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Community Guide systematic economic reviews provide information on the cost, economic benefit, cost-benefit, and cost-effectiveness of public health interventions recommended by the Community Preventive Services Task Force on the basis of evidence of effectiveness. The number and variety of economic evaluation studies in public health have grown substantially over time, contributing to methodologic challenges that required updates to the methods for Community Guide systematic economic reviews. This paper describes these updated methods.The 9-step Community Guide economic review process includes prioritization of topic, creation of a coordination team, conceptualization of review, literature search, screening studies for inclusion, abstraction of studies, analysis of results, translation of evidence to Community Preventive Services Task Force economic findings, and dissemination of findings and evidence gaps. The methods applied in each of these steps are reported in this paper.Two published Community Guide reviews, tailored pharmacy-based interventions to improve adherence to medications for cardiovascular disease and permanent supportive housing with housing first to prevent homelessness, are used to illustrate the application of the updated methods. The Community Preventive Services Task Force reached a finding of cost-effectiveness for the first intervention and a finding of favorable cost-benefit for the second on the basis of results from the economic reviews.The updated Community Guide economic systematic review methods provide transparency and improve the reliability of estimates that are used to derive a Community Preventive Services Task Force economic finding. This may in turn augment the utility of Community Guide economic reviews for communities making decisions about allocating limited resources to effective programs.

The Community Preventive Services Task Force periodically engages in a process to identify priority topics to guide their work. This article described the process and results for selecting priority topics to guide the work of the Community Preventive Services Task Force for the period 2020-2025.The Community Preventive Services Task Force started with Healthy People 2020 topics. They solicited input on topics from partner organizations and the public. The Community Preventive Services Task Force considered information on 8 criteria for each topic. They conducted preliminary voting and applied a priori decision rules regarding the voting results. The Community Preventive Services Task Force then engaged in facilitated deliberations and took a final vote. This process occurred October 2019-June 2020.From Healthy People 2020, a total of 37 topics were selected as the starting point. The initial voting and decision rules resulted in 3 topics being determined as priorities. Community Preventive Services Task Force members considered data and information on the criteria to inform their deliberations on an additional 7 topics. A total of 9 topics were selected as the set of priorities for 2020-2025.Having a process that is routine and data-driven ensures that the selection of priorities is sound. By reviewing priority topics every 5 years, the Community Preventive Services Task Force will continue to provide relevant recommendations on community preventive services to improve the nation's health.

CDC's 2006 recommendations for human immunodeficiency virus (HIV) testing state that all persons aged 13-64 years should be screened for HIV at least once, and that persons at higher risk for HIV infection, including sexually active gay, bisexual, and other men who have sex with men (MSM), should be rescreened at least annually (1). Authors of reports published since 2006, including CDC (2), suggested that MSM, a group that is at highest risk for HIV infection, might benefit from being screened more frequently than once each year. In 2013, the U.S. Preventive Services Task Force (USPSTF) found insufficient evidence to specify an HIV rescreening interval but recommended annual screening for MSM as a reasonable approach (3). However, some HIV providers have begun to offer more frequent screening, such as once every 3 or 6 months, to some MSM. A CDC work group conducted a systematic literature review and held four expert consultations to review programmatic experience to determine whether there was sufficient evidence to change the 2006 CDC recommendation (i.e., at least annual HIV screening of MSM in clinical settings). The CDC work group concluded that the evidence remains insufficient to recommend screening more frequently than at least once each year. CDC continues to recommend that clinicians screen asymptomatic sexually active MSM at least annually. Each clinician can consider the benefits of offering more frequent screening (e.g., once every 3 or 6 months) to individual MSM at increased risk for acquiring HIV infection, weighing their patients' individual risk factors, local HIV epidemiology, and local testing policies.

Understanding geographic variation in the numbers of men who have sex with men (MSM) and persons who inject drugs (PWID) is critical to targeting and scaling up HIV prevention programs, but population size estimates are not available at generalizable sub-national levels. We analyzed 1999–2010 National Health and Nutrition Examination Survey data on persons aged 18–59 years. We estimated weighted prevalence of recent (past 12 month) male-male sex and injection drug use by urbanicity (the degree to which a geographic area is urban) and US census region and calculated population sizes. Large metro areas (population ≥1,000,000) had higher prevalence of male-male sex (central areas, 4.4 % of men; fringe areas, 2.5 %) compared with medium/small metro areas (1.4 %) and nonmetro areas (1.1 %). Injection drug use did not vary by urbanicity and neither varied by census region. Three-quarters of MSM, but only half of PWID, resided in large metro areas. Two-thirds of MSM and two-thirds of PWID resided in the South and West. Efforts to reach MSM would benefit from being focused in large metro areas, while efforts to reach PWID should be delivered more broadly. These data allow for more effective allocation of funds for prevention programs.

The Centers for Disease Control and Prevention (CDC) recommended in 2006 that sexually active gay, bisexual, and other men who have sex with men (MSM) be screened for human immunodeficiency virus (HIV) at least annually. A workgroup comprising CDC and external experts conducted a systematic review of the literature, including benefits, harms, acceptability, and feasibility of annual versus more frequent screening among MSM, to determine whether evidence was sufficient to change the current recommendation. Four consultations with managers of public and nonprofit HIV testing programs, clinics, and mathematical modeling experts were conducted to provide input on the programmatic and scientific evidence. Mathematical models predicted that more frequent than annual screening of MSM could prevent some new HIV infections and would be more cost-effective than annual screening, but this evidence was considered insufficient due to study design. Evidence supports CDC’s current recommendation that sexually active MSM be screened at least annually. However, some MSM might benefit from more frequent screening. Future research should evaluate which MSM subpopulations would benefit most from more frequent HIV screening.

Objective To describe the prevalence and association of sexual risk behaviours and viral suppression among HIV-infected adults in the United States. Design Cross-sectional analysis of weighted data from a probability sample of HIV-infected adults receiving outpatient medical care. The facility and patient response rates were 76 and 51%, respectively. Methods We analysed 2009 interview and medical record data. Sexual behaviours were self-reported in the past 12 months. Viral suppression was defined as all viral load measurements in the medical record during the past 12 months less than 200 copies/ml. Results An estimated 98 022 (24%) HIV-infected adults engaged in unprotected vaginal or anal sex; 50 953 (12%) engaged in unprotected vaginal or anal sex with at least one partner of negative or unknown HIV status; 23 933 (6%) did so while not virally suppressed. Persons who were virally suppressed were less likely than persons who were not suppressed to engage in vaginal or anal sex [prevalence ratio, 0.88; 95% confidence interval (CI), 0.82-0.93]; unprotected vaginal or anal sex (prevalence ratio, 0.85; 95% CI, 0.73-0.98); and unprotected vaginal or anal sex with a partner of negative or unknown HIV status (prevalence ratio, 0.79; 95% CI, 0.64-0.99). Conclusion The majority of HIV-infected adults receiving medical care in the U.S. did not engage in sexual risk behaviours that have the potential to transmit HIV, and of the 12% who did, approximately half were not virally suppressed. Persons who were virally suppressed were less likely than persons who were not suppressed to engage in sexual risk behaviours.

The National HIV Behavioral Surveillance system (NHBS) was designed to monitor HIV prevalence and risk factors for infection among higher-risk individuals, i.e., sexually active men who have sex with men who attend venues, injection drug users who injected in the past 12 months, and heterosexuals living in low socioeconomic urban areas. These groups were selected as priorities for behavioral surveillance since they represent the major HIV transmission routes and the populations with the highest HIV burden. NHBS contributes to the nation’s program of HIV surveillance by being the only multi-site population-based system that provides estimates on key HIV prevention measures among high-risk HIV-negative individuals, HIV-positive individuals unaware of their infection, and HIV-positive individuals aware of their infection who are in and out of care. Accurate and precise data on the behaviors in these populations are critical for tracking the epidemic, planning effective responses, and monitoring and evaluating those responses. Reports in this supplement illustrate the uses of NHBS data at the national and local level and reflect ongoing efforts to improve the system and methods. As we look to the future, behavioral surveillance remains essential for characterizing and monitoring the burden of HIV infection and sexual and behavioral risks.

We assessed factors associated with HIV care among HIV-infected men who have sex with men (MSM). We used 2008 data on MSM from the National HIV Behavioral Surveillance System (NHBS). Venue-based, time–space sampling was used to recruit and interview men in 21 U.S. cities with high AIDS prevalence. Among self-reported HIV-positive MSM, we used generalized estimating equations (clustered on city of interview) to evaluate factors associated with delayed linkage to care (care entry >3 months after diagnosis), not currently receiving care (no visit for HIV care during the 6 months before the study interview), and not being on antiretroviral therapy (ART). Among 8,153 MSM, 882 (11 %) were self-reported HIV-positive. 25 % had delayed linkage, 12 % were not currently receiving care and among those with at least one heath care visit 30 % were not on ART. In multivariate analysis, lower income and testing positive at their first HIV test were associated with delayed linkage. Age 18–29 years, and not having health insurance were associated with not currently receiving care. Among those with at least one health care visit, being age 18–39 years, having private or no health insurance, and stimulant use were associated with not being on ART. These findings can inform efforts to improve engagement in care.

Purpose To estimate lifetime risk of receiving an HIV diagnosis in the United States if existing infection rates continue. Methods We used mortality, census, and HIV surveillance data for 2010 to 2014 to calculate age-specific probabilities of an HIV diagnosis. The probabilities were applied to a hypothetical cohort of 10 million live births to estimate lifetime risk. Results Lifetime risk was 1 in 68 for males and 1 in 253 for females. Lifetime risk for men was 1 in 22 for blacks, 1 in 51 for Hispanic/Latinos, and 1 in 140 for whites; and for women was 1 in 54 for blacks, 1 in 256 for Hispanic/Latinas, and 1 in 941 for whites. By risk group, the highest risk was among men who have sex with men (1 in 6) and the lowest was among male heterosexuals (1 in 524). Most of the states with the highest lifetime risk were in the South. Conclusions The estimates highlight different risks across populations and the need for continued improvements in prevention and treatment. They can also be used to communicate the risk of HIV infection and increase public awareness of HIV.

Background: A web-based HIV behavioral surveillance system (WHBS) has potential to collect behavioral data from men who have sex with men (MSM) not reached through traditional sampling methods. Six U.S. cities conducted a WHBS pilot in 2005-2007 to determine the feasibility to conduct a behavioral surveillance project entirely on the internet. Methods: Three sampling methods of adult MSM on the internet were explored: direct marketing (DM) using banner advertisements; respondent-driven sampling (RDS) using peer recruitment; and venue-based sampling (VBS) using internet venues. Results: A total of 8,434 complete MSM surveys were obtained: 8,109 through DM, 130 through RDS, and 195 through VBS. By methods, enrollment rates ranged from 70-90%; completion rates ranged from 67-95%. DM obtained the largest proportions of racial/ethnic minority MSM (36%) and MSM 18-20 years (19%). Conclusions: Only the DM method achieved a substantial number of complete MSM surveys. Successful implementation of an internet-based systematic sampling method may be problematic, but a convenience sample of MSM using banner advertisements is feasible and may produce useful and timely behavioral information from a large number of MSM.

Several assumptions determine whether respondent-driven sampling (RDS) is an appropriate sampling method to use with a particular group, including the population being recruited must know one another as members of the group (i.e., injection drug users [IDUs] must know each other as IDUs) and be networked and that the sample size is small relative to the overall size of the group. To assess these three assumptions, we analyzed city-specific data collected using RDS through the US National HIV Behavioral Surveillance System among IDUs in 23 cities. Overall, 5% of non-seed participants reported that their recruiter was “a stranger.” 20 cities with multiple field sites had ≥1 cross-recruitment, a proxy for linked networks. Sample sizes were small in relation to the IDU population size (median = 2.3%; range: 0.6%- 8.0%). Researchers must evaluate whether these three assumptions were met to justify the basis for using RDS to sample specific populations.

Background: Internet-based sampling methods may reach men who have sex with men (MSM) who don’t attend physical venues frequented by MSM and may be at higher risk of HIV infection. Methods: Multivariate logistic regression was used to examine characteristics of adult MSM participants in 2 studies conducted in the same 5 U.S. cities: the 2003-2005 National HIV Behavioral Surveillance System (NHBS) which used sampling from physical MSM venues (e.g., bars, clubs) and the 2007 Web-based HIV Behavioral Surveillance (WHBS) pilot which used sampling through online banner advertisements. Results: Among 5024 WHBS MSM, 95% attended a physical MSM venue in the past 12 months, and 75% attended weekly. WHBS MSM who were black, aged 18-21 years, not college educated, bisexual- or heterosexual-identifying, and reported unknown HIV serostatus were less likely to have attended a physical MSM venue in the past 12 months (all p Conclusions: Many MSM recruited online also attended physical venues, but attendance varied by sub-group. Participants in WHBS and NHBS differed, and WHBS may represent a group of MSM at higher risk of HIV infection. These findings suggest that an internet-based method may be a useful supplement to NHBS.

Objectives:During the past decade, the number and proportion of reported HIV cases in the United States acquired through heterosexual contact has increased markedly. CDC employs the National HIV Behavioral Surveillance System (NHBS) to monitor risk behaviors and HIV prevalence in high-risk populations. To identify a target population for conducting NHBS among heterosexuals at increased risk for HIV (NHBS-HET), CDC designed, implemented and evaluated a pilot study.Methods:The pilot study was conducted in 25 US metropolitan statistical areas in 2006-7. We recruited men and women who reported sex with at least one opposite-sex partner during the past year for a behavioral survey and HIV test. We investigated the relationship between newly diagnosed HIV infection and individual risk behaviors, sexual network characteristics, and social-structural characteristics to arrive at a definition of a heterosexual at increased risk of HIV.Results:Of 14,750 participants in the analysis, 207 (1.4%) had newly diagnosed HIV infection. Using low socioeconomic status (SES) as a criterion for defining a heterosexual at increased risk for HIV resulted in optimal rates of HIV prevalence, specificity, sensitivity and practicality.Conclusions:Results from the NHBS pilot study underscore the key role of social factors as determinants of HIV infection risk among U.S. heterosexuals, and low SES was incorporated into the definition of a heterosexual at increased risk for HIV in NHBS-HET cycles. Future cycles of NHBS-HET will help tailor prevention programs for those populations most at risk of HIV in the US.

Background During 2003-2005, the National HIV Behavioral Surveillance System (NHBS) enrolled men who have sex with men (MSM) from 12 different venue types in 15 metropolitan areas in the United States. Our goal was to examine whether limiting NHBS enrollment venues to gay bars and dance clubs could increase efficiency without changing the overall results and conclusions. Methods We used logistic regression analysis to compare the demographic characteristics and reported HIV risk behaviors among MSM enrolled in gay bars and dance clubs with those enrolled in sex venues and those enrolled in other venues. Results Of the 11,471 eligible men included in the analysis, 6419 (56%) were enrolled at bars and clubs, 481 (4%) at sex venues, and 4571 (40%) at other venues. Compared with men enrolled at bars and clubs, men enrolled at sex venues were more likely to be older, of nonwhite race/ethnicity, bisexual, infrequent gay venue attendees, and to have 10 or more male sex partners in the past 12 months. Men enrolled at other venues were more likely to be older and less likely to use noninjecting drugs in the past 12 months. The absolute differences in these characteristics between men enrolled in bars and clubs and those enrolled in comparison venue categories were small in most instances. Conclusions Although the differences in characteristics by venue category were not large in magnitude, there was evidence that restricting NHBS enrollment to bars and clubs would affect national estimates of behavioral risk factors among MSM.

An estimated 1.2 million persons in the USA are infected with HIV, of whom approximately 20% are unaware they are infected. HIV testing and knowledge of HIV serostatus have important individual and public health benefits, including reduction of morbidity, mortality and HIV transmission. Although testing is the necessary first step to prevention, more than half of the US adult population has never been tested for HIV. However, this proportion is increasing due to revised national recommendations to make HIV testing a routine part of healthcare, expansion of testing efforts at local, state and national levels, and progress in the development and adoption of new testing technologies. In this article, we describe the essential role of HIV testing as a public health prevention strategy, examine recent advances in HIV testing technologies and testing implementation, and identify future directions for HIV testing in the USA.

Correlates of main reasons for not HIV testing, HIV testing intentions, and potential use of an over-the-counter rapid HIV test (OTCRT) among men who have sex with men who have never tested for HIV (NTMSM) are unknown.We evaluated these correlates among 946 NTMSM from 6 US cities who participated in an internet-based survey in 2007.Main reasons for not testing were low perceived risk (32.2%), structural barriers (25.1%), and fear of testing positive (18.1%). Low perceived risk was associated with having fewer unprotected anal intercourse (UAI) partners and less frequent use of the internet for HIV information; structural barriers were associated with younger age and more UAI partners; fear of testing positive was associated with black and Hispanic race/ethnicity, more UAI partners, and more frequent use of the internet for HIV information. Strong testing intentions were held by 25.9% of all NTMSM and 14.8% of those who did not test because of low perceived risk. Among NTMSM who were somewhat unlikely, somewhat likely, and very likely to test for HIV, 47.4%, 76.5%, and 85.6% would likely use an OTCRT if it was available, respectively.Among NTMSM who use the internet, main reasons for not testing for HIV vary considerably by age, race/ethnicity, UAI, and use of the internet for HIV information. To facilitate HIV testing of NTMSM, programs should expand interventions and services tailored to address this variation. If approved, OTCRT might be used by many NTMSM who might not otherwise test for HIV.

1A combined measure of risk was used, that included behaviors such as having had 5 or more sex partners, exchanged sex for money or drugs, had a male sex partner who had sex with men or injected drugs, had a sex partner who was HIV-positive, injected drugs or used crack cocaine or methamphetamines, or was treated for an STD.

The National Human Immunodeficiency Virus (HIV) Behavioral Surveillance System (NHBS) is the Centers for Disease Control and Prevention's (CDC's) newest system for measuring HIV risk behaviors among three adult populations at highest risk for HIV infection in the U.S.: men who have sex with men, injecting drug users, and heterosexuals at risk of HIV infection. The system is implemented by state and local health departments in designated metropolitan statistical areas with the highest HIV/acquired immunodeficiency syndrome (AIDS) prevalence in the U.S. Prior to implementing the behavioral surveillance survey, project sites conduct a series of formative research activities. The data collected during this preparatory phase provide contextual information about HIV risk behaviors within the study population of interest and help project sites make decisions about field operations and other logistical issues. This article describes the activities undertaken in preparation for the first round of NHBS (2003–2007) and how those activities enhanced data collection for each behavioral surveillance cycle.

Objective To identify challenges that women face 2–9 months postpartum using qualitative data gathered by the Pregnancy Risk Assessment Monitoring System (PRAMS). Methods PRAMS is an on-going population-based surveillance system that collects self-reported information on maternal behaviors and experiences before, during, and after the birth of a live infant. We analyzed free text comment data from women in 10 states who answered the PRAMS survey in 2000. Preliminary analysis included a review of the comment data to identify major themes and a demographic comparison of women who commented (n = 3,417) versus women who did not (n = 12,497). Subsequent analysis included systematic coding of the data from 324 women that commented about postpartum concerns and evaluation to ensure acceptable levels of reliability among coders. Results We identified the following major themes, listed in order of frequency: (1) need for social support, (2) breastfeeding issues, (3) lack of education about newborn care after discharge, (4) need for help with postpartum depression, (5) perceived need for extended postpartum hospital stay, and (6) need for maternal insurance coverage beyond delivery. Conclusion The themes identified indicate that new mothers want more social support and education and that some of their concerns relate to policies regarding breastfeeding and medical care. These results can be used to inform programs and policies designed to address education and continuity of postpartum care for new mothers.

Objective: To assess trends in prenatal discussions about HIV testing and prenatal HIV testing during the period 1996–2001. Methods: Using data from the Pregnancy Risk Assessment Monitoring System, a population-based postpartum survey of women, we calculated the self-reported prevalences of discussion of prenatal HIV testing and testing. Data were analyzed using SUDAAN; trends were calculated by logistic regression for states having ≥3 years of data. Results: From 1996 to 2001, significant increases in prenatal discussions about HIV testing were seen in 15 of 17 states. During the period 1996–2001, the prevalence of testing increased significantly in 7 of 8 states. In all states, there was a significant, positive relationship between having a prenatal discussion about testing and having an HIV test (odds ratios ranged from 1.7 to 4.9). Conclusions: We found statistically significant increases in discussions and testing from 1996 through 2001, consistent with guidelines emphasizing routine prenatal testing. Health care providers may have a strong influence on women’s decisions to be tested. Because current guidelines call for simplified strategies to reduce barriers to universal prenatal HIV screening, trends in prenatal HIV testing should continue to be monitored to assess the impact of these changes.

HIV behavioral surveillance in the United States is conducted among three groups: infected populations, high-risk populations, and the general population. We describe the general population component of the overall U.S. HIV behavioral surveillance program and identify priority analyses. This component comprises several data systems (ongoing, systematic, population-based surveys) through which data on risk behaviors and HIV testing are collected, analyzed, and disseminated. Multiple data systems are needed to balance differences in scope and purpose, as well as strengths and weaknesses of the sampling frames, mode of administration, and frequency of data collection. In a concentrated epidemic, such as in the United States, general population data play a small but important role in monitoring the potential spread of infection more broadly, particularly given increases in HIV transmission through heterosexual contact.

While disease surveillance for HIV/AIDS is now widely conducted in the United States, effective HIV prevention programs rely primarily on changing behavior; therefore, behavioral data are needed to inform these programs. To achieve the goal of reducing HIV infections in the U.S., the Centers for Disease Control and Prevention, in cooperation with state and local health departments, implemented the National HIV Behavioral Surveillance System (NHBS) for injecting drug users (IDUs) in 25 selected metropolitan statistical areas (MSAs) throughout the United States in 2005. The surveillance system used respondent-driven sampling (RDS), a modified chain-referral method, to recruit IDUs for a survey measuring HIV-associated drug use and sexual risk behavior. RDS can produce population estimates for specific risk behaviors and demographic characteristics. Formative assessment activities—primarily the collection of qualitative data—provided information to better understand the IDU population and implement the surveillance activities in each city. This is the first behavioral surveillance system of its kind in the U.S. that will provide local and national data on risk for HIV and other blood-borne and sexually transmitted infections among IDUs for monitoring changes in the epidemic and prevention programs.

In collaboration with the Centers for Disease Control and Prevention, participating state and local health departments, universities, and community-based organizations applied venue-based, time-space sampling methods for the first wave of National HIV Behavioral Surveillance of men who have sex with men (NHBS-MSM). Conducted in 17 metropolitan areas in the United States and Puerto Rico from November 2003 through April 2005, NHBS-MSM methods included: ( 1) formative research to learn the venues, times, and methods to recruit MSM; ( 2) monthly sampling frames of eligible venues and day-time periods that met attendance, logistical, and safety criteria; and ( 3) recruitment of participants in accordance with randomly generated venue calendars. Participants were interviewed on HIV risk and prevention behaviors, referred to care when needed, and compensated for their time. By identifying the prevalence and trends of HIV risk and prevention behaviors, NHBS-MSM data may be used at local, state, and federal levels to help obtain, direct, and evaluate HIV prevention resources for MSM.

Objective: We reviewed data from multiple sources to examine distinguishing features of the HIV epidemic among women in the South. Goal: The goal of this study was to identify HIV and sexually transmitted disease (STD) prevention research priorities in the South. Study Design: Cases of HIV/AIDS and STDs were analyzed to compare rates by region and rates in urban versus rural areas. Data from interviews of persons reported with HIV/AIDS from rural areas in 4 southern states compared social and behavioral characteristics of men versus women. Results: The South is characterized by high AIDS and STD rates. The epidemic among southern women is distinguished by the predominance of heterosexually acquired infection, the disproportionate impact on blacks, the high proportion residing in rural areas, and multiple high-risk behaviors. Conclusions: Research to identify determinants of high-risk sex and drug-using behaviors among poor, minority men and women in less urban and rural southern regions is needed.

Objectives. Our objectives were to describe the methodology of the Pregnancy Risk Assessment Monitoring System (PRAMS), examine recent response rates, determine characteristics associated with response, and track response patterns over time. Methods. PRAMS is a mixed-mode surveillance system, using mail and telephone surveys. Rates for response, contact, cooperation, and refusal were computed for 2001. Logistic regression was used to examine the relationship between maternal and infant characteristics and the likelihood of response. Response patterns from 1996 to 2001 were compared for nine states. Results. The median response rate for the 23 states in 2001 was 76% (range: 49% to 84%). Cooperation rates ranged from 86% to 97% (median 91%); contact rates ranged from 58% to 93% (median 82%). Response rates were higher for women who were older, white, married, had more education, were first-time mothers, received early prenatal care, and had a normal birthweight infant. Education level was the most consistent predictor of response, followed by marital status and maternal race. From 1996 to 2001, response to the initial mailing decreased in all states compared, but the decrease was offset by increases in mail follow-up and telephone response rates. Overall response rates remained unchanged. Conclusions. The PRAMS mail/telephone methodology is an effective means of reaching most recent mothers in the 23 states examined, but some population subgroups are more difficult to reach than others. Through more intensive follow-up efforts, PRAMS states have been able to maintain high response rates over time despite decreases in response to the initial mailing.

Background: Voluntary counseling and testing is an important strategy for HIV prevention. For optimal impact, however, clients must return for HIV test results and counseling. The goal of this study was to document the frequency of self-reported failure to return for HIV test results (FTR) and associated reasons among persons at high risk for HIV infection. Methods: Respondents were recruited at gay bars (men who have sex with men [MSM]), by street intercept (injection drug users [IDUs]), or at sexually transmitted disease clinics (high-risk heterosexuals [HRHs]) in 7 US states in 2000. Self-reported history of and reasons for FTR were evaluated. Results: FTR was commonly reported among 2241 respondents: 10% of MSM, 20% of HRHs, and 27% of IDUs reported FTR at least once. FTR was significantly (P < 0.05) more common among those with higher perceived risk of HIV infection and significantly less common among HRHs who had completed more than high school (vs. high school or General Education Development certificate) or were employed part time (vs. unemployed). About one fourth of respondents cited fear of getting test results as an important reason for FTR. Conclusion: Self-reported occurrences of FTR in our venue-recruited sample were similar to proportions of FTR previously reported from publicly funded venues. Increased pretest counseling on fear of learning HIV status and on the availability of rapid testing may help to reduce FTR.

Respondent Driven Sampling (RDS) is a novel variant of link tracing sampling that has primarily been used to estimate the characteristics of hard-to-reach groups, such as the HIV prevalence of drug users.1 ‘Seeds’ are selected by convenience from a population of interest (target population) and given coupons. Seeds then use these coupons to recruit other people, who themselves become recruiters. Recruits are given compensation, usually money, for taking part in the survey and also an incentive for recruiting others. This process continues in recruitment ‘waves’ until the survey is stopped. Estimation methods are then applied to account for the biased recruitment, for example, the presumed over-recruitment of people with more acquaintances, in an attempt to generate estimates for the underlying population. RDS has quickly become popular and relied on by major public health organisations, including the US Centers for Disease Control and Prevention and Family Health International, chiefly because it is often found to be an efficient method of recruitment in hard-to-reach groups, but also because of the availability of custom written software incorporating inference methods that are designed to generate estimates that are representative of the wider population of interest, despite the biased sampling. As demonstrated by RDS's popularity,1 there was a clear need for new methods of data collection on hard-to-reach groups. However, RDS has not been without its critics. Its reliance on the target population for recruitment introduced ethicalw1 and sampling concerns.w2 If RDS estimates are overly biased or the variance is unacceptably high, then RDS will be little more than another method of convenience sampling. If these errors can be minimised however, then RDS has the potential to become a very useful survey methodology. In this editorial we highlight that ‘RDS’ includes both data collection and statistical inference methods, discuss the limitations …

Importance Human immunodeficiency virus (HIV) transmission risk is primarily dependent on behavior (sexual and injection drug use) and HIV viral load. National goals emphasize maximizing coverage along the HIV care continuum, but the effect on HIV prevention is unknown. Objectives To estimate the rate and number of HIV transmissions attributable to persons at each of the following 5 HIV care continuum steps: HIV infected but undiagnosed, HIV diagnosed but not retained in medical care, retained in care but not prescribed antiretroviral therapy, prescribed antiretroviral therapy but not virally suppressed, and virally suppressed. Design, Setting, and Participants A multistep, static, deterministic model that combined population denominator data from the National HIV Surveillance System with detailed clinical and behavioral data from the National HIV Behavioral Surveillance System and the Medical Monitoring Project to estimate the rate and number of transmissions along the care continuum. This analysis was conducted January 2013 to June 2014. The findings reflect the HIV-infected population in the United States in 2009. Main Outcomes and Measures Estimated rate and number of HIV transmissions. Results Of the estimated 1 148 200 persons living with HIV in 2009, there were 207 600 (18.1%) who were undiagnosed, 519 414 (45.2%) were aware of their infection but not retained in care, 47 453 (4.1%) were retained in care but not prescribed ART, 82 809 (7.2%) were prescribed ART but not virally suppressed, and 290 924 (25.3%) were virally suppressed. Persons who are HIV infected but undiagnosed (18.1% of the total HIV-infected population) and persons who are HIV diagnosed but not retained in medical care (45.2% of the population) were responsible for 91.5% (30.2% and 61.3%, respectively) of the estimated 45 000 HIV transmissions in 2009. Compared with persons who are HIV infected but undiagnosed (6.6 transmissions per 100 person-years), persons who were HIV diagnosed and not retained in medical care were 19.0% (5.3 transmissions per 100 person-years) less likely to transmit HIV, and persons who were virally suppressed were 94.0% (0.4 transmissions per 100 person-years) less likely to transmit HIV. Men, those who acquired HIV via male-to-male sexual contact, and persons 35 to 44 years old were responsible for the most HIV transmissions by sex, HIV acquisition risk category, and age group, respectively. Conclusions and Relevance Sequential steps along the HIV care continuum were associated with reduced HIV transmission rates. Improvements in HIV diagnosis and retention in care, as well as reductions in sexual and drug use risk behavior, primarily for persons undiagnosed and not receiving antiretroviral therapy, would have a substantial effect on HIV transmission in the United States.

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

The goals of the National HIV/AIDS Strategy are to reduce new human immunodeficiency virus (HIV) infections, increase access to care and improve health outcomes for persons living with HIV, and reduce HIV-related health disparities. In July 2013, by presidential executive order, the HIV Care Continuum Initiative was established, focusing on accelerating federal efforts to increase HIV testing, care, and treatment. Hispanics or Latinos are disproportionately affected by HIV infection; the annual rate of HIV diagnosis among Hispanics or Latinos is approximately three times that of non-Hispanic whites. To achieve the goals of the National HIV/AIDS Strategy, and to be consistent with the HIV Care Continuum Initiative, Hispanics or Latinos living with HIV infection need improved levels of care and viral suppression. Achieving these goals calls for 85% of Hispanics or Latinos with diagnosed HIV to be linked to care, 80% to be retained in care, and the proportion with an undetectable viral load (VL) to increase 20% by 2015. Analysis of data from the National HIV Surveillance System (NHSS) and the Medical Monitoring Project (MMP) regarding progress along the HIV care continuum during 2010 for Hispanics or Latinos with diagnosed HIV infection indicated that 80.3% of HIV-diagnosed Hispanics or Latinos were linked to care, 54.4% were retained in care, 44.4% were prescribed antiretroviral therapy (ART), and 36.9% had achieved viral suppression (VL result of ≤200 copies/mL). Among Hispanic or Latino males and females, the percentages that were linked to care, were prescribed ART, and had achieved viral suppression were similar; however, the percentage retained in care was lower among males compared with females. The levels of linkage to care and viral suppression were lower among Hispanics or Latinos with HIV infection attributed to injection drug use than among those with HIV infection attributed to heterosexual or male-to-male sexual contact. These data demonstrate the need for implementation of interventions and public health strategies that increase linkage to care, retention in care, and consistent ART among Hispanics or Latinos, particularly Hispanics or Latinos who inject drugs.

Background Men who have sex with men (MSM) represent over half of new HIV infections in the United States. It is important to understand the factors associated with engaging in risky sexual behavior to develop effective prevention interventions. Binge drinking (≥5 drinks on ≥1 occasion) is the most common form of excessive alcohol consumption. This study examines the relationship between binge drinking and sexual risk behaviors among MSM who are current drinkers and who were either HIV-negative or unaware of their HIV status. Methods Using the 2011 National HIV Behavioral Surveillance system and multivariable Poisson models with robust error estimates, we assessed the association between binge drinking and sexual risk behaviors among current drinkers. Prevalence ratios (PR) and 95% confidence intervals (CI) are presented. Results Overall, 85% of MSM were current drinkers, and 59% of MSM who drank reported ≥1 episode of binge drinking in the preceding 30 days. In multivariable models, binge drinking was associated with condomless anal intercourse (CAI) at last sex with an HIV-positive or unknown status partner (receptive: PR 1.3, 95% CI 1.1–1.6; insertive: PR 1.2, 95% CI 1.0–1.4), having exchanged sex for money or drugs at last sex (PR: 1.4, 95% CI 1.1–1.7), having concurrent partners in the past year (PR: 1.1, 95% CI 1.1–1.2), and having more CAI partners in the past year (PR: 1.2, 95% CI 1.0–1.4) compared to non-binge drinkers. Conclusions Evidence-based strategies for reducing binge drinking could help reduce risky sexual behavior among MSM.

Background: Effective HIV prevention programs rely on accurate estimates of the peract risk of HIV acquisition from sexual and parenteral exposures. We updated the previous risk estimates of HIV acquisition from parenteral, vertical, and sexual exposures, and assessed the modifying effects of factors including condom use, male circumcision, and antiretroviral therapy. Methods: We conducted literature searches to identify new studies reporting data regarding per-act HIV transmission risk and modifying factors. Of the 7339 abstracts potentially related to per-act HIV transmission risk, three meta-analyses provided pooled per-act transmission risk probabilities and two studies provided data on modifying factors. Of the 8119 abstracts related to modifying factors, 15 relevant articles, including three meta-analyses, were included. We used fixed-effects inversevariance models on the logarithmic scale to obtain updated estimates of certain transmission risks using data from primary studies, and employed Poisson regression to calculate relative risks with exact 95% confidence intervals for certain modifying factors. Results: Risk of HIV transmission was greatest for blood transfusion, followed by vertical exposure, sexual exposures, and other parenteral exposures. Sexual exposure risks ranged from low for oral sex to 138 infections per 10000 exposures for receptive anal intercourse. Estimated risks of HIV acquisition from sexual exposure were attenuated by 99.2% with the dual use of condoms and antiretroviral treatment of the HIVinfected partner. Conclusion: The risk of HIV acquisition varied widely, and the estimates for receptive anal intercourse increased compared with previous estimates. The risk associated with sexualintercourse was reducedmostsubstantially bythe combineduse of condomsand antiretroviral treatment of HIV-infected partners. 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins AIDS 2014, 28:1509‐1519

Objectives. To assess the level of HIV-related risk behavior among the general US adult population, we analyzed data from the first sexual behavior questions available for states to use with the Behavioral Risk Factor Surveillance System. Methods. The Behavioral Risk Factor Surveillance System is a state-specific, population-based, random telephone survey. In 1997, 25 states collected sexual behavior data. Annual prevalence estimates for selected behaviors were calculated and examined by sociodemographic characteristics. The correlation between actual and perceived HIV risk also was determined. Results. Most (77.1%) of the respondents reported just 1 sexual partner in the past year; 26.0% reported using a condom at last intercourse. Males, persons who were younger, and Blacks were more likely to report 2 or more partners but also more likely to report using a condom at last intercourse. Only 4.1% of the respondents reported a risk factor for HIV infection; 7.7% reported that they were at medium or high risk for HIV. Actual and perceived HIV risk were positively associated. Conclusions. Most US adults do not engage in HIV-related risk behavior; those that do are more likely to report protective behavior.

The design of education and prevention strategies to stem the spread of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) in rural areas depends on having accurate patterns of risk behavior and transmission in local areas. Interviews were conducted with people in rural areas and small cities in Delaware, Florida, Georgia and South Carolina who were at least 18 years old and infected with HIV in order to describe demographic characteristics, migration patterns and risk behaviors. Interviews were conducted with 608 people. Most respondents were male (66 percent), black (63 percent of men, 85 percent of women) and had been infected through sexual contact (67 percent of men, 66 percent of women). Most (65 percent) had lived away from a rural area or small city for at least one month; of those, 71 percent had moved from an urban area. Twenty-seven percent of respondents indicated they had been infected locally. People with a history of injection drug use were less likely to have been infected locally than those who had no history of injection drug use (6 percent vs. 26 percent among men, 3 percent vs. 40 percent among women, P

Background:To monitor heterosexually acquired HIV infection, it is important to understand transmission from persons infected with HIV to their sex partners.Goal:To describe sexual behaviors of persons infected with HIV that are related to transmission.Study Design:Cross-sectional interviews were co

s r s t e v p f s In a recent article, Dr. Scott raised ethical questions bout respondent-driven sampling, or RDS (Scott, 2008). r. Scott used data he collected in Chicago, Illinois in 2005 t the time that the National HIV Behavioural Surveillance ystem amongst injecting drug users (NHBS-IDU), sponored by the Centers for Disease Control and Prevention CDC), was being conducted. He asserted that RDS invites, f not promotes, violation of federal guidelines governing he protection of human research subjects and that the RDS esign generally, and the NHBS implementation specifially, resulted in data of questionable quality. CDC places he highest priority on human subjects protection and the thics of surveillance and research. We therefore comment n Dr. Scott’s article and then describe CDC plans for the ext NHBS-IDU cycle. Because NHBS uses a standard proocol in all sites (Lansky et al., 2007), we describe operations enerally, with details about the Chicago experience where elevant. Numerous controls for the protection of participants n research and surveillance activities are fundamental spects of the RDS method (Semaan, Santibanez, Garfein, eckathorn, & DesJarlais, 2008) and many were specifically sed in NHBS-IDU. The controls described below were put n place to assure the ethical conduct of NHBS-IDU. We isagree with Dr. Scott that “RDS assigns the lion’s share f responsibility for ethical conduct. . . to the human subjects

OBJECTIVE: To describe persons with HIV infection and AIDS but with persistently negative HIV antibody enzyme immunoassay (EIA) results. DESIGN: Surveillance for persons meeting a case definition for HIV-1-seronegative AIDS. SETTING: United States and Canada. PATIENTS: A total of eight patients with seronegative AIDS identified from July 1995 through September 1997. MAIN OUTCOME MEASURES: Clinical history of HIV disease, history of HIV test results, and CD4 cell counts from medical record review; results of testing with a panel of EIA for antibodies to HIV-1, and HIV-1 p24 antigen; and viral subtype. RESULTS: Negative HIV EIA results occurred at CD4 cell counts of 0-230 x 10(6)/l, and at HIV RNA concentrations of 105,000-7,943,000 copies/ml. Using a panel of HIV EIA on sera from three patients, none of the HIV EIA detected infection with HIV-1, and signal-to-cut-off ratios were < or = 0.8 or all test kits evaluated. Sera from five patients showed weak reactivity in some HIV EIA, but were non-reactive in other HIV EIA. All patients were infected with HIV-1 subtype B. CONCLUSIONS: Rarely, results of EIA tests for antibodies to HIV-1 may be persistently negative in some HIV-1 subtype B-infected persons with AIDS. Physicians treating patients with illnesses or CD4 cell counts suggestive of HIV infection, but for whom results of HIV EIA are negative, should consider p24 antigen, nucleic acid amplification, or viral culture testing to document the presence of HIV.

We studied sexual disease transmission behaviors among patients of a county sexually transmitted disease (STD) clinic in rural North Carolina. Six hundred-sixty patients responded to a 147-item questionnaire. Among those with symptoms (N = 358), 50% of the men and 66% of the women came to the clinic a week or more after experiencing symptoms of a curable infection. Sixty-eight percent of the men and 39% of the women reported having multiple sex partners in the last 3 months. Fifty-nine percent of men and women reported never using a condom during vaginal sex with their main partner. Condom non-use was twice as likely with main partners than with casual ones. Factors independently associated with condom non-use (older age, cohabitation, non–African-American race, and social norms for risky sex) did not vary by partner type after the correlational nature of these data was taken into account. STD-related behaviors among STD clinic clients in this rural county were at least as frequent as reported for urban populations. The relative absence of anonymity in a small community may play a role in several of the behaviors.

The goals of the National HIV/AIDS Strategy are to reduce new human immunodeficiency virus (HIV) infections, increase access to care and improve health outcomes for persons living with HIV, and reduce HIV-related health disparities. Recently, by executive order, the HIV Care Continuum Initiative was established, focusing on accelerating federal efforts to increase HIV testing, care, and treatment. Blacks are the racial group most affected, comprising 44% of new infections and also 44% of all persons living with HIV infection. To achieve the goals of NHAS, and to be consistent with the HIV Care Continuum Initiative, blacks with HIV need high levels of care and viral suppression. Achieving these goals calls for 85% of blacks with diagnosed HIV to be linked to care, 80% to be retained in care, and the proportion with an undetectable viral load (VL) to increase 20% by 2015. Analysis of data from the National HIV Surveillance System (NHSS) and the Medical Monitoring Project (MMP) regarding progress along the HIV care continuum during 2010 for blacks with diagnosed HIV infection indicated that 74.9% of HIV-diagnosed blacks were linked to care, 48.0% were retained in care, 46.2% were prescribed antiretroviral therapy (ART), and 35.2% had achieved viral suppression. Black males had lower levels of care and viral suppression than black females at each step along the HIV care continuum; in addition, levels of care and viral suppression for blacks aged25 years were lower than those for blacks aged ≥25 years at each step of the continuum. These data demonstrate the need for implementation of interventions and public health strategies that increase linkage to care and consistent ART among blacks, particularly black males and black youths.

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