Vital Signs: HIV Infection, Diagnosis, Treatment, and Prevention Among Gay, Bisexual, and Other Men Who Have Sex with Men - United States, 2010-2019.

BACKGROUND: Men who have sex with men (MSM) accounted for two thirds of new HIV infections in the United States in 2019 despite representing approximately 2% of the adult population. METHODS: CDC analyzed surveillance data to determine trends in estimated new HIV infections and to assess measures of undiagnosed infection and HIV prevention and treatment services including HIV testing, preexposure prophylaxis (PrEP) use, antiretroviral therapy (ART) adherence, and viral suppression, as well as HIV-related stigma. RESULTS: The estimated number of new HIV infections among MSM was 25,100 in 2010 and 23,100 in 2019. New infections decreased significantly among White MSM but did not decrease among Black or African American (Black) MSM and Hispanic/Latino MSM. New infections increased among MSM aged 25-34 years. During 2019, approximately 83% of Black MSM and 80% of Hispanic/Latino MSM compared with 90% of White MSM with HIV had received an HIV diagnosis. The lowest percentage of diagnosed infection was among MSM aged 13-24 years (55%). Among MSM with a likely PrEP indication, discussions about PrEP with a provider and PrEP use were lower among Black MSM (47% and 27%, respectively) and Hispanic/Latino MSM (45% and 31%) than among White MSM (59% and 42%). Among MSM with an HIV diagnosis, adherence to ART and viral suppression were lower among Black MSM (48% and 62%, respectively) and Hispanic/Latino MSM (59% and 67%) compared with White MSM (64% and 74%). Experiences of HIV-related stigma among those with an HIV diagnosis were higher among Black MSM (median = 33; scale = 0-100) and Hispanic/Latino MSM (32) compared with White MSM (26). MSM aged 18-24 years had the lowest adherence to ART (45%) and the highest median stigma score (39). CONCLUSION: Improving access to and use of HIV services for MSM, especially Black MSM, Hispanic/Latino MSM, and younger MSM, and addressing social determinants of health, such as HIV-related stigma, that contribute to unequal outcomes will be essential to end the HIV epidemic in the United States.

Vital Signs: Deaths Among Persons with Diagnosed HIV Infection, United States, 2010-2018.

BACKGROUND: Life expectancy for persons with human immunodeficiency virus (HIV) infection who receive recommended treatment can approach that of the general population, yet HIV remains among the 10 leading causes of death among certain populations. Using surveillance data, CDC assessed progress toward reducing deaths among persons with diagnosed HIV (PWDH). METHODS: CDC analyzed National HIV Surveillance System data for persons aged ≥13 years to determine age-adjusted death rates per 1,000 PWDH during 2010-2018. Using the International Classification of Diseases, Tenth Revision, deaths with a nonmissing underlying cause were classified as HIV-related or non-HIV-related. Temporal changes in total deaths during 2010-2018 and deaths by cause during 2010-2017 (2018 excluded because of delays in reporting), by demographic characteristics, transmission category, and U.S. Census region of residence at time of death were calculated. RESULTS: During 2010-2018, rates of death decreased by 36.6% overall (from 19.4 to 12.3 per 1,000 PWDH). During 2010-2017, HIV-related death rates decreased 48.4% (from 9.1 to 4.7), whereas non-HIV-related death rates decreased 8.6% (from 9.3 to 8.5). Rates of HIV-related deaths during 2017 were highest by race/ethnicity among persons of multiple races (7.0) and Black/African American persons (5.6), followed by White persons (3.9) and Hispanic/Latino persons (3.9). The HIV-related death rate was highest in the South (6.0) and lowest in the Northeast (3.2). CONCLUSION: Early diagnosis, prompt treatment, and maintaining access to high-quality care and treatment have been successful in reducing HIV-related deaths and remain necessary for continuing reductions in HIV-related deaths.

Vital Signs: Status of Human Immunodeficiency Virus Testing, Viral Suppression, and HIV Preexposure Prophylaxis - United States, 2013-2018.

BACKGROUND: Approximately 38,000 new human immunodeficiency virus (HIV) infections occur in the United States each year; these infections can be prevented. A proposed national initiative, Ending the HIV Epidemic: A Plan for America, incorporates three strategies (diagnose, treat, and prevent HIV infection) and seeks to leverage testing, treatment, and preexposure prophylaxis (PrEP) to reduce new HIV infections in the United States by at least 90% by 2030. Targets to reach this goal include that at least 95% of persons with HIV receive a diagnosis, 95% of persons with diagnosed HIV infection have a suppressed viral load, and 50% of those at increased risk for acquiring HIV are prescribed PrEP. Using surveillance, pharmacy, and other data, CDC determined the current status of these three initiative strategies. METHODS: CDC analyzed HIV surveillance data to estimate annual number of new HIV infections (2013-2017); estimate the percentage of infections that were diagnosed (2017); and determine the percentage of persons with diagnosed HIV infection with viral load suppression (2017). CDC analyzed surveillance, pharmacy, and other data to estimate PrEP coverage, reported as a percentage and calculated as the number of persons who were prescribed PrEP divided by the estimated number of persons with indications for PrEP. RESULTS: The number of new HIV infections remained stable from 2013 (38,500) to 2017 (37,500) (p = 0.448). In 2017, an estimated 85.8% of infections were diagnosed. Among 854,206 persons with diagnosed HIV infection in 42 jurisdictions with complete reporting of laboratory data, 62.7% had a suppressed viral load. Among an estimated 1.2 million persons with indications for use of PrEP, 18.1% had been prescribed PrEP in 2018. CONCLUSION: Accelerated efforts to diagnose, treat, and prevent HIV infection are needed to achieve the U.S. goal of at least 90% reduction in the number of new HIV infections by 2030.

Vital Signs: Human Immunodeficiency Virus Testing and Diagnosis Delays - United States.

BACKGROUND: Persons unaware of their human immunodeficiency virus (HIV) infection account for approximately 40% of ongoing transmissions in the United States. Persons are unaware of their infection because of delayed HIV diagnoses that represent substantial missed opportunities to improve health outcomes and prevent HIV transmission. METHODS: Data from CDC's National HIV Surveillance System were used to estimate, among persons with HIV infection diagnosed in 2015, the median interval (and range) from infection to diagnosis (diagnosis delay), based on the first CD4 test after HIV diagnosis and a CD4 depletion model indicating disease progression and, among persons living with HIV in 2015, the percentage with undiagnosed infection. Data from CDC's National HIV Behavioral Surveillance were analyzed to determine the percentage of persons at increased risk for HIV infection who had tested in the past 12 months and who had missed opportunities for testing. RESULTS: An estimated 15% of persons living with HIV in 2015 were unaware of their infection. Among the 39,720 persons with HIV infection diagnosed in 2015, the estimated median diagnosis delay was 3.0 years (interquartile range = 0.7-7.8 years); diagnosis delay varied by race/ethnicity (from 2.2 years among whites to 4.2 years among Asians) and transmission category (from 2.0 years among females who inject drugs to 4.9 years among heterosexual males). Among persons interviewed through National HIV Behavioral Surveillance, 71% of men who have sex with men, 58% of persons who inject drugs, and 41% of heterosexual persons at increased risk for HIV infection reported testing in the past 12 months. In each risk group, at least two thirds of persons who did not have an HIV test had seen a health care provider in the past year. CONCLUSIONS: Delayed HIV diagnoses continue to be substantial for some population groups and prevent early entry to care to improve health outcomes and reduce HIV transmission to others. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Health care providers and others providing HIV testing can reduce HIV-related adverse health outcomes and risk for HIV transmission by implementing routine and targeted HIV testing to decrease diagnosis delays.

Unmet Needs for Ancillary Services Among Hispanics/Latinos Receiving HIV Medical Care - United States, 2013-2014.

The prevalence of diagnosed human immunodeficiency virus (HIV) infection in Hispanics/Latinos in the United States is more than twice as high as the prevalence among non-Hispanic whites (1). Services that support retention in HIV medical care and assist with day-to-day living, referred to here as ancillary services, help persons living with HIV access HIV medical care, adhere to HIV treatment, and attain HIV viral suppression. The needs for these ancillary services among Hispanics/Latinos are not well described (2). To obtain nationally representative estimates of and reasons for unmet needs for such services among Hispanic/Latino adults receiving outpatient HIV medical care during 2013-2014, CDC analyzed data from the Medical Monitoring Project (MMP). The analysis found that Hispanics/Latinos in all age and sexual orientation/behavior subgroups reported substantial unmet needs, including 24% needing dental care, 21% needing eye or vision care, 15% needing food and nutrition services, and 9% needing transportation assistance. Addressing unmet needs for ancillary services among Hispanics/Latinos living with HIV might help increase access to HIV care, improve health outcomes, and reduce health disparities.

Unmet Needs for Ancillary Services Among Men Who Have Sex with Men and Who Are Receiving HIV Medical Care - United States, 2013-2014.

Gay, bisexual, and other men who have sex with men (MSM) are disproportionately affected by human immunodeficiency virus (HIV) in the United States (1). Ancillary services, defined as services that support retention in HIV medical care and assist with day-to-day living, can improve the health of HIV-infected MSM and help them achieve viral suppression (2). To assess the unmet needs for ancillary services among MSM receiving outpatient HIV medical care during 2013-2014, CDC used data from the Medical Monitoring Project (MMP), a surveillance system designed to assess clinical and behavioral characteristics of adults receiving HIV care, to obtain nationally representative estimates of, and identify reasons for, unmet needs (3). Based on self-reported needs of persons responding to the MMP survey, the most prevalent unmet needs were for non-HIV medical care services: approximately 23% had an unmet need for dental care, and 19% had an unmet need for eye or vision care. Unmet needs were most prevalent among young, non-Hispanic black, and Hispanic/Latino MSM. State and local health departments, community-based organizations, and health care providers might improve the health of MSM living with HIV by promoting access to ancillary services using strategies that increase patient awareness of how to obtain these services, especially among young, non-Hispanic black, and Hispanic/Latino MSM.

Vital Signs: Trends in HIV Diagnoses, Risk Behaviors, and Prevention Among Persons Who Inject Drugs - United States.

BACKGROUND: Persons who inject drugs (PWID) are at increased risk for poor health outcomes and bloodborne infections, including human immunodeficiency virus (HIV), hepatitis C virus and hepatitis B virus infections. Although substantial progress has been made in reducing HIV infections among PWID, recent changes in drug use could challenge this success. METHODS: CDC used National HIV Surveillance System data to analyze trends in HIV diagnoses. Further, National HIV Behavioral Surveillance interviews of PWID in 22 cities were analyzed to describe risk behaviors and use of prevention services among all PWID and among PWID who first injected drugs during the 5 years before their interview (new PWID). RESULTS: During 2008-2014, HIV diagnoses among PWID declined in urban and nonurban areas, but have leveled off in recent years. Among PWID in 22 cities, during 2005-2015, syringe sharing decreased by 34% among blacks/African Americans (blacks) and by 12% among Hispanics/Latinos (Hispanics), but remained unchanged among whites. The racial composition of new PWID changed during 2005-2015: the percentage who were black decreased from 38% to 19%, the percentage who were white increased from 38% to 54%, and the percentage who were Hispanic remained stable. Among new PWID interviewed in 2015, whites engaged in riskier injection behaviors than blacks. CONCLUSIONS: Decreases in HIV diagnoses among PWID indicate success in HIV prevention. However, emerging behavioral and demographic trends could reverse this success. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Access to comprehensive prevention services is essential for all PWID. Syringe services programs reduce syringe sharing and can help PWID access prevention and treatment services for HIV and other bloodborne diseases, such as hepatitis C and hepatitis B.

Vital Signs: Estimated Percentages and Numbers of Adults with Indications for Preexposure Prophylaxis to Prevent HIV Acquisition--United States, 2015.

BACKGROUND: In 2014, approximately 40,000 persons in the United States received a diagnosis of human immunodeficiency virus (HIV) infection. Preexposure prophylaxis (PrEP) with daily oral antiretroviral medication is a new, highly effective intervention that could reduce the number of new HIV infections. METHODS: CDC analyzed nationally representative data to estimate the percentages and numbers of persons in the United States, by transmission risk group, with indications for PrEP consistent with the 2014 U.S. Public Health Service's PrEP clinical practice guideline. RESULTS: Approximately 24.7% of sexually active adult men who have sex with men (MSM) (492,000 [95% confidence interval {CI} = 212,000-772,000]), 18.5% of persons who inject drugs (115,000 [CI = 45,000-185,000]), and 0.4% of heterosexually active adults (624,000 [CI = 404,000-846,000]), had substantial risks for acquiring HIV consistent with PrEP indications. CONCLUSIONS: Based on current guidelines, many MSM, persons who inject drugs, and heterosexually active adults have indications for PrEP. A higher percentage of MSM and persons who inject drugs have indications for PrEP than heterosexually active adults, consistent with distribution of new HIV diagnoses across these populations. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Clinical organizations, health departments, and community-based organizations should raise awareness of PrEP among persons with substantial risk for acquiring HIV infection and their health care providers. These data can be used to inform scale-up and evaluation of PrEP coverage. Increasing delivery of PrEP and other highly effective HIV prevention services could lower the number of new HIV infections occurring in the United States each year.

Vital Signs: Estimated Percentages and Numbers of Adults with Indications for Preexposure Prophylaxis to Prevent HIV Acquisition--United States, 2015.

BACKGROUND: In 2014, approximately 40,000 persons in the United States received a diagnosis of human immunodeficiency virus (HIV) infection. Preexposure prophylaxis (PrEP) with daily oral antiretroviral medication is a new, highly effective intervention that could reduce the number of new HIV infections. METHODS: CDC analyzed nationally representative data to estimate the percentages and numbers of persons in the United States, by transmission risk group, with indications for PrEP consistent with the 2014 U.S. Public Health Service's PrEP clinical practice guideline. RESULTS: Approximately 24.7% of sexually active adult men who have sex with men (MSM) (492,000 [95% confidence interval {CI} = 212,000-772,000]), 18.5% of persons who inject drugs (115,000 [CI = 45,000-185,000]), and 0.4% of heterosexually active adults (624,000 [CI = 404,000-846,000]), had substantial risks for acquiring HIV consistent with PrEP indications. CONCLUSIONS: Based on current guidelines, many MSM, persons who inject drugs, and heterosexually active adults have indications for PrEP. A higher percentage of MSM and persons who inject drugs have indications for PrEP than heterosexually active adults, consistent with distribution of new HIV diagnoses across these populations. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Clinical organizations, health departments, and community-based organizations should raise awareness of PrEP among persons with substantial risk for acquiring HIV infection and their health care providers. These data can be used to inform scale-up and evaluation of PrEP coverage. Increasing delivery of PrEP and other highly effective HIV prevention services could lower the number of new HIV infections occurring in the United States each year.

Vital Signs: HIV diagnosis, care, and treatment among persons living with HIV--United States, 2011.

In the United States, an estimated 1.2 million persons are living with human immunodeficiency virus (HIV), a serious infection that, if untreated, leads to illness and premature death. Persons living with HIV who use antiretroviral therapy (ART) and achieve very low levels of the virus (suppressed viral load) can have a nearly normal life expectancy and have very low risk for transmitting HIV to others. However, each year in the United States, nearly 50,000 persons become infected with HIV. Each step along the HIV care continuum (HIV diagnosis, prompt and sustained HIV medical care, and ART) is essential for achieving a suppressed viral load.

HIV/AIDS complacency and HIV infection among young men who have sex with men, and the race-specific influence of underlying HAART beliefs.

BACKGROUND: Among men who have sex with men (MSM) in the United States, the influence of HIV/AIDS complacency and beliefs about the efficacy of highly active antiretroviral therapy (HAART) on HIV-infection risk is unknown. METHODS: We analyzed data from a 1998-2000 cross-sectional 6-city survey of 1575 MSM aged 23 to 29 years who had never tested for HIV or had last tested HIV-negative to assess these plausible influences overall and by race/ethnicity. FINDINGS: Measured as strong endorsement for reduced HIV/AIDS concern due to HAART, HIV/AIDS complacency was associated with reporting ≥10 male sex partners (odds ratio [OR], 2.94; 95% confidence interval [CI], 2.12-4.07), unprotected anal intercourse with an HIV-positive or HIV-unknown-status male partner (OR, 2.06; 95% CI, 1.51-2.81), and testing HIV-positive (adjusted OR [AOR], 2.35; 95% CI, 1.38-3.98). Strong endorsement of the belief that HAART mitigates HIV/AIDS severity was more prevalent among black (21.8%) and Hispanic (21.3%) than white (9.6%) MSM (P < 0.001), and was more strongly associated with testing HIV-positive among black (AOR, 4.65; 95% CI, 1.97-10.99) and Hispanic (AOR, 4.12; 95% CI, 1.58-10.70) than white (AOR, 1.62; 95% CI, 0.64-4.11) MSM. CONCLUSIONS: Young MSM who are complacent about HIV/AIDS because of HAART may be more likely to engage in risk behavior and acquire HIV. Programs that target HIV/AIDS complacency as a means to reduce HIV incidence among young MSM should consider that both the prevalence of strong HAART-efficacy beliefs and the effects of these beliefs on HIV-infection risk might differ considerably by race/ethnicity.

A plausible causal model of HAART-efficacy beliefs, HIV/AIDS complacency, and HIV-acquisition risk behavior among young men who have sex with men.

Despite considerable research, the causal relationship remains unclear between HIV/AIDS complacency, measured as reduced HIV/AIDS concern because of highly active antiretroviral therapy (HAART), and HIV risk behavior. Understanding the directionality and underpinnings of this relationship is critical for programs that target HIV/AIDS complacency as a means to reduce HIV incidence among men who have sex with men (MSM). This report uses structural equation modeling to evaluate a theory-based, HIV/AIDS complacency model on 1,593 MSM who participated in a venue-based, cross-sectional survey in six U.S. cities, 1998-2000. Demonstrating adequate fit and stability across geographic samples, the model explained 15.0% of the variance in HIV-acquisition behavior among young MSM. Analyses that evaluated alternative models and models stratified by perceived risk for HIV infection suggest that HIV/AIDS complacency increases acquisition behavior by mediating the effects of two underlying HAART-efficacy beliefs. New research is needed to assess model effects on current acquisition risk behavior, and thus help inform prevention programs designed to reduce HIV/AIDS complacency and HIV incidence among young MSM.

Prevalence of HIV infection and prior HIV testing among young men who have sex with men. The Baltimore young men's survey.

Data are presented from the Baltimore Young Men's Survey, a cross-sectional, venue-based sample survey of risks associated with HIV and report of a prior HIV test, conducted between 1996 and 2000, and enrolling 843 young men who have sex with men (MSM) aged 15-29 years. HIV prevalence was 12.1% overall and racial disparities in HIV prevalence were pronounced (range, 2.9% among non-Hispanic whites to 27.1% among non-Hispanic blacks). Risks independently associated with being HIV-positive were: being between 26 and 29 years of age, being non-Hispanic black or of other/mixed race, having had 20 or more lifetime male sex partners, having been diagnosed with a sexually transmitted disease (STD), and not being currently enrolled in school. The majority of participants (78.9%) reported a prior HIV test. In multivariate analysis, being older, having had five or more lifetime male sex partners, having had anal intercourse with males, reporting an STD diagnosis, and reporting recent unprotected anal sex were associated with report of a prior HIV test. Prevention efforts must address high HIV prevalence among young non-Hispanic black MSM and must make testing and effective counseling for young MSM readily available.

The Young Men's Survey phase II: hepatitis B immunization and infection among young men who have sex with men.

OBJECTIVES: We measured the prevalence of hepatitis B virus (HBV) immunization and HBV infection among men aged 23 to 29 years who have sex with men. METHODS: We analyzed data from 2834 men who have sex with men in 6 US metropolitan areas. Participants were interviewed and tested for serologic markers of immunization and HBV infection in 1998 through 2000. RESULTS: Immunization prevalence was 17.2%; coverage was 21.0% among participants with private physicians or health maintenance organizations and 12.6% among those with no source of health care. Overall, 20.6% had markers of HBV infection, ranging from 13.7% among the youngest to 31.0% among the oldest participants. Among those susceptible to HBV, 93.5% had regular sources of health care, had been tested for HIV, or had been treated for a sexually transmitted disease. CONCLUSIONS: Although many young men who have sex with men have access to health care, most are not immunized against HBV. To reduce morbidity from HBV in this population, providers of health care, including sexually transmitted disease and HIV prevention services, should provide vaccinations or referrals for vaccination.

Unintentional HIV exposures from young men who have sex with men who disclose being HIV-negative.

OBJECTIVE: To evaluate the proportion of new sexual partners potentially exposed to HIV from young MSM who disclosed being HIV-negative. DESIGN: Cross-sectional, observational study of men aged 23-29 years recruited from randomly sampled MSM-identified venues in six US cities. METHODS: Participants were interviewed and tested for HIV. Analyses were restricted to MSM who reported last testing HIV-negative and having one or more new partners in the prior 6 months. RESULTS: Of 1701 MSM who reported a total of 11 793 new partners, 1075 (63%) disclosed being HIV-negative to 4253 (36%) new partners before having sex with them for the first time. Of disclosers, 352 (33%) reported last testing HIV-negative > 1 year before their interview and 80 (7%) tested HIV-positive (HIV-infected unaware). By race, 24% of black, 5% of Hispanic, and 3% of white disclosers tested HIV-positive. Of the 4253 new partners, 296 (7%) were partners of the 80 HIV-infected unaware MSM. By race, 22% of new partners of black, 3% of new partners of Hispanic, and 4% of new partners of white MSM, were partners of HIV-infected unaware MSM who disclosed being HIV-negative. CONCLUSIONS: Many new sex partners may be unintentionally exposed to HIV from young MSM, particularly those who are black and who disclose being HIV-negative based on an earlier test. Young MSM should test for HIV more frequently and consistently use condoms with all partners unless they are in a mutually monogamous relationship in which both partners have tested HIV-negative at least 3 months since their last potential HIV exposure.

HIV testing patterns and unrecognized HIV infection among young Asian and Pacific Islander men who have sex with men in San Francisco.

The HIV epidemic is rising in Asian and Pacific Islander men who have sex with men (API MSM), who are often first diagnosed with HIV at a late stage of disease. We investigated the HIV testing patterns, correlates of prior testing, and awareness of HIV infection of 495 API MSM aged 18-29 years recruited from venues in San Francisco, using standardized face-to-face interviews. One quarter of participants had never tested for HIV, citing reasons such as perceived low risk, fear of results, and fear of needles. Older age, gay sexual orientation, history of sexually transmitted disease, higher lifetime number of sexual partners, and higher acculturation were significantly and independently associated with prior testing. Thirteen (2.6%) tested HIV-positive, of whom eight were unaware of their infection, five perceived themselves to be at low risk for HIV, and five reported recent UAI. These findings underscore the need to increase access to culturally appropriate and targeted HIV testing and to change perceptions of risk in this population.

The effect of partner characteristics on HIV infection among African American men who have sex with men in the Young Men's Survey, Los Angeles, 1999-2000.

Previous studies have documented disparities in HIV prevalence by race among men who have sex with men (MSM), even after adjusting for traditional risk factors. In this analysis of data collected for the 1999-2000 Los Angeles Young Men's Survey, a cross-sectional venue-based survey of MSM aged 23-29, we investigated whether information on male sex-partner characteristics accounts for some of the racial/ethnic differences in HIV prevalence. In this sample of survey participants, we observed that African American MSM reported similar or lower levels of HIV risk behaviors compared with White MSM but much higher HIV prevalence (26% vs. 7.4%, respectively). In an unadjusted logistic regression model, African American participants had 4.4 times higher odds of HIV infection compared with White participants. In a multiple logistic regression model adjusting for participant behaviors, we observed elevation of the relative odds of HIV infection for African Americans compared with Whites (odds ratio [OR] = 6.9, 95% confidence limits [CL] = 2.5, 19). In a fully adjusted model, controlling for the effects of having older partners and more African American partners, we observed a 20% reduction in the relative odds of HIV for African American participants compared with White participants (OR = 5.5, 95% CL = 1.8, 17). Our findings suggest that differences in male partner types, namely older and African American partners, may account for some of the observed racial disparity in HIV infection, especially for African American MSM compared with White MSM in Los Angeles.

Prevalence of undiagnosed HIV infection among persons aged ≥13 years--National HIV Surveillance System, United States, 2005-2008.

In the United States, approximately 1.1 million adults and adolescents are living with human immunodeficiency virus (HIV) infection and, each year, another 50,000 become infected. At the end of 2008, approximately 20% of the persons living with HIV had an undiagnosed infection. Of those living with HIV at the end of 2008, nearly two thirds were racial/ethnic minorities and half were men who have sex with men (MSM). In 2007, HIV ranked fifth as a leading cause of death among persons aged 35-44 years in the United States but third among blacks or African Americans in this age group. In 40 states with longstanding confidential name-based HIV surveillance systems, 33% of the estimated 41,768 adults and adolescents diagnosed with HIV infection in 2008 developed acquired immunodeficiency syndrome (AIDS) within 1 year and, of these, 44% received their initial diagnosis in an acute care setting, suggesting that they received HIV testing late in the course of the infection. HIV-infected persons who are unaware of their infection or who receive a late diagnosis cannot benefit fully from timely initiation of therapy and are more likely to experience HIV-related morbidity and premature mortality. In addition, persons unaware of their infection are more likely to transmit HIV to others because of a higher prevalence of high-risk sexual behaviors and higher levels of viral RNA that continue to replicate without appropriate antiretroviral treatment.