriers and facilitators to routine testing.

Methods

Thirty-one CHCs were enrolled in the study. We compared those that did and did not receive funding support from the federal Ryan White HIV/AIDS Program. An anonymous survey was administered to a maximum five personnel from each CHC, including a senior administrator, the medical director, and three medical providers. Overall, 137 participants completed the survey.

Results

Among all CHCs, 53% of administrators reported having implemented routine HIV testing at their CHCs; however, only 33% of medical directors/providers reported having implemented routine HIV testing in their practices (p<0.05). Among administrators, 60% of those from Ryan White-supported CHCs indicated that both they and their CHCs were aware of CDC''s recommendations, compared with 27% of administrators from non-Ryan White-supported CHCs. The five most frequently reported barriers to the implementation of routine HIV testing were (1) constraints on providers'' time (68%), (2) time required to administer counseling (65%), (3) time required to administer informed consent (52%), (4) lack of funding (35%), and (5) need for additional training (34%). In a multivariable logistic regression model, the provision of on-site HIV testing by nonmedical staff resulted in increased odds of conducting routine HIV testing (odds ratio [OR] = 9.84, 95% confidence interval [CI] 1.77, 54.70). However, the amount of time needed to administer informed consent was associated with decreased odds of providing routine testing (OR=0.21, 95% CI 0.05, 0.92).

Conclusions

Routine HIV testing is not currently being implemented uniformly among Massachusetts CHCs. Future efforts to increase implementation should address personnel concerns regarding time and staff availability.In the United States, more than one million people are estimated to be living with human immunodeficiency virus (HIV); 21% are undiagnosed and/or remain unaware of their HIV infection.^1–3 Almost 40% are diagnosed late in the course of infection and receive an acquired immunodeficiency syndrome (AIDS) diagnosis within one year of their first positive HIV test result.³ To address the large number of undiagnosed HIV cases and high proportion of individuals presenting late to care, the Centers for Disease Control and Prevention (CDC) published revised recommendations in September 2006 that sought to establish HIV testing as a routine component of medical care similar to other screening procedures. Specifically, the CDC guidelines recommend that providers in all health-care settings, including hospital emergency departments, primary care practices, and community clinics, offer voluntary HIV testing to all patients aged 13–64 years and all pregnant women as an opt-out procedure, meaning that patients are to be notified that an HIV test will be conducted unless the patient declines.⁴ Separate written consent and prevention counseling as prerequisites for testing are no longer recommended.Release of the revised recommendations has sparked a national debate, and responses among the medical community have been mixed, with a majority of U.S. health professional organizations endorsing all or parts of the CDC recommendations.^5–7 While potentially increasing rates of HIV testing by streamlining consent⁸ and reducing associated stigma through normalization as a routine clinical procedure,^9,10 the elimination of a separate consent process and mandatory prevention counseling remains incompatible with several state laws or regulations and has been met with some concern.^5,11–14 Physician barriers to HIV testing include insufficient time, burdensome consent process, lack of knowledge/training about HIV testing and the CDC revised recommendations, difficulty locating HIV testing consent forms, lack of patient acceptance, competing priorities, and inadequate reimbursement.^15,16A growing body of research has examined efforts to improve HIV testing rates in a variety of health-care settings, including a public, urban medical care system,¹⁷ U.S. Department of Veterans Affairs health-care facilities,^18,19 hospital emergency departments,²⁰ a sexually transmitted disease (STD) clinic,²¹ and community health centers (CHCs).^22–24 However, while studies of CHCs have described programs to implement routine testing and largely reported patient-level data, little research to date has examined barriers to implementation among CHC personnel. CHCs represent an important source of primary care for people who are low-income, from racial/ethnic and sexual minority groups, immigrants, and those seeking mental health and substance abuse treatment services.²⁵ These populations are also disproportionately affected by HIV/AIDS, suggesting that CHCs can and do serve as an important resource for HIV/AIDS prevention and treatment.²⁶ In fact, from 1999 to 2004, CHCs conducted 7% of the total HIV tests supported by CDC yet identified 12% of the total HIV-positive results.²⁷In Massachusetts, providers face unique barriers to implementing routine testing. Despite the issuance of a June 2009 clinical advisory by the state health department supporting routine HIV testing in primary and urgent care settings, state law requires specific written informed consent before testing a patient for HIV, which is inconsistent with CDC''s recommendation to no longer require separate informed consent.^28–31 Consequently, written informed consent may be perceived as a barrier for providers to offer routine testing to patients, as this process typically requires a detailed conversation and providers are often working under already limited time constraints.^8,16 Understanding the facilitators and barriers to the implementation of routine HIV testing among CHCs in Massachusetts may have relevance to other U.S. states, where laws remain inconsistent with CDC HIV testing guidelines.^30,31We sought to gain a better understanding of HIV testing efforts among Massachusetts CHC personnel, including awareness of the CDC revised recommendations and any efforts to implement and support routine HIV testing in primary care settings. Analyses were stratified by respondent type (i.e., medical provider, administrator, and director) and funding mechanism, comparing health centers that did and did not receive support from the Ryan White HIV/AIDS Program, the federal program primarily responsible for HIV-related health services.³² Understanding the barriers and facilitators to implementing CDC''s revised recommendations may prove useful for designing educational materials and structural or individual-level interventions that will aid in conducting testing procedures in a more effective and efficient way.     

The Status of the National HIV Surveillance System,United States, 2013

The burden of HIV disease in the United States is monitored by using a comprehensive surveillance system. Data from this system are used at the federal, state, and local levels to plan, implement, and evaluate public health policies and programs. Implementation of HIV reporting has differed by area, and for the first time in early 2013, estimated data on diagnosed HIV infection were available from all 50 states, the District of Columbia, and six U.S. dependent areas. The newly available data for the entire U.S. as well as several other key changes to the surveillance system support the need to provide an updated summary of the status of the National HIV Surveillance System.Surveillance data for human immunodeficiency virus (HIV) infection have been used for many years at the federal, state, and local levels to monitor the spread of HIV, plan prevention programs and health-care services, and allocate funding for prevention and care.^1–6 The continued and increasing need for high-quality, usable surveillance data was underscored by the release of the 2010 National HIV/AIDS Strategy (NHAS), which calls for a coordinated national response to HIV in the United States.⁷ To maximize the ability to monitor trends in HIV in the U.S. and progress toward meeting prevention goals, the Centers for Disease Control and Prevention (CDC) has developed a comprehensive National HIV Surveillance System (NHSS) that guides data collection and reporting.In 2007, Glynn et al. reported on the status of HIV case surveillance in the U.S. as of 2006.¹ At that time, national data on HIV infection were available only for cases diagnosed through 2004 in 33 states with long-term confidential name-based HIV reporting. Implementation of reporting differed by area; however, by April 2008, all 50 states, the District of Columbia (DC), and six U.S. dependent areas (American Samoa, Guam, Northern Mariana Islands, Puerto Rico, Republic of Palau, and the U.S. Virgin Islands) had implemented confidential name-based HIV infection reporting.^8–10 The 2011 HIV Surveillance Report included, for the first time, estimated data on diagnosed HIV infections for all areas.² Changes have occurred in HIV surveillance that support the need to describe the current status of the NHSS.