Hepatitis C virus infection and co-infection with HIV among persons who inject drugs in 10 U.S. cities-National HIV Behavioral Surveillance, 2018.

BACKGROUND: Characterizing acute and chronic hepatitis C virus (HCV) infection and HIV/HCV co-infection among persons who inject drugs (PWID) can inform elimination efforts. METHODS: During 2018 National HIV Behavioral Surveillance in 10 U.S. metropolitan statistical areas (MSAs), PWID were recruited using respondent-driven sampling and offered a survey, HIV testing, and HCV antibody and RNA testing. We examined prevalence and associated characteristics of HCV infection and HIV/HCV co-infection. Associations were assessed using log-linked Poisson regression models with robust standard errors accounting for clustering by recruitment chain and adjusting for MSA and network size. RESULTS: Overall, 44.2% had current HCV infection (RNA detected), with 3.9% classified as acute infection (HCV antibody non-reactive/RNA detected) and 40.3% as chronic (HCV antibody reactive/RNA detected). Four percent had HIV/HCV co-infection. Current HCV infection was significantly higher among PWID who were male, White, injected >1 time/day, shared syringes in past year, and shared injection equipment in past year. PWID who were transgender, injecting >5 years, and most often injected speedball (heroin and cocaine together) or stimulants alone were more likely to have HIV/HCV co-infection. Among PWID who never previously had HCV infection, 9.9% had acute HCV infection. Among PWID who started injecting ≤5 years ago, 41.5% had already acquired HCV infection. CONCLUSIONS: Acute and chronic HCV infections were substantial among a sample of PWID in 10 U.S. MSAs. Accessibility to HCV RNA testing, promoting safer practices, and intervening early with harm reduction programs for recent injection initiates will be critical to disease elimination efforts for PWID.

Unmet need for medication for opioid use disorder among persons who inject drugs in 23 U.S. cities.

BACKGROUND: Persons who inject drugs (PWID) are at increased risk of HIV and hepatitis C virus (HCV) infections and premature mortality due to drug overdose. Medication for opioid use disorder (MOUD), such as methadone or buprenorphine, reduces injecting behaviors, HIV and HCV transmission, and mortality from opioid overdose. Using data from National HIV Behavioral Surveillance, we evaluated the unmet need for MOUD among PWID in 23 U.S. cities. METHODS: PWID were recruited by respondent-driven sampling, interviewed, and tested for HIV. This analysis includes PWID who were ≥18 years old and reported injecting drugs and opioid use in the past 12 months. We used Poisson regression to examine factors associated with self-reported unmet need for MOUD and reported adjusted prevalence ratios (aPR) with 95% confidence intervals. RESULTS: Of 10,879 PWID reporting using opioids, 68.8% were male, 48.2% were ≥45 years of age, 38.8% were non-Hispanic White, 49.6% experienced homelessness, and 28.0% reported an unmet need for MOUD in the past 12 months. PWID who were more likely to report unmet need for MOUD experienced homelessness (aPR 1.26; 95% CI: 1.19-1.34), were incarcerated in the past 12 months (aPR 1.15; 95% CI: 1.08-1.23), injected ≥once a day (aPR 1.42; 95% CI: 1.31-1.55), reported overdose (aPR 1.33; 95% CI: 1.24-1.42), and sharing of syringes (aPR 1.14; 95% CI: 1.06-1.23). CONCLUSIONS: The expansion of MOUD provision for PWID is critical. Integrating syringe service programs and MOUD provision and linking PWID who experience overdose, incarceration or homelessness to treatment with MOUD could improve its utilization among PWID.

Structural and Psychosocial Syndemic Conditions and Condomless Anal Intercourse Among Transgender Women - National HIV Behavioral Surveillance Among Transgender Women, Seven Urban Areas, United States, 2019-2020.

Psychosocial and structural syndemic conditions, including polydrug use and experiencing homelessness, frequently co-occur and might jointly increase HIV risk. Limited studies have assessed racial and ethnic differences in exposure to syndemic conditions and behaviors associated with HIV transmission among transgender women. This report examines the relation between syndemic conditions and condomless anal intercourse (CAI) among transgender women in seven urban areas in the United States to develop HIV prevention interventions for transgender women. During 2019-2020, transgender women in seven urban areas were recruited using respondent-driven sampling for a biobehavioral survey. Reported syndemic conditions (psychosocial: polydrug use, sexual violence, and psychological distress; structural: homelessness, incarceration, and exchange sex) were summed to create a syndemic score. Using modified Poisson regression to account for RDS, the study assessed whether the strength of the association between syndemic score and CAI differed by race and ethnicity. To assess additive interaction, the relative excess prevalence owing to interaction (REPI) and 95% CIs for selected pairs of syndemic conditions on CAI prevalence stratified by race and ethnicity were estimated. Of 1,348 transgender women (Black = 546, White = 176, and Hispanic = 626), 55% reported CAI; and 24% reported ≥3 syndemic conditions. Reporting additional syndemic conditions was associated with CAI for White, Hispanic, and Black participants. The association was significantly stronger for White than Black and Hispanic participants. Limited significant superadditive interactions were found, although the majority were between structural syndemic conditions. Racial and ethnic differences in REPI estimates were observed. Reporting more syndemic conditions was associated with increased CAI across racial and ethnic groups, demonstrating that HIV prevention efforts for transgender women should address structural and psychosocial syndemic conditions. Results differed by race and ethnicity, indicating that syndemic-focused interventions for transgender women should be tailored to racial and ethnic groups.

Overview and Methodology of the National HIV Behavioral Surveillance Among Transgender Women - Seven Urban Areas, United States, 2019-2020.

Transgender women, especially transgender women of color, are disproportionately affected by HIV. However, no surveillance system collects data on HIV risk factors among this population. To address this gap, CDC developed a surveillance system entitled National HIV Behavioral Surveillance Among Transgender Women (NHBS-Trans) to assess behavioral and contextual data through systematic biobehavioral surveillance to monitor behavioral risk factors, prevention usage, and HIV prevalence among transgender women. NHBS-Trans used respondent-driven sampling in seven urban areas in the United States. Trained interviewers used a standardized, anonymous questionnaire to collect information on HIV-related behavioral risk factors, HIV testing, and use of prevention services. Each of the seven participating project areas recruited approximately 200 eligible transgender women and offered anonymous HIV testing. Overall, in the seven project areas, 1,757 participants completed the eligibility screener for NHBS-Trans during 2019-2020; of these, 6.6% were seeds (i.e., a limited number of initial participants who were chosen by referrals from persons and community-based organizations who knew or were part of the local population of transgender women). A total of 1,637 (93.2%) participants were eligible, consented, and completed the interview. Of these, 1,624 (99.2%) agreed to HIV testing. Of the total 1,637 participants, 29 participants did not report identity of woman or transgender woman, resulting in a final sample of 1,608 transgender women. NHBS-Trans project area staff members (n = 14) reported that the survey was timely and addressed a critical need for HIV surveillance in a population that is often overlooked. The MMWR supplement includes this overview report on NHBS-Trans, which describes the methods (history, participant eligibility criteria, questionnaire, data collection, and HIV testing) as well as evaluation of project implementation and the performance of the questionnaire content, specifically the acceptability for transgender women. The other NHBS-Trans reports in the supplement include information on pre-exposure prophylaxis use, psychosocial syndemic conditions and condomless anal intercourse, nonprescription hormone use, homelessness, discrimination and the association between employment discrimination and health care access and use, and social support and the association between certain types of violence and harassment (gender-based verbal and physical abuse or harassment, physical intimate partner abuse or harassment, and sexual violence) and suicidal ideation. NHBS-Trans provides important data related to the goals of the Ending the HIV Epidemic in the U.S. initiative. Findings from NHBS-Trans can help guide community leaders, clinicians, and public health officials in improving access to and use of HIV prevention and treatment services by transgender women.

Using serial cross-sectional surveys to create a retrospective nested cohort to determine HIV incidence from 20 US cities.

OBJECTIVE: To estimate HIV incidence using successive cross-sectional surveys by creating retrospective nested cohorts among MSM, people who inject drugs (PWID), and heterosexually active persons (HET). DESIGN: Cohorts were created among participants who had at least one repeat observation across four surveillance cycles from National HIV Behavioral Surveillance in 20 US cities. METHODS: Repeat participants were identified using a combination of date of birth, race/ethnicity, metropolitan statistical area, and gender. The analysis was limited to participants who tested negative for HIV at baseline and were assumed to be at risk between cycles. We calculated person-years at risk from the individual time between cycles and used the total number of seroconversions to estimate incidence and a Poisson distribution to approximate variance. Rate ratios were calculated using age, gender, race/ethnicity, and region. RESULTS: From 2008 to 2019, successive surveys recaptured nested cohorts of 1747 MSM, 3708 PWID, and 1396 HET. We observed an incidence rate of 2.5 per 100 person-years [95% confidence interval (CI) 2.1-2.8) among MSM; 0.6 per 100 person-years (95% CI 0.5-0.7) among PWID; and 0.3 per 100 person-years (95% CI 0.1-0.4) among HET. HIV incidence was higher among younger MSM, black MSM (compared with white MSM), and PWID residing in the South and territories (compared with the Midwest). CONCLUSION: These estimates are consistent with previously published incidence estimates from prospective cohort studies among these populations. Using repeat cross-sectional surveys to simulate a cohort, may serve as another strategy in estimating HIV incidence.

Socioeconomic and racial/ethnic spatial polarization and incarceration among people who inject drugs in 19 US metropolitan areas, 2015.

The purpose of this study is to test, for the first time, the association between spatial social polarization and incarceration among people who inject drugs (PWID) in 19 large U.S. metropolitan statistical areas (MSAs) in 2015. PWID were recruited from MSAs for the Centers for Disease Control and Prevention's 2015 National HIV Behavioral Surveillance. Administrative data were used to describe the ZIP-code areas, counties, and MSAs where PWID lived. We operationalized spatial polarization using the Index of Concentration at the Extremes (ICE), a measure that reflects polarization in race and household income at the ZIP-code level. We tested the association between spatial polarization and odds of past-year arrest and detainment using multilevel multivariable models. We found 37% of the sample reported being incarcerated in the past year. Report of past-year incarceration varied by race/ethnicity: 45% of non-Hispanic white PWID reported past-year incarceration, as did 25% of non-Hispanic Black PWID, and 43% of Hispanic/Latino PWID (N = 9047). Adjusted odds ratios suggest that Black PWID living in ZIP-code areas with a higher ICE score, meaning more white and affluent, had higher odds of past-year incarceration, compared to white PWID. In previous research, incarceration has been found to be associated with HIV acquisition and can deter PWID from engaging in harm reduction activities.

Estimating the impact of HIV PrEP regimens containing long-acting injectable cabotegravir or daily oral tenofovir disoproxil fumarate/emtricitabine among men who have sex with men in the United States: a mathematical modelling study for HPTN 083.

Background: The HPTN 083 trial demonstrated superiority of HIV pre-exposure prophylaxis (PrEP) containing long-acting injectable cabotegravir (CAB) to daily oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) among men who have sex with men (MSM). We compared the potential population-level impact of TDF/FTC and CAB among MSM in Atlanta, Georgia. Methods: An MSM HIV transmission model was calibrated to Atlanta-specific data on HIV prevalence and PrEP usage (percentage of uninfected MSM on PrEP), assuming only PrEP-indicated MSM used PrEP. CAB effectiveness (efficacy × adherence) of 91% was estimated using data from HPTN 083 and previous TDF/FTC trials. We estimated HIV infections averted over 5/10 years if TDF/FTC use were maintained, or if all TDF/FTC users switched to CAB in January 2022 (vs. no PrEP or continued TDF/FTC use). CAB scenarios with 10%/20% more users were also considered. Progress towards Ending the HIV Epidemic (EHE) goals (75%/90% fewer HIV infections in 2025/2030 vs. 2017) was estimated. Findings: We predicted TDF/FTC at current usage (∼28%) would avert 36.3% of new HIV infections (95% credible interval 25.6-48.7%) among all Atlanta MSM over 2022-2026 vs. no PrEP. Switching to CAB with similar usage may prevent 44.6% (33.2-56.6%) infections vs. no PrEP and 11.9% (5.2-20.2%) infections vs. continued TDF/FTC. Increasing CAB usage 20% could increase the incremental impact over TDF/FTC to 30.0% over 2022-2026, getting ∼60% towards reaching EHE goals (47%/54% fewer infections in 2025/2030). Reaching the 2030 EHE goal would require 93% CAB usage. Interpretation: If CAB effectiveness were like HPTN 083, CAB could prevent more infections than TDF/FTC at similar usage. Increased CAB usage could contribute substantially towards reaching EHE goals, but the usage required to meet EHE goals is unrealistic. Funding: NIH, MRC.

HIV Pre-exposure Prophylaxis Persistence and Adherence Among Men Who Have Sex With Men in Four US Cities.

BACKGROUND: HIV pre-exposure prophylaxis (PrEP) persistence and adherence are critical to ending the HIV epidemic in the United States. SETTING: In 2017 National HIV Behavioral Surveillance, HIV-negative men who have sex with men (MSM) in 4 US cities completed a survey, HIV testing, and dried blood spots at recruitment. METHODS: We assessed 3 PrEP outcomes: persistence (self-reported PrEP use at any time in the past 12 months and had tenofovir, emtricitabine, or tenofovir diphosphate detected in dried blood spots), adherence at ≥4 doses/week (self-reported past-month PrEP use and tenofovir diphosphate concentration ≥700 fmol/punch), and adherence at 7 doses/week (self-reported past-month PrEP use and tenofovir diphosphate concentration ≥1250 fmol/punch). Associations with key characteristics were examined using log-linked Poisson regression models with generalized estimating equations. RESULTS: Among 391 MSM who took PrEP in the past year, persistence was 80% and was lower among MSM who were younger, had lower education, and had fewer sex partners. Of 302 MSM who took PrEP in the past month, adherence at ≥4 doses/week was 80% and adherence at 7 doses/week was 66%. Adherence was lower among MSM who were younger, were Black, and had fewer sex partners. CONCLUSIONS: Although persistence and adherence among MSM were high, 1 in 5 past-year PrEP users were not persistent and 1 in 5 past-month PrEP users were not adherent at levels that would effectively protect them from acquiring HIV (ie, ≥4 doses/week). Efforts to support PrEP persistence and adherence should include MSM who are young, are Black, and have less education.

Intimate partner violence, HIV-risk behaviors, and HIV screening among heterosexually active persons at increased risk for infection.

ABSTRACTIntimate partner violence (IPV) can increase a person's risk of HIV and other sexually transmitted infections (STIs), and may affect access to sexual health services. We assessed the prevalence of HIV screening and IPV among heterosexually-active persons using data from the 2016 National HIV Behavioral Surveillance. Participants were eligible if they were 18-60 years old, could complete the interview in English or Spanish, and reported having sex with an opposite sex partner in the previous 12 months. People who reported neither injection drug use within the past 12 months nor prior HIV diagnosis, and persons with valid responses to questions regarding HIV screening and physical/sexual IPV within the past 12 months were included (N = 7,777). Overall, 17% reported IPV in the previous 12 months and 19% had never had HIV screening. Abused persons were more likely to have been screened for HIV and to report high risk behaviors than non-abused persons. There was no difference in the proportion being offered HIV screening by their health care provider in the previous year. Findings suggest an integrated approach to violence prevention and sexual health may help increase awareness about clinical best practices and reduce risk for HIV/STIs among at-risk communities.

Physical and Sexual Violence and Sexual Behaviors Among Men Who Have Sex with Men in 22 U.S. Cities-National HIV Behavioral Surveillance, 2017.

National prevalence of physical and sexual violence and its relationship to sexual behaviors are unknown among men who have sex with men (MSM). We estimated 12-month prevalence of physical and sexual violence and assessed relationships between violence and sexual behaviors among MSM. Data were obtained from National HIV Behavioral Surveillance 2017 that used time-space sampling methods to recruit and interview MSM in 22 U.S. cities. Weighted percentages with 95% confidence intervals (CI) were reported. Adjusted prevalence ratios (aPR) and 95% CIs were calculated using logistic regression with predicted marginal means. Overall, 10.2% (95% CI: 9.3%-11.2%) of MSM experienced physical violence only, 3.2% (95% CI: 2.7%-3.7%) experienced sexual violence only, and 2.3% (95% CI: 1.9%-2.7%) experienced both types of violence, in the past 12 months. Compared to MSM who did not experience violence, those who did reported higher percentages of unemployment, poverty, homelessness, same-sex discrimination, non-injection drug use, and binge drinking. Violence was not independently associated with condomless anal sex among MSM. MSM who experienced both types of violence were more likely than those who did not experience violence to have had four or more male sex partners (aPR=1.18, 95% CI: 1.02-1.37). MSM who experienced both types of violence (aPR=2.49, 95% CI: 1.52-4.09), sexual violence (aPR=2.27, 95% CI: 1.47-3.52), or physical violence (aPR=1.76, 95% CI: 1.27-2.44) were more likely than those who did not experience violence to have had exchange sex. Recent physical violence and sexual violence are common among MSM. Findings highlight the importance of violence screening and suggest the need for tailored interventions that improve the safety and economic security of MSM who experience violence, including those who exchange sex.

A Key Comprehensive System for Biobehavioral Surveillance of Populations Disproportionately Affected by HIV (National HIV Behavioral Surveillance): Cross-sectional Survey Study.

BACKGROUND: The National HIV Behavioral Surveillance (NHBS) is a comprehensive system for biobehavioral surveillance conducted since 2003 in 3 populations disproportionately affected by HIV: gay, bisexual, and other men who have sex with men (MSM); people who inject drugs; and heterosexually active persons at increased risk for HIV infection (HET). This ongoing and systematic collection and analysis of data is needed to identify baseline prevalence of behavioral risk factors and prevention service use, as well as to measure progress toward meeting HIV prevention goals among key populations disproportionately affected by HIV. OBJECTIVE: This manuscript provides an overview of NHBS from 2003 to 2019. METHODS: NHBS is conducted in rotating, annual cycles; these 3 annual cycles are considered a round. Venue-based, time-space sampling is used for the MSM population. Respondent-driven sampling is used for people who inject drugs and HET populations. A standardized, anonymous questionnaire collects information on HIV-related behavioral risk factors, HIV testing, and use of prevention services. In each cycle, approximately 500 eligible persons from each participating area are interviewed and offered anonymous HIV testing. RESULTS: From 2003 to 2019, 168,600 persons were interviewed and 143,570 agreed to HIV testing across 17 to 25 cities in the United States. In the fifth round (2017 to 2019), over 10,000 (10,760-12,284) persons were interviewed each of the 3 population cycles in 23 cities. Of those, most (92%-99%) agreed to HIV testing. Several cities also conducted sexually transmitted infection or hepatitis C testing. CONCLUSIONS: NHBS is critical for monitoring the impact of the Ending the HIV Epidemic in the United States initiative. Data collected from NHBS are key to describe trends in key populations and tailor new prevention activities to ensure high prevention impact. NHBS data provide valuable information for monitoring and evaluating national HIV prevention goals and guiding national and local HIV prevention efforts. Furthermore, NHBS data can be used by public health officials and researchers to identify HIV prevention needs, allocate prevention resources, and develop and improve prevention programs directed to the populations of interest and their communities.

Factors Associated with Use of HIV Prevention and Health Care Among Transgender Women - Seven Urban Areas, 2019-2020.

Transgender women* are disproportionately affected by HIV. Among 1,608 transgender women who participated in CDC's National HIV Behavioral Surveillance (NHBS) during 2019-2020, 42% received a positive HIV test result (1). This report provides results from seven U.S. urban areas where the 2019-2020 NHBS questionnaire was administered. Thirty-eight percent of participants reported having previously received a positive test result for HIV. Detrimental socioeconomic factors, including low income (44%), homelessness (39%), and severe food insecurity in the past 12 months (40%), were common and associated with lower receipt of HIV prevention and treatment services. Having a usual health care source or a provider with whom the participant was comfortable discussing gender-related health issues was associated with improved HIV prevention and treatment outcomes, including HIV testing, preexposure prophylaxis (PrEP) use, and viral suppression. These findings illustrate the benefit of gender-affirming approaches used by health care providers (2), and highlight the challenging socioeconomic conditions faced by many transgender women. Ensuring access to gender-affirming health care approaches and addressing the socioeconomic challenges of many transgender women could improve access to and use of HIV prevention and care in this population and will help achieve the goals of the Ending the HIV Epidemic in the United States initiative (3).

Racial, Ethnic, and Gender Disparities in Awareness of Preexposure Prophylaxis Among HIV-Negative Heterosexually Active Adults at Increased Risk for HIV Infection - 23 Urban Areas, United States, 2019.

In 2019, heterosexual sex accounted for 23% of new HIV diagnoses in the United States and six dependent areas (1). Although preexposure prophylaxis (PrEP) can safely reduce the risk for HIV infection among heterosexual persons, this group is underrepresented in PrEP research (2). CDC analyzed National HIV Behavioral Surveillance (NHBS) data to describe PrEP awareness among heterosexually active adults in cities with high HIV prevalence. Overall, although 32.3% of heterosexually active adults who were eligible were aware of PrEP, <1% used PrEP. Racial, ethnic, and gender disparities were identified, with the lowest awareness of PrEP among residents of Puerto Rico (5.8%) and Hispanic or Latino (Hispanic) men (19.5%) and women (17.6%). Previous studies have found that heterosexual adults are interested in taking PrEP when they are aware of it (3); tailoring PrEP messaging, including Spanish-language messaging, to heterosexual adults, might increase PrEP awareness and mitigate disparities in use.

HIV Infection and HIV-Associated Behaviors Among Persons Who Inject Drugs - 23 Metropolitan Statistical Areas, United States, 2018.

In the United States, 10% of HIV infections diagnosed in 2018 were attributed to unsafe injection drug use or male-to-male sexual contact among persons who inject drugs (PWID) (1). In 2017, among PWID or men who have sex with men and who inject drugs (MSM-ID), 76% of those who received a diagnosis of HIV infection lived in urban areas* (2). To monitor the prevalence of HIV infection and associated behaviors among persons who reported injecting drugs in the past 12 months, including MSM-ID, CDC's National HIV Behavioral Surveillance (NHBS) conducts interviews and HIV testing among populations of persons at high risk for HIV infection (MSM, PWID, and heterosexually active adults at increased risk for HIV infection) in selected metropolitan statistical areas (MSAs) (3). The estimated HIV infection prevalence among PWID in 23 MSAs surveyed in 2018 was 7%. Among HIV-negative PWID, an estimated 26% receptively shared syringes and 68% had condomless vaginal sex during the preceding 12 months. During the same period, 57% had been tested for HIV infection, and 55% received syringes from a syringe services program (SSP). While overall SSP use did not significantly change since 2015, a substantial decrease in SSP use occurred among Black PWID, and HIV prevalence among Black PWID was higher than that among Hispanic and White PWID. These findings underscore the importance of continuing and expanding HIV prevention programs and community-based strategies for PWID, such as those provided by SSPs, especially following service disruptions created by the COVID-19 pandemic (4). Efforts are needed to ensure that PWID have low-barrier access to comprehensive and integrated needs-based SSPs (where legally permissible) that include provision of sterile syringes and safe syringe disposal, HIV and hepatitis C virus (HCV) testing and referrals to HIV and HCV treatment, HIV preexposure prophylaxis, and treatment for substance use and mental health disorders.

Black men who have sex with men living in states with HIV criminalization laws report high stigma, 23 U.S. cities, 2017.

OBJECTIVES: To examine the association between HIV laws, perceived community stigma, and behaviors and to compare differences between and within Black and White men who have sex with men (MSM). DESIGN/METHODS: National HIV Behavioral Surveillance conducted interviews and HIV testing with MSM in 23 U.S. cities in 2017 using venue-based sampling methods. We used weighted cross-sectional data to compare MSM living in states with versus without HIV laws using Rao-Scott chi-square tests. We modeled the association between stigma and state HIV laws within racial groups to obtain adjusted prevalence ratios (aPR) and 95% confidence intervals (CIs). RESULTS: Among 7392 MSM, 56% lived in a state with HIV laws. In law states, Black MSM were more likely than White MSM to report their community would discriminate against persons with HIV (PWH) (59 versus 34%), not support the rights of PWH (20 versus 9%), not be friends with PWH (19 versus 10%), believe PWH 'got what they deserved' (27 versus 16%), and be intolerant of MSM (14 versus 5%). Adjusted for confounders, Black MSM in HIV law states were more likely to think their community would discriminate against PWH (aPR, 1.14; 95% CI, 1.02-1.29; P = 0.02) and be intolerant toward MSM (aPR, 2.02; 95% CI, 1.43-2.86; P < 0.001) than Black MSM in states without such laws. CONCLUSIONS: HIV laws were related to higher stigma, but only for Black MSM. Future research regarding HIV-related laws should account for racial/ethnic disparities. Modernizing laws can delegitimize stigma and promote focusing on effective HIV prevention strategies.

Is the severity of the Great Recession's aftershocks correlated with changes in access to the combined prevention environment among people who inject drugs?

BACKGROUND: The 2008 Recession was a global event that led to funding cuts for programs and services in the United States; though this recession officially ended in 2009, its aftershocks continued through 2012. We evaluated the relationship between the severity of the Great Recession's aftermath and spatial access to combined prevention services (i.e. HIV testing, syringe service programs, substance use disorder treatment program) for people who inject drugs (PWID) living in 19 metropolitan statistical areas (MSAs) in the United States. METHODS: The unit of analysis was the ZIP code; we sampled ZIP codes in these 19 MSAs where ≥1 PWID lived in 2009 and 2012, according to the CDC's National HIV Behavioral Surveillance. We used administrative data to describe the combined prevention environment (i.e., spatial access to HIV testing) for each ZIP code, and measured the severity of the recession's aftermath in each ZIP code, and in the counties and MSAs where these ZIP codes were located. Multilevel modeling estimated associations between changes in the aftermath of the Great Recession and ZIP code-level changes in spatial access to combined prevention services from 2009 to 2012. RESULTS: 675 ZIP codes located in 36 counties and 19 MSAs were included in this analysis. From 2009 to 2012, 21% of ZIP code areas lost access to combined prevention services and 14% gained access. ZIP codes with higher poverty rates relative to their respective MSAs were less likely to lose access (aOR: 0.91; 95% CI: 0.88, 0.95) and more likely to gain access (aOR: 1.05; 95% CI: 1.01, 1.09); there is some evidence to suggest the former association was attenuated for ZIP codes with higher percentages of non-Hispanic white residents. CONCLUSION: Combined prevention services for PWID living in these 675 ZIP codes demonstrated resilience in the aftermath of the Great Recession. Future research should explore whether community-based and federal HIV prevention initiatives contributed to this resilience, particularly in areas with higher concentrations of people of color.

An application of agent-based modeling to explore the impact of decreasing incarceration rates and increasing drug treatment access on sero-discordant partnerships among people who inject drugs.

BACKGROUND: People who inject drugs (PWID) lag behind other key populations in HIV care continuum outcomes. The impacts of criminal justice reform and increasing drug treatment access on HIV have been underexplored. METHODS: We developed agent-based models (ABM) of sexual partnerships among PWID and non-PWID, and injection equipment-sharing partnerships among PWID in five US cities (Baltimore, Boston, Miami, New York City, San Francisco) over 3 years. The first set of ABM projected changes in partnership discordance among PWID as a function of decreasing ZIP code-level incarceration rates. The second set projected discordance as a function of increasing ZIP code-level drug treatment access. ABM were parameterized and validated overall, and by city and PWID race/ethnicity (Black, Latino, White) using National HIV Behavioral Surveillance data, administrative ZIP code-level data, surveillance reports and prior literature. Informed by research on prisoner release and community-level HIV prevalence, reductions in incarceration rates were fixed at 5% and 30% and respectively projected to increase ZIP code-level HIV prevalence by 2% and 12%. Increases in drug treatment access were fixed at 30% and 58%. RESULTS: In each city, a 30% reduction in ZIP code-level incarceration rates and 12% increase in ZIP code-level HIV prevalence significantly increased sero-discordance among at least one racial/ethnic group of PWID by 1-3 percentage points. A 5% reduction in incarceration rates, and 30% and 58% increases in drug treatment access, led to isolated significant changes in sero-discordance among Black and White PWID that were less than 1 percentage point. CONCLUSION: Reductions in incarceration rates may lead to short-term increases in sero-discordant partnerships among some PWID by increasing community-level HIV prevalence. Efforts to increase HIV testing, engagement in care and community reintegration post release, should be strengthened in the wake of incarceration reform. Additional research should confirm these findings and explore the lack of widespread impacts of drug treatment in this study.

Place-Based Correlates of Exchange Sex Among People Who Inject Drugs in 19 U.S. Metropolitan Areas, 2012.

This study examined overall and gender-specific associations between place-based characteristics and opposite-sex exchange sex among people who inject drugs (PWID) in the U.S. PWID were recruited from 19 metropolitan statistical areas (MSAs) for the Centers for Disease Control and Prevention's 2012 National HIV Behavioral Surveillance. Administrative data were used to describe the economic, social, and political features of the ZIP codes, MSAs, counties, and states where PWID lived. Multilevel modeling estimated associations of place characteristics and exchange sex. We found that 52% of women and 23% of men reported past-year opposite-sex exchange sex (N = 7599). Female PWID living in states with stronger policies supporting working caregivers had lower odds of exchange sex (aOR = 0.80; 95% CI 0.69, 0.94). PWID living in ZIP codes with greater economic deprivation had higher odds of exchange sex (aOR = 1.10; 95% CI 1.03, 1.17). We found that a high percentage of male PWID exchanged sex with women; determinants and risks of this group merit exploration. If future research establishes that the relationships identified here are causal, interventions to reduce exchange sex among PWID should include policies supporting working caregivers and reducing poverty rates.

Assessment of PrEP Awareness, PrEP Discussion with a Provider, and PrEP Use by Transmission Risk Group with an Emphasis on the Southern United States.

The number of new HIV diagnoses is highest in the South. Many persons who might benefit from pre-exposure prophylaxis (PrEP) are not engaged in the HIV PrEP continuum of care. We analyzed National HIV Behavioral Surveillance data to assess engagement in the PrEP continuum of care among persons with increased HIV risk. We compared PrEP awareness, discussion with a clinical provider, and use among persons living in the South to those living elsewhere in the United States. PrEP awareness was lowest among heterosexual persons (7%), highest among men who have sex with men (85%), and 26% among persons who inject drugs. PrEP use was low among each population (≤ 35% for all cycles). There was limited evidence of differences in PrEP use between persons in southern and non-southern U.S. Efforts are needed to increase use of PrEP among each of the groups with increased HIV risk.

RESUMEN: El número de nuevos diagnósticos de virus de la inmunodeficiencia humana (VIH) es más alto en el sur. Muchas personas que podrían beneficiarse de la profilaxis preexposición (PrEP) no participan en la VIH-PrEP continuidad de la atención. Analizamos datos del Sistema Nacional de Vigilancia del Comportamiento Relacionado con el VIH (conocido en inglés como National HIV Behavioral Surveillance System) para evaluar la participación en la PrEP continuidad de la atención en personas con mayor riesgo de contraer el VIH. Comparamos concientización de PrEP, discusión con un proveedor clínico, y uso entre personas que viven en el sur con las personas que viven en otras partes de los Estados Unidos. Concientización de PrEP fue más baja entre personas heterosexuales (7%), más alta entre hombres que tienen relaciones sexuales con hombres (91%), y 26% entre personas que se inyectan drogas. Utilización de PrEP fue baja para todas las poblaciones (≤35% para todos los ciclos). La evidencia de diferencias en el uso de PrEP entre personas que viven en el sur con personas que no viven en el sur de los Estados Unidos fue limitada. Se necesitan esfuerzos para aumentar el uso de PrEP entre estos grupos con más riesgo de contraer el VIH.

Health Care Coverage and Preexposure Prophylaxis (PrEP) Use Among Men Who Have Sex With Men Living in 22 US Cities With vs Without Medicaid Expansion, 2017.

Objectives. To compare health care coverage and utilization between men who have sex with men (MSM) in Medicaid expansion versus nonexpansion states.Methods. We used cross-sectional weighted data from the National HIV Behavioral Surveillance system, which used venue-based methods to interview and test MSM in 22 US cities from June through December, 2017 (n = 8857). We compared MSM in Medicaid expansion versus nonexpansion states by using the Rao-Scott χ2 test stratified by HIV status. We used multivariable logistic regression to model the relationship between Medicaid expansion, coverage, and preexposure prophylaxis (PrEP) use.Results. MSM in expansion states were more likely to have insurance (87.9% vs 71.6%), have Medicaid (21.3% vs 3.8%), discuss PrEP with a provider (58.8% vs 44.3%), or use PrEP (31.1% vs 17.5%).Conclusions. Medicaid expansion is associated with higher coverage and care, including PrEP.Public Health Implications. States may consider expanding Medicaid to help end the HIV epidemic.