OBJECTIVE: State public health departments use federal funding to examine and address social determinants of health (SDOH) within their communities to improve health and advance health equity. Yet, most federal funding is categorical (ie, funding used for a specific program or narrow purpose), which can create barriers to addressing social and structural drivers of inequity. The Preventive Health and Health Services Block Grant (PHHS Block Grant) is a flexible funding mechanism that provides health departments the latitude to identify and fund initiatives that address local public health needs. It is unclear, however, to what extent health departments use this flexible resource to incorporate SDOH into their programs. DESIGN: Cross-sectional, descriptive analysis of state health department PHHS Block Grant program administrative data. SETTING: This study examined PHHS Block Grant budgets and workplans for the federal Fiscal Year 2021 to assess whether state health departments aligned their grant-funded program with the national objectives associated with the Healthy People 2030 SDOH Framework. PARTICIPANTS: Forty-seven states and the District of Columbia were included in this study. MAIN OUTCOME MEASURES: Percent of states that used PHHS Block Grant funds to address SDOH; proportion of funding allocated to address SDOH; percentage of programs that addressed SDOH. RESULTS: Three-fourths (75%) of states allocated funds to 97 programs aligning with at least 1 Healthy People 2030 SDOH-related objective. Fifty of the programs were fully or primarily funded by the PHHS Block Grant. Results also show that as the states' PHHS Block Grant funding level increased so did the percent of states that allocated funding toward SDOH programs. CONCLUSION: This study shows that state health departments are using the PHHS Block Grant to address SDOH, and that the grant plays an important funding role for these programs. States are incorporating the grant into their funding strategies to address SDOH.

New developments in the treatment and management of phenylketonuria (PKU) as well as advances in molecular testing have emerged since the National Institutes of Health 2000 PKU Consensus Statement was released. An NIH State-of-the-Science Conference was convened in 2012 to address new findings, particularly the use of the medication sapropterin to treat some individuals with PKU, and to develop a research agenda. Prior to the 2012 conference, five working groups of experts and public members met over a 1-year period. The working groups addressed the following: long-term outcomes and management across the lifespan; PKU and pregnancy; diet control and management; pharmacologic interventions; and molecular testing, new technologies, and epidemiologic considerations. In a parallel and independent activity, an Evidence-based Practice Center supported by the Agency for Healthcare Research and Quality conducted a systematic review of adjuvant treatments for PKU; its conclusions were presented at the conference. The conference included the findings of the working groups, panel discussions from industry and international perspectives, and presentations on topics such as emerging treatments for PKU, transitioning to adult care, and the U.S. Food and Drug Administration regulatory perspective. Over 85 experts participated in the conference through information gathering and/or as presenters during the conference, and they reached several important conclusions. The most serious neurological impairments in PKU are preventable with current dietary treatment approaches. However, a variety of more subtle physical, cognitive, and behavioral consequences of even well-controlled PKU are now recognized. The best outcomes in maternal PKU occur when blood phenylalanine (Phe) concentrations are maintained between 120 and 360 μmol/L before and during pregnancy. The dietary management treatment goal for individuals with PKU is a blood Phe concentration between 120 and 360 μmol/L. The use of genotype information in the newborn period may yield valuable insights about the severity of the condition for infants diagnosed before maximal Phe levels are achieved. While emerging and established genotype-phenotype correlations may transform our understanding of PKU, establishing correlations with intellectual outcomes is more challenging. Regarding the use of sapropterin in PKU, there are significant gaps in predicting response to treatment; at least half of those with PKU will have either minimal or no response. A coordinated approach to PKU treatment improves long-term outcomes for those with PKU and facilitates the conduct of research to improve diagnosis and treatment. New drugs that are safe, efficacious, and impact a larger proportion of individuals with PKU are needed. However, it is imperative that treatment guidelines and the decision processes for determining access to treatments be tied to a solid evidence base with rigorous standards for robust and consistent data collection. The process that preceded the PKU State-of-the-Science Conference, the conference itself, and the identification of a research agenda have facilitated the development of clinical practice guidelines by professional organizations and serve as a model for other inborn errors of metabolism.

TB may disproportionately affect persons who use drugs (PWUD),1–3 but the TB incidence rate among PWUD has not been estimated in the United States (U.S). California has the highest TB case burden and the highest frequency of current drug use: in 2019, 23.5% of incident TB cases in the U.S. occurred in California (5.3/100,000), and the state has an estimated 4.7 million PWUD.4,5 A better understanding of the intersection between drug use and TB will promote equity-informed interventions that account for social aspects of TB risk.6 In the study presented here, we estimate the incidence of TB disease among PWUD in California, describe the characteristics of TB patients who use drugs, and evaluate drug use as a risk factor for adverse treatment outcomes. | | We analyzed surveillance data of incident TB disease reported to the California Department of Public Health (CDPH; Richmond, CA, USA) TB registry in persons ≥12 years of age from 2015–2019. The denominator population of PWUD (who reported drug use in the past year) was derived from the National Survey of Drug Use and Mental Health (NSDUH) of noninstitutionalized civilians who were aged ≥12 years and resided in fixed-address households. We accessed prevalence estimates derived from the NSDUH through the Restricted Online Data Access System.7 NSDUH prevalence estimates are based on 2 years of pooled sample data and, because each year had two estimates (e.g., for 2018 data for 2017–2018 and 2018–2019), we used the average for the annual denominator value. We considered persons with TB who use drugs (PWUD-TB) as patients who reported any injecting or noninjecting drug use in the year preceding TB diagnosis. We used the NSDUH past-year variable ‘Any illicit drug use’ as the PWUD population denominator. We determined whether cases were attributable to recent transmission using a plausible source-case algorithm that associates genetic isolates with likely TB source cases.8 We defined TB treatment noncompletion as premature treatment cessation due to loss to follow-up, refusal, or nonadherence. We defined treatment extension as the completion of an appropriate regimen in more than 12 months, excluding patients with multidrug-resistant TB. We calculated the annual incidence of TB disease among PWUD aged ≥12 years from 2015 to 2019 by dividing the annual frequency of PWUD-TB by the corresponding NSDUH prevalence estimate of past-year drug use for California, stratified by place of birth. We used the χ2 test for comparison of categorical variables and the Wilcoxon rank-sum test for continuous variables (α = 0.05). Finally, we constructed multivariable log-binomial models to determine the independent association of drug use with treatment extension and treatment noncompletion (α = 0.05). This activity was determined to meet the requirements of public health surveillance by the Centers for Disease Control and Prevention (CDC) as defined in 45 CFR 46.102(l)(2), and thus did not require institutional board review. CDPH also determined this work to be non-research. Informed consent was not required.

AIM: To evaluate healthcare provider awareness and uptake of the Centers for Medicare & Medicaid Services (CMS) billing for coronavirus disease 2019 (COVID-19) prevention counselling and the delivery of prevention counselling to patients awaiting severe acute respiratory syndrome coronavirus 2 test results. DESIGN: Cross sectional survey of US-based healthcare providers in February 2021. METHODS: Analysis of associations with healthcare provider-reported awareness of CMS prevention counselling guidance and billing with provider type, specialty, and work setting. RESULTS: A total of 1919 healthcare providers responded to the survey. Overall, 38% (726/1919) of providers reported awareness of available CMS reimbursement for COVID-19 patient counselling and 29% (465/1614) of CMS billing-eligible providers reported billing for this counselling. Among physicians, those aware of CMS guidance were significantly more likely to bill (58%) versus those unaware (10%). Among RNSights respondents eligible for CMS billing (n = 114), 31% of those aware of the guidance reported billing as compared to 0% of those not aware.

BACKGROUND: The B.1.167.2 (Delta) variant quickly became the predominant circulating SARS-CoV-2 strain in the United States during Summer 2021. Missouri identified a high number of outbreaks in long-term care facilities (LTCF) across the state with low vaccination rates among LTCF staff members and poor adherence to mitigation measures within local communities. AIM: This report aims to describe COVID-19 outbreaks that occurred in Missouri LTCFs impacting staff and residents during the surge of the Delta variant. METHODS: Outbreaks of COVID-19 in 178 LTCFs were identified by the Missouri Department of Health and Senior Services. Case data from LTCFs with the highest burden of disease were analyzed to assess disease transmission, vaccination status, and outcomes among residents and staff. Additional investigational measures included onsite visits to facilities with recent COVID-19 outbreaks in communities with substantial transmission to assess mitigation measures. FINDINGS: During 22(nd) April - 29(th) July 2021, 159 COVID-19 cases among 72 staff members and 87 residents, were identified in 10 LTCFs. Over 74.7% of resident cases were vaccinated compared to 23.6% of staff cases. Vaccinated residents had a lower proportion of hospitalizations and deaths reported compared to unvaccinated residents. Data analysis and contact tracing efforts from a sample of the facilities suggest staff members were likely a major factor in introducing SARS-CoV-2 virus into the facilities. Adherence to COVID-19 mitigation measures varied at the visited facilities. CONCLUSION: Data showed that vaccination rates varied between staff cases and resident cases in facilities with high burden outbreaks. Differences were identified in mitigation practices in at least two facilities.

PURPOSE: Information on incentives for COVID-19 testing is needed to understand effective practices that encourage testing uptake. We describe characteristics of those who received an incentive after performing a rapid antigen test. DESIGN: Cross-sectional descriptive analysis of survey data. SETTING: During April 29-May 9, 2021, COVID-19 rapid antigen testing was offered in 2 Maryland cities. SAMPLE: Convenience sample of 553 adults (≥18 years) who tested and received an incentive; 93% consented to survey. MEASURES: Survey questions assessed reasons for testing, testing history, barriers, and demographics. ANALYSIS: Robust Poisson regressions were used to determine characteristic differences based on testing history and between participants who would re-test in the future without an incentive vs participants who would not. RESULTS: The most common reasons for testing were the desire to be tested (n = 280; 54%) and convenience of location (n = 146; 28%). Those motivated by an incentive to test (n = 110; 21%) were 5.83 times as likely to state they would not test again without an incentive, compared to those with other reasons for testing (95% CI: 2.67-12.72, P < .001). CRITICAL LIMITATIONS: No comparative study group. CONCLUSION: Results indicate internal motivation and convenience were prominent factors supporting testing uptake. Incentives may increase community testing participation, particularly among people who have never tested. Keywords COVID-19, pandemic, incentives, health behavior, community testing.

OBJECTIVE: To establish a pathoepidemiological model to evaluate the role of SARS-CoV-2 infection in the first 10 companion animals that died while infected with SARS-CoV-2 in the US. ANIMALS: 10 cats and dogs that tested positive for SARS-CoV-2 and died or were euthanized in the US between March 2020 and January 2021. PROCEDURES: A standardized algorithm was developed to direct case investigations, determine the necessity of certain diagnostic procedures, and evaluate the role, if any, that SARS-CoV-2 infection played in the animals' course of disease and death. Using clinical and diagnostic information collected by state animal health officials, state public health veterinarians, and other state and local partners, this algorithm was applied to each animal case. RESULTS: SARS-CoV-2 was an incidental finding in 8 animals, was suspected to have contributed to the severity of clinical signs leading to euthanasia in 1 dog, and was the primary reason for death for 1 cat. CONCLUSIONS AND CLINICAL RELEVANCE: This report provides the global community with a standardized process for directing case investigations, determining the necessity of certain diagnostic procedures, and determining the clinical significance of SARS-CoV-2 infections in animals with fatal outcomes and provides evidence that SARS-CoV-2 can, in rare circumstances, cause or contribute to death in pets.

Workplace activities involving close contact with coworkers and customers can lead to transmission of SARS-CoV-2, the virus that causes COVID-19 (1,2). Information on the approach to and effectiveness of COVID-19 workplace investigations is limited. In May 2020, Public Health - Seattle & King County (PHSKC), King County, Washington established a COVID-19 workplace surveillance and response system to enhance COVID-19 contact tracing and identify outbreaks in workplaces. During June 15-November 15, 2020, a total of 2,881 workplaces in King County reported at least one case of COVID-19. Among 1,305 (45.3%) investigated workplaces,* 524 (40.3%) met the definition of a workplace outbreak.(†) Among 306 (58.4%) workplaces with complete data,(§) an average of 4.4 employee COVID-19 cases(¶) (median = three; range = 1-65) were identified per outbreak, with an average attack rate among employees of 17.5%. PHSKC and the Washington State Department of Health optimized resources by establishing a classification scheme to prioritize workplace investigations as high, medium, or low priority based on workplace features observed to be associated with increased COVID-19 spread and workforce features associated with severe disease outcomes. High-priority investigations were significantly more likely than medium- and low-priority investigations to have two or more cases among employees (p<0.001), two or more cases not previously linked to the workplace (p<0.001), or two or more exposed workplace contacts not previously identified during case interviews (p = 0.002). Prioritization of workplace investigations allowed for the allocation of limited resources to effectively conduct workplace investigations to limit the potential workplace spread of COVID-19. Workplace investigations can also serve as an opportunity to provide guidance on preventing workplace exposures to SARS-CoV-2, facilitate access to vaccines, and strengthen collaborations between public health and businesses.

The flexibility federal block grants provide recipients poses challenges for evaluation. These challenges include aggregating data on wide-ranging activities grant recipients implement and the outcomes they achieve. In 2014, we began designing an evaluation to address the challenges of assessing outcomes and to improve outcome accountability for the Preventive Health and Health Services Block Grant. Through the use of evaluability assessment methodology, review of existing data and the literature, and key informant interviews, we developed a measurement framework to assess outcomes resulting from recipients’ ability to use grant funds to meet their locally prioritized needs. We argue our evaluation approach demonstrates that block grants, and other similarly flexible programs, can be evaluated through appropriately designed measures. Our efforts challenge the idea that flexibility presents an insurmountable barrier to evaluation and outcome accountability for federal block grants.

More than one-quarter of the adults living with diagnosed HIV infection in the US are women. Binge drinking (i.e., ≥4 alcoholic drinks per occasion for women) is associated with poor HIV treatment compliance, HIV incidence, and unplanned pregnancy. However, little is known about the prevalence of binge drinking among women of childbearing age who are living with HIV (WLWH) and health risk behaviours among those who binge drink. Using the 2013-2014 data cycles of Medical Monitoring Project, we assessed the weighted prevalence of drinking patterns by socio-demographic, clinical and reproductive characteristics of 946 WLWH. Logistic regression was used to calculate unadjusted and adjusted prevalence ratios and 95% confidence intervals. Overall, 39% of WLWH reported current drinking and 10% reported binge drinking. Compared to non-drinkers, binge drinkers were less likely to adhere to antiretroviral therapy (ART) or be virally suppressed. In multivariate analyses, binge drinking among WLWH was associated with smoking, drug use, and reduced ART adherence compared to non-drinkers, increasing the likelihood of negative clinical outcomes. WLWH may benefit from a comprehensive approach to reducing binge drinking including alcohol screening and brief interventions and evidence-based policy strategies that could potentially improve adherence to HIV treatment.

This study assessed the spectrum of initial symptoms at the onset of polymerase chain reaction-confirmed coronavirus disease 2019 (COVID-19) among health care personnel in King County, Washington.

BACKGROUND: The Medical Monitoring Project (MMP) is a national population-based behavioral and clinical surveillance system of adults with diagnosed HIV in the United States, and it is sponsored by the Centers for Disease Control and Prevention (CDC). Its purpose is to provide locally and nationally representative estimates of factors affecting HIV transmission risk and clinical outcomes. OBJECTIVE: This study aimed to describe the rationale for and methodology of the MMP, in addition to its contribution to evaluating and monitoring HIV prevention, care, and treatment efforts in the United States. METHODS: MMP employs a stratified 2-stage sample design to select annual samples of persons living with diagnosed HIV from the National HIV Surveillance System and conducts interviews and medical record abstractions with participating persons. RESULTS: MMP data are published routinely via annual reports, conference presentations, and scientific publications. Data may be accessed upon request from the CDC, contingent on the guidelines established for the security and confidentiality of HIV surveillance data. CONCLUSIONS: MMP is the only source of annual population-based data on the behaviors and clinical care of persons with diagnosed HIV in the United States. It provides essential information for monitoring progress toward national treatment and prevention goals and guiding efforts to improve the health of persons with diagnosed HIV and prevent HIV transmission. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/15453.

Homelessness is a challenge to retention in HIV care and adherence to antiretroviral therapy. We describe the sociodemographic and behavioral characteristics of HIV-positive adults who reported recent homelessness. The Medical Monitoring Project is a complex sample survey of HIV-positive adults receiving medical care in the United States. We used weighted interview and medical record data collected from June 2009 to May 2015 to estimate the prevalence of depression, substance use, and HIV risk behaviors among adults experiencing recent homelessness. From 2009 to 2015, 8.3% of HIV-positive adults experienced recent homelessness. Homeless adults were more likely than housed adults to have major depression, to binge drink, use non-injection drugs, use injection drugs, and smoke. Over 60% of homeless adults were sexually active during the past year, with homeless adults reporting more condomless sex with an HIV-negative or unknown status sex partner than housed adults. Programs attempting to improve the health outcomes of HIV-positive homeless persons and reduce ongoing HIV transmission can focus on providing basic needs, such as housing, and ancillary services, such as mental health counseling or substance abuse treatment and counseling.

For American Indian and Alaska Native tribes and communities, cultural and traditional teachings and practices are important protective factors that provide their people with strength and resilience to lead healthful lives. Tribal leaders have expressed that these practices are not widely understood by federal agencies, and often are not supported with financial and technical resources. Tribes may choose not to apply for government funding opportunities because the practices that work best for their populations are not described in the funding announcement. In February 2015, the Tribal Advisory Committee (TAC) of the Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry (CDC/ATSDR) recommended that CDC convene a group of knowledgeable cultural advisors to increase understanding of the role of tribal practices to support physical, emotional, and spiritual well-being. The purpose was to craft specific language to include in CDC’s funding opportunities to support implementation of these practices.

BACKGROUND: Despite recommendations for preventive health services and routine HIV care for HIV-positive women, limited data are available regarding uptake of recommendations. METHODS: We used data from the 2013-2014 data cycles of the Medical Monitoring Project. We calculated weighted estimates and used multivariable logistic regression with adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) to examine associations between preventive health screenings, routine HIV care (based on viral load (VL) and CD4 measures as proxies), and sociodemographic factors. RESULTS: Of 2,766 women, 47.7% were >/= 50 years old, 61.7% non-Hispanic black, 37.2% had > high school education, 63.3% had been living with HIV for >/= 10 years, 68.4% were living </=the federal poverty level, 67.3% had public health insurance; 93.8%were prescribed antiretroviral therapy (ART); 66.1%had sustained/durable suppression (12 months). For women aged >/= 18 years, cervical cancer, breast cancer, and STI screenings were documented for 44.3%, 27.6%, and 34.7%, respectively; 26% did not meet 6-month, and 37% did not meet 12-month, VL and CD4 test measure goals. In multivariable analyses, women with no VLs in past 6 months were less likely to be durably suppressed, and women who did not have >/= three CD4 or VL tests (past 12 months) were less likely to be living above the poverty level, and more likely to have public insurance, compared to private health insurance (p < 0.05). CONCLUSION: Receipt of recommended preventive care was suboptimal. Targeted interventions are warranted to help ensure access to comprehensive HIV care and prevention services for women.

The Southeast accounted for most HIV diagnoses (52%) in the United States in 2015. Primary care providers (PCPs) play a vital role in HIV prevention for at-risk persons and treatment of persons living with HIV. We studied HIV-related training, knowledge, and clinical practices among PCPs in the Southeast to address knowledge gaps to inform HIV prevention strategies. Between April and August 2017, we conducted an on-line survey of a representative sample of PCPs in six Southeast jurisdictions with high rates of HIV diagnoses (Atlanta; Baltimore; Baton Rouge; District of Columbia; Miami; New Orleans). We defined HIV-related training as self-reported completion of any certified HIV/STD course or continuing education in past 24 months (prior to survey completion). We assessed associations between training and HIV testing practices, familiarity with nonoccupational post-exposure prophylaxis (nPEP) and pre-exposure prophylaxis (PrEP), and ever prescribing nPEP or PrEP. There were 820 participants after fielding 4595 surveys (29.6% adjusted response rate). In weighted analyses, 36.3% reported HIV-related training. Using adjusted prevalence ratio (aPR) and confidence intervals (CI), we found that PCPs with HIV-related training (compared to those with no training) were more likely to be familiar with nPEP (aPR = 1.32, 95% CI 1.05, 1.67) and PrEP (aPR = 1.67, 95% CI 1.19, 2.38); and to have ever prescribed PrEP to patients (aPR = 1.75, 95% CI 1.10, 2.78). Increased HIV-related trainings among PCPs in high HIV prevalence Southeast jurisdictions may be warranted. Strengthening nPEP and PrEP familiarity among PCPs in Southeast may advance national HIV prevention goals.

Black women are disproportionately affected by HIV, accounting for 61% of women diagnosed in 2016. Black women with HIV are less likely to be adherent to antiretroviral therapy (ART) and virally suppressed compared to women of other racial/ethnic groups. We analyzed 2013-2014 data from 1703 black women patients in the Centers for Disease Control and Prevention's Medical Monitoring Project to examine whether select psychological and social determinants of health (SDH) factors were associated with ART adherence and viral suppression. We calculated weighted estimates and used multivariable logistic regression with adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) to examine correlates of ART adherence and viral suppression. Women who had not been incarcerated in the past 12 months (aPR = 1.24; CI: 1.04-1.48) and had not experienced discrimination in a health care setting since their HIV diagnosis (aPR = 1.06; 1.00-1.11) were slightly more likely to be adherent to ART. Women who lived above the federal poverty level were more likely to be virally suppressed during the past 12 months (aPR = 1.09; CI: 1.01-1.18). More research is warranted to identify the best strategies to create health care settings that encourage black women's HIV care engagement, and to address other key SDH and/or psychological factors.

BACKGROUND: Differences by sex in cardiovascular comorbid conditions among human immunodeficiency virus (HIV)-infected persons aged 50-64 years have been understudied; even fewer data are available for persons aged >/=65 years. METHODS: We used matched interview and medical record abstraction data from the 2009-2012 data cycles of the Medical Monitoring Project, a nationally representative sample of HIV-infected adults in care. We included men and women aged 50-64 and >/=65 years at time of interview. We calculated weighted prevalence estimates and used logistic regression to compute adjusted prevalence differences and 95% confidence intervals (CIs) assessing sex differences in various characteristics and cardiovascular comorbid conditions. Comorbid conditions included overweight/obesity (body mass index >/=25), abnormal total cholesterol level (defined as >/=200 mg/dL), diagnosed diabetes mellitus, or diagnosed hypertension. RESULTS: Of 7436 participants, 89.5% were aged 50-64 years and 10.4% aged >/=65 years, 75.1% were men, 40.4% (95% CI, 33.5%-47.2%) were non-Hispanic black, 72.0% (70.4%-73.6%) had HIV infection diagnosed >/=10 years earlier. After adjustment for sociodemographic and behavioral factors, women aged 50-64 years were more likely than men to be obese (adjusted prevalence difference, 8.4; 95% CI, 4.4-12.3), have hypertension (3.9; .1-7.6), or have high total cholesterol levels (9.9; 6.2-13.6). Women aged >/=65 years had higher prevalences of diabetes mellitus and high total cholesterol levels than men. CONCLUSIONS: Cardiovascular comorbid conditions were prevalent among older HIV-infected persons in care; disparities existed by sex. Closer monitoring and risk-reduction strategies for cardiovascular comorbid conditions are warranted for older HIV-infected persons, especially older women.

On August 8, 2018, the New York City Department of Health and Mental Hygiene notified CDC about two high school students hospitalized for pneumonia of unknown etiology who had recently returned from community service trips constructing houses near Tijuana in Baja California, Mexico. Patients had developed fever 9 and 11 days after travel, followed by rash and lower respiratory symptoms. Symptoms did not improve with multiple courses of antibacterial medications, and the patients subsequently received diagnoses of coccidioidomycosis, a fungal disease commonly known as valley fever.

Background: The use of Antiretroviral Therapy (ART) in HIV-infected persons has proven to be effective in the reduction of risk of disease progression and prevention of HIV transmission. Objective: U.S. Antiretroviral Therapy (ART) guidelines specify recommended initial, alternative initial, and not-recommended regimens, but data on ART prescribing practices and real-world effectiveness are sparse. Methods: Nationally representative annual cross sectional survey of HIV-infected adults receiving medical care in the United States, 2009-2012 data cycles. Using data from 18,095 participants, we assessed percentages prescribed ART regimens based on medical record documentation and the associations between ART regimens and viral suppression (most recent viral load test <200 copies/ml in past year) and ART-related side effects. Results: Among HIV-infected adults receiving medical care in the United States, 91.8% were prescribed ART; median time since ART initiation to interview date was 9.8 years. The percentage prescribed ART was significantly higher in 2012 compared to 2009 (92.7% vs 88.7%; p < 0.001). Of those prescribed ART, 51.6% were prescribed recommended initial regimens, 6.1% alternative initial regimens, 29.0% not-recommended as initial regimens, and 13.4% other regimens. Overall, 79.5% achieved viral suppression and 15.7% reported side effects. Of those prescribed ART and initiated ART in the past year, 80.5% were prescribed recommended initial regimens. Conclusion: Among persons prescribed ART, the majority were prescribed recommended initial regimens. Monitoring of ART use should be continued to provide ongoing assessments of ART effectiveness and tolerability in the United States.

The prevalence of diagnosed human immunodeficiency virus (HIV) infection among Hispanics/Latinos in the United States is approximately twice that of non-Hispanic whites (1). Barriers to, and experiences with, medical care have been found to vary by sex (2). Describing characteristics of Hispanics/Latinos in care by sex can help identify disparities and inform delivery of tailored services to this underserved population. Data from the 2013 and 2014 cycles of the Medical Monitoring Project (MMP) were analyzed to describe demographic, behavioral, and clinical characteristics among Hispanics/Latinos by sex. MMP is an annual cross-sectional, nationally representative surveillance system that, during 2013-2014, collected information about behaviors, medical care, and clinical outcomes among adults receiving outpatient HIV care. Hispanic/Latina women were significantly more likely than were men to live in poverty (78% versus 54%), report not speaking English well (38% versus 21%), and receive interpreter (27% versus 16%), transportation (35% versus 21%), and meal (44% versus 26%) services. There were no significant differences between Hispanic/Latino women and men in prescription of antiretroviral therapy (ART) (95% versus 96%) or sustained viral suppression (68% versus 73%). Although women faced greater socioeconomic and language-related challenges, the clinical outcomes among Hispanic/Latina women were similar to those among men, perhaps reflecting their higher use of ancillary services. Levels of viral suppression for Hispanics/Latinos are lower than those found among non-Hispanic whites (3) and lower than the national prevention goal of at least 80% of persons with diagnosed HIV infection. Providers should be cognizant of the challenges faced by Hispanics/Latinos with HIV infection in care and provide referrals to needed ancillary services.

BACKGROUND: Women with HIV diagnoses are less likely to be virally suppressed than men. Women of different racial/ethnic groups may be differentially affected by sociodemographic factors. We examined differences in viral suppression among women by race/ethnicity and associated variables to inform prevention interventions. METHODS: We used data from the 2010-2014 cycles of the Medical Monitoring Project, a cross-sectional survey of HIV-positive adults in care. We limited analyses to black, Hispanic, and white women. We calculated weighted prevalences of recent viral suppression (undetectable or <200 copies/mL) and sustained viral suppression (consistent viral suppression during the past 12 months) among women by race/ethnicity. We computed adjusted prevalence differences (aPDs) and 95% confidence intervals (CIs) for viral suppression by racial/ethnic group, controlling for selected variables, including available social determinants of health variables. RESULTS: Among women, 62.9% were black, 19.8% Hispanic, and 17.3% white. Overall, 74.3% had recent viral suppression, and 62.3% had sustained viral suppression. Compared with white women (79.7%, CI: 77.2 to 82.2), black (72.5%, CI: 70.3 to 74.7; PD: 7.2) and Hispanic (75.4%, CI: 72.6 to 78.3; PD: 4.3) women were less likely to have recent viral suppression. In multivariable analyses, after adjusting for antiretroviral therapy adherence, HIV disease stage, age, homelessness, and education, black-white aPDs remained significant for recent (aPD: 4.8, CI: 1.6 to 8.1) and sustained (aPD: 5.0, CI: 1.1 to 9.0) viral suppression. CONCLUSION: Viral suppression was suboptimal for all women, but more for black and Hispanic women. Differences between black, Hispanic, and white women may be partially due to antiretroviral therapy adherence, HIV disease stage, and social determinants of health factors.

Among 230,360 women with diagnosed HIV in the United States (U.S.), ~ 8,500 give birth annually, and unplanned pregnancies (as with HIV-negative women) are prevalent. However, unplanned pregnancies and contraceptive use among HIV-positive women have been understudied. To examine unplanned pregnancies and contraceptive use among HIV-positive women, we used 2013-2014 data from the Medical Monitoring Project (MMP), an HIV surveillance system that produces national estimates for HIV-positive adults in care in the U.S. (Pregnancy outcome dates were from years 1986-2015 for this cohort of women who were interviewed during 2013-2014; median year of reported pregnancy outcome was year 2003). Women in HIV care and diagnosed with HIV before age 45 (reproductive age) were included. We calculated adjusted prevalence ratios (aPR) of unplanned pregnancies with 95% confidence intervals (CI). For women who were aged 18-44 years at time of interview, we computed weighted prevalences of contraceptive use (previous 12 months) by method, including permanent (i.e., sterilization), short-acting (i.e., pills, depo-progesterone acetate (DMPA)), long-acting reversible contraceptives (LARC) (i.e., implants), and barriers (i.e., condoms). Six hundred seventy-one women met criteria for the unplanned pregnancy analysis; median age at HIV diagnosis = 24.6 years, and 78.1% (CI:74.5-81.7) reported >/= 1 unplanned pregnancy. Women reporting unplanned pregnancies were more likely to be non-Hispanic white (aPR = 1.20; CI 1.05-1.38) or non-Hispanic black (aPR = 1.14; CI 1.01-1.28) than Hispanic, to be above the poverty level (aPR = 1.09; CI 1.01-1.18), and to have not received care from an OB/GYN in the year before interview (aPR = 1.13; CI 1.04-1.22). Among 1,142 total pregnancies, 795 (69.6%) were live births; 70 (7.8%) were born HIV-positive; 42 (60%) of those born HIV-positive were unplanned pregnancies. For the contraceptives analysis (n = 957 women who were aged 18-44 at time of interview), 90.5% reported using at least one contraceptive, including 59.7% reporting barrier methods, 29.9% reporting permanent sterilization, and 22.8% reporting short-term methods in the previous year. LARC was used by only 5.3% of women. Women who reported use of LARC or DMPA were more likely to be aged 18-29 years (aPR = 3.08; CI 1.61-5.89) or 30-39 years (aPR = 2.86; CI 1.76-4.63) compared with women aged 40-44 years. Unplanned pregnancies were prevalent and LARC use was low; prevention efforts should strengthen pregnancy planning and contraceptive awareness for HIV-positive women during clinical visits.

Smoking increases HIV-related and non-HIV-related morbidity and mortality for persons with HIV infection. We estimated changes in cigarette smoking among adults with HIV and adults in the general U.S. population from 2009 to 2014 to inform HIV smoking cessation programs. Among HIV-positive adults, rates of current smoking declined from 37.6% (confidence interval [CI]: 34.7-40.6) in 2009 to 33.6% (CI: 29.8-37.8) in 2014. Current smoking among U.S. adults declined from 20.6% (CI: 19.9-21.3) in 2009 to 16.8% (CI: 16.2-17.4) in 2014. HIV-positive adults in care were significantly more likely to be current smokers compared with the general U.S. population; they were also less likely to quit smoking. For both HIV-positive adults in care and the general population, disparities were noted by racial/ethnic, educational level, and poverty-level subgroups. For most years, non-Hispanic blacks, those with less than high school education, and those living below poverty level were more likely to be current smokers and less likely to quit smoking compared with non-Hispanic whites, those with greater than high school education, and those living above poverty level, respectively. To decrease smoking-related causes of illness and death and to decrease HIV-related disparities, smoking cessation interventions are vital as part of routine care with HIV-positive persons. Clinicians who care for HIV-positive persons who smoke should utilize opportunities to discuss and implement smoking cessation strategies during routine clinical visits.

OBJECTIVES: During 2010-2014, the Centers for Disease Control and Prevention implemented the National Public Health Improvement Initiative (NPHII) to assist 73 public health agencies in conducting activities to increase accreditation readiness, improve efficiency and effectiveness through quality improvement, and increase performance management capacity. A summative evaluation of NPHII was conducted to examine whether awardees met the initiative's objectives, including increasing readiness for accreditation. DESIGN: A nonexperimental, utilization-focused evaluation with a multistrand, sequential mixed-methods approach was conducted to monitor awardee accomplishments and activities. Data analysis included descriptive statistics, as well as subanalyses of data by awardee characteristics. Thematic analysis using deductive a priori codes was used for qualitative analysis. RESULTS: Ninety percent of awardees reported completing at least 1 accreditation prerequisite during NPHII, and more than half reported completing all 3 prerequisites by the end of the program. Three-fourths of awardees that completed a self-assessment reported closing gaps for at least 1 Public Health Accreditation Board (PHAB) standard. Within 3 years of the launch of PHAB accreditation, 7 NPHII awardees were accredited; another 38 had formally applied for accreditation. CONCLUSIONS: Through NPHII, awardees increased collaborative efforts around accreditation readiness, accelerated timelines for preparing for accreditation, and prioritized the completion of required accreditation activities.

OBJECTIVES: To inform the development of HIV care strategies for older women with HIV infection, an understudied group, we compared the psychosocial, behavioral, and clinical characteristics of HIV-positive women aged ≥50 (older women) with those aged 18-49 (younger women). METHODS: We examined factors among HIV-positive women in care using data from the 2009 through 2013 cycles of a nationally representative sample of HIV-positive adults in care (Medical Monitoring Project). We compared psychosocial, clinical, and behavioral factors among women aged ≥50 years at interview versus those aged <50 years. We calculated weighted frequency estimates and performed logistic regression to compute adjusted prevalence ratios (aPR) and 95% confidence intervals (CIs) for the comparison of characteristics among women aged ≥50 versus <50 years. RESULTS: Of 22,145 participants, 6186 were women; 40.7% (CI 39.1-42.3) were ≥50 years, and 35.2% of older women reported being sexually active. Compared with women <50 years, women aged ≥50 years were more likely to be dose adherent (aPR = 1.19; CI 1.07-1.33), prescribed antiretroviral therapy and have sustained viral load suppression (aPR = 1.03; CI 1.00-1.18), and were less likely to report any depression (aPR = 0.92; CI 0.86-0.99), to report condomless sex with a negative or unknown partner if sexually active (aPR = 0.56; CI 0.48-0.67), and to have received HIV/sexually transmitted infection (STI) prevention counseling from a healthcare provider (aPR = 0.82; CI 0.76-0.88). CONCLUSIONS: These data suggest that older women in HIV care have more favorable outcomes in some clinical areas, but may warrant increased HIV/STI prevention counseling from their care providers, especially if sexually active.

Background: The National Violent Death Reporting System (NVDRS) captures homicides that law enforcement or coroner/medical examiners deem as gang-related but the criteria used may vary across locations. Also, the existing gang-related variable likely underestimates the number of homicides that are associated with gang activity. This study utilizes NVDRS data to identify "gang-like" homicides which are not currently captured as "gang-related.". Methods: A set of criteria recommended by a panel of experts in gang violence, was applied to homicides collected in the NVDRS. These criteria, termed "gang-like" characteristics, were developed in order to better identify homicides consistent with gang activity. The narratives of the identified cases were then reviewed to refine the operational standard. After the reviews were complete, the typology was modified to finalize the operationalization of "gang-like" homicides. Results: A total of 481 gang-like homicides were identified using the "gang-like" criteria. This represents an increase of almost 69% over the 696 gang-related homicides captured in NVDRS dataset.Gang-like and gang-related homicides combined represented 6.6% of homicides that occurred from 2005 to 2008. Among the 16 states included in this analysis, Colorado (15.5%) and Oklahoma (14%) had the highest percentage of homicides that were either gang-related or gang-like.Maryland had the greatest relative increase (227.3%) between gang related and gang-like homicides. Conclusion: The new "gang-like" variable complements the existing "gang-related" variable by providing an automated, standardized way to identify homicides that have circumstances consistent with gang activity. This new variable might be useful to states and localities seeking an efficient way to monitor homicides potentially resulting from gang activity. Additional efforts are needed to standardize the reporting of homicides associated with gang activity.

PURPOSE: We examined factors associated with antiretroviral therapy (ART) adherence among transgender women living with HIV (TWLWH). METHODS: We used combined data from the 2009 to 2013 cycles of Medical Monitoring Project, an HIV surveillance system designed to produce nationally representative estimates of the characteristics of HIV-infected adults receiving HIV medical care in the United States. Rao-Scott chi-square tests and multivariable logistic regression were used to identify factors associated with dose adherence (defined as taking 100% of prescribed ART doses in the past 3 days). RESULTS: Among TWLWH who reported current ART use, an estimated 80.5% self-reported dose adherence. Multivariable factors independently associated with lower (<100%) dose adherence were younger age (30-39 vs. 40 and over), not having health insurance coverage, depression, lower self-efficacy to take medication as prescribed, and having greater than one daily ART dose. CONCLUSION: Our findings suggest several ways to potentially improve ART adherence of TWLWH including tailoring efforts to address the needs of TWLWH under age 40, increasing access to health insurance coverage, addressing mental health morbidities, building skills to improve medication adherence self-efficacy, and simplifying ART regimens when possible.

OBJECTIVE: This study was conducted to identify factors contributing to health satisfaction outcomes among emerging adults (ages 18-25) with diabetes. METHOD: SEARCH for Diabetes in Youth study participants whose diabetes was prevalent in 2001 and were ≥18 years of age when they completed a 2008-2009 follow-up survey (n = 340) were included. We developed a health resilience model (HRM) to identify potentially modifiable factors (anticipatory guidance, social support, physical activity, quality of life) associated with health outcomes (satisfaction with health care, overall personal health, self-report of hemoglobin A1c [HbA1c]). Proportional odds logistic regression models were used to examine relationships between modifiable factors and health outcomes while adjusting for predetermined characteristics; linear regression models were used for reported HbA1c. Comparison of participants who reported HbA1c versus nonreporters was conducted. RESULTS: A majority (70%) of participants rated satisfaction with health care ≥7 out of 10, and most (71%) rated overall health as good, very good, or excellent. Satisfaction with health care was independent of change in provider between the ages of 17 and 24. After controlling for predetermined characteristics, we found that the odds of increased satisfaction with health care and overall personal health were 1.3 and 1.2 greater, respectively, when participants discussed additional diabetes-related anticipatory guidance topics with a provider and 1.3 and 2.1, respectively, for each 10-unit change in quality of life score. Relationship between HbA1c level and modifiable factors was not significant; however, participants reporting HbA1c had higher ratings of health care and overall health versus nonreporters. CONCLUSIONS: HRM describes relationships between modifiable factors and patient-reported outcomes of satisfaction with health care and overall personal health among a cohort of ethnically and racially diverse emerging adults with longstanding diabetes, over half of whom experienced a change in provider. HRM may discern candidate areas for intervention, such as effective anticipatory guidance that can impact satisfaction with health care and overall health, to promote positive health outcomes.

BACKGROUND: Health surveys of the general US population are inadequate for monitoring human immunodeficiency virus (HIV) infection because the relatively low prevalence of the disease (<0.5%) leads to small subpopulation sample sizes. OBJECTIVE: To collect a nationally and locally representative probability sample of HIV-infected adults receiving medical care to monitor clinical and behavioral outcomes, supplementing the data in the National HIV Surveillance System. This paper describes the sample design and weighting methods for the Medical Monitoring Project (MMP) and provides estimates of the size and characteristics of this population. METHODS: To develop a method for obtaining valid, representative estimates of the in-care population, we implemented a cross-sectional, three-stage design that sampled 23 jurisdictions, then 691 facilities, then 9,344 HIV patients receiving medical care, using probability-proportional-to-size methods. The data weighting process followed standard methods, accounting for the probabilities of selection at each stage and adjusting for nonresponse and multiplicity. Nonresponse adjustments accounted for differing response at both facility and patient levels. Multiplicity adjustments accounted for visits to more than one HIV care facility. RESULTS: MMP used a multistage stratified probability sampling design that was approximately self-weighting in each of the 23 project areas and nationally. The probability sample represents the estimated 421,186 HIV-infected adults receiving medical care during January through April 2009. Methods were efficient (i.e., induced small, unequal weighting effects and small standard errors for a range of weighted estimates). CONCLUSION: The information collected through MMP allows monitoring trends in clinical and behavioral outcomes and informs resource allocation for treatment and prevention activities.