High Seroprevalence of Hepatitis C Virus Among Cisgender Women Who Exchange Sex in the Seattle, Washington Area.

BACKGROUND: Injection drug use (IDU) is a risk factor for hepatitis C virus (HCV) acquisition and occurs disproportionately among women who exchange sex (WES). However, little is known about HCV epidemiology in this population. We estimated HCV seroprevalence, identified correlates of HCV seropositivity, and characterized social networks by HCV serostatus and IDU history among WES in the Seattle, Washington, area. METHODS: This was a secondary analysis of data from the 2016 National HIV Behavioral Surveillance survey in the Seattle, Washington area, a cross-sectional survey that used respondent-driven sampling (RDS) to enroll WES for money or drugs (N = 291). All participants were offered rapid HCV-antibody testing. We estimated HCV seropositivity and used log regression methods to estimate crude and adjusted prevalence ratios (PRs) for correlates of HCV seropositivity among WES. Using RDS recruitment chain data, we computed homophily indices to estimate the extent to which participants were likely to recruit another participant with the same HCV serostatus and IDU history. RESULTS: In the study sample of WES in the Seattle, Washington area, 79% reported lifetime IDU and 60% were HCV seropositive. HCV seropositivity was strongly associated with ever injecting drugs (PRadj: 7.7 [3.3, 18.0]). The RDS homophily scores for HCV seropositivity (0.07) and ever injecting drugs (0.02) suggested that participants did not tend to recruit others with the same characteristics beyond what would be expected by chance. CONCLUSION: Among this sample of WES in Seattle, Washington area, HCV seroprevalence was high and strongly associated with a history of IDU. The high burden of HCV among WES suggests this marginalized group would benefit from additional harm reduction services and targeted HCV treatment campaigns to reduce forward transmission. We saw little evidence of preferential recruitment among WES who were HCV seropositive or reported a history of IDU, suggesting the potential futility of peer-based referrals for HCV treatment.

A public health approach to monitoring HIV with resistance to HIV pre-exposure prophylaxis.

BACKGROUND: The risk of HIV pre-exposure prophylaxis (PrEP) failure with sufficient medication adherence is extremely low but has occurred due to transmission of a viral strain with mutations conferring resistance to PrEP components tenofovir (TDF) and emtricitabine (FTC). The extent to which such strains are circulating in the population is unknown. METHODS: We used HIV surveillance data to describe primary and overall TDF/FTC resistance and concurrent viremia among people living with HIV (PLWH). HIV genotypes conducted for clinical purposes are reported as part of HIV surveillance. We examined the prevalence of HIV strains with mutations conferring intermediate to high level resistance to TDF/FTC, defining primary resistance (predominantly K65R and M184I/V mutations) among sequences reported within 3 months of HIV diagnosis and total resistance for sequences reported at any time. We examined trends in primary resistance during 2010-2019 and total resistance among all PLWH in 2019. We also monitored resistance with viremia (≥1,000 copies/mL) at the end of 2019 among PLWH. RESULTS: Between 2010 and 2019, 2,172 King County residents were diagnosed with HIV; 1,557 (72%) had a genotypic resistance test within three months; three (0.2%) had primary TDF/FTC resistance with both K65R and M184I/V mutations. Adding isolated resistance for each drug resulted in 0.3% with primary TDF resistance and 0.8% with primary FTC resistance. Of 7,056 PLWH in 2019, 4,032 (57%) had genotype results, 241 (6%) had TDF/FTC resistance and 15 (0.4% of those with a genotype result) had viremia and TDF/FTC resistance. CONCLUSIONS: Primary resistance and viremia combined with TDF/FTC resistance are uncommon in King County. Monitoring trends in TDF/FTC resistance coupled with interventions to help ensure PLWH achieve and maintain viral suppression may help ensure that PrEP failure remains rare.

Direct and Indirect Effects of a Project ECHO Longitudinal Clinical Tele-Mentoring Program on Viral Suppression for Persons With HIV: A Population-Based Analysis.

BACKGROUND: Project Extension for Community Health Outcomes (ECHO) aims to connect community providers to academic specialists, deliver longitudinal clinical mentorship and case consultations, plus encourage dissemination of knowledge and resources. The impact on outcomes for persons with HIV (PWH) is uncertain. SETTING: PWH in Washington and Oregon outside of the Seattle and Portland metro areas, January 2011 to March 2018. METHODS: Using viral load (VL) surveillance data, we assessed difference in the percentage of PWH who were virally suppressed among PWH whose providers participated versus did not participate in Project ECHO. Analyses included multiple mixed-effects regression models, adjusting for time and for patient, provider, and clinic characteristics. RESULTS: Based on 65,623 VL results, Project ECHO participation was associated with an increase in the percentage of patients with VL suppression (13.7 percentage points greater; P < 0.0001), although the effect varied by estimated provider PWH patient volume. The difference was 14.7 percentage points ( P < 0.0001) among patients of providers who order <20 VL's/quarter and 2.3 and -0.6 percentage points among patients of providers who order 20-40 or >40 VL's/quarter, respectively ( P > 0.5). The magnitude of difference in VL suppression was associated with the number of sessions attended. Among patients of lower-volume providers who did not participate, VL suppression was 6.2 percentage points higher if providers worked in a clinic where another provider did participate ( P < 0.0001). CONCLUSION: Project ECHO is associated with improvement in VL suppression for PWH whose providers participate or work in the same clinic system as a provider who participates, primarily because of benefits for patients of lower-volume providers.

Community and Provider Perspectives on Molecular HIV Surveillance and Cluster Detection and Response for HIV Prevention: Qualitative Findings From King County, Washington.

ABSTRACT: Responding quickly to HIV outbreaks is one of four pillars of the U.S. Ending the HIV Epidemic (EHE) initiative. Inclusion of cluster detection and response in the fourth pillar of EHE has led to public discussion concerning bioethical implications of cluster detection and response and molecular HIV surveillance (MHS) among public health authorities, researchers, and community members. This study reports on findings from a qualitative analysis of interviews with community members and providers regarding their knowledge and perspectives of MHS. We identified five key themes: (a) context matters, (b) making sense of MHS, (c) messaging, equity, and resource prioritization, (d) operationalizing confidentiality, and (e) stigma, vulnerability, and power. Inclusion of community perspectives in generating innovative approaches that address bioethical concerns related to the use of MHS data is integral to ensure that widely accessible information about the use of these data is available to a diversity of community members and providers.

Detection and Response to an HIV Cluster: People Living Homeless and Using Drugs in Seattle, Washington.

INTRODUCTION: The HIV epidemic in King County, Washington has traditionally been highly concentrated among men who have sex with men, and incidence has gradually declined over 2 decades. In 2018, King County experienced a geographically concentrated outbreak of HIV among heterosexual people who inject drugs. METHODS: Data sources to describe the 2018 outbreak and King County's response were partner services interview data, HIV case reports, syringe service program client surveys, hospital data, and data from a rapid needs assessment of homeless individuals and people who inject drugs. In 2020, the authors examined the impact of delays in molecular sequence analyses and cluster member size thresholds, for identifying genetically similar clusters, on the timing of outbreak identification. RESULTS: In 2018, the health department identified a North Seattle cluster, growing to 30 people with related HIV infections diagnosed in 2008-2019. In total, 70% of cluster members were female, 77% were people who inject drugs, 87% were homeless, and 27% reported exchanging sex. Intervention activities included a rapid needs assessment, 2,485 HIV screening tests in a jail and other outreach settings, provision of 87,488 clean syringes in the outbreak area, and public communications. A lower cluster size threshold and more rapid receipt and analyses of data would have identified this outbreak 4-16 months earlier. CONCLUSIONS: This outbreak shows the vulnerability of people who inject drugs to HIV infection, even in areas with robust syringe service programs and declining HIV epidemics. Although molecular HIV surveillance did not identify this outbreak, it may have done so with a lower threshold for defining clusters and more rapid receipt and analyses of HIV genetic sequences.

Predictive Value of Time-Space Clusters for HIV Transmission in Washington State, 2017-2019.

BACKGROUND: Pillar 4 of the United States' End the HIV Epidemic plan is to respond quickly to HIV outbreaks, but the utility of CDC's tool for identifying HIV outbreaks through time-space cluster detection has not been evaluated. The objective of this evaluation is to quantify the ability of the CDC time-space cluster criterion to predict future HIV diagnoses and to compare it to a space-time permutation statistic implemented in SaTScan software. SETTING: Washington State from 2017 to 2019. METHODS: We applied both cluster criteria to incident HIV cases in Washington State to identify clusters. Using a repeated-measures Poisson model, we calculated a rate ratio comparing the 6 months after cluster detection with a baseline rate from 24 to 12 months before the cluster was detected. We also compared the demographics of cases within clusters with all other incident cases. RESULTS: The CDC criteria identified 17 clusters containing 192 cases in the 6 months after cluster detection, corresponding to a rate ratio of 1.25 (95% confidence interval: 0.95 to 1.65) relative to baseline. The time-space permutation statistic identified 5 clusters containing 25 cases with a rate ratio of 2.27 (95% confidence interval: 1.28 to 4.03). Individuals in clusters identified by the new criteria were more likely to be of Hispanic origin (61% vs 20%) and in rural areas (51% vs 12%). CONCLUSIONS: The space-time permutation cluster analysis is a promising tool for identification of clusters with the largest growth potential for whom interruption may prove most beneficial.

The Epidemiology of HIV Among People Born Outside the United States, 2010-2017.

OBJECTIVE: Although some studies have reported a higher incidence of HIV infection among non-US-born people than among US-born people, national data on this topic are scarce. We compared the epidemiology of HIV infection between US-born and non-US-born residents of the United States and examined the characteristics of non-US-born people with diagnosed HIV infection by region of birth (ROB). METHODS: We used a cross-sectional study design to produce national, population-based data describing HIV infection among US-born and non-US-born people. We analyzed National HIV Surveillance System data for people with HIV infection diagnosed during 2010-2017 and reported to the Centers for Disease Control and Prevention (CDC). We compared data on demographic characteristics, transmission risk category, and stage 3 infection (AIDS) classification within 3 months of HIV diagnosis, by nativity and ROB. RESULTS: During 2010-2017, 328 317 children and adult US residents were diagnosed with HIV infection and were reported to CDC: 214 973 (65.5%) were US-born, 50 301 (15.3%) were non-US-born, and 63 043 (19.2%) were missing data on country of birth. After adjusting for missing country of birth, 266 147 (81.1%) people were US-born and 62 170 (18.9%) were non-US-born. This group accounted for 15 928 of 65 645 (24.2%) HIV diagnoses among girls and women and 46 242 of 262 672 (17.6%) HIV diagnoses among boys and men. A larger percentage of non-US-born people than US-born people had stage 3 infection (AIDS) at HIV diagnosis (31.2% vs 23.9%). Among non-US-born people with HIV diagnoses, 19 876 (39.5%) resided in the South. CONCLUSIONS: Characterizing non-US-born people with HIV infection is essential for developing effective HIV interventions, particularly in areas with large immigrant populations.

Predictors of Failure to Reach Viral Suppression Within 1 Year After Human Immunodeficiency Virus Diagnosis: A Surveillance-Based Analysis.

BACKGROUND: Identifying factors associated with poor human immunodeficiency virus (HIV) care continuum outcomes in the first year after HIV diagnosis could guide care engagement efforts at the time of diagnosis. METHODS: We analyzed data from newly diagnosed persons living with HIV (PLWH) who received a partner services (PS) interview in King County, WA from January 1, 2013, to June 30, 2016. The outcome measure was failure to reach viral suppression, defined as the lack of an HIV RNA result <200 copies/mL reported to surveillance within one year after diagnosis. We constructed Kaplan-Meier curves of time to viral suppression and examined associations between viral suppression and demographic characteristics, substance use, housing status, and plan for HIV care. RESULTS: Among 549 individuals, 69 (13%) did not achieve viral suppression within 1 year. Failure to reach suppression was associated with having no plan for HIV care at the time of PS interview (n = 72; 13% of the total population; RR, 1.19; 95% CI, 1.04-1.36] and unstable housing (n = 81; 15% of the total population; [RR, 1.19; 95% CI, 1.05-1.35). Among persons with one of these two risk factors, 76% achieved viral suppression, compared with 91% of those with stable housing and a plan for care. Overall, 80% of persons who ultimately reached suppression did so by 7.3 months. CONCLUSIONS: Providing early support services to PLWH who have unstable housing or no plan for care at the time of HIV partner services interview and to those who do not reach viral suppression shortly after diagnosis could improve the HIV care continuum.

Outbreak of Human Immunodeficiency Virus Infection Among Heterosexual Persons Who Are Living Homeless and Inject Drugs - Seattle, Washington, 2018.

Although diagnoses of human immunodeficiency virus (HIV) infection among persons who inject drugs in the United States are declining, an HIV outbreak among such persons in rural Indiana demonstrated that population's vulnerability to HIV infection (1). In August 2018, Public Health-Seattle and King County (PHSKC) identified a cluster of cases of HIV infection among persons living homeless, most of whom injected drugs. Investigation identified 14 related cases diagnosed from February to mid-November 2018 among women who inject drugs and men who have sex with women (MSW) who inject drugs and their sex partners. All 14 persons were living homeless in an approximately 3-square-mile area and were part of a cluster of 23 cases diagnosed since 2008. Twenty-seven cases of HIV infection were diagnosed among women and MSW who inject drugs in King County during January 1-November 15, 2018, a 286% increase over the seven cases diagnosed in 2017. PHSKC has alerted medical and social service providers and the public about the outbreak, expanded HIV testing among persons who inject drugs or who are living homeless, and is working to increase the availability of clinical and prevention services in the geographic area of the outbreak. This outbreak highlights the vulnerability of persons who inject drugs, particularly those who also are living homeless, to outbreaks of HIV infection, even in areas with high levels of viral suppression and large syringe services programs (SSPs).

Reconciling the evaluation of co-morbidities among HIV care patients in two large data systems: the Medical Monitoring Project and CFAR Network of Integrated Clinical Systems.

The estimated burden of chronic disease among people living with HIV (PLWH) varies considerably by data source, due to differences in case definitions, analytic approaches, and underlying patient populations. We evaluated the burden of diabetes (DM) and chronic kidney disease (CKD) in two large data systems that are commonly queried to evaluate health issues affecting HIV care patients: the Medical Monitoring Project (MMP), a nationally representative sample, and the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS), a clinical cohort. In order to reconcile these two data sources, we addressed issues common to observational data, including selection bias, missing data, and development of case definitions. The overall adjusted estimated prevalence of DM and CKD in MMP was 12.7% and 7.6%, respectively, and the overall prevalence of DM and CKD in CNICS was 9.9% and 8.3%, respectively; prevalence estimates increased with age in both data sources. After reconciling the approach to analyzing MMP and CNICS data, sub-group specific prevalence estimates of DM and CKD was generally similar in both data sources. Both data sources suggest a considerable burden of disease among older adults in HIV care. MMP and CNICS can provide reliable data to monitor HIV co-morbidities in the US.

The Changing Burden of HIV Attributable to Methamphetamine Among Men Who Have Sex with Men in King County, Washington.

Methamphetamine use is a key driver of HIV transmission among men who have sex with men (MSM). We evaluated trends in incident HIV diagnosis rates among methamphetamine using and nonusing MSM and assessed the relationship between methamphetamine use and demographic, behavioral, and clinical characteristics among MSM newly diagnosed with HIV. We analyzed several sources of HIV and behavioral surveillance data to estimate incident rates of HIV diagnoses and the population attributable risk percent corresponding to methamphetamine use among MSM in King County, Washington. Missing values were recovered through multiple imputation. We report descriptive statistics and adjusted odds ratios yielded from multivariable logistic regression models. Between 2010 and 2015, the HIV diagnosis rate among methamphetamine-using MSM declined from 31.2 to 11.5 per 1000 MSM (vs. 6.4-3.9 per 1000 MSM overall), and the percent of new diagnoses attributable to methamphetamine use declined from 25% to 13%. During the same period, methamphetamine use among HIV-negative MSM remained relatively stable. Among MSM newly diagnosed with HIV, methamphetamine-using MSM were more likely to be unstably housed (24% vs. 6%), to have engaged in transactional sex (19% vs. 4%), and to have had female partners (17% vs. 10%). Methamphetamine-using MSM were less likely to be virally suppressed at 6 (31% vs. 54%) and 12 (59% vs. 73%) months following an HIV diagnosis. The declining HIV diagnosis rate among methamphetamine-using MSM is encouraging, but this subgroup continues to have considerable HIV risk and health disparities.

Tuberculosis Mortality in the United States: Epidemiology and Prevention Opportunities.

Rationale: More information on risk factors for death from tuberculosis in the United States could help reduce the tuberculosis mortality rate, which has remained steady for more than a decade.Objective: To identify risk factors for tuberculosis-related death in adults.Methods: We performed a retrospective study of 1,304 adults with tuberculosis who died before treatment completion and 1,039 frequency-matched control subjects who completed tuberculosis treatment in 2005 to 2006 in 13 states reporting 65% of U.S. tuberculosis cases. We used in-depth record abstractions and a standard algorithm to classify deaths in persons with tuberculosis as tuberculosis-related or not. We then compared these classifications to causes of death as coded in death certificates. We used multivariable logistic regression to calculate adjusted odds ratios for predictors of tuberculosis-related death among adults compared with those who completed tuberculosis treatment.Results: Of 1,304 adult deaths, 942 (72%) were tuberculosis related, 272 (21%) were not, and 90 (7%) could not be classified. Of 847 tuberculosis-related deaths with death certificates available, 378 (45%) did not list tuberculosis as a cause of death. Adjusting for known risks, we identified new risks for tuberculosis-related death during treatment: absence of pyrazinamide in the initial regimen (adjusted odds ratio, 3.4; 95% confidence interval, 1.9-6.0); immunosuppressive medications (adjusted odds ratio, 2.5; 95% confidence interval, 1.1-5.6); incomplete tuberculosis diagnostic evaluation (adjusted odds ratio, 2.2; 95% confidence interval, 1.5-3.3), and an alternative nontuberculosis diagnosis before tuberculosis diagnosis (adjusted odds ratio, 1.6; 95% confidence interval, 1.2-2.2).Conclusions: Most persons who died with tuberculosis had a tuberculosis-related death. Intensive record review revealed tuberculosis as a cause of death more often than did death certificate diagnoses. New tools, such as a tuberculosis mortality risk score based on our study findings, may identify patients with tuberculosis for in-hospital interventions to prevent death.

Locating People Diagnosed With HIV for Public Health Action: Utility of HIV Case Surveillance and Other Data Sources.

INTRODUCTION: Human immunodeficiency virus (HIV) case surveillance and other health care databases are increasingly being used for public health action, which has the potential to optimize the health outcomes of people living with HIV (PLWH). However, often PLWH cannot be located based on the contact information available in these data sources. We assessed the accuracy of contact information for PLWH in HIV case surveillance and additional data sources and whether time since diagnosis was associated with accurate contact information in HIV case surveillance and successful contact. MATERIALS AND METHODS: The Case Surveillance-Based Sampling (CSBS) project was a pilot HIV surveillance system that selected a random population-based sample of people diagnosed with HIV from HIV case surveillance registries in 5 state and metropolitan areas. From November 2012 through June 2014, CSBS staff members attempted to locate and interview 1800 sampled people and used 22 data sources to search for contact information. RESULTS: Among 1063 contacted PLWH, HIV case surveillance data provided accurate telephone number, address, or HIV care facility information for 239 (22%), 412 (39%), and 827 (78%) sampled people, respectively. CSBS staff members used additional data sources, such as support services and commercial people-search databases, to locate and contact PLWH with insufficient contact information in HIV case surveillance. PLWH diagnosed <1 year ago were more likely to have accurate contact information in HIV case surveillance than were PLWH diagnosed ≥1 year ago ( P = .002), and the benefit from using additional data sources was greater for PLWH with more longstanding HIV infection ( P < .001). PRACTICE IMPLICATIONS: When HIV case surveillance cannot provide accurate contact information, health departments can prioritize searching additional data sources, especially for people with more longstanding HIV infection.

A Cluster Randomized Evaluation of a Health Department Data to Care Intervention Designed to Increase Engagement in HIV Care and Antiretroviral Use.

BACKGROUND: Many US health departments have implemented Data to Care interventions, which use HIV surveillance data to identify persons who are inadequately engaged in HIV medical care and assist them with care reengagement, but the effectiveness of this strategy is uncertain. METHODS: We conducted a stepped-wedge, cluster-randomized evaluation of a Data to Care intervention in King County, Washington, 2011 to 2014. Persons diagnosed as having HIV for at least 6 months were eligible based on 1 of 2 criteria: (1) viral load (VL) greater than 500 copies/mL and CD4 less than 350 cells/µL at the last report in the past 12 months or (2) no CD4 or VL reported to the health department for at least 12 months. The intervention included medical provider contact, patient contact, and a structured individual interview. Health department staff assisted patients with reengagement using health systems navigation, brief counseling, and referral to support services. We clustered all eligible cases in the county by the last known medical provider and randomized the order of clusters for intervention, creating contemporaneous intervention and control periods (cases in later clusters contributed person-time to the control period at the same time that cases in earlier clusters contributed person-time to the intervention period). We compared the time to viral suppression (VL <200 copies/mL) for individuals during intervention and control periods using a Cox proportional hazards model. RESULTS: We identified 997 persons (intention to treat [ITT]), 18% of whom had moved or died. Of the remaining 822 (modified ITT), 161 (20%) had an undetectable VL reported before contact and 164 (20%) completed the individual interview. The hazard ratio (HR) for time to viral suppression did not differ between the intervention and control periods in ITT (HR, 1.21 [95% confidence interval, 0.85-1.71]) or modified ITT (HR, 1.18 [95% confidence interval, 0.83-1.68]) analysis. CONCLUSIONS: The Data to Care intervention did not impact time to viral suppression.

Foreign-Born Individuals with HIV in King County, WA: A Glimpse of the Future of HIV?

To better understand country of birth-related shifts in the demography of people newly diagnosed with HIV infection, we compared demographic and clinical characteristics of foreign-born and U.S.-born residents of King County, WA diagnosed with HIV from 2006 to 2015. The proportion of cases that were foreign-born increased from 23 to 34% during this time. Most foreign-born cases were born in Africa (34%), Latin America (32%), Asia (22%), or Europe (7%). Latin Americans and Asians were similar to U.S.-born individuals by HIV risk factor and gender, while Africans were more likely to be female and less often men who have sex with men. In 2015, approximately 15% of cases presumptively newly diagnosed in King County were foreign-born individuals who self-reported a pre-immigration HIV diagnosis. Increases in foreign-born individuals previously diagnosed out of country may lead to inaccuracy in the count of new diagnoses, including an over-estimate of community-acquired HIV in King County.

Integrating HIV Surveillance and Field Services: Data Quality and Care Continuum in King County, Washington, 2010-2015.

OBJECTIVES: To assess how integration of HIV surveillance and field services might influence surveillance data and linkage to care metrics. METHODS: We used HIV surveillance and field services data from King County, Washington, to assess potential impact of misclassification of prior diagnoses on numbers of new diagnoses. The relationship between partner services and linkage to care was evaluated with multivariable log-binomial regression models. RESULTS: Of the 2842 people who entered the King County HIV Surveillance System in 2010 to 2015, 52% were newly diagnosed, 41% had a confirmed prior diagnosis in another state, and 7% had an unconfirmed prior diagnosis. Twelve percent of those classified as newly diagnosed for purposes of national HIV surveillance self-reported a prior HIV diagnosis that was unconfirmed. Partner services recipients were more likely than nonrecipients to link to care within 30 days (adjusted risk ratio [RR] = 1.10; 95% confidence interval [CI] = 1.03, 1.18) and 90 days (adjusted RR = 1.07; 95% CI = 1.01, 1.14) of diagnosis. CONCLUSIONS: Integration of HIV surveillance, partner services, and care linkage efforts may improve the accuracy of HIV surveillance data and facilitate timely linkage to care.

Projected demographic composition of the United States population of people living with diagnosed HIV.

The transformation of HIV from a fatal disease to lifelong disease has resulted in an HIV-infected population that is growing and aging, placing new and increasing demands on public programs and health services. We used National HIV Surveillance System and US census data to project the demographic composition of the population of people living with diagnosed HIV (PLWDH) in the United States through 2045. The input parameters for the projections include: (1) census projections, (2) number of people with an existing HIV diagnosis in 2013, (3) number of new HIV diagnoses in 2013, and (4) death rate within the PLWDH population in 2013. Sex-, risk group-, and race-specific projections were estimated through an adapted Leslie Matrix Model for age-structured populations. Projections for 2013-2045 suggest that the number of PLWDH in the U.S. will consistently grow, from 917,294 to 1,232,054, though the annual growth rate will slow from 1.8% to 0.8%. The number of PLWDH aged 55 years and older will increase from 232,113 to 470,221. The number of non-Hispanic (NH) African Americans/Blacks and Hispanics is projected to consistently grow, shifting the racial/ethnic composition of the US PLWDH population from 32 to 23% NH-White, 42 to 38% NH-Black, and 20-32% Hispanic between 2013 and 2045. Given current trends, the composition of the PLWDH population is projected to change considerably. Public health practitioners should anticipate large shifts in the age and racial/ethnic structure of the PLWDH population in the United States.

Emerging Regional and Racial Disparities in the Lifetime Risk of Human Immunodeficiency Virus Infection Among Men who Have Sex With Men: A Comparative Life Table Analysis in King County, WA and Mississippi.

BACKGROUND: Little is known about the lifetime risk of human immunodeficiency virus (HIV) diagnosis among US men who have sex with men (MSM), trends in risk and how risk varies between populations. METHODS: We used census and HIV surveillance data to construct life tables to estimate the cumulative risk of HIV diagnosis among cohorts of MSM born 1940 to 1994 in King County, Washington (KC) and Mississippi (MS). RESULTS: The cumulative risk of HIV diagnosis progressed in 3 phases. In phase 1, risk increased among MSM in successive cohorts born 1940 to 1964. Among men born 1955 to 1965 (the peak risk cohort), by age 55 years, 45% of white KC MSM, 65% of black KC MSM, 22% of white MS MSM, and 51% of black MS MSM had been diagnosed with HIV. In phase 2, men born 1965 to 1984, risk of diagnosis among KC MSM declined almost 60% relative to the peak risk cohort. A similar pattern of decline occurred in white MS MSM, with a somewhat smaller decline observed in black MS MSM. In phase 3, men born 1985 to 1994, the pattern of risk diverged. Among white KC MSM, black KC MSM, and white MS MSM, HIV risk increased slightly compared with men born 1975 to 1984, with 6%, 14%, and 2% diagnosed by age 27 years, respectively. Among black MS MSM born 1985 to 1994, HIV risk rose dramatically, with 35% HIV diagnosed by age 27 years. CONCLUSIONS: The lifetime risk of HIV diagnosis has substantially declined among MSM in KC and among white MSM in MS, but is rising dramatically among black MSM in MS.

Jail Booking as an Occasion for HIV Care Reengagement: A Surveillance-Based Study.

OBJECTIVES: To examine population and HIV care outcomes of people living with HIV/AIDS (PLWHA) at their first incarceration of 2014 in 2 county jails in King County, Washington. METHODS: Using HIV surveillance data linked with jail booking data, we examined demographic information, viral loads, CD4 counts, and incarceration details for the period prior to jail booking, during incarceration, and year following jail release. RESULTS: In 2014, 202 PLWHA were incarcerated, 51% of whom were virally nonsuppressed at booking. This population represented approximately 3% of all HIV-diagnosed persons and 7% of virally nonsuppressed persons in King County. Within a year of release, 62% were virally suppressed, compared with 79% of the general HIV-diagnosed population in King County. CONCLUSIONS: Incarcerated PLWHA are disproportionately virally nonsuppressed compared with nonincarcerated PLWHA up to a year after release from jail. Public Health Implications. Coordination of health information exchange between the health department and jails could enhance public health efforts to improve the HIV care continuum.

Evidence of Local HIV Transmission in the African Community of King County, Washington.

Little is known about the frequency of ongoing HIV transmission within U.S. African immigrant communities. We used HIV surveillance and partner services data to describe African-born persons newly reported with HIV infection in King County (KC), WA from 1/1/2010 to 12/31/2013. We performed phylogenetic clustering analysis of HIV-1 pol to identify putative transmission events within this population. From 2010 to 2013, 1148 KC adults were reported with HIV, including 102 (9 %) born in Africa. Forty-one African-born cases were interviewed and reported diagnosis after arrival in the U.S. Fourteen (34 %) reported ≥1 negative test prior to diagnosis, and 9 (26 %) reported ≥1 negative test after U.S. arrival. Pol genotypes were available for seven of these nine. For two of these seven, a KC case was the nearest phylogenetic neighbor; two others were infected with subtype B virus. We found substantial evidence of ongoing HIV transmission in the African community of KC.