Trends in HIV Testing Among US Adults, Aged 18-64 Years, 2011-2017.

In 2006, Centers for Disease Control and Prevention (CDC) recommended HIV screening in healthcare or clinical settings for all persons aged 13-64 years and annual rescreening for populations at high risk for HIV. We used the Behavioral Risk Factor Surveillance System to describe the prevalence and trends of ever tested for HIV and tested for HIV in the past 12 months among US adults. The percentage of ever tested increased from 42.9% in 2011 to 45.9% in 2017; testing in the past 12 months increased from 13.2% in 2011 to 14.8% in 2017. Despite these increases, less than half of US adults have ever been tested for HIV over ten years after CDC's recommendations. Increasing the prevalence of routine HIV screening and rescreening among individuals at high risk will reduce the number of undiagnosed persons with HIV infection and thus prevent new HIV infections-a key strategy in the Ending the HIV Epidemic initiative.

Prenatal HIV Testing and the Impact of State HIV Testing Laws, 2004 to 2011.

OBJECTIVE: This study aimed to analyze prenatal human immunodeficiency virus (HIV) testing rates over time and describe the impact of state HIV testing laws on prenatal testing. METHODS: During 2004-2011, self-reported prenatal HIV testing data for women with live births in 35 states and New York City were collected. Prevalence of testing was estimated overall and by state and year. An annual percent change was calculated in states with at least 6 years of data to analyze testing changes over time. An attorney-coder used WestlawNext to identify states with laws that direct prenatal care providers to screen all pregnant women or direct all women to be tested for HIV and document changes in laws to meet this threshold. RESULTS: The overall prenatal HIV testing rate for 2004 through 2011 combined was 75.7%. State-level data showed a wide range of testing rates (43.2%-92.8%) for 2004 through 2011 combined. In areas with 6 years of data, 4 experienced an annual drop in testing (Alaska, Arkansas, Colorado, and Illinois). States that changed laws to meet the threshold generally had the highest testing rates, averaging 80%, followed by states with a preexisting law, at approximately 70%. States with no law, or no law meeting the threshold, had an average prenatal testing rate of 65%. CONCLUSIONS: Prenatal HIV testing remained stable between 2004 and 2011 but remained below universal recommendations. Testing varied widely across states and was generally higher in areas that changed their laws to meet the threshold or had preexisting prenatal HIV testing laws, compared with those with no or limited prenatal HIV testing language.

How well are U.S. primary care providers assessing whether their male patients have male sex partners?

Identifying patients at-risk for HIV infection, such as men who have sex with men (MSM), is an important step in providing HIV testing and prevention interventions. It is unknown how primary care providers (PCPs) assess MSM status and related HIV-risk factors. We analyzed data from a panel-derived web-based survey for healthcare providers conducted in 2014 to describe how PCPs in the U.S. determined their patients' MSM status. We calculated adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) to describe PCP characteristics associated with systematically determining MSM status (i.e., PCP used "a patient-completed questionnaire" or "routine verbal review of sex history"). Among the 1008 PCPs, 56% determined MSM status by routine verbal review of sexual history; 41% by patient disclosure; 39% by questions driven by symptoms/history; 23% by using a patient-completed questionnaire, and 9% didn't determine MSM status. PCPs who systematically determined MSM status (n=665; 66%) were more likely to be female (aPR=1.16, CI=1.06-1.26), to be affiliated with a teaching hospital (aPR=1.15, CI=1.06-1.25), to routinely screen all patients aged 13-64 for HIV (aPR=1.29, CI=1.18-1.41), and to estimate that 6% or more of their male patients are MSM (aPR=1.14, CI=1.01-1.30). The majority of PCPs assessed MSM status and HIV risk factors through routine verbal reviews of sexual history. Implementing a systematic approach to identify MSM status and assess risk may allow PCPs to identify more patients needing frequent HIV testing and other preventive services, while mitigating socio-cultural barriers to obtaining such information.

Stigmatizing Attitudes Toward People Living with HIV Among Adults and Adolescents in the United States.

Stigmatizing attitudes toward people living with HIV (PLWH) cause psychological distress for PLWH and hinder HIV prevention efforts. We estimated the prevalence of stigmatizing attitudes among 6809 adults and 885 adolescents who responded to online surveys in 2015. Fear of casual contact with PLWH was reported by 17.5% [95% confidence interval (CI) 16.3-18.6%] of adults and 31.6% (CI 27.8-35.4%) of adolescents. Among adults, 12.5% (CI 11.6-13.5%) endorsed a measure of moral judgment toward PLWH. Stigmatizing attitudes toward PLWH persist in the United States. Continued monitoring of these attitudes and efforts to reduce associated stigma are warranted.

Factors Associated With Condom Use Among Sexually Active US Adults, National Survey of Family Growth, 2006-2010 and 2011-2013.

BACKGROUND: Condom-less sex can increase the risk of acquiring or transmitting HIV. AIM: To characterize the prevalence of condom use at the most recent sex act and identify factors associated with use of a condom at the most recent sex act in adults in the United States. METHODS: Data from the cross-sectional National Survey of Family Growth from cycles 2006 through 2010 and 2011 through 2013 were analyzed for sexually active men and women 18 to 44 years old who reported having sex (vaginal, anal, or oral) with an opposite-sex partner in the past 12 months. HIV-related sexual risk behaviors (SRBs) in the past 12 months included sex with at least four opposite-sex partners; exchanging sex for money or drugs; sex with an injection drug user; sex with an HIV-positive person; sex with a man who previously had sex with a man (women only); sex with a man (men only); or sex with a partner who had sex with other partners. OUTCOMES: The outcome for this analysis was condom use at the most recent anal or vaginal sex act. RESULTS: Overall prevalence of condom use was 24.8%; only 33.8% of adults with at least one SRB reported the use of a condom. Only 46.4% of unmarried or single men (vs 14.7% married or cohabitating men) and 32.3% unmarried or single women (vs 14.1% married or cohabitating women) with SRBs reported using a condom at the most recent sexual encounter and were less likely to use a condom at the most recent sexual encounter compared with those who did not report SRBs. We did not find a significant relation between using a condom and SRBs in married or cohabitating men and women. STRENGTHS AND LIMITATIONS: Our analysis adds to the literature on how condom use varies by marital status. We measured the use of condoms at the most recent sexual act, which might not reflect an individual's previous behavior of condom use. Nonetheless, condom use at the most recent sexual act has been documented in previous studies as a valid proxy of condom use over time. CONCLUSION: Continued efforts are needed to promote condom use in heterosexual adults in the United States, particularly those at high risk for HIV, namely individuals engaging in anal sexual acts and with multiple sex partners. Nasrullah M, Oraka E, Chavez PR, et al. Factors Associated With Condom Use Among Sexually Active US Adults, National Survey of Family Growth, 2006-2010 and 2011-2013. J Sex Med 2017;14:541-550.

Trends in HIV prevalence and HIV testing among young MSM: five United States cities, 1994-2011.

We examined trends in cross-sectional HIV prevalence (a surrogate for incidence) and past 12 month testing behavior among young men who have sex with men (MSM). The Young Men's Survey and the National HIV Behavioral Surveillance System conducted interviews and HIV testing among MSM recruited by venue-based sampling during 1994-2011. Using data from five cities, we determined whether interview year was associated with HIV prevalence and recent testing for MSM ages 18-22 and 23-29 years, after adjusting for city, race/ethnicity, and education. Multivariable analysis demonstrated an overall increase in prevalence among MSM ages 23-29 years, driven by an increase in Baltimore. There was no change in HIV prevalence among MSM ages 18-22 years overall, although prevalence increased in Baltimore. HIV testing increased significantly for both age groups. Gains in HIV testing are encouraging, but increasing prevalence among young MSM in Baltimore suggests increasing incidence and the need for additional efforts for this population.

Population Percentage and Population Size of Men Who Have Sex With Men in the United States, 2017-2021: Meta-Analysis of 5 Population-Based Surveys.

BACKGROUND: Male-to-male sexual transmission continues to account for the greatest proportion of new HIV diagnoses in the United States. However, calculating population-specific surveillance metrics for HIV and other sexually transmitted infections requires regularly updated estimates of the number and proportion of men who have sex with men (MSM) in the United States, which are not collected by census surveys. OBJECTIVE: The purpose of this analysis was to estimate the number and percentage of MSM in the United States from population-based surveys. METHODS: We used data from 5 population-based surveys to calculate weighted estimates of the proportion of MSM in the United States and pooled these estimates using meta-analytic procedures. We estimated the proportion of MSM using sexual behavior-based questions (encompassing anal or oral sex) for 3 recall periods-past 12 months, past 5 years, and lifetime. In addition, we estimated the proportion of MSM using self-reported identity and attraction survey responses. The total number of MSM and non-MSM in the United States were calculated from estimates of the percentage of MSM who reported sex with another man in the past 12 months. RESULTS: The percentage of MSM varied by recall period: 3.3% (95% CI 1.7%-4.9%) indicated sex with another male in the past 12 months, 4.7% (95% CI 0.0%-33.8%) in the past 5 years, and 6.2% (95% CI 2.9%-9.5%) in their lifetime. There were comparable percentages of men who identified as gay or bisexual (3.4%, 95% CI 2.2%-4.6%) or who indicated that they are attracted to other men (4.9%, 95% CI 3.1%-6.7%) based on pooled estimates. Our estimate of the total number of MSM in the United States is 4,230,000 (95% CI 2,179,000-6,281,000) based on the history of recent sexual behavior (sex with another man in the past 12 months). CONCLUSIONS: We calculated the pooled percentage and number of MSM in the United States from a meta-analysis of population-based surveys collected from 2017 to 2021. These estimates update and expand upon those derived from the Centers for Disease Control and Prevention in 2012 by including estimates of the percentage of MSM based on sexual identity and sexual attraction. The percentage and number of MSM in the United States is an important indicator for calculating population-specific disease rates and eligibility for preventive interventions such as pre-exposure prophylaxis.

Changes to the sample design and weighting methods of a public health surveillance system to also include persons not receiving HIV medical care.

OBJECTIVES: The Medical Monitoring Project (MMP) is a public health surveillance system that provides representative estimates of the experiences and behaviors of adults with diagnosed HIV in the United States. In 2015, the sample design and frame of MMP changed from a system that only included HIV patients to one that captures the experiences of persons receiving and not receiving HIV care. We describe methods investigated for calculating survey weights, the approach chosen, and the benefits of using a dynamic surveillance registry as a sampling frame. METHODS: MMP samples adults with diagnosed HIV from the National HIV Surveillance System, the HIV case surveillance registry for the United States. In the methodological study presented in this manuscript, we compared methods that account for sample design and nonresponse, including weighting class adjustment vs. propensity weighting and a single-stage nonresponse adjustment vs. sequential adjustments for noncontact and nonresponse. We investigated how best to adjust for non-coverage using surveillance data to post-stratify estimates. RESULTS: After assessing these methods, we chose as our preferred procedure weighting class adjustments and a single-stage nonresponse adjustment. Classes were constructed using variables associated with respondents' characteristics and important survey outcomes, chief among them laboratory results available from surveillance that served as a proxy for medical care. CONCLUSIONS: MMPs weighting procedures reduced sample bias by leveraging auxiliary information on medical care available from the surveillance registry sampling frame. Expanding MMPs population of focus provides important information on characteristics of persons with diagnosed HIV that complement the information provided by the surveillance registry. MMP methods can be applied to other disease registries or population-monitoring systems when more detailed information is needed for a population, with the detailed information obtained efficiently from a representative sample of the population covered by the registry.

A National Behavioral and Clinical Surveillance System of Adults With Diagnosed HIV (The Medical Monitoring Project): Protocol for an Annual Cross-Sectional Interview and Medical Record Abstraction Survey.

BACKGROUND: The Medical Monitoring Project (MMP) is a national population-based behavioral and clinical surveillance system of adults with diagnosed HIV in the United States, and it is sponsored by the Centers for Disease Control and Prevention (CDC). Its purpose is to provide locally and nationally representative estimates of factors affecting HIV transmission risk and clinical outcomes. OBJECTIVE: This study aimed to describe the rationale for and methodology of the MMP, in addition to its contribution to evaluating and monitoring HIV prevention, care, and treatment efforts in the United States. METHODS: MMP employs a stratified 2-stage sample design to select annual samples of persons living with diagnosed HIV from the National HIV Surveillance System and conducts interviews and medical record abstractions with participating persons. RESULTS: MMP data are published routinely via annual reports, conference presentations, and scientific publications. Data may be accessed upon request from the CDC, contingent on the guidelines established for the security and confidentiality of HIV surveillance data. CONCLUSIONS: MMP is the only source of annual population-based data on the behaviors and clinical care of persons with diagnosed HIV in the United States. It provides essential information for monitoring progress toward national treatment and prevention goals and guiding efforts to improve the health of persons with diagnosed HIV and prevent HIV transmission. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/15453.

Methods to include persons living with HIV not receiving HIV care in the Medical Monitoring Project.

The Medical Monitoring Project (MMP) is an HIV surveillance system that provides national estimates of HIV-related behaviors and clinical outcomes. When first implemented, MMP excluded persons living with HIV not receiving HIV care. This analysis will describe new case-surveillance-based methods to identify and recruit persons living with HIV who are out of care and at elevated risk for mortality and ongoing HIV transmission. Stratified random samples of all persons living with HIV were selected from the National HIV Surveillance System in five public health jurisdictions from 2012-2014. Sampled persons were located and contacted through seven different data sources and five methods of contact to collect interviews and medical record abstractions. Data were weighted for non-response and case reporting delay. The modified sampling methodology yielded 1159 interviews (adjusted response rate, 44.5%) and matching medical record abstractions for 1087 (93.8%). Of persons with both interview and medical record data, 264 (24.3%) would not have been included using prior MMP methods. Significant predictors were identified for successful contact (e.g., retention in care, adjusted Odds Ratio [aOR] 5.02; 95% Confidence Interval [CI] 1.98-12.73), interview (e.g. moving out of jurisdiction, aOR 0.24; 95% CI: 0.12-0.46) and case reporting delay (e.g. rural residence, aOR 3.18; 95% CI: 2.09-4.85). Case-surveillance-based sampling resulted in a comparable response rate to existing MMP methods while providing information on an important new population. These methods have since been adopted by the nationally representative MMP surveillance system, offering a model for public health program, research and surveillance endeavors seeking inclusion of all persons living with HIV.

How can PRAMS survey response rates be improved among American Indian mothers? Data from 10 states.

OBJECTIVES: To examine the low response rates to the Pregnancy Risk Assessment and Monitoring System (PRAMS) survey for American Indian (AI) mothers by comparing characteristics of AI participants, AI non-participants, non-Hispanic White (NHW) participants, and NHW non-participants. METHODS: We analyzed 2000-2002 data from states whose population was at least 5% AI or Alaska Native (AN) (n = 10). Mothers who returned a questionnaire (regardless of completion) or who spoke by telephone with PRAMS personnel were defined as contacts. Mothers who completed a PRAMS questionnaire were defined as respondents. We described overall and state-specific maternal characteristics from birth certificates for both those who were contacted and those not contacted and computed contact and response rates. RESULTS: Contact rates varied by state, ranging from 49% to 92% for AI and AN mothers and 82-93% for NHW mothers. However, once contacted, most mothers completed a questionnaire (85-99%). Both AI and NHW mothers were less likely to be contacted if they were <29 years of age, unmarried, multiparous and had

Prenatal HIV testing in the US-Mexico border region, 2005: the Brownsville-Matamoros Sister City Project for Women's Health.

INTRODUCTION: Routine prenatal human immunodeficiency virus (HIV) screening provides a critical opportunity to diagnose HIV infection, begin chronic care, and prevent mother-to-child transmission. However, little is known about the prevalence of prenatal HIV testing in the US-Mexico border region. We explored the correlation between prenatal HIV testing and sociodemographic, health behavior, and health exposure characteristics. METHODS: The study sample consisted of women who delivered live infants in 2005 in hospitals with more than 100 deliveries per year and resided in Matamoros, Tamaulipas, Mexico (n = 489), or Cameron County, Texas (n = 458). We examined univariate and bivariate distributions of HIV testing in Matamoros and Cameron County and quantified the difference in odds of HIV testing by using logistic regression. RESULTS: The prevalence of prenatal HIV testing varied by place of residence--57.6% in Matamoros and 94.8% in Cameron County. Women in Cameron County were significantly more likely than those in Matamoros to be tested. Marital status, education, knowledge of methods to prevent HIV transmission (adult-to-adult), discussion of HIV screening with a health care professional during prenatal care, and previous HIV testing were significantly associated with prenatal HIV testing in Matamoros, although only the latter 2 variables were significant in Cameron County. CONCLUSION: Although national policies in both the United States and Mexico recommend prenatal testing for HIV, a greater proportion of women in Cameron County were tested, compared with women in Matamoros. Efforts between Matamoros and Cameron County to improve HIV testing during pregnancy in the border region should consider correlates for testing in each community.

Reproductive health surveillance in the US-Mexico border region, 2003-2006: the Brownsville-Matamoros Sister City Project for Women's Health.

INTRODUCTION: High birth and immigration rates in the US-Mexico border region have led to large population increases in recent decades. Two national, 10 state, and more than 100 local government entities deliver reproductive health services to the region's 14 million residents. Limited standardized information about health risks in this population hampers capacity to address local needs and assess effectiveness of public health programs. METHODS: We worked with binational partners to develop a system for reproductive health surveillance in the sister communities of Matamoros, Tamaulipas, Mexico, and Cameron County, Texas, as a model for a broader regional approach. We used a stratified, systematic cluster-sampling design to sample women giving birth in hospitals in each community during an 81-day period (August 21-November 9) in 2005. We conducted in-hospital computer-assisted personal interviews that addressed prenatal, behavioral, and lifestyle factors. We evaluated survey response rates, data quality, and other attributes of effective surveillance systems. We estimated population coverage using vital records data. RESULTS: Among the 999 women sampled, 947 (95%) completed interviews, and the item nonresponse rate was low. The study sample included 92.7% of live births in Matamoros and 98.3% in Cameron County. Differences between percentage distributions of birth certificate characteristics in the study and target populations did not exceed 2.0. Study population coverage among hospitals ranged from 92.9% to 100.0%, averaging 97.3% in Matamoros and 97.4% in Cameron County. CONCLUSION: Results indicate that hospital-based sampling and postpartum interviewing constitute an effective approach to reproductive health surveillance. Such a system can yield valuable information for public health programs serving the growing US-Mexico border population.

Changes in perceived discrimination in healthcare settings reported by HIV patients in the United States from 1996 to 2011-2013.

: Discrimination in healthcare settings is a barrier to healthcare engagement. We analyzed two nationally representative datasets to assess change in discrimination in healthcare settings reported by HIV patients from 1996 to 2011-2013. Perceived discrimination in healthcare settings significantly decreased over time, from 24% in 1996 to 15% in 2011-2013. Improvements over time in HIV clinicians' engagement in prevention discussions with patients following federal agencies' recommendations may have been a contributing factor.

Characteristics associated with lack of HIV testing during pregnancy and delivery in 36 U.S. states, 2004-2013.

The Centers for Disease Control and Prevention and the American Congress of Obstetricians and Gynecologists recommend universal prenatal HIV testing to prevent perinatal HIV transmission in the U.S.; since the 1990s perinatal HIV transmission has declined. In 2006, 74% of women with a recent live birth reported testing for HIV prenatally or at delivery. We used Pregnancy Risk Assessment Monitoring System data from 36 states and New York City from 2004 to 2013 (N = 387,424) to assess characteristics associated with lack of self-reported testing and state-to-state variability in these associations. Overall, 75.2% (95% confidence interval [CI] 75.0-75.5) of women with a recent live birth reported an HIV test. There were significant differences in testing prevalence by state, ranging from 91.8% (95% CI 91.0-92.6) in New York to 42.3% (95% CI 41.7-43.5) in Utah. In adjusted analysis, characteristics associated with no reported testing included being married, white, non-Hispanic, multiparous, not smoking during pregnancy, and having neither Medicaid nor Special Supplemental Nutritional Program for Women, Infants, and Children. White married women were 57% (adjusted prevalence ratio [aPR] 1.57, 95% CI 1.52-1.63) more likely to report no test compared to white unmarried women. Multiparous married women were 57% (aPR 1.57, 95% CI 1.51-1.64) more likely to report no test compared to multiparous unmarried women. Women who were married, white, non-Hispanic, and multiparous women were 23% less likely to be tested than other women combined. Marital status was significantly associated with lower prevalence of testing in 35 of the 37 reporting areas, and race was significant in 30 of 35 states with race information. The prevalence of reported HIV testing during pregnancy or at delivery remains below 80%. Opportunities exist to increase HIV testing among pregnant women, particularly among certain subpopulations.

Methods to Obtain a Representative Sample of Ryan White-Funded Patients for a Needs Assessment in Los Angeles County: Results from a Replicable Approach.

The Health Resources and Services Administration requires that jurisdictions receiving Ryan White (RW) funding justify need, set priorities, and provide allocations using evidence-based methods. Methods and results from the 2011 Los Angeles Coordinated HIV/AIDS Needs Assessment-Care (LACHNA-Care) study are presented. Individual-level weights were applied to expand the sample from 400 to 18 912 persons, consistent with the 19 915 clients in the system. Awareness, need, and utilization for medical outpatient care were high (>90%). Other services (eg, child care) had limited awareness (21%). Majority of participants reported at least 1 service gap (81%). Lack of insurance (risk ratio [RR] = 3.0, 95% confidence interval [CI]: 1.5-6.2), substance use (RR = 2.9, 95% CI: 1.3-6.4), and past lapses in medical care (RR = 2.8, 95% CI: 1.3-5.9) were associated with gaps. Within clusters, past incarceration was associated with gaps for housing (RR = 13.5, 95% CI: 3.5-52.1), transportation (RR = 3.2, 95% CI: 1.2-8.4), and case management (RR = 4.0, 95% CI: 1.3-12.2). Applied methods resulted in representative data instrumental to RW program planning efforts.

Trends in Racial and Ethnic Disparities in Antiretroviral Therapy Prescription and Viral Suppression in the United States, 2009-2013.

OBJECTIVES: To examine trends in racial/ethnic disparities in antiretroviral therapy (ART) prescription and viral suppression among HIV-infected persons in care, overall and among men who have sex with men (MSM), from 2009 to 2013. DESIGN: The Medical Monitoring Project (MMP) is a complex sample survey of HIV-infected adults receiving medical care in the United States. METHODS: We used weighted interview and medical record data collected June 2009-May 2014 to estimate the prevalence of ART prescription and viral suppression among racial/ethnic groups overall and among MSM. RESULTS: We found significant increases in ART prescription and viral suppression among all racial/ethnic groups from 2009 to 2013, both overall and among MSM. By 2013, overall and among MSM, the Hispanic-white disparity in ART prescription was nonexistent, and the black-white disparity was not significant after accounting for differences between blacks and whites in age and length of HIV diagnosis. Despite reductions in racial/ethnic disparities in viral suppression over the time period, significant disparities remained among the total population, even after adjusting for differences in racial/ethnic group characteristics. Encouragingly, however, there was no significant Hispanic-white disparity in viral suppression among MSM by 2013. CONCLUSIONS: Despite significant improvements in ART prescription and viral suppression in recent years, racial and ethnic disparities persist, particularly for black persons. If the United States is to achieve the National HIV/AIDS Strategy goal of reducing HIV-related health disparities, continued efforts to accelerate the rate of improvement in ART prescription and viral suppression among Hispanic and black persons may need to be prioritized.

Design and Weighting Methods for a Nationally Representative Sample of HIV-infected Adults Receiving Medical Care in the United States-Medical Monitoring Project.

BACKGROUND: Health surveys of the general US population are inadequate for monitoring human immunodeficiency virus (HIV) infection because the relatively low prevalence of the disease (<0.5%) leads to small subpopulation sample sizes. OBJECTIVE: To collect a nationally and locally representative probability sample of HIV-infected adults receiving medical care to monitor clinical and behavioral outcomes, supplementing the data in the National HIV Surveillance System. This paper describes the sample design and weighting methods for the Medical Monitoring Project (MMP) and provides estimates of the size and characteristics of this population. METHODS: To develop a method for obtaining valid, representative estimates of the in-care population, we implemented a cross-sectional, three-stage design that sampled 23 jurisdictions, then 691 facilities, then 9,344 HIV patients receiving medical care, using probability-proportional-to-size methods. The data weighting process followed standard methods, accounting for the probabilities of selection at each stage and adjusting for nonresponse and multiplicity. Nonresponse adjustments accounted for differing response at both facility and patient levels. Multiplicity adjustments accounted for visits to more than one HIV care facility. RESULTS: MMP used a multistage stratified probability sampling design that was approximately self-weighting in each of the 23 project areas and nationally. The probability sample represents the estimated 421,186 HIV-infected adults receiving medical care during January through April 2009. Methods were efficient (i.e., induced small, unequal weighting effects and small standard errors for a range of weighted estimates). CONCLUSION: The information collected through MMP allows monitoring trends in clinical and behavioral outcomes and informs resource allocation for treatment and prevention activities.

Prevalence of selected maternal behaviors and experiences, Pregnancy Risk Assessment Monitoring System (PRAMS), 1999.

PROBLEM/CONDITION: Various maternal behaviors and experiences before, during, and after pregnancy (e.g., unintended pregnancy, late entry into prenatal care, cigarette smoking, not breast-feeding) are associated with adverse health outcomes for both the mother and the infant. Information regarding maternal behaviors and experiences is needed to monitor trends, to enhance the understanding of the relations between behaviors and health outcomes, to plan and evaluate programs, to direct policy decisions, and to monitor progress toward Healthy People 2000 and 2010 objectives. REPORTING PERIOD COVERED: This report covers data from 1993 through 1999. DESCRIPTION OF SYSTEM: The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing, state- and population-based surveillance system designed to monitor selected self-reported maternal behaviors and experiences that occur before, during, and after pregnancy among women who deliver a live-born infant. PRAMS employs a mixed-mode data collection methodology; up to three self-administered surveys are mailed to a sample of mothers, and nonresponders are followed up with a telephone interview. Self-reported survey data are linked to selected birth certificate data and weighted for sample design, nonresponse, and noncoverage to create annual PRAMS analysis data sets. PRAMS generates statewide estimates of various perinatal health topics among women delivering a live infant. Data for 1999 from 17 states are examined. In addition, trend data are examined for 12 states that had at least 3 years of data during 1993-1999. RESULTS: In 1999, the prevalence of unintended pregnancy resulting in a live birth ranged from 33.7% to 52% across the 17 states. During 1993-1999, only one state reported a decreasing trend in the prevalence of unintended pregnancy. Women aged <20 years, black women, women with less than or equal to a high school education, and women receiving Medicaid were more likely to report unintended pregnancy. The prevalence of late or no entry into prenatal care ranged from 16.1% to 29.9%. The prevalence of late or no entry into prenatal care significantly decreased over time in seven of the 12 states with trend data. In general, women aged <20 years, black women, women with less than a high school education, and women receiving Medicaid were more likely to report late or no entry into prenatal care. The prevalence of smoking during the last 3 months of pregnancy ranged from 6.2% to 27.2%, and the prevalence decreased in five states from 1993 to 1999. Overall, smoking during the last 3 months of pregnancy was associated with younger age (<25 years), non-Hispanic ethnicity, having less than or equal to a high school education, receiving Medicaid, and delivering a low birthweight infant. The prevalence of physical abuse by a husband or partner during pregnancy ranged from 2.1% to 6.3%. No trends were observed for physical abuse from 1996 to 1999, the only years for which these data were available. Across the 17 states, only Medicaid status was consistently associated with experiencing physical abuse during pregnancy. The prevalence of breast-feeding initiation ranged from 48% to 89%. Ten of 12 states with trend data reported increases in the prevalence of breast-feeding initiation. Overall, women aged <20 years, women with less than or equal to a high school education, and women receiving Medicaid were less likely to breast-feed. The prevalence of breast-feeding duration for at least 4 weeks ranged from 34.9% to 78.1%. From 1993 to 1999, increases in levels of breast-feeding for at least 4 weeks were observed in eight states. Women aged <25 years, black women, women with less than or equal to a high school education, and women receiving Medicaid were generally less likely to breast-feed for at least 4 weeks. The prevalence of back sleep position for infants ranged from 35.1% to 74.6%. Increases in the use of the back sleep position were observed in all 12 states with trend data from 1996 to 1999. Black race and having less than or equal to a high school education were consistently associated with not using the back sleep position. INTERPRETATION: For surveillance during 1993-1999, the majority or all states observed increases in breast-feeding initiation, breast-feeding for at least 4 weeks, and back sleep position. Approximately one half of the states observed decreases for late or no entry into prenatal care and smoking during the last 3 months of pregnancy. Little or no progress was observed in the prevalence of unintended pregnancy or physical abuse during pregnancy. With few exceptions, the 17 states failed to meet the Healthy People 2000 objectives for the seven reported behaviors in 1999. Certain de