Behavior Change Among HIV-Negative Men Who Have Sex with Men Not Using PrEP in the United States.

This study measures changes in condomless anal sex (CAS) among HIV-negative men who have sex with men (MSM) who are not taking pre-exposure prophylaxis (PrEP). It considers the 2014-2019 cycles of the American Men's Internet Survey, a serial, cross-sectional web-based survey of US cisgender MSM aged ≥ 15 years, in which ~ 10% of each year's sample is drawn from the previous year. Among those surveyed for 2 years who remained HIV-negative and off PrEP, reports of having any CAS and of CAS partner number were compared across years. We disaggregated by partner HIV status, and considered demographic predictors. The overall population saw a significant 2.2 percentage-point (pp) increase in reports of any CAS year-over-year. Sub-populations with the largest year-on-year increases were 15-24-year-olds (5.0-pp) and Hispanic respondents (5.1-pp), with interaction (young Hispanic respondents = 12.8-pp). On the relative scale, these numbers correspond to 3.2%, 7.2%, 7.3% and 18.7%, respectively. Absolute increases were concentrated among partners reported as HIV-negative. Multivariable analyses for CAS initiation found effects concentrated among Hispanic and White youth and residents of fringe counties of large metropolitan areas. CAS partner number increases were similarly predicted by Hispanic identity and young age. Although condom use remains more common than PrEP use, increasing CAS among MSM not on PrEP suggests potential new HIV transmission pathways. Concentration of increases among 18-24-year-old MSM portends future increases in the proportion of newly diagnosed HIV that occur among youth. Concentration among young Hispanic MSM will likely expand existing disparities. Although reducing barriers to PrEP remains vital, condom promotion for MSM remains a key public health practice and appears to be missing key audiences. LGBTQ+-inclusive sex education is one avenue for enhancing these efforts.

Vaccination May Be Economically and Epidemiologically Advantageous Over Frequent Screening for Gonorrhea Prevention.

BACKGROUND: Gonorrhea's rapid development of antimicrobial resistance underscores the importance of new prevention modalities. Recent evidence suggests that a serogroup B meningococcal vaccine may be partially effective against gonococcal infection. However, the viability of vaccination and the role it should play in gonorrhea prevention are an open question. METHODS: We modeled the transmission of gonorrhea over a 10-year period in a heterosexual population to find optimal patterns of year-over-year investment of a fixed budget in vaccination and screening programs. Each year, resources could be allocated to vaccinating people or enrolling them in a quarterly screening program. Stratifying by mode (vaccination vs. screening), sex (male vs. female), and enrollment venue (background screening vs. symptomatic visit), we consider 8 different ways of controlling gonorrhea. We then found the year-over-year pattern of investment among those 8 controls that most reduced the incidence of gonorrhea under different assumptions. A compartmental transmission model was parameterized from existing literature in the US context. RESULTS: Vaccinating men with recent symptomatic infection, which selected for higher sexual activity, was optimal for population-level gonorrhea control. Given a prevention budget of $3 per capita, 9.5% of infections could be averted ($299 per infection averted), decreasing gonorrhea sequelae and associated antimicrobial use by similar percentages. These results were consistent across sensitivity analyses that increased the budget, prioritized incidence or prevalence reductions in women, or lowered screening costs. Under a scenario where only screening was implemented, just 5.5% of infections were averted. CONCLUSIONS: A currently available vaccine, although only modestly effective, may be superior to frequent testing for population-level gonorrhea control.

An Interactive Modeling Tool for Projecting the Health and Direct Medical Cost Impact of Changes in the Sexually Transmitted Diseases Prevention Program Budgets.

CONTEXT: Estimating the return on investment for public health services, tailored to the state level, is critical for demonstrating their value and making resource allocation decisions. However, many health departments have limited staff capacity and expertise to conduct economic analyses in-house. PROGRAM: We developed a user-friendly, interactive Excel-based spreadsheet model that health departments can use to estimate the impact of increases or decreases in sexually transmitted infection (STI) prevention funding on the incidence and direct medical costs of chlamydia, gonorrhea, syphilis, and STI-attributable HIV infections. Users tailor results to their jurisdictions by entering the size of their population served; the number of annual STI diagnoses; their prior annual funding amount; and their anticipated new funding amount. The interface was developed using human-centered design principles, including focus groups with 15 model users to collect feedback on an earlier model version and a usability study on the prototype with 6 model users to finalize the interface. IMPLEMENTATION: The STI Prevention Allocation Consequences Estimator ("SPACE Monkey 2.0") model will be publicly available as a free downloadable tool. EVALUATION: In the usability testing of the prototype, participants provided overall positive feedback. They appreciated the clear interpretations, outcomes expressed as direct medical costs, functionalities to interact with the output and copy charts into external applications, visualization designs, and accessible information about the model's assumptions and limitations. Participants provided positive responses to a 10-item usability evaluation survey regarding their experiences with the prototype. DISCUSSION: Modeling tools that synthesize literature-based estimates and are developed with human-centered design principles have the potential to make evidence-based estimates of budget changes widely accessible to health departments.

The Cost of Operating Sexual Health Clinics During the Ending the (HIV) Epidemic Initiative in New York City.

BACKGROUND: As part of New York State's Ending the Epidemic (EtE) initiative, sexual health clinics (SHCs) in New York City invested in clinic enhancements and expanded their HIV-related services to increase access to HIV prevention interventions and treatment. The objective of this study was to estimate and describe the change in SHC operating costs related to clinic enhancements and expanded patient services implemented as part of the EtE initiative. METHODS: A comprehensive microcosting approach was used to collect retrospective cost information from SHCs, broken down by category and programmatic activity. Cost information was collected from 8 clinics across New York City during two 6-month time periods before (2015) and during (2018-2019) EtE. RESULTS: Eight SHCs reported comprehensive cost data. Costs increased by $800,000 on average per clinic during the 6-month EtE period. The cost per visit at an SHC increased by $120 on average to $381 (ranging from $302 to $464) during the EtE period. Personnel costs accounted for 69.9% of EtE costs, and HIV-related medications accounted for 8.9% of costs. Employment of social workers and patient navigators increased costs by approximately $150,000 on average per clinic. Postexposure prophylaxis was the costliest medication with average expenditures of $103,800 per clinic. CONCLUSIONS: This study demonstrates the key drivers of cost increases when offering enhanced HIV services in SHCs. Documenting the changes in resources necessary to implement these services and their costs can inform other health departments on the viability of offering enhanced HIV services within their own clinics.

Social Vulnerability and Rurality Associated With Higher Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection-Induced Seroprevalence: A Nationwide Blood Donor Study-United States, July 2020-June 2021.

BACKGROUND: Most studies on health disparities during the coronavirus disease 2019 (COVID-19) pandemic focused on reported cases and deaths, which are influenced by testing availability and access to care. This study aimed to examine severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody seroprevalence in the United States and its associations with race/ethnicity, rurality, and social vulnerability over time. METHODS: This repeated cross-sectional study used data from blood donations in 50 states and Washington, DC, from July 2020 through June 2021. Donor zip codes were matched to counties and linked with Social Vulnerability Index (SVI) and urban-rural classification. SARS-CoV-2 antibody seroprevalences induced by infection and infection-vaccination combined were estimated. Association of infection-induced seropositivity with demographics, rurality, SVI, and its 4 themes were quantified using multivariate regression models. RESULTS: Weighted seroprevalence differed significantly by race/ethnicity and rurality, and increased with increasing social vulnerability. During the study period, infection-induced seroprevalence increased from 1.6% to 27.2% and 3.7% to 20.0% in rural and urban counties, respectively, while rural counties had lower combined infection- and vaccination-induced seroprevalence (80.0% vs 88.1%) in June 2021. Infection-induced seropositivity was associated with being Hispanic, non-Hispanic Black, and living in rural or more socially vulnerable counties, after adjusting for demographic and geographic covariates. CONCLUSIONS: The findings demonstrated increasing SARS-CoV-2 seroprevalence in the United States across all geographic, demographic, and social sectors. The study illustrated disparities by race-ethnicity, rurality, and social vulnerability. The findings identified areas for targeted vaccination strategies and can inform efforts to reduce inequities and prepare for future outbreaks.

Costs Associated With Incorporation of Network Approaches Into Sexually Transmitted Disease Program Activities.

BACKGROUND: Network approaches can be used to study sociosexual partnerships and identify individuals at high risk of infection. Little is known about the cost structure of these services and their association with STD diagnoses. METHOD: We collected costs associated with using a peer network strategy to recruit men who have sex with men and transwomen of color in 4 counties in North Carolina: Guilford, Forsyth, Durham, and Wake from February through October 2019. We used a comprehensive costing approach to gather detailed retrospective information on the intervention cost, broken down by category and programmatic activity. RESULTS: The sociosexual networks collected consisted of 31 initial seeds (index cases) and 49 peers of those seeds. In peers, 5 cases of human immunodeficiency virus (HIV) and 10 cases of syphilis were identified. The cost per case (HIV or syphilis) identified was $7325. Personnel costs accounted for 80% of total expenditures, followed by laboratory expenses (12%). Personnel cost was distributed between disease intervention specialist patient navigators (51%), nonclinical (37%), and management (12%) staff. General administration was the costliest programmatic activity (37%), followed by case management and field services (37%), and study activities (11%). The estimated average cost per patient tested was $2242. CONCLUSIONS: Finding positive peer cases in nonclinical settings is costly but may be crucial for limiting the spread of sexually transmitted diseases. The cost of staff was the major driver. This study demonstrates that using a network strategy can be a cost-effective way to identify, test, and refer patients at high risk of syphilis and HIV infections to care.

Racial and Ethnic Disparities in COVID-19 Vaccination Coverage: The Contribution of Socioeconomic and Demographic Factors.

INTRODUCTION: Health disparities among racial and ethnic and socioeconomic groups are pervasive, and the COVID-19 pandemic has not been an exception. This study explores the key demographic and socioeconomic factors related to racial and ethnic disparities in COVID-19 vaccination coverage. METHODS: Using recent (January 2021-March 2021) data on adults from the U.S. Census Bureau Household Pulse Survey, a regression-based decomposition method was used to estimate how much of the observed racial and ethnic disparities in vaccination coverage could be explained by particular socioeconomic and demographic factors (i.e., age, number of children and adults in household). RESULTS: Demographics, socioeconomic factors, and experiencing economic hardship during the pandemic each explained a statistically significant portion of vaccination coverage disparities between non-Hispanic White and racial/ethnic minority individuals. The largest disparity was observed among people who identified as Hispanic or Latino, whose vaccination coverage was 8.0 (95% CI=7.1, 8.9) percentage points lower than that of their non-Hispanic White counterparts. Socioeconomic factors explained 4.8 (95% CI=4.3, 5.2) percentage points of this disparity, and economic hardship explained an additional 1.4 (95% CI=1.2, 1.6) percentage points. CONCLUSIONS: This paper identified the key factors related to racial and ethnic disparities in adult vaccination coverage. The variables that explained the largest portions of the disparities were age, education, employment, and income. The study findings can help to inform efforts to increase equitable vaccine access and engage various segments of the population to prevent the further exacerbation of COVID-19 health disparities.

Costs of Identifying Cases of Syphilis Using Rapid Syphilis Tests in Multiple Nonclinical Settings in the United States.

BACKGROUND: Outreach screening is a common strategy for detecting cases of syphilis in high-risk populations. New rapid syphilis tests allow for quicker response times and may alter the costs of detecting and treating syphilis in nonclinical settings. METHODS: Between May and October of 2017, we collected detailed retrospective cost data from 2 outreach screening programs engaging people experiencing homelessness and LGBTQ populations. Comprehensive and retrospective cost information, disaggregated by cost category, programmatic activity, and source of support, was collected during and after the testing period. RESULTS: Across all sites, rapid syphilis tests were conducted on 595 people at an average cost of $213 per person. Twenty-three cases of syphilis were confirmed and treated for an average cost of $5517 per case, ranging from $3604 at a rehabilitation facility to $13,140 at LGBTQ venues served by a mobile clinic. Personnel contributed the most to total costs (56.4%), followed by supplies (12.8%) and the use of buildings (10.4%). Expenditures by programmatic activity varied substantially across sites. CONCLUSIONS: Testing costs varied between venues, reflecting differences in the models used and intensity of services provided. Although staff costs are the major driver, buildings and supplies costs are also significant. Our findings suggest that outreach screenings using rapid syphilis tests may be a feasible and cost-effective tool for health departments when targeting known high-prevalence areas and hard-to-reach populations.

Assessment of the Cost-Effectiveness of a Brief Video Intervention for Sexually Transmitted Disease Prevention.

BACKGROUND: Cost-effective, scalable interventions are needed to address high rates of sexually transmitted diseases (STDs) in the United States. Safe in the City, a 23-minute video intervention designed for STD clinic waiting rooms, effectively reduced new infections among STD clinic clients. A cost-effectiveness analysis of this type of intervention could inform whether it should be replicated. METHODS: The cost-effectiveness of a brief video intervention was calculated under a baseline scenario in which this type of intervention was expanded to a larger patient population. Alternative scenarios included expanding the intervention over a longer period or to more clinics, including HIV prevention benefits, and operating the intervention part time. Program costs, net costs per STD case averted, and the discounted net cost of the intervention were calculated from a health sector perspective across the scenarios. Monte Carlo simulations were used to calculate 95% confidence intervals surrounding the cost-effectiveness measures. RESULTS: The net cost per case averted was $75 in the baseline scenario. The net cost of the intervention was $108,015, and most of the alternative scenarios found that the intervention was cost saving compared with usual care. CONCLUSIONS: Single session, video-based interventions can be highly cost effective when implemented at scale. Updated video-based interventions that account for the changing STD landscape in the United States could play an important role in addressing the recent increases in infections.

Increases in the Estimated Number of Reported Gonorrhea Cases Among Men Who Have Sex With Men: The Role of Testing.

The rate of reported gonorrhea among men who have sex with men has been steadily increasing in recent years, but little is known about how much changing testing practices and incidence each contribute to this trend. We report that both factors are likely contributing to the observed rate increases.

Disparities in Incidence of Human Immunodeficiency Virus Infection Among Black and White Women - United States, 2010-2016.

Incident human immunodeficiency virus (HIV) infections among adolescent females and women declined during 2010-2016, with the largest decrease (21%) occurring among black women (1). However, in 2016, although black women accounted for 13% of the U.S. female population, 60% of new HIV infections among women were in black women, indicating persisting disparities (1). CDC used the population attributable proportion (PAP) disparity measure to describe the proportional decrease in HIV infection among black and white women combined that would be realized if the group with the higher rate (blacks) had the same rate as did the group with the lower rate (whites) (2). Analyses indicated that an estimated 3,900 of 4,200 (93%) incident HIV infections among black women in 2016 would not have occurred if rates were the same for black and white women. The PAP disparity measure decreased from 0.75 in 2010 to 0.70 in 2016, suggesting that if incidence rates for black women were the same as those for white women, the annual number of incident HIV infections among black and white women would have been 75% lower in 2010 and 70% lower in 2016. Continued efforts are needed to identify and address social and structural determinants associated with HIV-related disparities to eliminate these disparities and decrease HIV incidence among black women.

Changes in Disparities in Estimated HIV Incidence Rates Among Black, Hispanic/Latino, and White Men Who Have Sex With Men (MSM) in the United States, 2010-2015.

BACKGROUND: During 2008-2015, the estimated annual HIV incidence rate in the United States decreased for each transmission risk category, except for men who have sex with men (MSM). Racial/ethnic disparities exist, with higher incidence rates for Black and Hispanic/Latino MSM. SETTING: This analysis examines changes, 2010-2015, in disparities of HIV incidence among Black, Hispanic/Latino and White MSM. METHODS: We compared results from the rate ratio, rate difference, weighted and unweighted index of disparity, and population attributable proportion. We calculated incidence rates for MSM using HIV surveillance data and published estimates of the MSM population in the United States. We generated 95% confidence intervals for each measure and used the Z statistic and associated P values to assess statistical significance. FINDINGS: Results from all but one measure, Black-to-White rate difference, indicate that racial/ethnic disparities increased during 2010-2015; not all results were statistically significant. There were statistically significant increases in the Hispanic/Latino-to-White MSM incidence rate ratio (29%, P < 0.05), weighted index of disparity with the rate for White MSM as the referent group (9%, P < 0.05), and the population attributable proportion index (10%, P < 0.05). If racial/ethnic disparities among MSM had been eliminated, a range of 55%-61% decrease in overall MSM HIV incidence would have been achieved during 2010-2015. CONCLUSIONS: A large reduction in overall annual HIV incidence among MSM can be achieved by eliminating racial/ethnic disparities among MSM. Removing social and structural causes of racial/ethnic disparities among MSM can be effective in reducing overall annual HIV incidence among MSM.

Impacts of Federal Prevention Funding on Reported Gonorrhea and Chlamydia Rates.

INTRODUCTION: The Centers for Disease Control and Prevention allocates funds annually to jurisdictions nationwide for sexually transmitted infection prevention activities. The objective of this study was to assess the effectiveness of federal sexually transmitted infection prevention funding for reducing rates of reported sexually transmitted infections. METHODS: In 2017-2018, finite distributed lag regression models were estimated to assess the impact of sexually transmitted infection prevention funding (in 2016 dollars per capita) on reported chlamydia rates from 2000 to 2016 and reported gonorrhea rates from 1981 to 2016. Including lagged funding measures allowed for assessing the impact of funding over time. Controls for state-level socioeconomic factors, such as poverty rates, were included. RESULTS: Results from the main model indicate that a 1% increase in annual funding would cumulatively decrease chlamydia and gonorrhea rates by 0.17% (p<0.10) and 0.33% (p<0.05), respectively. Results were similar when stratified by sex, with significant decreases in rates of reported chlamydia and gonorrhea in males of 0.33% and 0.34% (both p<0.05) respectively, and in rates of reported gonorrhea in females of 0.32% (p<0.05). The results were generally consistent across alternative model specifications and other robustness tests. CONCLUSIONS: The significant inverse associations between federal sexually transmitted infection prevention funding and rates of reported chlamydia and gonorrhea suggest that federally funded sexually transmitted infection prevention activities have a discernable effect on reducing the burden of sexually transmitted infections. The reported sexually transmitted infection rate in a given year depends more on prevention funding in previous years than on prevention funding in the current year, demonstrating the importance of accounting for lagged funding effects.

Short-term impact of PM2.5 on contemporaneous asthma medication use: Behavior and the value of pollution reductions.

Asthma ranks among the most costly of chronic diseases, accounting for over $50 billion annually in direct medical expenditures in the United States. At the same time, evidence has accumulated that fine particulate matter pollution can exacerbate asthma symptoms and generate substantial economic costs. To measure these costs, we use a unique nationwide panel dataset tracking asthmatic individuals' use of rescue medication and their exposure to PM2.5 (particulate matter with an aerodynamic diameter of <2.5 µm) concentration between 2012 and 2017, to estimate the causal relationship between pollution and inhaler use. Our sample consists of individuals using an asthma digital health platform, which relies on a wireless sensor to track the place and time of inhaler use events, as well as regular nonevent location and time indicators. These data provide an accurate measurement of inhaler use and allow spatially and temporally resolute assignment of pollution exposure. Using a high-frequency research design and individual fixed effects, we find that a 1 µg/m3 (12%) increase in weekly exposure to PM2.5 increases weekly inhaler use by 0.82%. We also show that there is seasonal, regional, and income-based heterogeneity in this response. Using our response prediction, and an estimate from the literature on the willingness to pay to avoid asthma symptoms, we show that a nationwide 1 µg/m3 reduction in particulate matter concentration would generate nearly $350 million annually in economic benefits.

Recent Changes in Prevention Funding to Areas With High Racial and Ethnic Disparities in Sexually Transmitted Disease Rates.

We examined changes in federal sexually transmitted disease funding allocations to areas with high racial/ethnic disparities in sexually transmitted diseases after the implementation of a funding formula in 2014. The funding formula increased prevention funding allocations to areas with high relative racial/ethnic disparities. Results were mixed for areas with high absolute disparities.