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To estimate trends in the proportion of sexually active U.S. adults with HIV (PWH) reporting an HIV-discordant sexual partner taking preexposure prophylaxis (PrEP) and proportion of partners taking PrEP.The Medical Monitoring Project is a complex sample survey of U.S. adults with diagnosed HIV.We used annual cross-sectional data collected during June 2015-May 2020 to estimate the annual percentage change (EAPC), overall and by selected characteristics, in reported partner PrEP use among PWH with HIV-discordant partners (N = 8707) and reported PrEP use among these partners (N = 15 844).The proportion of PWH reporting PrEP use by one or more HIV-discordant sex partner rose 19.5% annually (11.3 to 24.4%). The prevalence rose from 6.0 to 17.4% (EAPC, 25.8%) among Black PWH, 10.1 to 26.0% (EAPC, 19.5%) among Hispanic/Latino PWH, and 20.8 to 34.6% (EAPC, 16.3%) among White PWH. Among MSM with HIV, the prevalence increased from 9.6 to 32.6% (EAPC, 28.2%) among Black MSM, 16.6 to 36.0% (EAPC, 15.6%) among Hispanic/Latino MSM, and 24.9 to 44.1% (EAPC, 17.9%) among White MSM. Among HIV-discordant sex partners, the proportion reported to be taking PrEP increased 21.1% annually (7.8 to 18.8%). Reported PrEP use rose from 4.9 to 14.2% (EAPC, 29.9%) among Black partners, 6.5 to 16.8% (EAPC, 20.3%) among Hispanic/Latino partners, and 12.7 to 26.1% (EAPC, 17.0%) among White partners.One in five HIV-discordant sexual partners of PWH was reported to be taking PrEP. PrEP use rose among all examined populations, although the increases did not eliminate disparities in PrEP use.

Objectives. To assess geographic differences in reaching national targets for viral suppression, homelessness, and HIV-related stigma among people with HIV and key factors associated with these targets. Methods. We used data from the Medical Monitoring Project (2017–2020) and the National HIV Surveillance System (2019) to report estimates nationally and for 17 US jurisdictions. Results. Viral suppression (range = 55.3%–74.7%) and estimates for homelessness (range = 3.6%–11.9%) and HIV-related stigma (range for median score = 27.5–34.4) varied widely by jurisdiction. No jurisdiction met any of the national 2025 targets, except for Puerto Rico, which exceeded the target for homelessness (3.6% vs 4.6%). Viral suppression and antiretroviral therapy dose adherence were lowest, and certain social determinants of health (i.e., housing instability, HIV-related stigma, and HIV health care discrimination) were highest in Midwestern states. Conclusions. Jurisdictions have room for improvement in reaching the national 2025 targets for ending the HIV epidemic and in addressing other measures associated with adverse HIV outcomes—especially in the Midwest. Working with local partners will help jurisdictions determine a tailored approach for addressing barriers to meeting national targets. (Am J Public Health. 2022;112(7):1059–1067. https://doi.org/10.2105/AJPH.2022.306843 )

To investigate unmet needs for HIV ancillary care services by healthcare coverage type and Ryan White HIV/AIDS Program (RWHAP) assistance among adults with HIV.We analyzed data using the 2017-2019 cycles of the CDC Medical Monitoring Project, an annual, cross-sectional study designed to produce nationally representative estimates of characteristics among adults with diagnosed HIV.Unmet need was defined as needing, but not receiving, one or more HIV ancillary care services. We estimated prevalence ratios (PRs) and 95% confidence intervals (CIs) using predicted marginal means to examine associations between healthcare coverage type and unmet needs for HIV ancillary care services, adjusting for age. Associations were stratified by receipt of RWHAP assistance.Unmet needs for HIV ancillary care services were highest among uninsured persons (58.7%) and lowest among those with private insurance living with at least 400% of the federal poverty level (FPL; 21.7%). Uninsured persons who received RWHAP assistance were less likely than those who did not receive RWHAP assistance to have unmet needs for HIV clinical support services (aPR: 0.21; 95% CI: 0.16-0.28) and other medical services (aPR: 0.75; 95% CI: 0.59-0.96), but not subsistence services (aPR: 0.97; 95% CI: 0.74-1.27). Unmet needs for other medical services and subsistence services did not differ by RWHAP assistance among those with Medicaid, Medicare, or other healthcare coverage.RWHAP helped reduce some needs for uninsured persons. However, with growing socioeconomic inequities following the coronavirus disease 2019 pandemic, expanding access to needed services for all people with HIV could improve key outcomes.

Summary Background In the USA, COVID-19 vaccines became available in mid-December, 2020, with adults aged 65 years and older among the first groups prioritised for vaccination. We estimated the national-level impact of the initial phases of the US COVID-19 vaccination programme on COVID-19 cases, emergency department visits, hospital admissions, and deaths among adults aged 65 years and older. Methods We analysed population-based data reported to US federal agencies on COVID-19 cases, emergency department visits, hospital admissions, and deaths among adults aged 50 years and older during the period Nov 1, 2020, to April 10, 2021. We calculated the relative change in incidence among older age groups compared with a younger reference group for pre-vaccination and post-vaccination periods, defined by the week when vaccination coverage in a given age group first exceeded coverage in the reference age group by at least 1%; time lags for immune response and time to outcome were incorporated. We assessed whether the ratio of these relative changes differed when comparing the pre-vaccination and post-vaccination periods. Findings The ratio of relative changes comparing the change in the COVID-19 case incidence ratio over the post-vaccine versus pre-vaccine periods showed relative decreases of 53% (95% CI 50 to 55) and 62% (59 to 64) among adults aged 65 to 74 years and 75 years and older, respectively, compared with those aged 50 to 64 years. We found similar results for emergency department visits with relative decreases of 61% (52 to 68) for adults aged 65 to 74 years and 77% (71 to 78) for those aged 75 years and older compared with adults aged 50 to 64 years. Hospital admissions declined by 39% (29 to 48) among those aged 60 to 69 years, 60% (54 to 66) among those aged 70 to 79 years, and 68% (62 to 73), among those aged 80 years and older, compared with adults aged 50 to 59 years. COVID-19 deaths also declined (by 41%, 95% CI –14 to 69 among adults aged 65–74 years and by 30%, –47 to 66 among those aged ≥75 years, compared with adults aged 50 to 64 years), but the magnitude of the impact of vaccination roll-out on deaths was unclear. Interpretation The initial roll-out of the US COVID-19 vaccination programme was associated with reductions in COVID-19 cases, emergency department visits, and hospital admissions among older adults. Funding None.

To evaluate HIV care continuum trends over time among women with HIV (WWH).The Medical Monitoring Project (MMP) is a complex sample survey of adults with diagnosed HIV in the United States.We used 2015-2019 MMP data collected from 5139 adults with diagnosed HIV infection who identified as cisgender women. We calculated weighted percentages with 95% confidence intervals (CIs) for all characteristics and estimated annual percentage change (EAPC) and the associated 95% CI to assess trends. EAPCs were considered meaningful from a public health perspective if at least 1% with P values less than 0.05.Among cisgender women with diagnosed HIV infection during 2015-2019, 58.8% were Black or African American (95% CI 54.4-63.3), 19% were Hispanic/Latina (95% CI 14.7-23.2), and 16% were Non-Hispanic White (95% CI 14.1-17.9) persons. There was a meaningful increase in the percentage who ever had stage 3 HIV disease from 55.8% (95% CI 51.0-60.5) in 2015 to 61.5% (95% CI 58.1-64.8) in 2019 (EAPC 1.7%; CI 1.5-1.9; P 0.001). There were no meaningful changes over time among women, overall, in retention in care, antiretroviral therapy (ART) prescription, ART adherence, missed appointments, or recent or sustained viral suppression.The HIV care continuum outcomes among WWH did not meaningfully improve from 2015 to 2019, raising a concern that Ending the HIV Epidemic in the US (EHE) initiative goals will not be met. To improve health and reduce transmission of HIV among WWH, multifaceted interventions to retain women in care, increase ART adherence, and address social determinants of health are urgently needed.

Hispanic or Latino (Hispanic) persons with HIV experience disparities in HIV health outcomes compared with some other racial and ethnic groups. A previous report found that the percentages of Hispanic persons who received HIV care, were retained in care, and were virally suppressed were lower than those among non-Hispanic White persons with HIV (1). HIV stigma and discrimination are human rights issues associated with adverse HIV outcomes; eliminating stigma and discrimination among persons with HIV is a national priority*

PURPOSE: The purpose of this study was to analyze trends in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing and test positivity among persons aged

Ancillary care services are essential for supporting care engagement and viral suppression among persons with HIV. Estimating unmet needs for ancillary care services may help address care barriers and improve clinical outcomes, but recent, nationally representative estimates are lacking. Using CDC Medical Monitoring Project data from 2015–2018, we report representative estimates of unmet needs for ancillary care services and associations with HIV clinical outcomes among U.S. adults with HIV. Data were collected through interview and medical record abstraction. We described weighted percentages for all characteristics and associations with HIV clinical outcomes using prevalence ratios with predicted marginal means, adjusting for potential confounding. Substantial unmet needs were reported; unmet needs were higher among persons with social determinants of poor health, persons who engaged in drug use or binge drinking, and those who experienced depression or anxiety. Having unmet needs for care was associated with adverseHIV clinical outcomes, with a dose response effect between number of unmet needs and outcomes. Expanding ancillary care access based on a comprehensive care model, strengthening partnerships between providers to connect patients to essential services, and tailoring services based on need may help reduce disparities in unmet needs and improve outcomes.

The U.S. COVID-19 vaccination program launched on December 14, 2020. The Advisory Committee on Immunization Practices recommended prioritizing COVID-19 vaccination for specific groups of the U.S. population who were at highest risk for COVID-19 hospitalization and death, including adults aged ≥75 years*; implementation varied by state, and eligibility was gradually expanded to persons aged ≥65 years beginning in January 2021. By April 19, 2021, eligibility was expanded to all adults aged ≥18 years nationwide.† To assess patterns of COVID-19 vaccination coverage among U.S. adults, CDC analyzed data submitted on vaccinations administered during December 14, 2020-May 22, 2021, by age, sex, and community-level characteristics. By May 22, 2021, 57.0% of persons aged ≥18 years had received ≥1 COVID-19 vaccine dose; coverage was highest among persons aged ≥65 years (80.0%) and lowest among persons aged 18-29 years (38.3%). During the week beginning February 7, 2021, vaccination initiation among adults aged ≥65 years peaked at 8.2%, whereas weekly initiation among other age groups peaked later and at lower levels. During April 19-May 22, 2021, the period following expanded eligibility to all adults, weekly initiation remained

Introduction Intimate partner violence is associated with adverse health consequences among people with diagnosed HIV, which could have implications for disease progression and transmission. However, nationally representative estimates of intimate partner violence among people with diagnosed HIV are lacking. Investigators used nationally representative data to estimate the prevalence of physical violence by an intimate partner among adults with diagnosed HIV and examine the differences by selected characteristics. Methods This analysis included interview and medical record data from the 2015−2017 cycles of the Medical Monitoring Project, analyzed in 2019. Weighted percentages and 95% CIs were used to report the prevalence of intimate partner violence among people with diagnosed HIV (N=11,768). Bivariate and multivariate differences in intimate partner violence by sociodemographic, behavioral, and clinical characteristics were examined using Rao–Scott chi-square tests (p Results Among people with diagnosed HIV, 26.3% reported having ever experienced intimate partner violence, and 4.4% reported having experienced intimate partner violence in the past 12 months. The prevalence of intimate partner violence differed by gender and gender/sexual identity. People who experienced intimate partner violence in the past 12 months were more likely to engage in behaviors associated with elevated HIV transmission risk and have unmet needs for supportive services. People who recently experienced intimate partner violence were less likely to be engaged in routine HIV care but were more likely to seek emergency care services and have poor HIV clinical outcomes. Conclusions This study's findings support the need for screening people with diagnosed HIV for intimate partner violence and offering linkage to supportive services. Screening for intimate partner violence among people with diagnosed HIV, coupled with supportive services and counseling, may lead to improved safety and HIV clinical outcomes and decreased need for emergency and inpatient medical services.

Compared with other age groups, older adults (defined here as persons aged ≥65 years) are at higher risk for COVID-19-associated morbidity and mortality and have therefore been prioritized for COVID-19 vaccination (1,2). Ensuring access to vaccines for older adults has been a focus of federal, state, and local response efforts, and CDC has been monitoring vaccination coverage to identify and address disparities among subpopulations of older adults (2). Vaccine administration data submitted to CDC were analyzed to determine the prevalence of COVID-19 vaccination initiation among adults aged ≥65 years by demographic characteristics and overall. Characteristics of counties with low vaccination initiation rates were quantified using indicators of social vulnerability data from the 2019 American Community Survey.* During December 14, 2020-April 10, 2021, nationwide, a total of 42,736,710 (79.1%) older adults had initiated vaccination. The initiation rate was higher among men than among women and varied by state. On average, counties with low vaccination initiation rates (

Failure to maintain viral suppression may be attributed to suboptimal care engagement. Using data collected during 2015-2018, we describe nationally representative estimates of engagement in care among US adults with diagnosed HIV, overall and by viral suppression. Of those who felt they did not receive enough care, we described detailed information on barriers to care by viral suppression. We reported weighted percentages and evaluated differences between groups using Rao-Scott chi-square tests (p < .05). Persons who were not virally suppressed were less likely to be retained in care (57.3 vs. 90.8%). Common barriers to care included life circumstances that impeded receipt of care (50.0%), financial barriers (34.5%), and not feeling sick enough to take medicine (32.0%). Barriers to care varied by viral suppression status, and people who were not virally suppressed were more likely to report more than one barrier to care. These findings demonstrate that barriers can be multifaceted; addressing barriers to care by expanding comprehensive care models in HIV care settings could improve clinical outcomes among people with HIV.

During 2018, estimated incidence of human immunodeficiency virus (HIV) infection among Hispanic and Latino (Hispanic/Latino) persons in the United States was four times that of non-Hispanic White persons (1). Hispanic/Latino men who have sex with men (MSM) accounted for 24% (138,023) of U.S. MSM living with diagnosed HIV infection at the end of 2018 (1). Antiretroviral therapy (ART) adherence is crucial for viral suppression, which improves health outcomes and prevents HIV transmission (2). Barriers to ART adherence among Hispanic/Latino MSM have been explored in limited contexts (3); however, nationally representative analyses are lacking. The Medical Monitoring Project reports nationally representative estimates of behavioral and clinical experiences of U.S. adults with diagnosed HIV infection. This analysis used Medical Monitoring Project data collected during 2015-2019 to examine ART adherence and reasons for missing ART doses among HIV-positive Hispanic/Latino MSM (1,673). On a three-item ART adherence scale with 100 being perfect adherence, 77.3% had a score of ≥85. Younger age, poverty, recent drug use, depression, and unmet needs for ancillary services were predictors of lower ART adherence. The most common reason for missing an ART dose was forgetting; 63.9% of persons who missed ≥1 dose reported more than one reason. Interventions that support ART adherence and access to ancillary services among Hispanic/Latino MSM might help improve clinical outcomes and reduce transmission.

Comparison of social determinants of health and clinical outcomes between HIV-positive persons who inject drugs (PWID) and HIV-positive persons who do not inject drugs is essential to understanding disparities and informing HIV prevention and care efforts; however, nationally representative estimates are lacking. Interview and medical record data were collected for the Medical Monitoring Project during 2015–2018 among U.S. adults with diagnosed HIV. Among HIV-positive PWID (N=340) and HIV-positive persons who do not inject drugs (N=11,475), we reported weighted percentages and prevalence ratios with predicted marginal means to compare differences between groups (P

To evaluate whether reported prevalence of unemployment, subsistence needs, and symptoms of depression and anxiety among adults with diagnosed HIV during the COVID-19 pandemic were higher than expected.The Medical Monitoring Project (MMP) is a complex sample survey of adults with diagnosed HIV in the United States.We analyzed 2015-2019 MMP data using linear regression models to calculate expected prevalence, along with corresponding prediction intervals (PI), for unemployment, subsistence needs, depression, and anxiety for June-November 2020. We then assessed whether observed estimates fell within the expected prediction interval for each characteristic, overall and among specific groups.Overall, the observed estimate for unemployment was higher than expected (17% vs. 12%) and exceeded the upper limit of the PI. Those living in households with incomes ≥400% of FPL were the only group where the observed prevalence of depression and anxiety during the COVID-19 period was higher than the PIs; in this group, the prevalence of depression was 9% compared with a predicted value of 5% (75% higher) and the prevalence of anxiety was 11% compared with a predicted value 5% (137% higher). We did not see elevated levels of subsistence needs, although needs were higher among Black and Hispanic compared with White persons.Efforts to deliver enhanced employment assistance to persons with HIV and provide screening and access to mental health services among higher income persons may be needed to mitigate the negative effects of the US COVID-19 pandemic.

People living with HIV (PLWH) who experience homelessness have poorer clinical outcomes than people with HIV who are not homeless; however, there is limited information on PLWH who experience other forms of housing instability. We used interviews and medical record abstraction data from the Medical Monitoring Project, collected 2018-2019 (N = 4,050), to describe sociodemographic characteristics and clinical outcomes of adults with HIV by whether people experienced unstable housing in the past 12 months. Overall, 21% were unstably housed, of which 55.2% were unstably housed but not homeless. People who were unstably housed were more likely to be younger, have lower educational attainment, be previously incarcerated, live at or below the poverty level, and have poorer mental health and clinical outcomes, independent of homelessness. Interventions to address housing instability, integrated with clinical care, could benefit not just PLWH who are homeless but also those who are unstably housed.

Objective: Transgender women with diagnosed HIV experience social and structural factors that could negatively affect their overall health and HIV-related health outcomes. We describe estimates from the Centers for Disease Control and Prevention Medical Monitoring Project (MMP) of sociodemographic characteristics, HIV stigma, discrimination, and mental health outcomes among transgender women with diagnosed HIV. Methods: We analyzed pooled data of all transgender women with diagnosed HIV (N = 217) from the 2015 through 2018 MMP cycles. We reported unweighted frequencies, weighted percentages, and 95% CIs for all characteristics. We post-stratified data to known population totals by age, race and ethnicity, and sex at birth from the National HIV Surveillance System. Results: Approximately 46% of transgender women with diagnosed HIV identified as Black or African American, 67% lived at or below the federal poverty level, 18% had experienced homelessness in the past year, 26% experienced mild to severe symptoms of depression, 30% experienced mild to severe anxiety symptoms, 32% reported physical violence by an intimate partner, and 30% reported forced sex during their lifetime. Despite 80% being very satisfied with their current HIV care, 94% experienced current HIV stigma and 20% experienced health care–related discrimination since being diagnosed with HIV. Among transgender women with diagnosed HIV who experienced discrimination, 46% and 51% experienced health care discrimination attributed to their gender and sexual orientation or sexual practices, respectively. Conclusions: Our findings underscore a need to address unmet ancillary services, such as housing, intimate partner violence, and mental health needs, and the need for strategies to reduce experiences with HIV stigma and discrimination in care for transgender women with diagnosed HIV in the United States.

Understanding behavioral characteristics and health outcomes of people with HIV (PWH) who inject drugs and PWH who use drugs, but do not inject, can help inform public health interventions and improve HIV clinical outcomes. However, recent, nationally representative estimates are lacking. We used 2015–2018 Medical Monitoring Project data to examine health outcome differences among adults with diagnosed HIV who injected drugs or who only used non-injection drugs in the past year. Data were obtained from participant interviews and medical record abstraction. We reported weighted percentages and prevalence ratios with predicted marginal means to assess differences between groups (P

Disparities in vaccination coverage by social vulnerability, defined as social and structural factors associated with adverse health outcomes, were noted during the first 2.5 months of the U.S. COVID-19 vaccination campaign, which began during mid-December 2020 (1). As vaccine eligibility and availability continue to expand, assuring equitable coverage for disproportionately affected communities remains a priority. CDC examined COVID-19 vaccine administration and 2018 CDC social vulnerability index (SVI) data to ascertain whether inequities in COVID-19 vaccination coverage with respect to county-level SVI have persisted, overall and by urbanicity. Vaccination coverage was defined as the number of persons aged ≥18 years (adults) who had received ≥1 dose of any Food and Drug Administration (FDA)-authorized COVID-19 vaccine divided by the total adult population in a specified SVI category.† SVI was examined overall and by its four themes (socioeconomic status, household composition and disability, racial/ethnic minority status and language, and housing type and transportation). Counties were categorized into SVI quartiles, in which quartile 1 (Q1) represented the lowest level of vulnerability and quartile 4 (Q4), the highest. Trends in vaccination coverage were assessed by SVI quartile and urbanicity, which was categorized as large central metropolitan, large fringe metropolitan (areas surrounding large cities, e.g., suburban), medium and small metropolitan, and nonmetropolitan counties.§ During December 14, 2020-May 1, 2021, disparities in vaccination coverage by SVI increased, especially in large fringe metropolitan (e.g., suburban) and nonmetropolitan counties. By May 1, 2021, vaccination coverage was lower among adults living in counties with the highest overall SVI; differences were most pronounced in large fringe metropolitan (Q4 coverage = 45.0% versus Q1 coverage = 61.7%) and nonmetropolitan (Q4 = 40.6% versus Q1 = 52.9%) counties. Vaccination coverage disparities were largest for two SVI themes: socioeconomic status (Q4 = 44.3% versus Q1 = 61.0%) and household composition and disability (Q4 = 42.0% versus Q1 = 60.1%). Outreach efforts, including expanding public health messaging tailored to local populations and increasing vaccination access, could help increase vaccination coverage in high-SVI counties.

During 2016, 6% of persons in the United States who received a diagnosis of human immunodeficiency virus (HIV) infection had their HIV infection attributed to injection drug use (1). Injection practices and sexual behaviors among HIV-positive persons who inject drugs, such as injection equipment sharing and condomless sex, can increase HIV transmission risk; nationally representative estimates of the prevalences of these behaviors are lacking. The Medical Monitoring Project (MMP) is an annual, cross-sectional survey that reports nationally representative estimates of clinical and behavioral characteristics among U.S. adults with diagnosed HIV (2). CDC used MMP data to assess high-risk injection practices and sexual behaviors among HIV-positive persons who injected drugs during the preceding 12 months and compared their HIV transmission risk behaviors with those of HIV-positive persons who did not inject drugs. During 2015-2017, approximately 10% (weighted percentage estimate) of HIV-positive persons who injected drugs engaged in distributive injection equipment sharing (giving used equipment to another person for use); nonsterile syringe acquisition and unsafe disposal methods were common. Overall, among HIV-positive persons who injected drugs, 80% received no treatment, and 57% self-reported needing drug or alcohol treatment. Compared with HIV-positive persons who did not inject drugs, those who injected drugs were more likely to have a detectable viral load (48% versus 35%; p = 0.008) and engage in high-risk sexual behaviors (p

A syringe services program (SSP) was established following the Indiana HIV outbreak among persons who inject drugs (PWID) in Scott County. Among Indiana-based PWID, we examined injection behaviors associated with HIV status, SSP use after its establishment, and changes in injection behaviors after the outbreak response. During 2016, we interviewed 200 PWID and assessed injection behaviors before the response by HIV status. We reported injection behaviors prior to the response and used Fisher’s exact Chi square tests (P

National guidelines recommend that HIV providers systematically monitor retention in care to identify and re-engage persons suboptimally in care. We described (1) U.S.-based outpatient HIV care facilities that systematically monitor retention in care, and (2) characteristics of patients attending facilities that monitored retention in care. We used data collected during 6/2014–5/2015 from the Medical Monitoring Project, an annual, cross-sectional survey that produces nationally representative estimates of characteristics of HIV-positive persons in medical care. We described systematic monitoring of retention in care among facilities and patients attending facilities providing this service using weighted percentages and 95% confidence intervals, and used Rao-Scott chi-square tests (p < .05) to assess differences by selected characteristics. Overall, 67% of facilities systematically monitored retention in care, and 81% of patients attended these facilities. Federally qualified health centers, community-based organizations, health departments, non-private practices, and Ryan White HIV/AIDS Program (RWHAP)-funded facilities were more likely to systematically monitor retention in care. Persons living in poverty, and those who were homeless or incarcerated, or injected drugs were more likely to attend facilities with this service. Although systematic monitoring of retention in care is accessible for many patients, improvements at other, non-RWHAP-funded facilities may help in reaching national prevention goals.

HIV nucleotide sequence data can identify clusters of persons with genetically similar strains suggesting transmission. We simulated the effect of lowered data completeness, defined by the percent of persons with diagnosed HIV with a reported sequence, on transmission patterns and detection of growing HIV transmission clusters. We analyzed HIV surveillance data for persons with HIV diagnosed during 2008-2014 who resided in Michigan or Washington. We calculated genetic distances, constructed the inferred transmission network for each jurisdiction, and compared transmission network characteristics and detection of growing transmission clusters in the full dataset with artificially reduced datasets. Simulating lower levels of completeness resulted in decreased percentages of persons linked to a cluster from high completeness (full dataset) to low completeness (5%) (Michigan: 54%-18%; Washington, 46%-16%). Patterns of transmission between certain populations remained robust as data completeness level was reduced. As data completeness was artificially decreased, sensitivity of cluster detection substantially diminished in both states. In Michigan, sensitivity decreased from 100% with the full dataset, to 62% at 50% completeness and 21% at 25% completeness. In Washington, sensitivity decreased from 100% with the full dataset, to 71% at 50% completeness and 29% at 25% completeness. Lower sequence data completeness limits the ability to detect clusters that may benefit from investigation; however, inferences can be made about transmission patterns even with low data completeness, given sufficient numbers. Data completeness should be prioritized, as lack of or delays in detection of transmission clusters could result in additional infections.

BACKGROUND: Detecting recent and rapid spread of HIV can help prioritize prevention and early treatment for those at highest risk of transmission. HIV genetic sequence data can identify transmission clusters, but previous approaches have not distinguished clusters of recent, rapid transmission. We assessed an analytic approach to identify such clusters in the United States. METHODS: We analyzed 156,553 partial HIV-1 polymerase sequences reported to the National HIV Surveillance System and inferred transmission clusters using two genetic distance thresholds (0.5% and 1.5%) and two time periods for diagnoses (all years and 2013–2015, i.e., recent diagnoses). For rapidly growing clusters (with ≥5 diagnoses during 2015), molecular clock phylogenetic analysis estimated the time to most recent common ancestor for all divergence events within the cluster. Cluster transmission rates were estimated using these phylogenies. RESULTS: A distance threshold of 1.5% identified 103 rapidly growing clusters using all diagnoses and 73 using recent diagnoses; at 0.5%, 15 clusters were identified using all diagnoses and 13 using recent diagnoses. Molecular clock analysis estimated that the 13 clusters identified at 0.5% using recent diagnoses had been diversifying for a median of 4.7 years, compared with 6.5–13.2 years using other approaches. The 13 clusters at 0.5% had a transmission rate of 33/100 person-years, compared with previous national estimates of 4/100 person-years. CONCLUSIONS: Our approach identified clusters with transmission rates 8 times those of previous national estimates. This method can identify groups involved in rapid transmission and help programs effectively direct and prioritize limited public health resources.

Background and Objective Community mitigation strategies could help reduce COVID-19 incidence, but there are few studies that explore associations nationally and by urbanicity. In a national county-level analysis, we examined the probability of being identified as a county with rapidly increasing COVID-19 incidence (rapid riser identification) during the summer of 2020 by implementation of mitigation policies prior to the summer, overall and by urbanicity. Methods We analyzed county-level data on rapid riser identification during June 1–September 30, 2020 and statewide closures and statewide mask mandates starting March 19 (obtained from state government websites). Poisson regression models with robust standard error estimation were used to examine differences in the probability of rapid riser identification by implementation of mitigation policies (P-value Results Counties in states that closed for 0–59 days were more likely to become a rapid riser county than those that closed for >59 days, particularly in nonmetropolitan areas. The probability of becoming a rapid riser county was 43% lower among counties that had statewide mask mandates at reopening (adjusted prevalence ratio = 0.57; 95% confidence intervals = 0.51–0.63); when stratified by urbanicity, associations were more pronounced in nonmetropolitan areas. Conclusions These results underscore the potential value of community mitigation strategies in limiting the COVID-19 spread, especially in nonmetropolitan areas.

Data on use of and barriers to HIV ancillary care services among people who inject drugs (PWID) with HIV can inform interventions intended to improve access to care, but national estimates are lacking. We analyzed data on PWID with HIV from the CDC Medical Monitoring Project. Overall, 79% had an unmet need for ≥1 service. Services with the highest unmet need included: dental care (38%), drug/alcohol treatment (20%), transportation assistance (20%), and HIV peer group support (20%). Unmet needs for mental health services (13% vs. 23%) and HIV peer group support (15% vs. 29%) were lower among persons attending Ryan White HIV/AIDS Program (RWHAP)-funded facilities for HIV care. Barriers to care services varied by service type. Modeling components of the RWHAP structure in non-RWHAP funded facilities, including integration of support services and use of patient navigation services in the HIV medical care setting, may improve outcomes among PWID with HIV.

Poverty, crowded housing, and other community attributes associated with social vulnerability increase a community's risk for adverse health outcomes during and following a public health event (1). CDC uses standard criteria to identify U.S. counties with rapidly increasing coronavirus disease 2019 (COVID-19) incidence (hotspot counties) to support health departments in coordinating public health responses (2). County-level data on COVID-19 cases during June 1-July 25, 2020 and from the 2018 CDC social vulnerability index (SVI) were analyzed to examine associations between social vulnerability and hotspot detection and to describe incidence after hotspot detection. Areas with greater social vulnerabilities, particularly those related to higher representation of racial and ethnic minority residents (risk ratio [RR] = 5.3; 95% confidence interval [CI] = 4.4-6.4), density of housing units per structure (RR = 3.1; 95% CI = 2.7-3.6), and crowded housing units (i.e., more persons than rooms) (RR = 2.0; 95% CI = 1.8-2.3), were more likely to become hotspots, especially in less urban areas. Among hotspot counties, those with greater social vulnerability had higher COVID-19 incidence during the 14 days after detection (212-234 cases per 100,000 persons for highest SVI quartile versus 35-131 cases per 100,000 persons for other quartiles). Focused public health action at the federal, state, and local levels is needed not only to prevent communities with greater social vulnerability from becoming hotspots but also to decrease persistently high incidence among hotspot counties that are socially vulnerable.

BACKGROUND: Understanding sexual partnerships of HIV-positive persons, particularly at the dyad level, can help in quantifying HIV transmission risk. We described sexual partnerships among HIV-positive men who have sex with men (MSM), including partnerships with a high risk for sexual HIV transmission. SETTING: The Medical Monitoring Project is an annual, cross-sectional study that reports representative estimates on U.S. HIV-positive adults. METHODS: During 2015–2019, we assessed sexual behaviors by interview, and viral load results from medical records. Among sexually active HIV-positive MSM (n = 4923), we described prevalence of high-risk sex, defined as: (1) not having sustained viral suppression, and (2) having condomless sex with an HIV-negative partner not known to be taking pre-exposure prophylaxis or an HIV-unknown partner. We described sexual partnerships among HIV-positive MSM (n = 13,024 partnerships among 4923 MSM). For HIV-discordant partnerships (n = 7768), we reported the proportion involved in high-risk sex, and associations with high-risk sex using prevalence ratios with predicted marginal means, controlling for age of the HIV-positive partner (P < 0.05). RESULTS: More than half (66%) of sexually active HIV-positive MSM had condomless sex; 11% had high-risk sex. Blacks were more likely to have detectable viral loads, but less likely to have condomless sex, making prevalence of high-risk sex comparable between racial/ethnic groups. Dyad-level analyses among HIV-discordant partnerships indicated that prevalence of high-risk sex was higher among partnerships with HIV-positive white MSM, which was not observed using person-level data alone. CONCLUSIONS: In the context of ending the HIV epidemic, behavioral and clinical surveillance data can help monitor HIV transmission risk and target prevention efforts to reduce transmission among populations at disproportionate risk.

Objectives. To describe and control an outbreak of HIV infection among people who inject drugs (PWID). Methods. The investigation included people diagnosed with HIV infection during 2015 to 2018 linked to 2 cities in northeastern Massachusetts epidemiologically or through molecular analysis. Field activities included qualitative interviews regarding service availability and HIV risk behaviors. Results. We identified 129 people meeting the case definition; 116 (90%) reported injection drug use. Molecular surveillance added 36 cases to the outbreak not otherwise linked. The 2 largest molecular groups contained 56 and 23 cases. Most interviewed PWID were homeless. Control measures, including enhanced field epidemiology, syringe services programming, and community outreach, resulted in a significant decline in new HIV diagnoses. Conclusions. We illustrate difficulties with identification and characterization of an outbreak of HIV infection among a population of PWID and the value of an intensive response. Public Health Implications. Responding to and preventing outbreaks requires ongoing surveillance, with timely detection of increases in HIV diagnoses, community partnerships, and coordinated services, all critical to achieving the goal of the national Ending the HIV Epidemic initiative.

Amphetamine use is higher among men who have sex with men (MSM) compared with other men, and is associated with sexual behavior linked to HIV transmission. No national estimates of amphetamine use among MSM with HIV have been published. We used data from the Medical Monitoring Project, a nationally representative sample of persons with diagnosed HIV, to describe patterns in amphetamine use in the past 12 months among MSM during 2015–2016 (N = 3796). Prevalence of amphetamine use in this population was 9.6% (95% CI 7.6, 11.6%) in the past 12 months. MSM who used amphetamines were more likely to have condomless sex with partners without HIV or of unknown serostatus (PR 1.87; 95% CI 1.62, 2.16) and less likely to be durably virally suppressed (PR 0.81; 95% CI 0.71, 0.91). Interventions to address amphetamine use and associated transmission risk behaviors among MSM living with HIV may decrease transmission.

The Department of Health and Human Services recommends drug resistance testing at linkage to HIV care. Because receipt and timing of testing are not well characterized, we examined testing patterns among persons with diagnosed HIV who are linked to care. Using surveillance data in six jurisdictions for persons aged ≥13 years with HIV infection diagnosed in 2013, we assessed the proportion receiving testing, and among these, the proportion receiving testing at linkage. Multivariable log-binomial regression modeling estimated associations between selected characteristics and receipt of testing (1) overall, and (2) at linkage among those tested. Of 9,408 persons linked to care, 66% received resistance testing, among whom 68% received testing at linkage. Less testing was observed among male persons who inject drugs (PWID), compared with men who have sex with men (adjusted prevalence ratio [aPR]: 0.88; 95% confidence interval [CI]: 0.81–0.97) and persons living in areas with population

Zika virus is an emerging mosquito-borne flavivirus that typically causes an asymptomatic infection or mild illness, although infection during pregnancy is a cause of microcephaly and other serious brain abnormalities. Guillain-Barre syndrome and other neurologic complications can occur in adults after Zika virus infection. However, there are few published reports describing postnatally acquired Zika virus disease among children. During January 2015-July 2016, a total of 158 cases of confirmed or probable postnatally acquired Zika virus disease among children aged

BACKGROUND Engagement in care is central to reducing mortality for HIV-infected persons and achieving the White House National AIDS Strategy of 80% viral suppression in the US by 2020. Where an HIV-infected person lives impacts his or her ability to achieve viral suppression. Reliable transportation access for healthcare may be a key determinant of this place-suppression relationship. METHODS ZIP code tabulation areas (ZCTAs) were the units of analysis. We used geospatial and ecologic analyses to examine spatial distributions of neighborhood-level variables (eg, transportation accessibility) and associations with: (1) community linkage to care, and (2) community viral suppression. Among Atlanta ZCTAs with data for newly diagnosed HIV cases (2006-2010), we used Moran I to evaluate spatial clustering and linear regression models to evaluate associations between neighborhood variables and outcomes. RESULTS In 100 ZCTAs with 8413 newly diagnosed HIV-positive residents, a median of 60 HIV cases were diagnosed per ZCTA during the 5-year period. We found significant clustering of ZCTAs with low linkage to care and viral suppression (Moran I = 0.218, P < 0.05). In high-poverty ZCTAs, a 10% point increase in ZCTA-level household vehicle ownership was associated with a 4% point increase in linkage to care (P = 0.02, R = 0.16). In low-poverty ZCTAs, a 10% point increase in ZCTA-level household vehicle ownership was associated with a 30% point increase in ZCTA-level viral suppression (P = 0.01, R = 0.08). CONCLUSIONS Correlations between transportation variables and community-level care linkage and viral suppression vary by area poverty level and provide opportunities for interventions beyond individual-level factors.

We tested a couples HIV testing and counseling (CHTC) intervention with male couples in Atlanta by randomizing eligible couples to receive either CHTC or separate individual voluntary HIV counseling and testing (iVCT). To evaluate the acceptability and safety of CHTC, main outcomes were satisfaction with the intervention and the proportions of couples reporting intimate partner violence (IPV) and relationship dissolution after the service. The results indicated that the service was very acceptable to men (median 7-item index of satisfaction was 34 for CHTC and 35 for iVCT, P = .4). There was no difference in either incident IPV (22% versus 17% for CHTC and iVCT, respectively, P = .6) or relationship dissolution (42% versus 51% for CHTC and iVCT, respectively, P = .5). Based on the preliminary data, CHTC is safe for male couples, and it is equally acceptable to iVCT for men who have main partners.

CDC recommends Zika virus testing for potentially exposed persons with signs or symptoms consistent with Zika virus disease, and recommends that health care providers offer testing to asymptomatic pregnant women within 12 weeks of exposure. During January 3-March 5, 2016, Zika virus testing was performed for 4,534 persons who traveled to or moved from areas with active Zika virus transmission; 3,335 (73.6%) were pregnant women. Among persons who received testing, 1,541 (34.0%) reported at least one Zika virus-associated sign or symptom (e.g., fever, rash, arthralgia, or conjunctivitis), 436 (9.6%) reported at least one other clinical sign or symptom only, and 2,557 (56.4%) reported no signs or symptoms. Among 1,541 persons with one or more Zika virus-associated symptoms who received testing, 182 (11.8%) had confirmed Zika virus infection. Among the 2,557 asymptomatic persons who received testing, 2,425 (94.8%) were pregnant women, seven (0.3%) of whom had confirmed Zika virus infection. Although risk for Zika virus infection might vary based on exposure-related factors (e.g., location and duration of travel), in the current setting in U.S. states, where there is no local transmission, most asymptomatic pregnant women who receive testing do not have Zika virus infection.

Please cite this paper as: Bramley et al. Intensive care unit patients with 2009 pandemic influenza A (H1N1pdm09) virus infection – United States, 2009. Influenza and Other Respiratory Viruses 6(601), e134–e142. Background The influenza A (H1N1pdm09) [pH1N1] virus resulted in intensive care unit (ICU) admissions, acute respiratory distress syndrome (ARDS), and death. Objectives To describe the characteristics of ICU patients with pH1N1 virus infection in the United States during the spring and fall of 2009 and to describe the factors associated with severe complications including ARDS and death. Patients/Methods Through two national case-series conducted during spring and fall of 2009, medical charts were reviewed on ICU patients with laboratory-confirmed pH1N1 infection by real-time reverse-transcriptase polymerase chain reaction. Results The majority (77%) of 154 patients hospitalized in an ICU were

Please cite this paper as: Jhung et al. (2011) Preliminary results of 2009 pandemic influenza surveillance in the United States using the Aggregate Hospitalization and Death Reporting Activity. Influenza and Other Respiratory Viruses 5(5), 321–327. Background To augment established influenza surveillance systems in the United States, the Centers for Disease Control and Prevention and the Council of State and Territorial Epidemiologists implemented the Aggregate Hospitalization and Death Reporting Activity (AHDRA) in August 2009. The AHDRA was designed to meet increased demands for timely and detailed information describing illness severity during the 2009 H1N1 influenza A (pH1N1) pandemic response. Objectives We describe the implementation of AHDRA and provide preliminary results from this new surveillance activity. Methods All 50 US states were asked to report influenza-associated hospitalizations and deaths to AHDRA each week using either a laboratory-confirmed or syndromic surveillance definition. Aggregate counts were used to calculate age-specific weekly and cumulative rates per 100 000, and laboratory-confirmed reports were used to estimate the age distribution of pH1N1 influenza-associated hospitalizations and deaths. Results From August 30, 2009, through April 6, 2010, AHDRA identified 41 689 laboratory-confirmed influenza-associated hospitalizations and 2096 laboratory-confirmed influenza-associated deaths. Aggregate Hospitalization and Death Reporting Activity rates peaked earlier than hospitalization and death rates seen in previous influenza seasons with other surveillance systems, and the age distribution of cases revealed a tendency for hospitalizations and deaths to occur in persons

Background No existing measures of HIV care access consider both spatial proximity to services and provider-related characteristics in a single measure. We developed and applied a tool to: (1) quantify spatial access to HIV care services (supply) and (2) identify underserved areas with respect to HIV cases (demand), by travel mode, in Atlanta. Methods Building on a study of HIV care engagement, data from an HIV care provider database, and HIV case counts by zip code tabulation area (ZCTA) from AIDSVu.org, we fit a discrete choice model to estimate practice characteristics most salient in defining patient care access. Modified spatial gravity modeling quantified supply access based on discrete choice model results separately for travel by car and by public transportation. Relative access scores were calculated by ZCTA, and underserved areas (defined as having low supply access and high HIV case count) were identified for each travel mode. Results Characteristics retained in the final model included: travel distance, available provider-hours, availability of ancillary services, and whether Ryan White patients were accepted. HIV provider supply was higher in urban versus suburban/rural areas for both travel modes, with lower supply access if traveling by public transportation. Underserved areas were concentrated in south and east Atlanta if traveling by public transportation, overlapping with many areas of high poverty. Approximately 7.7 %, if traveling by car, and 64.3 %, if traveling by public transportation, of Atlanta-based persons with diagnosed HIV infection resided in underserved areas. Conclusion These findings highlight underserved areas in south and east Atlanta if traveling by public transit. Conceptualizing access to medical services spatially and by travel mode may help bridge gaps between patient needs and service availability and improve HIV outcomes. Electronic supplementary material The online version of this article (doi:10.1186/s40064-016-2515-8) contains supplementary material, which is available to authorized users.

BackgroundMen who have sex with men (MSM) in the United States are at high risk for human immunodeficiency virus (HIV) and poor HIV related outcomes. Maps can be used to identify, quantify, and address gaps in access to HIV care among HIV-positive MSM, and tailor intervention programs based on the needs of patients being served. ObjectiveThe objective of our study was to assess the usability of a Google map question embedded in a Web-based survey among Atlanta-based, HIV-positive MSM, and determine whether it is a valid and reliable alternative to collection of address-based data on residence and last HIV care provider. MethodsAtlanta-based HIV-positive MSM were recruited through Facebook and from two ongoing studies recruiting primarily through venue-based sampling or peer referral (VBPR). Participants were asked to identify the locations of their residence and last attended HIV care provider using two methods: (1) by entering the street address (gold standard), and (2) “clicking” on the locations using an embedded Google map. Home and provider addresses were geocoded, mapped, and compared with home and provider locations from clicked map points to assess validity. Provider location error values were plotted against home location error values, and a kappa statistic was computed to assess agreement in degree of error in identifying residential location versus provider location. ResultsThe median home location error across all participants was 0.65 miles (interquartile range, IQR, 0.10, 2.5 miles), and was lower among Facebook participants (P

Please cite this paper as: Jhung et al. (2011) Preliminary results of 2009 pandemic influenza surveillance in the United States using the Aggregate Hospitalization and Death Reporting Activity. Influenza and Other Respiratory Viruses 5(5), 321–327. Background To augment established influenza surveillance systems in the United States, the Centers for Disease Control and Prevention and the Council of State and Territorial Epidemiologists implemented the Aggregate Hospitalization and Death Reporting Activity (AHDRA) in August 2009. The AHDRA was designed to meet increased demands for timely and detailed information describing illness severity during the 2009 H1N1 influenza A (pH1N1) pandemic response. Objectives We describe the implementation of AHDRA and provide preliminary results from this new surveillance activity. Methods All 50 US states were asked to report influenza‐associated hospitalizations and deaths to AHDRA each week using either a laboratory‐confirmed or syndromic surveillance definition. Aggregate counts were used to calculate age‐specific weekly and cumulative rates per 100 000, and laboratory‐confirmed reports were used to estimate the age distribution of pH1N1 influenza‐associated hospitalizations and deaths. Results From August 30, 2009, through April 6, 2010, AHDRA identified 41 689 laboratory‐confirmed influenza‐associated hospitalizations and 2096 laboratory‐confirmed influenza‐associated deaths. Aggregate Hospitalization and Death Reporting Activity rates peaked earlier than hospitalization and death rates seen in previous influenza seasons with other surveillance systems, and the age distribution of cases revealed a tendency for hospitalizations and deaths to occur in persons