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.

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.

Rectal application of a highly osmolar personal lubricant in a macaque model induces acute cytotoxicity but does not increase risk of SHIV infection.

BACKGROUND: Personal lubricant use is common during anal intercourse. Some water-based products with high osmolality and low pH can damage genital and rectal tissues, and the polymer polyquaternium 15 (PQ15) can enhance HIV replication in vitro. This has raised concerns that lubricants with such properties may increase STD/HIV infection risk, although in vivo evidence is scarce. We use a macaque model to evaluate rectal cytotoxicity and SHIV infection risk after use of a highly osmolar (>8,000 mOsm/kg) water-based lubricant with pH of 4.4, and containing PQ15. METHODS: Cytotoxicity was documented by measuring inflammatory cytokines and epithelial tissue sloughing during six weeks of repeated, non-traumatic lubricant or control buffer applications to rectum and anus. We measured susceptibility to SHIVSF162P3 infection by comparing virus doses needed for rectal infection in twenty-one macaques treated with lubricant or control buffer 30 minutes prior to virus exposure. RESULTS: Lubricant increased pro-inflammatory cytokines and tissue sloughing while control buffer (phosphate buffered saline; PBS) did not. However, the estimated AID50 (50% animal infectious dose) was not different in lubricant- and control buffer-treated macaques (p = 0.4467; logistic regression models). CONCLUSIONS: Although the test lubricant caused acute cytotoxicity in rectal tissues, it did not increase susceptibility to infection in this macaque model. Thus neither the lubricant-induced type/extent of inflammation nor the presence of PQ15 affected infection risk. This study constitutes a first step in the in vivo evaluation of lubricants with regards to HIV transmission.

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

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

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

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

HIV sexual transmission risk among serodiscordant couples: assessing the effects of combining prevention strategies.

BACKGROUND: The number of strategies to prevent HIV transmission has increased following trials evaluating antiretroviral therapy (ART), preexposure prophylaxis (PrEP) and male circumcision. Serodiscordant couples need guidance on the effects of these strategies alone, and in combination with each other, on HIV transmission. METHODS: We estimated the sexual risk of HIV transmission over 1-year and 10-year periods among male-male and male-female serodiscordant couples. We assumed the following reductions in transmission: 80% from consistent condom use; 54% from circumcision in the negative male partner of a heterosexual couple; 73% from circumcision in the negative partner of a male-male couple; 71% from PrEP in heterosexual couples; 44% from PrEP in male-male couples; and 96% from ART use by the HIV-infected partner. FINDINGS: For couples using any single prevention strategy, a substantial cumulative risk of HIV transmission remained. For a male-female couple using only condoms, estimated risk over 10 years was 11%; for a male-male couple using only condoms, estimated risk was 76%. ART use by the HIV-infected partner was the most effective single strategy in reducing risk; among male-male couples, adding consistent condom use was necessary to keep the 10-year risk below 10%. CONCLUSION: Focusing on 1-year and longer term transmission probabilities gives couples a better understanding of risk than those illustrated by data for a single sexual act. Long-term transmission probabilities to the negative partner in serodiscordant couples can be high, though these can be substantially reduced with the strategic use of preventive methods, especially those that include ART.

A holistic approach to addressing HIV infection disparities in gay, bisexual, and other men who have sex with men.

Gay, bisexual, and other men who have sex with men (MSM) have been disproportionately affected by HIV and AIDS since the beginning of the epidemic in the United States and in many other parts of the world. The HIV epidemic is inextricably tied to other health problems that disproportionately affect gay, bisexual, and other MSM including psychological comorbidities, substance use, sexual victimization, stigmatization, and multiple forms of discrimination. These interrelated health problems and social issues can be characterized as a syndemic of mutually reinforcing conditions or epidemics. Moreover, the syndemic is directed by biological, behavioral, psychosocial, and structural determinants. Addressing HIV within the context of a larger syndemic will require a more holistic approach to HIV prevention and treatment that recognizes the interplay between biological, behavioral, psychosocial, and structural factors that affect the health and well-being of sexual minority men.

Estimating the impact of state budget cuts and redirection of prevention resources on the HIV epidemic in 59 California local health departments.

BACKGROUND: In the wake of a national economic downturn, the state of California, in 2009-2010, implemented budget cuts that eliminated state funding of HIV prevention and testing. To mitigate the effect of these cuts remaining federal funds were redirected. This analysis estimates the impact of these budget cuts and reallocation of resources on HIV transmission and associated HIV treatment costs. METHODS AND FINDINGS: We estimated the effect of the budget cuts and reallocation for California county health departments (excluding Los Angeles and San Francisco) on the number of individuals living with or at-risk for HIV who received HIV prevention services. We used a Bernoulli model to estimate the number of new infections that would occur each year as a result of the changes, and assigned lifetime treatment costs to those new infections. We explored the effect of redirecting federal funds to more cost-effective programs, as well as the potential effect of allocating funds proportionately by transmission category. We estimated that cutting HIV prevention resulted in 55 new infections that were associated with $20 million in lifetime treatment costs. The redirection of federal funds to more cost-effective programs averted 15 HIV infections. If HIV prevention funding were allocated proportionately to transmission categories, we estimated that HIV infections could be reduced below the number that occurred annually before the state budget cuts. CONCLUSIONS: Reducing funding for HIV prevention may result in short-term savings at the expense of additional HIV infections and increased HIV treatment costs. Existing HIV prevention funds would likely have a greater impact on the epidemic if they were allocated to the more cost-effective programs and the populations most likely to acquire and transmit the infection.

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.

Return on public health investment: CDC's Expanded HIV Testing Initiative.

BACKGROUND: Over a 3-year period, the Centers for Disease Control and Prevention invested $102.3 million in a large-scale HIV testing program, the Expanded HIV Testing Initiative for populations disproportionally affected by HIV. Policy makers, who must optimize public health given a set budget, are interested in the financial return on investment (ROI) of large-scale HIV testing. METHODS: We conducted an ROI analysis using expenditure and outcome data from the program. A health system perspective was used that included all program expenditures including medical costs of treating newly diagnosed patients. We incorporated benefits of HIV transmissions averted from persons diagnosed of their infection through the Initiative compared with when, on average, those persons would have been diagnosed without the Initiative (3 years later in the base case). HIV transmissions were derived from a published mathematical model of HIV transmission. In sensitivity analysis, we tested the effect of 1-year to 5-year alternate testing intervals and differences in the prevalence of undiagnosed HIV infection. RESULTS: Under the Initiative, 2.7 million persons were tested for HIV, there was a newly diagnosed HIV positivity rate of 0.7%, and an estimated 3381 HIV infections were averted. It achieved a return of $1.95 for every dollar invested. ROI ranged from $1.46 to $2.01 for alternative testing intervals of 1-5 years and remained above $1 (positive return on investment) with a prevalence of undiagnosed HIV infection as low as 0.12%. CONCLUSIONS: The expanded testing Initiative yielded ROI values of >$1 under a broad range of sensitivity analyses and provides further support for large-scale HIV testing programs.

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.

Estimated future HIV prevalence, incidence, and potential infections averted in the United States: a multiple scenario analysis.

OBJECTIVES: To estimate the potential future burden of HIV in the United States under different intervention scenarios. METHODS: We modeled future HIV incidence, prevalence, and infections averted using 2006 estimates of HIV incidence (55,400 new infections per year), prevalence (1,107,000 persons living with HIV), and transmission rate (5.0 per 100 persons living with HIV). We modeled 10-year trends for 3 base-case scenarios (steady incidence, steady transmission rate, declining transmission rate based on the 2000-2006 trend) and 2 intensified HIV intervention scenarios (50% reduction in transmission rate within 10 and 5 years). RESULTS: Base-case scenarios predicted HIV prevalence increases of 24%-38% in 10 years. Reducing the transmission rate by 50% within 10 years reduces incidence by 40%; prevalence increases 20% to an estimated 1,329,000 persons living with HIV. Halving the transmission rate within 5 years reduces incidence by 46%; prevalence increases 13%, to 1,247,000. Although in year 10 incidence is similar regardless of the intervention time frame, more infections are averted when halving the transmission rate within 5 years. CONCLUSIONS: HIV prevalence will likely increase creating additional demands for health care services. These analyses are instructive for setting HIV prevention goals for the nation and assessing potential cost savings of intensified HIV prevention efforts.

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.

Summary of comments and recommendations from the CDC consultation on the HIV/AIDS Epidemic and prevention in the Hispanic/Latino community.

In April 2008, the U.S. Centers for Disease Control and Prevention (CDC) hosted a national consultation meeting of academic researchers, public health officials, service providers, and community leaders to examine the HIV/AIDS epidemic and prevention needs of Hispanics/Latinos in the United States and its territories. The consultation engaged key stakeholders to review available information on HIV-related behavioral research and prevention efforts, describe gaps in current HIV prevention programs and research on Hispanics/Latinos, and identify community and societal-level factors that can increase vulnerability of Hispanics/Latinos for acquiring or transmitting HIV infection. Recommendations were also made to CDC for future collaboration with the Hispanic/Latino community in areas of HIV prevention research and prevention programs. This article summarizes participants' recommendations for HIV prevention research, program and capacity building, policy and planning, and partnerships and communication. These recommendations will be used by CDC to inform the development of a National Plan of Action for HIV/AIDS prevention among Hispanics/Latinos, and can provide a framework for use by other federal and non-federal agencies, academic researchers, community-based organizations, and policymakers as they seek to curtail the HIV epidemic among Hispanics/Latinos.

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.

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.

Prevalence of unprotected anal intercourse among HIV-diagnosed MSM in the United States: a meta-analysis.

OBJECTIVE: To integrate the empirical findings on the prevalence of unprotected anal intercourse (UAI) among HIV-diagnosed men who have sex with men (MSM) in the United States. METHODS: Comprehensively searching MEDLINE, EMBASE, PsycINFO (2000-2007), hand searching bibliographic lists, and contacting researchers. Thirty US studies (n = 18,121) met selection criteria. Analyses were conducted using random-effects models and meta-regression. RESULTS: The prevalence of UAI was considerably higher with HIV-seropositive partners (30%; 95% confidence interval 25-36) than with serostatus unknown (16%; 95% confidence interval 13-21) or HIV-seronegative partners (13%; 95% confidence interval 10-16). The prevalence of UAI with either a serostatus unknown or HIV-seronegative partner was 26%. The UAI prevalence did not differ by the length of the behavioral recall window but did vary by the type of anal intercourse (insertive vs. receptive). Studies with the following features had a lower UAI prevalence: recruiting participants before 2000, MSM of color being the majority of study sample, recruiting participants from medical settings, using random or systematic sampling methods, and having interviewers administer the questionnaire. Being on antiretroviral therapy, having an undetectable viral load, and reporting more than 90% medication adherence were not associated with UAI. CONCLUSION: Most HIV-diagnosed MSM protect partners during sexual activity, but a sizeable percentage continues to engage in sexual behaviors that place others at risk for HIV infection and place themselves at risk for other sexually transmitted infections. Prevention with positives programs continues to be urgently needed for MSM in the United States.