HIV-Related Risk Behaviors Among Male High School Students Who Had Sexual Contact with Males - 17 Large Urban School Districts, United States, 2009-2013.

Young persons aged 13-24 years accounted for an estimated 22% of all new diagnoses of human immunodeficiency virus (HIV) infection in the United States in 2014. Most new HIV diagnoses among youths occur among males who have sex with males (MSM). Among all MSM, young black MSM accounted for the largest number of new HIV diagnoses in 2014 (1). To determine whether the prevalence of HIV-related risk behaviors among black male high school students who had sexual contact with males differed from the prevalence among white and Hispanic male students who had sexual contact with males, potentially contributing to the racial/ethnic disparities in new HIV diagnoses, CDC analyzed data from Youth Risk Behavior Surveys conducted by 17 large urban school districts during 2009-2013. Although other studies have examined HIV-related risk behaviors among MSM (2,3), less is known about MSM aged <18 years. Black male students who had sexual contact with males had a lower or similar prevalence of most HIV-related risk behaviors than did white and Hispanic male students who had sexual contact with males. These findings highlight the need to increase access to effective HIV prevention strategies for all young MSM.

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.

Cost-utility analysis of the housing and health intervention for homeless and unstably housed persons living with HIV.

We present a cost-utility analysis based on data from the Housing and Health (H&H) Study of rental assistance for homeless and unstably housed persons living with HIV in Baltimore, Chicago and Los Angeles. As-treated analyses found favorable associations of housing with HIV viral load, emergency room use, and perceived stress (an outcome that can be quantitatively linked to quality of life). We combined these outcome data with information on intervention costs to estimate the cost-per-quality-adjusted-life-year (QALY) saved. We estimate that the cost-per-QALY-saved by the HIV-related housing services is $62,493. These services compare favorably (in terms of cost-effectiveness) to other well-accepted medical and public health services.

Results from two online surveys comparing sexual risk behaviors in Hispanic, black, and white men who have sex with men.

Many men who have sex with men (MSM) are among those who increasingly use the internet to find sexual partners. Few studies have compared behavior by race/ethnicity in internet-based samples of MSM. We examined the association of race/ethnicity with HIV risk-related behavior among 10,979 Hispanic, black, and white MSM recruited online. Significant variations by race/ethnicity were found in: age, income level, sexual orientation, number of lifetime male and female sexual partners, and rates of unprotected anal intercourse (UAI). Black and Hispanic men were more likely to report anal intercourse during the last sexual encounter, but white men were more likely to report UAI. In multivariate analysis, UAI was associated with HIV infection and sex with a main partner. Significant risk behavior variations by race/ethnicity were found. Research is needed to better target online interventions to MSM who engage in UAI or have other risk factors for transmitting or acquiring HIV.

Sexual health, HIV, and sexually transmitted infections among gay, bisexual, and other men who have sex with men in the United States.

The sexual health of gay, bisexual, and other men who have sex with men (MSM) in the United States is not getting better despite considerable social, political and human rights advances. Instead of improving, HIV and sexually transmitted infections (STIs) remain disproportionately high among MSM and have been increasing for almost two decades. The disproportionate and worsening burden of HIV and other STIs among MSM requires an urgent re-assessment of what we have been doing as a nation to reduce these infections, how we have been doing it, and the scale of our efforts. A sexual health approach has the potential to improve our understanding of MSM's sexual behavior and relationships, reduce HIV and STI incidence, and improve the health and well-being of MSM.

Randomized trial of the effects of housing assistance on the health and risk behaviors of homeless and unstably housed people living with HIV.

Homelessness affects HIV risk and health, but little is known about the longitudinal effects of rental assistance on the housing status and health of homeless and unstably housed people living with HIV/AIDS. Homeless/unstably housed people living with HIV/AIDS (N = 630) were randomly assigned to immediate Housing Opportunities for People with AIDS (HOPWA) rental assistance or customary care. Self-reported data, CD4, and HIV viral load were collected at baseline, 6, 12, and 18 months. Results showed that housing status improved in both groups, with greater improvement occurring in the treatment group. At 18 months, 51% of the comparison group had their own housing, limiting statistical power. Intent-to-treat analyses demonstrated significant reductions in medical care utilization and improvements in self-reported physical and mental health; significant differential change benefiting the treatment group was observed for depression and perceived stress. Significant differences between homeless and stably housed participants were found in as-treated analyses for health care utilization, mental health, and physical health. HOPWA rental assistance improves housing status and, in some cases, health outcomes of homeless and unstably housed people living with HIV/AIDS.

Potential Contributions of Clinical and Community Testing in Identifying Persons with Undiagnosed HIV Infection in the United States.

BACKGROUND: An estimated 166,155 individuals in the United States have undiagnosed HIV infection. We modeled the numbers of HIV-infected individuals who could be diagnosed in clinical and community settings by broadly implementing HIV screening guidelines. SETTING: United States. METHODS: We modeled testing for general population (once lifetime) and high-risk populations (annual): men who have sex with men, people who inject drugs, and high-risk heterosexuals. We used published data on HIV infections, HIV testing, engagement in clinical care, and risk status disclosure. RESULTS: In clinical settings, about 76 million never-tested low-risk and 2.6 million high-risk individuals would be tested, yielding 36,000 and 55,000 HIV diagnoses, respectively. In community settings, 30 million low-risk and 4.4 million high-risk individuals would be tested, yielding 75,000 HIV diagnoses. CONCLUSION: HIV testing in clinical and community settings diagnoses similar numbers of individuals. Lifetime and risk-based testing are both needed to substantially reduce undiagnosed HIV.

Moral agency and the sexual transmission of HIV.

Sexual transmission of HIV occurs because an infected person has unprotected sex with a previously uninfected person. The majority of HIV infections are transmitted by individuals who are unaware of their infection, and most persons who are diagnosed with HIV significantly reduce or eliminate risk behaviors once they learn they have HIV. However, a minority of known-infected individuals engage in transmission risk behavior, sometimes without disclosure to their partners. Such behavior may involve a breakdown or temporary suspension of moral mechanisms, such as personal responsibility beliefs and anticipatory self-evaluative reactions to one's behavior. The present article reviews the literature on sexual transmission risk behavior within A. Bandura's (1999) theoretical framework of moral agency. The article first reviews evidence for the operation of moral agency in transmission risk behavior and HIV status disclosure. Next, suggestive evidence is presented for the operation of mechanisms of moral disengagement described by Bandura. Finally, the article reviews a small number of interventions that have been shown to be effective in reducing transmission risk behavior, through the lens of moral agency, and make recommendations for future intervention research. (PsycINFO Database Record (c) 2009 APA, all rights reserved).

A review of the Centers for Disease Control and Prevention's response to the HIV/AIDS crisis among Blacks in the United States, 1981-2009.

Among US racial/ethnic groups, Blacks are at the highest risk of acquiring HIV/AIDS. In response, the Centers for Disease Control and Prevention (CDC) has launched the Heightened National Response to Address the HIV/AIDS Crisis Among African Americans, which seeks to engage public and nonpublic partners in a synergistic effort to prevent HIV among Blacks. The CDC also recently launched Act Against AIDS, a campaign to refocus attention on the domestic HIV/AIDS crisis. Although the CDC's efforts to combat HIV/AIDS among Blacks have achieved some success, more must be done to address this crisis. New initiatives include President Obama's goal of developing a National HIV/AIDS Strategy to reduce HIV incidence, decrease HIV-related health disparities, and increase access to care, especially among Blacks and other disproportionately affected populations.

Intentional abstinence among homeless and unstably housed persons living with HIV/AIDS.

Some persons living with HIV/AIDS (PLWHA) engage in periods of sexual abstinence. Baseline data from a larger study of homeless/unstably housed PLWHA indicated that 20% (125/644) intentionally abstained from sex in the past 90 days. Reasons included: (1) 'not interested' (n = 78); (2) did not want to infect someone (n = 46); and (3) did not have a partner (n = 37). Abstinence was less likely among all who had a main partner. Among men who have sex with men (MSM), abstinence was less likely among those with a detectable viral load. It was more likely among heterosexual men who were experiencing current housing problems and who had at least a high school education. Among women, abstinence was less likely among African Americans and those whose social networks were more aware of their HIV status. Better understanding of motivations to abstain may improve how programs serving PLWHA address this issue.

The effects of HIV stigma on health, disclosure of HIV status, and risk behavior of homeless and unstably housed persons living with HIV.

HIV-related stigma negatively affects the lives of persons living with HIV/AIDS (PLWHA). Homeless/unstably housed PLWHA experience myriad challenges and may be particularly vulnerable to the effects of HIV-related stigma. Homeless/unstably housed PLWHA from 3 U.S. cities (N = 637) completed computer-assisted interviews that measured demographics, self-assessed physical and mental health, medical utilization, adherence, HIV disclosure, and risk behaviors. Internal and perceived external HIV stigma were assessed and combined for a total stigma score. Higher levels of stigma were experienced by women, homeless participants, those with a high school education or less, and those more recently diagnosed with HIV. Stigma was strongly associated with poorer self-assessed physical and mental health, and perceived external stigma was associated with recent non-adherence to HIV treatment. Perceived external stigma was associated with decreased HIV disclosure to social network members, and internal stigma was associated with drug use and non-disclosure to sex partners. Interventions are needed to reduce HIV-related stigma and its effects on the health of homeless/unstably housed PLWHA.

Factors associated with adherence to highly active antiretroviral therapy in homeless or unstably housed adults living with HIV.

The aim of this study is to investigate adherence to highly active antiretroviral therapy (HAART) in persons living with HIV/AIDS (PLWHA) who are homeless or unstably housed. We evaluated homeless or unstably housed PLWHA (n=644) in three US cities were enrolled in the Housing and Health Study. Using baseline data and controlling for gender, race, age, and education, we examined associations between self-reported two- and Seven-day adherence and access to healthcare, mental health, substance use, and attitudes toward HIV medical therapy. Of the 644 participants, 358 (55%) were currently on HAART. For two-day adherence, 280 (78%) reported missing no prescribed doses (100% adherence), and for seven-day adherence, 291 (81%) reported > or =90% adherence. Logistic regression analyses indicated being younger, not having health insurance, and drug use were associated with missing > or =1 dose over the past two days. Scoring lower on SF-36 mental component summary scale and having greater risk of depression (CES-D) and stress (Perceived Stress Scale) were associated with poorer adherence for both two- and seven-day outcomes. Negative attitudes toward HIV treatment were also associated with lower adherence. Adherence to HIV medications in this population is similar to other groups. Coexisting problems of access to healthcare, higher risk of mental health problems, along with poorer attitudes toward treatment are associated with increased likelihood of missing doses. Comprehensive models of HIV care that include a continuum of medical and social services are essential for treating this population.

Associations between substance use, sexual risk taking and HIV treatment adherence among homeless people living with HIV.

Prior research suggests that the interconnections between substance use, HIV risk and lack of adherence to HIV medications are especially strong among homeless individuals. Thus, study of these interconnections warrants public health attention. The objectives of this paper are to describe patterns of alcohol and drug use, associations between substance use and participation in high-risk sex, and associations between substance use and adherence to HIV treatment regimens among a sample of 602 homeless or unstably housed HIV-seropositive individuals who are part of a housing-based intervention--the Housing and Health Study. Participants experienced high levels of substance use. Significant associations were found between substance use and adherence to HIV treatment medications, and between substance use and high-risk sexual practices within the entire group. Group analyses by sexual orientation/gender show that the association between substance use and treatment adherence is found primarily among heterosexual males whereas the relationship between several drugs and high-risk sexual practices is strongest among gay and bisexual men. Health professionals working with HIV-seropositive individuals should routinely ascertain housing status and screen for substance use and risky sex.

Meta-analysis of cognitive-behavioral interventions on HIV-positive persons' mental health and immune functioning.

OBJECTIVE: To evaluate the efficacy of cognitive-behavioral interventions (CBIs) for improving the mental health and immune functioning of people living with HIV (PLWH). DESIGN: Comprehensive searches of electronic databases from 1988 to 2005, hand searches of journals, reference lists of articles, and contacts with researchers. Meta-analytic approaches were used in synthesizing findings. MAIN OUTCOME MEASURES: Intervention effects on symptoms of depression, anxiety, and anger, stress, and CD4 cell counts were assessed. RESULTS: Data from 15 controlled trials were analyzed. Significant intervention effects were observed for improving symptoms of depression (d = 0.33), anxiety (d = 0.30), anger (d = 1.00), and stress (d = 0.43). There is limited evidence suggesting intervention effects on CD4 cell counts (d = 0.08). The aggregated effect size estimates for depression and anxiety were statistically significant in trials that provided stress management skills training and had more than 10 intervention sessions. CONCLUSION: CBIs are efficacious in improving various psychological states of PLWH. Future research should examine the relationship among interventions, psychological states, medication adherence, and immune functions, and identify other relevant factors associated with intervention effects.

Health status, health care use, medication use, and medication adherence among homeless and housed people living with HIV/AIDS.

OBJECTIVES: We sought to compare health status, health care use, HIV anti-retroviral medication use, and HIV medication adherence among homeless and housed people with HIV/AIDS. METHODS: Data were obtained from a cross-sectional, multisite behavioral survey of adults (N=7925) recently reported to be HIV positive. RESULTS: At the time interviews were conducted, 304 respondents (4%) were homeless. Self-ratings of mental, physical, and overall health revealed that the health status of homeless respondents was poorer than that of housed respondents. Also, homeless respondents were more likely to be uninsured, to have visited an emergency department, and to have been admitted to a hospital. Homeless respondents had lower CD4 counts, were less likely to have taken HIV anti-retroviral medications, and were less adherent to their medication regimen. Homeless respondents needed more HIV social and medical services, but nearly all respondents in both groups had received needed services. Housing status remained a significant predictor of health and medication outcomes after we controlled for potential confounding variables. CONCLUSIONS: Homeless people with HIV/AIDS are at increased risk of negative health outcomes, and housing is a potentially important mechanism for improving the health of this vulnerable group.

Do prevention interventions reduce HIV risk behaviours among people living with HIV? A meta-analytic review of controlled trials.

OBJECTIVE: To conduct a meta-analytic review of HIV interventions for people living with HIV (PLWH) to determine their overall efficacy in reducing HIV risk behaviours and identify intervention characteristics associated with efficacy. METHODS: Comprehensive searches included electronic databases from 1988 to 2004, hand searches of journals, reference lists of articles, and contacts with researchers. Twelve trials met the stringent selection criteria: randomization or assignment with minimal bias, use of statistical analysis, and assessment of HIV-related behavioural or biologic outcomes at least 3 months after the intervention. Random-effects models were used to aggregate data. RESULTS: Interventions significantly reduced unprotected sex [odds ratio (OR), 0.57; 95% confidence interval (CI) 0.40-0.82] and decreased acquisition of sexually transmitted diseases (OR, 0.20; 95% CI, 0.05-0.73). Non-significant intervention effects were observed for needle sharing (OR, 0.47, 95% CI, 0.13-1.71). As a whole, interventions with the following characteristics significantly reduced sexual risk behaviours: (1) based on behavioural theory; (2) designed to change specifically HIV transmission risk behaviours; (3) delivered by health-care providers or counsellors; (4) delivered to individuals; (5) delivered in an intensive manner; (6) delivered in settings where PLWH receive routine services or medical care; (7) provided skills building, or (8) addressed a myriad of issues related to mental health, medication adherence, and HIV risk behaviour. CONCLUSION: Interventions targeting PWLH are efficacious in reducing unprotected sex and acquisition of sexually transmitted diseases. Efficacious strategies identified in this review should be incorporated into community HIV prevention efforts and further evaluated for effectiveness.

Relative efficacy of a multisession sexual risk-reduction intervention for young men released from prisons in 4 states.

OBJECTIVES: We compared the effects of an enhanced multisession intervention with a single-session intervention on the sexual risk behavior of young men released from prison. METHODS: Young men, aged 18 to 29 years, were recruited from US prisons in 4 states and systematically assigned to the prerelease single-session intervention or the pre- and postrelease enhanced intervention. Both interventions addressed HIV, hepatitis, and other sexually transmitted infections; the enhanced intervention also addressed community reentry needs (e.g., housing, employment). Assessment data were collected before intervention, and 1, 12, and 24 weeks after release. RESULTS: A total of 522 men were included in intent-to-treat analyses. Follow-up rates ranged from 76% to 87%. Unprotected vaginal or anal sex during the 90 days before incarceration was reported by 86% of men in the enhanced intervention and 89% in the single-session intervention (OR=0.78; 95% CI=0.46, 1.32). At 24 weeks, 68% of men assigned to the enhanced intervention reported unprotected vaginal or anal sex compared with 78% of those assigned to the single-session intervention (OR=0.40; 95% CI=0.18, 0.88). CONCLUSION: Project START demonstrated the efficacy of a sexual risk-reduction intervention that bridges incarceration and community reentry.

Is HIV/AIDS stigma dividing the gay community? Perceptions of HIV-positive men who have sex with men.

Stigma surrounding HIV/AIDS has existed since the beginning of the epidemic, but little is known about HIV/AIDS stigma within the gay community and how it affects men who have sex with men (MSM) living with HIV. A better understanding of the effects of stigma on this population is needed to reduce it and its harmful effects. Our study used quantitative data from 206 HIV-positive MSM and qualitative data from 250 to document beliefs about HIV/AIDS stigma within the gay community and to measure its effects on sexual risk behaviors, substance use behaviors, serostatus disclosure, and mental health. Stigma was associated with increased levels of anxiety, loneliness, depressive symptoms, engaging in avoidant coping strategies, and history of suicidal ideation. HIV/AIDS stigma exists within the gay community and has a negative effect on the mental health of people living with HIV. HIV/AIDS stigma should be monitored closely so that we may better understand how to address it.