Prevalence and public health implications of state laws that criminalize potential HIV exposure in the United States.

For the past three decades, legislative approaches to prevent HIV transmission have been used at the national, state, and local levels. One punitive legislative approach has been enactment of laws that criminalize behaviors associated with HIV exposure (HIV-specific criminal laws). In the USA, HIV-specific criminal laws have largely been shaped by state laws. These laws impose criminal penalties on persons who know they have HIV and subsequently engage in certain behaviors, most commonly sexual activity without prior disclosure of HIV-positive serostatus. These laws have been subject to intense public debate. Using public health law research methods, data from the legal database WestlawNext© were analyzed to describe the prevalence and characteristics of laws that criminalize potential HIV exposure in the 50 states (plus the District of Columbia) and to examine the implications of these laws for public health practice. The first state laws were enacted in 1986; as of 2011 a total of 67 laws had been enacted in 33 states. By 1995, nearly two-thirds of all laws had been enacted; by 2000, 85 % of laws had been enacted; and since 2000, an additional 10 laws have been enacted. Twenty-four states require persons who are aware that they have HIV to disclose their status to sexual partners and 14 states require disclosure to needle-sharing partners. Twenty-five states criminalize one or more behaviors that pose a low or negligible risk for HIV transmission. Nearly two-thirds of states in the USA have legislation that criminalizes potential HIV exposure. Many of these laws criminalize behaviors that pose low or negligible risk for HIV transmission. The majority of laws were passed before studies showed that antiretroviral therapy (ART) reduces HIV transmission risk and most laws do not account for HIV prevention measures that reduce transmission risk, such as condom use, ART, or pre-exposure prophylaxis. States with HIV-specific criminal laws are encouraged to use the findings of this paper to re-examine those laws, assess the laws' alignment with current evidence regarding HIV transmission risk, and consider whether the laws are the best vehicle to achieve their intended purposes.

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.

HIV infection risk, behaviors, and attitudes about testing: are perceptions changing?

BACKGROUND: People at high risk for HIV infection could be increasing their risk behaviors, especially now that improved treatments for HIV infection are available. GOAL: The goal was to investigate whether risk behaviors, perceptions of personal risk for HIV infection, and attitudes toward HIV testing among high-risk persons in Oregon differed in 1996 and 1998. STUDY DESIGN: Data from the HIV Testing Survey (HITS), a cross-sectional survey administered to HIV-negative men who have sex with men (MSM), heterosexual adults at high-risk for sexually transmitted diseases (STD), and intravenous drug users (IDUs) at high risk for HIV infection in 1996 (HITS-I), were compared with data from a similar group surveyed in 1998 (HITS-II). RESULTS: Proportions of participants reporting specific risk behaviors remained relatively constant in 1996 and 1998. Personal risk of HIV infection was perceived as low by 54% of HITS-II participants and 61.2% of HITS-I participants (odds ratio [OR], 1.2; 95% confidence interval [CI], 0.9-1.7). IDUs in HITS-II were more likely than IDUs in HITS-I to perceive their risk as low (OR, 2.1; 95% CI, 1.2-3.7). CONCLUSION: Persons at high risk might underestimate their risk for HIV infection while practicing risky behaviors. The prevalence of risk behaviors in these populations could be considered the baseline against which to measure future prevention efforts.

HIV testing within at-risk populations in the United States and the reasons for seeking or avoiding HIV testing.

OBJECTIVES: We determined proportions of high-risk persons tested for HIV, the reasons for testing and not testing, and attitudes and perceptions regarding HIV testing, information that is critical for planning prevention programs. METHODS: Cross-sectional interview study of persons at high risk for HIV infection (men who have sex with men [MSM]; injection drug users [IDUs]; and heterosexual persons recruited from gay bars, street outreach, and sexually transmitted disease clinics) among six states participating in the HIV Testing Survey (HITS) in 1995 to 1996 (HITS-I) and 1998 to 1999 (HITS-II). RESULTS: Overall testing rates were lower in the HITS-I (1226/1599 [77%]) than in the HITS-II (1375/1711 [80%]) (p =.01). Persons <25 years old tested less frequently than those >or=25 years old (HITS-I: 71% vs. 78%, respectively, p=.007; HITS-II: 63% vs. 85%, respectively, p<.001). The main reasons for testing and not testing were the same in both surveys, but the proportions of reasons for not testing differed (e.g., "unlikely exposed to HIV" [HITS-I (17%) vs. HITS-II (30%), p<.0001], "afraid of finding out HIV-positive" [HITS-I (27%) vs. HITS-II (18%), p<.0001]). Attitudes regarding HIV testing differed among tested and untested respondents, especially among MSM. CONCLUSIONS: HIV testing rates were higher in the HITS-II, but testing rates decreased among the youngest respondents. Denial of HIV risk factors and fear of being HIV-positive were the principal reasons for not being tested. Availability of new HIV therapies may have contributed to decreased fear of finding out that one is HIV infected as a reason to avoid testing. The increased proportion of persons at risk who did not test because they believed they were unlikely to have been exposed highlights the need for prevention efforts to address risk perceptions.