BACKGROUND: Leading Change is one of five Executive Core Qualifications (ECQs) used in developing leaders in the federal government. Leadership development programs that incorporate multirater feedback and executive coaching are valuable in developing competencies to lead change. METHODS: We examined the extent by which coaching influenced Leading Change competencies and identified effective tools and resources used to enhance the leadership capacity of first- and midlevel leaders at Centers for Disease Control and Prevention's National Center for HIV/AIDS, Viral Hepatitis, Sexually Transmitted Diseases, and Tuberculosis Prevention. Data included qualitative data collected via semi-structured interviews that focused on leadership changes made by leaders in the Coaching and Leadership Initiative (CaLI), a leadership development program for Team Leads and Branch Chiefs. FINDINGS: Ninety-six participants completed leadership coaching; 94 (98%) of whom completed one or more interviews. Of those 94 respondents, 74 (79%) reported improvements in their ability to lead change in 3 of 4 leading change competencies: creativity and innovation, flexibility, and resilience. All respondents indicated tools and resources that were effective in leading change: 49 (52%) participated in instructor-led activities during their CaLI experience; 33 (35%) experiential activities; 94 (100%) developmental relationships, assessment, and feedback; and 25 (27%) self-development. CONCLUSIONS/APPLICATION TO PRACTICE: First- and midlevel leaders in a public health agency benefitted from using leadership coaching in developing competencies to lead organizational change. Leadership development programs might benefit from examining Leading Change competencies and including instructor-led and experiential activities as an additional component of a comprehensive leadership development program.

Homeless youth experience increased risk of contracting HIV, making HIV testing imperative in this population. We analyzed factors associated with HIV testing among homeless youth in Atlanta, Georgia using data from the 2015 Atlanta Youth Count and Needs Assessment. The analysis included 693 homeless youth aged 14-25 years, of whom 88.4% reported ever being tested for HIV, and 74.6% reported being tested within the previous year. Prevalence of ever testing for HIV was significantly higher among youth who reported risk factors for HIV (sexually active, transactional sex, or ever having an STI). Higher prevalence of testing within the last year was significantly associated with experiencing physical abuse or transactional sex. However, reporting ≥ 4 sexual partners or not using condoms were not associated with higher testing. Although testing prevalence among homeless youth was high, homeless youth engaging in certain high risk behaviors could benefit from further promotion of HIV testing.

The Centers for Disease Control and Prevention (CDC) works for a future free of HIV/AIDS, viral hepatitis, sexually transmitted diseases (STDs), and tuberculosis (TB). Policy can have powerful effects on the complex, multisectoral factors that influence the population-level morbidity, mortality, and health disparities of these and other diseases.1-4 Public health policy approaches comprise laws, regulations, incentive systems, or other standardized procedures and practices aimed at influencing institutional and individual behavior to improve health and health equity.5,6 Laws and policies that were not designed to achieve health-related objectives also can have important, albeit unintended, health effects. A systematic study of the association between policies and population health is needed to guide the development and implementation of health-promoting policy strategies that are feasible and effective and that minimize harms. This supplemental issue of Public Health Reports provides timely research on policy interventions that have the potential to reduce the incidence, morbidity, or mortality of HIV/AIDS, viral hepatitis, STDs, and TB. Furthermore, the articles in this supplement demonstrate a typology of public health law and policy research that supports vital and comprehensive examination of the evidence on which policy interventions can be based. We summarize the proposed research typology, apply it to the diversity of articles included in this supplement, and discuss future directions for this important field of research.

OBJECTIVE: Federal funds have been spent to reduce the disproportionate effects of HIV/AIDS on racial/ethnic minority groups in the United States. We investigated the association between federal domestic HIV funding and age-adjusted HIV death rates by race/ethnicity in the United States during 1999-2017. METHODS: We analyzed HIV funding data from the Kaiser Family Foundation by federal fiscal year (FFY) and US age-adjusted death rates (AADRs) by race/ethnicity (Hispanic, non-Hispanic white, non-Hispanic black, and Asian/Pacific Islander and American Indian/Alaska Native [API+AI/AN]) from Centers for Disease Control and Prevention WONDER detailed mortality files. We fit joinpoint regression models to estimate the annual percentage change (APC), average APC, and changes in AADRs per billion US dollars in HIV funding, with 95% confidence intervals (CIs). For 19 data points, the number of joinpoints ranged from 0 to 4 on the basis of rules set by the program or by the user. A Monte Carlo permutation test indicated significant (P < .05) changes at joinpoints, and 2-sided t tests indicated significant APCs in AADRs. RESULTS: Domestic HIV funding increased from $10.7 billion in FFY 1999 to $26.3 billion in FFY 2017, but AADRs decreased at different rates for each racial/ethnic group. The average rate of change in AADR per US billion dollars was -9.4% (95% CI, -10.9% to -7.8%) for Hispanic residents, -7.8% (95% CI, -9.0% to -6.6%) for non-Hispanic black residents, -6.7% (95% CI, -9.3% to -4.0%) for non-Hispanic white residents, and -5.2% (95% CI, -7.8% to -2.5%) for non-Hispanic API+AI/AN residents. CONCLUSIONS: Increased domestic HIV funding was associated with faster decreases in age-adjusted HIV death rates for Hispanic and non-Hispanic black residents than for residents in other racial/ethnic groups. Increasing US HIV funding could be associated with decreasing future racial/ethnic disparities in the rate of HIV-related deaths.

Employee turnover is a major challenge facing the federal workforce, which has lost more employees to voluntary turnover than any other form of turnover. This study determined the associations between engagement, demographic factors, and voluntary turnover intention by analyzing 2015 Federal Employee Viewpoint Survey data. The findings indicate that employees with higher engagement levels are less likely to report an intention to leave their jobs than those with lower engagement levels. All engagement factors—perceptions of supervisors, leaders, and intrinsic work experience—are independently associated with turnover intention. Demographics also influenced turnover intention; being younger, male, and in a supervisory role and having a higher education level and shorter tenure were more likely to indicate turnover intention. Increasing employee engagement can have a positive effect on retaining a productive federal workforce. To retain an effective federal workforce, human capital management practices are needed to optimize factors that reduce turnover intention.

Background: Employee engagement, exemplified by positive perceptions of supervisors, workplace, and job, improves productivity and employee retention. We identified the extent of and barriers to employee engagement at Centers for Disease Control and Prevention's (CDC) National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP). Methods: In 2015, NCHHSTP's leadership collected baseline data through a centerwide Employee Engagement Pulse Survey (EEPS) from NCHHSTP's full-time Civil Service employees, U.S. Public Health Service Commissioned Corps officers, and Title 42 service fellows. EEPS included six demographic questions; nine Likert-type scale questions measuring 26 perceptions related to immediate supervisors, the work environment, and job satisfaction; and four open-ended questions soliciting recommendations for improvement. Findings: Among 727 of 1,171 staff (response rate = 62%), positive perceptions of supervisors ranged from a high of 94% (supervisor conducts performance reviews) to a low of 63% (supervisor assists employees with career development). Perceptions of work experience ranged from 98% (respondents were willing to put in extra effort to get a job done) to 68% (respondents' talents were used well in the workplace). Perceptions of job satisfaction ranged from 87% (support from their coworkers) to 69% (satisfaction with opportunities to learn or grow professionally). Conclusion/Application to Practice: Overall, NCHHSTP staff have positive perceptions of their work, their leaders, and the agency. Other public- and private-sector employers might be able to improve their employees' engagement and retention by listening to their opinions and needs and frequently recognizing their individual achievements. NCHHSTP's workforce development initiatives can be used as a model for assessing a baseline of their employees' engagement.

A new initiative aims to reduce new infections by 75% within five years.

CONTEXT: Public health managers' leadership skills can be improved through multirater feedback and coaching. OBJECTIVE: To explore to what extent participation in a coaching intervention influences leadership behaviors of first- and second-level leaders in a federal public health agency. DESIGN: Team leads and branch chiefs in the Centers for Disease Control and Prevention's (CDC's) National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) were invited to participate in the Coaching and Leadership Initiative (CaLI), which incorporates the US Office of Personnel Management (OPM) Leadership 360 assessment, 6 coaching sessions, and 2 in-depth interviews. SETTING: NCHHSTP is one of 16 CDC national centers, institute, and offices. PARTICIPANTS: Staff serving as team leads or branch chiefs. MAIN OUTCOME MEASURES: Two in-depth interviews explored CaLI's influence on leadership behaviors regarding the government-wide Leading People executive core qualification. RESULTS: A total of 103 (93%) CaLI participants completed the OPM 360 feedback, 82 (80%) completed leadership coaching; 71 of 82 (87%) completed phase 1 interview, and 46 of 71 (65%) completed phase 2 interview. Eighty unique participants completed 1 or more interviews; all indicated that CaLI helped provide new perspectives, practices, and approaches that led to better communication and relationships, different approaches to conflict resolution, and awareness of individual leadership practices. Of the 71 participants who completed phase 1 evaluation, 66 (93%) said they made changes in developing others, 56 (79%) completed conflict management and team building, and 16 (23%) completed leveraging diversity. Of the 46 participants who completed both phase 1 and phase 2 interviews and among those who made changes post-CaLI, 23 of 26 (88%) sustained those leadership changes in developing others, 21 of 27 (78%) in team building; 24 of 34 (71%) in conflict management; and 5 of 10 (50%) in leveraging diversity. CONCLUSIONS: This study demonstrates the benefits and effectiveness of using multirater feedback and leadership coaching for first- and midlevel public health leaders.

Homelessness is a substantial barrier to consistent, recommended HIV care, access and adherence to antiretroviral therapy (ART), and sustained viral suppression, thus increasing the risk for morbidity and transmission. We used data from the Medical Monitoring Project for June 1, 2015-May 31, 2017 to estimate the weighted prevalence of homelessness among persons with diagnosed HIV (PWH) (N = 7665) overall and by selected sociodemographic, behavioral, and clinical characteristics. Prevalence of homelessness was 8.5%. PWH experiencing homelessness were > 3 times as likely to have needed and not received shelter or housing services (32% vs. 10%), > 4 times as likely to inject drugs (9% vs. 2%), and > 7 times as likely to engage in exchange sex (10% vs. 1%), respectively, compared with PWH who did not experience homelessness. Homelessness was associated with lower HIV care retention, ART dose adherence, and sustained viral suppression. This analysis demonstrates substantial need for enhanced treatment, care, and service delivery for PWH experiencing homelessness. Research has demonstrated that housing assistance programs improve HIV-related outcomes and diminish HIV risk behaviors; therefore, housing assistance for PWH should be prioritized in public health policies and practice.

BACKGROUND: Hepatitis B virus (HBV) infection can be prevented through vaccination; however previous data show that only about 24%-45% of U.S. adults at high risk of HBV infection are protected. Our aims were to assess prevalence and trends in protective levels of hepatitis B surface antibody from 2003-2014 and explore factors associated with protection among U.S. adults at high risk. METHODS: Data were from the 2003-2014 National Health and Nutrition Examination Surveys. Our sample included adults, aged 18-49 years, who were tested for HBV and reported at least one of the following infection risks: history of STD, sex with men (for male respondents), infection with HIV, and injection drug use. We calculated the prevalence of hepatitis B surface antibody (anti-HBs, >/=10mIU/mL), indicative of immunity from vaccination among respondents for three 4-year time intervals (2003-2006, 2007-2010, and 2011-2014) and applied the Cochran-Mantel-Haenszel test to assess trends. Using multivariable logistic regression, we examined factors associated with positive anti-HBs serology. RESULTS: From 2003-2014, the prevalence of positive anti-HBs serology was 23.4%. Prevalence increased from 2003-2006 (16.3%) to 2007-2010 (27.3%), but no change occurred from 2007-2010 (27.3%) to 2011-2014 (28.1%). Among factors predicting positive anti-HBs serology were young age, female sex, and higher education. CONCLUSIONS: By 2014, less than one-third of adults, aged 18-49 years, at risk of infection exhibited anti-HBs >/=10 mIU/mL indicative of protection. Because these adults account for a substantial proportion of unprotected adults, targeted intervention strategies are essential to achieve the goal of hepatitis B elimination.

BACKGROUND: HIV diagnoses among females in the United States declined 22% from 2010 to 2015, including a 27% decline in diagnoses among black females. Despite this progress, disparities persist. Black females accounted for 60% of new HIV diagnoses among females in 2015. Geographic disparities also exist. This article describes geographic differences in HIV diagnoses among black females in the United States, from 2010 to 2015. MATERIALS AND METHODS: We examined HIV surveillance data from 2010 to 2015 to determine in which geographic areas decreases or increases in HIV diagnoses occurred. We used data from the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention's (NCHHSTP) AtlasPlus to calculate percent changes in HIV diagnosis rates by geographic region for black females >/=13 years of age. RESULTS: The number of new HIV diagnoses declined 27% among black females from 2010 to 2015. The highest rates of HIV diagnosis per 100,000 population of black females, from 2010 to 2015, were in the Northeast and the South. In 2015, five of the eight states reporting the highest rates of HIV diagnosis (i.e., the highest quartile) were in the South. CONCLUSIONS: HIV diagnosis rates decreased nationally among black females, but the decreases were not uniform within regions or across the United States. Some states experienced increases, and black females in the South and Northeast remain disproportionately affected. Additional research is needed to ascertain factors associated with the increases to continue progress toward reducing HIV-related disparities among females in the United States.

HIV care outcomes must be improved to reduce new human immunodeficiency virus (HIV) infections and health disparities. HIV infection-related care outcome measures were examined for U.S.-born and non-U.S.-born black persons aged >/=13 years by using National HIV Surveillance System data from 40 U.S. areas. These measures include late-stage HIV diagnosis, timing of linkage to medical care after HIV diagnosis, retention in care, and viral suppression. Ninety-five percent of non-U.S.-born blacks had been born in Africa or the Caribbean. Compared with U.S.-born blacks, higher percentages of non-U.S.-born blacks with HIV infection diagnosed during 2016 received a late-stage diagnoses (28.3% versus 19.1%) and were linked to care in </=1 month after HIV infection diagnosis (76.8% versus 71.3%). Among persons with HIV diagnosed in 2014 and who were alive at year-end 2015, a higher percentage of non-U.S.-born blacks were retained in care (67.8% versus 61.1%) and achieved viral suppression (68.7% versus 57.8%). Care outcomes varied between African- and Caribbean-born blacks. Non-U.S.-born blacks achieved higher care outcomes than U.S.-born blacks, despite delayed entry to care. Possible explanations include a late-stage presentation that requires immediate linkage and optimal treatment and care provided through government-funded programs.

Socioeconomic disparities in morbidity and mortality, including their underlying social and economic determinants, have been recorded for centuries.1 In the United States, studies have identified racial/ethnic, economic, and social gradients associated with HIV, sexually transmitted infections (STIs), viral hepatitis, and tuberculosis (TB).2 In our editorial regarding this theme issue of AJPH, we present a critical summary of the main findings of selected articles and describe the related implications for policy, practice, and future applied research for reducing disparities in youths’ risk behaviors and infections with HIV, STIs, viral hepatitis, and TB among different US population groups.

The Centers for Disease Control and Prevention (CDC) has explicit goals for reducing inequalities in youth risk behaviors, as well as HIV, viral hepatitis, sexually transmitted diseases (STDs), and tuberculosis (TB) within the nation. To achieve these goals, CDC conducts research and implements policies and high-impact prevention programs that are cost-effective and scalable in order to meet the needs of the most heavily affected populations and geographic areas (bit.ly/2yclpxg). These priority infections and youth risk behaviors are unequally distributed among populations within the country that are often defined by race and ethnicity, sex, gender identity, geography, age, sexual orientation, and socioeconomic status.

OBJECTIVES: To assess changes in disparities of HIV diagnosis rates among Black women aged 18 years or older living in the United States. METHODS: We calculated estimated annual percent changes (EAPCs) in annual diagnosis rates, rate differences (absolute disparity), and rate ratios (relative disparity) for groups (total, US-born, and non-US-born) of Black women (referent was all White women) with diagnosed HIV infection, using data reported to the National HIV Surveillance System. RESULTS: Of 39 333 Black women who received an HIV diagnosis during 2008 to 2016, 21.4% were non-US-born. HIV diagnosis rates declined among all Black women, with the smallest decline among non-US-born groups (EAPC = -3.1; P </= .001). Absolute disparities declined for both US-born and non-US-born Black women; however, the relative disparity declined for Black women overall and US-born Black women, whereas it increased for non-US-born (including Caribbean- and Africa-born) Black women. CONCLUSIONS: Differences in disparities in HIV diagnoses exist between US-, and non-US-born (specifically Caribbean- and Africa-born) Black women. Accounting for the heterogeneity of the Black women's population is crucial in measuring and monitoring progress toward eliminating health disparities among Black women.

OBJECTIVES: Social determinants of health (SDHs) are the complex, structural, and societal factors that are responsible for most health inequities. Since 2003, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) has researched how SDHs place communities at risk for communicable diseases and poor adolescent health. We described the frequency and types of SDHs discussed in articles authored by NCHHSTP. METHODS: We used the MEDLINE/PubMed search engine to systematically review the frequency and type of SDHs that appeared in peer-reviewed publications available in PubMed from January 1, 2009, through December 31, 2014, with a NCHHSTP affiliation. We chose search terms to identify articles with a focus on the following SDH categories: income and employment, housing and homelessness, education and schooling, stigma or discrimination, social or community context, health and health care, and neighborhood or built environment. We classified articles based on the depth of topic coverage as "substantial" (ie, one of </=3 foci of the article) or "minimal" (ie, one of >/=4 foci of the article). RESULTS: Of 862 articles authored by NCHHSTP, 366 (42%) addressed the SDH factors of interest. Some articles addressed >1 SDH factor (366 articles appeared 568 times across the 7 categories examined), and we examined them for each category that they addressed. Most articles that addressed SDHs (449/568 articles; 79%) had a minimal SDH focus. SDH categories that were most represented in the literature were health and health care (190/568 articles; 33%) and education and schooling (118/568 articles; 21%). CONCLUSIONS: This assessment serves as a baseline measurement of inclusion of SDH topics from NCHHSTP authors in the literature and creates a methodology that can be used in future assessments of this topic.

Despite improvements in its treatment, HIV infection continues to affect Blacks disproportionally. Using National HIV Surveillance System data from 50 U.S. states and the District of Columbia, we examined demographic and epidemiologic differences between U.S.-born and non-U.S.-born Black adults. Of 110,452 Black adults reported with diagnosed HIV during 2008-2014 with complete country of birth information, 11.1% were non-U.S.-born. Non-U.S.-born were more likely to be older, female, have HIV infection attributed to heterosexual contact, have been diagnosed late, and live in the northeastern U.S. region. During 2014, the HIV diagnosis rate among African-born Black females was 1.4 times the rate of U.S.-born Black males, 2 times the rate of African-born Black males, and 5.3 times the rate of U.S.-born Black females. We elucidate the differences between U.S.-born and non-U.S.-born Blacks on which to base culturally appropriate HIV-prevention programs and policies.

The public health infrastructure required for achieving health equity is multidimensional and complex. The infrastructure should be responsive to current and emerging priorities and capable of providing the foundation for developing, planning, implementing, and evaluating health initiatives. This article discusses these infrastructure requirements by examining how they are operationalized in the organizational infrastructure for promoting health equity at the Centers for Disease Control and Prevention, utilizing the nation's premier public health agency as a lens. Examples from the history of the Centers for Disease Control and Prevention's work in health equity from its centers, institute, and offices are provided to identify those structures and functions that are critical to achieving health equity. Challenges and facilitators to sustaining a health equity organizational infrastructure, as gleaned from the Centers for Disease Control and Prevention's experience, are noted. Finally, we provide additional considerations for expanding and sustaining a health equity infrastructure, which the authors hope will serve as "food for thought" for practitioners in state, tribal, or local health departments, community-based organizations, or nongovernmental organizations striving to create or maintain an impactful infrastructure to achieve health equity.

In February 2010, CDC's National Center for HIV/AIDS, Viral Hepatitis, Sexually Transmitted Disease (STD), and Tuberculosis (TB) Prevention (NCHHSTP) formally institutionalized workforce development and capacity building (WDCB) as one of six overarching goals in its 2010-2015 Strategic Plan. Annually, workforce team members finalize an action plan that lays the foundation for programs to be implemented for NCHHSTP's workforce that year. This paper describes selected WDCB programs implemented by NCHHSTP during the last 4 years in the three strategic goal areas: (1) attracting, recruiting, and retaining a diverse and sustainable workforce; (2) providing staff with development opportunities to ensure the effective and innovative delivery of NCHHSTP programs; and (3) continuously recognizing performance and achievements of staff and creating an atmosphere that promotes a healthy work-life balance. Programs have included but are not limited to an Ambassador Program for new hires, career development training for all staff, leadership and coaching for mid-level managers, and a Laboratory Workforce Development Initiative for laboratory scientists. Additionally, the paper discusses three overarching areas-employee communication, evaluation and continuous review to guide program development, and the implementation of key organizational and leadership structures to ensure accountability and continuity of programs. Since 2010, many lessons have been learned regarding strategic approaches to scaling up organization-wide public health workforce development and capacity building. Perhaps the most important is the value of ensuring the high-level strategic prioritization of this issue, demonstrating to staff and partners the importance of this imperative in achieving NCHHSTP's mission.

BACKGROUND: A workforce that resembles the society it serves is likely to be more effective in improving health equity for racial and ethnic minorities in the U.S. Racial and ethnic minorities are underrepresented in the U.S. public health professions. Project Imhotep is operated by Morehouse College with funding and technical assistance from CDC. Imhotep trains racial and ethnic minority students for entry into graduate and professional training programs for careers in the public health sciences. The curriculum focuses on biostatistics, epidemiology, and occupational safety and health with practical training in statistical data analysis, scientific writing, and oral presentation skills. PURPOSE: To describe the Imhotep program and highlight some of its outcomes. METHODS: Data were collected every year by self-administered questionnaire or follow-up telephone and e-mail interviews of students who participated in Imhotep during 1982-2010 and were followed through December 2013. RESULTS: Findings demonstrated that 100% of the 481 trained students earned bachelor's degrees; 73.2% earned graduate degrees (53% earned master's degrees, 11.1% earned medical degrees, and 7.3% earned other doctoral degrees); and 60% entered public health careers. CONCLUSIONS: The Imhotep program has improved the representation of racial and ethnic minorities among public health professionals in the U.S. A diverse workforce involving Imhotep graduates could augment the pool of pubic health professionals who make strategic and tactical decisions around program design and resource allocation that impact health in the most affected communities.

The number of persons under correctional supervision in the United States increased in the mid-1970s and peaked in 2009 (Bureau of Justice Statistics, 2013). Though in subsequent years, incarcerated populations declined slightly, the United States continues to have one of the highest rates of incarceration among developed nations, and in the world, with 1 in 4 American adults behind bars (Pew Center on the States, 2012). Though detained populations are predominantly male, in the past 30 years, the number of women inmates in correctional facilities has increased dramatically. From 1977–2004, the number of U.S. female prisoners serving more than a year grew by 757%, while during the same period, the number of male prisoners grew by 388% (Frost, Greene, & Pranis, 2006). The growth of women in jails and prisons has surpassed male inmate population growth in 50 states (Frost, Greene, & Pranis, 2006). From 2000 to 2009, the number of women incarcerated in state or federal prisons rose by 21.6%, compared to a 15.6% increase for men (Mauer, 2013). | Nationally, there are more than eight times as many women under correctional supervision as there were in 1980 (American Civil Liberties Union, 2006). The United States has the highest incarceration rate for women in the world. In 2006, the rate was approximately 123 per 100,000 for women, which is much higher than those of England (17 per 100,000), France (6 per 100,000), Russia (73 per 100,000), and Thailand (88 per 100,000) (Hartney, 2006).

CONTEXT: Employee performance evaluation motivates and rewards exceptional individual performance that advances the achievement of organizational goals. The Centers for Disease Control and Prevention (CDC) and its operating units evaluate employee performance annually and reward exceptional performance with a cash award or quality step increase in pay. A summary performance rating (SPR) of "exceptional" indicated personal achievements in 2011 that were beyond expectations described in the employee's performance plan. OBJECTIVE: To determine whether personal attributes and job setting of civil service employees were associated with an exceptional SPR in National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) in 2011. DESIGN: Data from the CDC 2011 performance management database collected in 2012 were analyzed in 2013 to identify SPR, personal attributes, and job settings of full-time civil service employees. Multivariate logistic regression controlled for confounding and stratified analysis detected effect modifiers of the association between receiving an exceptional SPR in 2011 and gender, race/ethnicity, education, job location, job series, grade level, years in grade, years of federal service, supervisory role, and NCHHSTP division. RESULTS: Among the 1037 employees, exceptional SPR was independently associated with: female gender (adjusted odds ratio: 1.7 [1.3, 2.3]), advanced degrees (doctorate: 1.7 [1.1, 2.5] master's: [1.1, 2.0]), headquarters location (2.8 [1.9, 4.1]), higher pay grade (3.3 [2.4, 4.5]) and years in grade (0-1 years: 1.7 [1.3, 2.4]; 2-4 years: 1.5 [1.1, 2.0]), division level (Division A: 5.0 [2.5, 9.9]; Division B: 5.5 [3.5, 8.8]), and supervisory status (at a lower-pay grade) (odds ratio: 3.7 [1.1, 11.3]). CONCLUSIONS: Exceptional SPR is independently associated with personal employee attributes and job settings that are not modifiable by interventions designed to improve employee performance based on accomplishments.

We examined differences in HIV-infected U.S.-born and foreign-born black mothers who delivered perinatally HIV-exposed and -infected children during 1995-2004 in the Pediatric Spectrum of HIV Disease Project, a longitudinal cohort study. Prevalence ratios were calculated to explain differences in perinatal HIV prevention opportunities comparing U.S.-born to foreign-born and African-born to Caribbean-born black mothers. U.S.-born compared with foreign-born HIV-infected black mothers were significantly more likely to have used cocaine or other non-intravenous illicit drugs, exchanged money or drugs for sex, known their HIV status before giving birth, received intrapartum antiretroviral (ARV) prophylaxis, and delivered a premature infant; and were significantly less likely to have received prenatal care or delivered an HIV-infected infant. African-born compared with Caribbean-born black mothers were more likely to receive intrapartum ARV prophylaxis. These differences by maternal geographical origin have important implications for perinatal HIV transmission prevention, and highlight the validity of disaggregating data by racial/ethnic subgroups.

his supplemental issue of Public Health Reports (PHR) presents a selection of innovative approaches, studies, and lessons learned from efforts to implement program collaboration and service integration (PCSI) in the prevention and control of human immunodeficiency virus (HIV) infection, viral hepatitis, sexually transmitted diseases (STDs), and tuberculosis (TB) in the United States. Promotion of a comprehensive approach for these diseases is an important cross-cutting goal for the Centers for Disease Control and Prevention's (CDC's) National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP).1 | NCHHSTP's PCSI efforts are intended to strengthen collaborative work across disease areas and to integrate services that are provided by related programs at the client level. The catalyst for this systems change stems from the enhanced understanding of how these diseases synergistically relate with one another.2 With the rise of infectious disease syndemics (e.g., HIV and TB3) and the resultant increase in burden of disease,4 guidance has been produced to help state and local health departments better integrate service delivery.2,5–7 PCSI aims to organize and blend interrelated prevention strategies in an effort to provide more comprehensive delivery of services.2

BACKGROUND: Breast cancer is the second-leading cause of cancer-related deaths among women aged <50 years. Studies on the effects of breast cancer mortality among young women are limited. PURPOSE: To assess trends in breast cancer mortality rates among women aged 20-49 years, estimate years of potential life lost (YPLL), and the value of productivity losses due to premature mortality. METHODS: Age-adjusted rates and rate ratios (RRs) were calculated using 1970-2008 U.S. mortality data. Breast cancer mortality rates over time were assessed using Joinpoint regression modeling. YPLL was calculated using number of cancer deaths and the remaining life expectancy at the age of death. Value of productivity losses was estimated using the number of deaths and the present value of future lifetime earnings. RESULTS: From 1970 to 2008, the age-adjusted breast cancer mortality rate among young women was 12.02/100,000. Rates were higher in the Northeast (RR=1.03, 95% CI, 1.02-1.04). The annual decline in breast cancer mortality rates among blacks was smaller (-0.68%) compared with whites (-2.02%). The total number of deaths associated with breast cancer was 225,866, which accounted for an estimated 7.98 million YPLL. The estimated total productivity loss in 2008 was $5.49 billion and individual lifetime lost earnings were $1.10 million. CONCLUSIONS: Considering the effect of breast cancer on women of working age and the disproportionate impact on black women, more age-appropriate interventions with multiple strategies are needed to help reduce these substantial health and economic burdens, improve survival, and in turn reduce productivity costs associated with premature death.

At the end of 2009, approximately 1.1 million persons in the United States were living with human immunodeficiency virus (HIV) infection, with approximately 50,000 new infections annually. The prevalence of HIV continues to be greatest among gay, bisexual, and other men who have sex with men (MSM), who comprised approximately half of all persons with new infections in 2009. Disparities also exist among racial/ethnic minority populations, with blacks/African Americans and Hispanics/Latinos accounting for approximately half of all new infections and deaths among persons who received an HIV diagnosis in 2009. Improving survival of persons with HIV and reducing transmission involve a continuum of services that includes diagnosis, linkage to and retention in HIV medical care, and ongoing HIV prevention interventions.

Identifying how social determinants of health (SDH) influence the burden of disease in communities and populations is critically important to determine how to target public health interventions and move toward health equity. A holistic approach to disease prevention involves understanding the combined effects of individual, social, health system, and environmental determinants on geographic area-based disease burden. Using 2006-2008 gonorrhea surveillance data from the National Notifiable Sexually Transmitted Disease Surveillance and SDH variables from the American Community Survey, we calculated the diagnosis rate for each geographic area and analyzed the associations between those rates and the SDH and demographic variables. The estimated product moment correlation (PMC) between gonorrhea rate and SDH variables ranged from 0.11 to 0.83. Proportions of the population that were black, of minority race/ethnicity, and unmarried, were each strongly correlated with gonorrhea diagnosis rates. The population density, female proportion, and proportion below the poverty level were moderately correlated with gonorrhea diagnosis rate. To better understand relationships among SDH, demographic variables, and gonorrhea diagnosis rates, more geographic area-based estimates of additional variables are required. With the availability of more SDH variables and methods that distinguish linear from non-linear associations, geographic area-based analysis of disease incidence and SDH can add value to public health prevention and control programs. (2012 by the authors; licensee MDPI, Basel, Switzerland.)

Recent epidemiologic reports show that black women are at risk for HIV infection and other sexually transmitted diseases (STDs). In this report, we go beyond race and consider a number of social and economic trends that have changed the way many black women experience life. We discuss poverty, loss of status and support linked to declining marriage participation, and female-headed single-parent household structure-all of which influence sexual risks. We also discuss the Centers for Disease Control and Prevention-led national efforts to advance consideration of social determinants of health (SDH) and promotion of health equity in public health activities that may have impact on black and other women.

Approximately 1.1 million adults and adolescents are living with human immunodeficiency virus (HIV) infection in the United States, with 48,200--64,500 persons newly infected each year (1,2). At the beginning of the HIV epidemic in the United States in the early 1980s, the majority of persons with an HIV diagnosis were white men who have sex with men (MSM) (3,4). MSM continue to comprise a substantial proportion of persons newly infected with HIV, and the proportion of HIV infections among racial/ethnic minorities and women has increased (5). (These categories are not mutually exclusive.) Monitoring the burden of the epidemic among specific population groups provides guidance for targeting prevention and treatment efforts and allows assessment of intervention success. | | HIV infection is a notifiable disease in all states and the District of Columbia (DC). Since 1982, all 50 U.S. states and DC have reported stage 3-HIV infection, acquired immunodeficiency syndrome (AIDS), to CDC in a uniform format. In 1994, CDC implemented data management for national surveillance of early-stage HIV infection integrated with AIDS case surveillance, at which time 25 states with confidential, name-based HIV surveillance began submitting de-identified case reports to CDC. Eventually, additional states implemented name-based HIV surveillance, and all states had implemented such surveillance by April 2008. CDC regards data from states with confidential, name-based, HIV surveillance systems as sufficient to monitor trends for HIV infection after 4 continuous years of reporting (5).

This supplement to Public Health Reports (PHR) focuses on data systems and their use in addressing social determinants of health (SDH). This particular topic requires attention now given the evidence of increasing burden and worsening inequities in some health outcomes, in spite of decades of work to change individual behaviors, as well as the need to be efficient in our use of existing data. A holistic approach to disease prevention is urgently needed to reduce the inequities that have been perpetuated in our society for so long. | Despite concerted, targeted, and coordinated efforts to reduce inequities in health outcomes, gross inequities still exist,1–4 and some evidence indicates that the gap between the best health outcomes and the worst health outcomes is growing.1,3–5 Well-meaning efforts have substantially focused on individual-related behavior changes, with less focus on wider social and structural determinants of health, which can be defined as follows:6,7 | Structural factors include those physical, social, cultural, organizational, community, economic, legal, or policy aspects of the environment that impede or facilitate efforts to avoid disease transmission. Social factors include the economic and social conditions that influence the health of people and communities as a whole, and include the conditions for early childhood development, education, employment, income and job security, food security, health services, and access to services, housing, social exclusion, and stigma.8 | In addition to addressing individual factors, there is an urgent need to address social and structural factors and to better understand their relationship to each other as we develop effective programs and policies to reduce inequities.