OBJECTIVES: The risk of mother-to-child HIV transmission can be reduced to </=0.5% if the mother's HIV status is known before delivery. This study describes 2006-2014 trends in diagnosed HIV infection documented on delivery discharge records and associated sociodemographic characteristics among women who gave birth in US hospitals. METHODS: We analyzed data from the 2006-2014 National Inpatient Sample and identified delivery discharges and women with diagnosed HIV infection by using International Classification of Diseases, Ninth Revision, Clinical Modification codes. We used a generalized linear model with log link and binomial distribution to assess trends and the association of sociodemographic characteristics with an HIV diagnosis on delivery discharge records. RESULTS: During 2006-2014, an HIV diagnosis was documented on approximately 3900-4400 delivery discharge records annually. The probability of having an HIV diagnosis on delivery discharge records decreased 3% per year (adjusted relative risk [aRR] = 0.97; 95% CI, 0.94-0.99), with significant declines identified among white women aged 25-34 (aRR = 0.93; 95% CI, 0.88-0.97) or those using Medicaid (aRR = 0.93; 95% CI, 0.90-0.97); among black women aged 25-34 (aRR = 0.95; 95% CI, 0.92-0.99); and among privately insured women who were black (aRR = 0.96; 95% CI, 0.92-0.99), Hispanic (aRR = 0.92; 95% CI, 0.86-0.98), or aged 25-34 (aRR = 0.96; 95% CI, 0.92-0.99). The probability of having an HIV diagnosis on delivery discharge records was greater for women who were black (aRR = 8.45; 95% CI, 7.56-9.44) or Hispanic (aRR = 1.56; 95% CI, 1.33-1.83) than white; for women aged 25-34 (aRR = 2.33; 95% CI, 2.12-2.55) or aged >/=35 (aRR = 3.04; 95% CI, 2.79-3.31) than for women aged 13-24; and for Medicaid recipients (aRR = 2.70; 95% CI, 2.45-2.98) or the uninsured (aRR = 1.87; 95% CI, 1.60-2.19) than for privately insured patients. CONCLUSION: During 2006-2014, the probability of having an HIV diagnosis declined among select sociodemographic groups of women delivering neonates. High-impact prevention efforts tailored to women remaining at higher risk for HIV infection can reduce the risk of mother-to-child HIV transmission.

In May 2018, a study of birth defects in infants born to women with diagnosed human immunodeficiency virus (HIV) infection in Botswana reported an eightfold increased risk for neural tube defects (NTDs) among births with periconceptional exposure to antiretroviral therapy (ART) that included the integrase inhibitor dolutegravir (DTG) compared with other ART regimens (1). The World Health Organization* (WHO) and the U.S. Department of Health and Human Services(dagger) (HHS) promptly issued interim guidance limiting the initiation of DTG during early pregnancy and in women of childbearing age with HIV who desire pregnancy or are sexually active and not using effective contraception. On the basis of additional data, WHO now recommends DTG as a preferred treatment option for all populations, including women of childbearing age and pregnant women. Similarly, the U.S. recommendations currently state that DTG is a preferred antiretroviral drug throughout pregnancy (with provider-patient counseling) and as an alternative antiretroviral drug in women who are trying to conceive.( section sign) Since 1981 and 1994, CDC has supported separate surveillance programs for HIV/acquired immunodeficiency syndrome (AIDS) (2) and birth defects (3) in state health departments. These two surveillance programs can inform public health programs and policy, linkage to care, and research activities. Because birth defects surveillance programs do not collect HIV status, and HIV surveillance programs do not routinely collect data on occurrence of birth defects, the related data have not been used by CDC to characterize birth defects in births to women with HIV. Data from these two programs were linked to estimate overall prevalence of NTDs and prevalence of NTDs in HIV-exposed pregnancies during 2013-2017 for 15 participating jurisdictions. Prevalence of NTDs in pregnancies among women with diagnosed HIV infection was 7.0 per 10,000 live births, similar to that among the general population in these 15 jurisdictions, and the U.S. estimate based on data from 24 states. Successful linking of data from birth defects and HIV/AIDS surveillance programs for pregnancies among women with diagnosed HIV infection suggests that similar data linkages might be used to characterize possible associations between maternal diseases or maternal use of medications, such as integrase strand transfer inhibitors used to manage HIV, and pregnancy outcomes. Although no difference in NTD prevalence in HIV-exposed pregnancies was found, data on the use of integrase strand transfer inhibitors in pregnancy are needed to understand the safety and risks of these drugs during pregnancy.

BACKGROUND: Medical advancements have improved the survival of persons with perinatally acquired HIV infection (PHIV). We describe persons living with diagnosed PHIV and assess receipt of HIV care, retention in care, and viral suppression. METHODS: Data reported to the National HIV Surveillance System (NHSS) through December 2017 were used to characterize persons living with diagnosed PHIV by year-end 2015 in the United States and 6 dependent areas. NHSS data from 40 jurisdictions with complete laboratory reporting were used to assess receipt of HIV care (>/=1 CD4 or viral load during 2015), retention in HIV care (>/=2 CD4 or viral load tests >/=3 months apart during 2015) and viral suppression (<200 copies/mL during 2015) among persons with PHIV diagnosed by year-end 2014 and alive at year-end 2015. RESULTS: By year-end 2015, 11,747 persons were living with PHIV and half were aged 18-25 years. Of 9,562 persons with HIV diagnosed by year-end 2014 and living with PHIV at year-end 2015 in the 40 jurisdictions, 75.4% received any care, 61.1% were retained in care, and 49.0% achieved viral suppression. Persons </=17 years of age had a significantly higher prevalence of being retained in care (PR=1.2, 95%CI=1.2-1.3) and virally suppressed (PR=1.4, 95%CI=1.3-1.5) than persons aged 18-25 years. CONCLUSIONS: Efforts to improve care outcomes among persons with PHIV are needed. Enhanced collaboration between pediatric and adult medical providers may ensure continuity of care during the transition from adolescence to adulthood.

BACKGROUND: The benefits of combination antiretroviral (ARV) prophylaxis for infants whose HIV exposure is recognized near birth have been established, and the benefits of early ARV therapy are well known. Decisions about ARVs can be supported by the probability that the child has acquired HIV. METHODS: Using 2005-2010 data from Enhanced Perinatal Surveillance of the Centers for Disease Control and Prevention, we developed a tool for use at birth to help predict HIV acquisition of HIV-exposed infants to support ARV management. A logistic regression model, fit using a fully Bayesian approach, was used to determine maternal variables predictive of infant HIV acquisition. We created a score index from these variables, established the sensitivity and specificity of each possible score, and determined the distribution of scores among infants, with and without HIV, in our study population. RESULTS: Multivariable analysis of data from 8740 HIV-exposed infants (176 infected and 8564 uninfected) yielded 4 maternal variables in the perinatal HIV acquisition prediction model: sexually transmitted infection, substance use, last HIV viral load before delivery and ARV use. Using the regression coefficient estimates, we rescaled each possible score to make the maximum score equal to 100. For each score, sensitivity and specificity were determined; the area under the receiver operating characteristic curve was 0.79. Median index scores for infants with HIV and without HIV were 43 (first quartile 27 and third quartile 60), and 12 (first quartile, 0 and thirs quartile, 29), respectively. CONCLUSIONS: Decisions to begin infants on 3 ARVs-whether considered therapeutic or prophylactic-can be supported by data available on the day of birth.

The number of infants with HIV born in the United States has decreased for years, approaching the Centers for Disease Control and Prevention's incidence goal for eliminating perinatal HIV transmission. We reviewed recent literature on perinatal HIV in the United States. Among perinatally HIV-exposed infants (whose mothers have HIV, without regard to infants' HIV diagnosis), prenatal and natal antiretroviral use has increased, maternal HIV infection is more frequently diagnosed prior to pregnancy, and breastfeeding is uncommon. In contrast, mothers of infants with HIV are tested at a lower rate for HIV, receive prenatal care less often, receive antiretrovirals (prenatal and natal) less often, and breastfeed more often. The incidence of perinatal HIV remains 5 times as high among black than white infants. The annual number of births to women with HIV was estimated last for 2006 (8,700), but has likely decreased. The numbers of women of childbearing age living with HIV and HIV diagnoses have decreased. The estimated time from HIV infection to diagnosis remains long among women and men who acquired HIV heterosexually. It is important to review the epidemiology and to continue monitoring outcomes and other health indicators for reproductive age adults living with HIV and their infants.

OBJECTIVES: The annual number of women with HIV infection who delivered infants in the United States was estimated to be 8700 in 2006. An accurate, current estimate is important for guiding perinatal HIV prevention efforts. Our objective was to analyze whether the 2006 estimate was consistent with the number of infants with HIV infection observed in the United States and with other data on perinatal HIV transmission. METHODS: We compared the number of infants born with HIV in 2015 (n = 53) with data on interventions to prevent perinatal HIV transmission (eg, maternal HIV diagnosis before and during pregnancy and prenatal antiretroviral use). We also estimated the annual number of deliveries to women living with HIV by using the number of women of childbearing age living with HIV during 2008-2014 and the estimated birth rate among these women. Finally, we determined any changes in the annual number of infants born to women with HIV from 2007-2015, among 19 states that reported these data. RESULTS: The low number of infants born in the United States with HIV infection and the uptake of interventions to prevent perinatal HIV transmission were not consistent with the 2006 estimate (n = 8700), even with the best uptake of interventions to prevent perinatal HIV transmission. Given the birth rate among women with HIV (estimated at 7%) and the number of women aged 13-44 living with HIV during 2008-2014 (n = 111 273 in 2008, n = 96 363 in 2014), no more than about 5000 women with HIV would be giving birth. Among states consistently reporting the annual number of births to women with HIV, the number declined about 14% from 2008 to 2014. CONCLUSION: The current annual number of women with HIV infection delivering infants in the United States is about 5000, which is substantially lower than the 2006 estimate. More accurate estimates would require comprehensive reporting of perinatal HIV exposure.

BACKGROUND: Diagnoses of HIV infection among children in the United States (US) have been declining; however, a notable percentage of diagnoses are among those born outside the United States. The impact of foreign birth among children with diagnosed infections has not been examined in the United States. METHOD: Using the CDC National HIV Surveillance System, we analyzed data for children aged <13 years with diagnosed HIV infection ("children") in the United States (reported from 50 states and the District of Columbia) during 2008-2014, by place of birth and selected characteristics. RESULTS: There were 1,516 children (726 US-born [47.9%] and 676 foreign-born [44.6%]). US-born children accounted for 70.0% in 2008, declining to 32.3% in 2013, and 40.9% in 2014. Foreign-born children have exceeded US-born children in number since 2011.Age at diagnosis was younger for US-born than foreign-born children (0-18 months: 72.6% vs. 9.8%; 5-12 years: 16.9% vs. 60.3%). HIV diagnoses in mothers of US-born children were made more often before pregnancy (49.7% vs 21.4%), or during pregnancy (16.6% vs 13.9%), and less often after birth (23.7% vs 41%). Custodians of US-born children were more often biological parents (71.9% vs 43.2%), and less likely to be foster or non-related adoptive parents (10.4% vs 55.1%).Of 676 foreign-born children with known place of birth, 65.5% were born in sub-Saharan Africa and 14.3% in Eastern Europe. The top countries of birth were Ethiopia, Ukraine, Uganda, Haiti, and Russia. CONCLUSION: The increasing number of foreign-born children with diagnosed HIV infection in the United States requires specific considerations for care and treatment.

OBJECTIVES: Assess outcomes along the care continuum for HIV-infected people who inject drugs (PWID), by type of facility and stage of infection at diagnosis. METHODS: Data reported by 28 jurisdictions to the National HIV Surveillance System by December 2014 were used to identify PWID aged ≥13 years, diagnosed with HIV infection before December 31, 2013. Analyses used the CDC definition of linkage to care (LTC), retention in care (RIC), and viral suppression (VS), and are stratified by age, sex, race/ethnicity, and type of facility and stage of HIV infection at diagnosis. RESULTS: Of 1,409 PWID diagnosed with HIV in 2013, 1,116 (79.2%) were LTC with the lowest percentages among males (78.4%); blacks (77.5%) ages 13-24 years (69.0%); those diagnosed in early stage infection (71.6%); and at screening, diagnostic, or referral agencies (60.0%). Of 80,958 PWID living with HIV in 2012, 40,234 (49.7%) were RIC and 34,665 (42.8%) achieved VS. The lowest percentages for RIC and VS were among males (47.1% and 41.3% respectively); those diagnosed with late stage disease (47.1% and 42.4%); and young people. Whites had the lowest RIC (47.0%) while blacks had the lowest VS (41.1%). CONCLUSION: Enhanced LTC activities are needed for PWID diagnosed at screening, diagnostic or referral agencies versus those diagnosed at inpatient or outpatient settings, especially among young people and blacks diagnosed in early stage infection. Less than half of PWID are retained in care or reach viral suppression indicating the need for continued engagement and return to care activities over the long term.

Hispanics or Latinos represent about 17% of the total U.S. population and are disproportionately affected by human immunodeficiency virus (HIV) infection in the United States. In 2013, the rate of HIV diagnosis among Hispanics or Latinos (18.7) was nearly three times that of non-Hispanic whites (6.6). To better characterize HIV infection among Hispanics or Latinos aged >/=13 years in the United States, CDC analyzed data from the National HIV Surveillance System (NHSS). During 2008-2013, the rate of diagnoses of HIV infection among adult and adolescent Hispanics or Latinos decreased from 28.3 per 100,000 population in 2008 to 24.3 in 2013 (estimated annual percentage change [EAPC] = -3.6); however, the number of diagnoses among males with infection attributed to male-to-male sexual contact increased 16%, from 6,141 in 2008 to 7,098 in 2013 (EAPC = 3.0). In 2013, the rate of diagnosis of HIV infection among males (41.3) was six times the rate among females (6.8). During 2008-2013, behavioral risk factors for HIV infection among Hispanics or Latino differed among males and females and by place of birth. Among Hispanic or Latino males born in Puerto Rico, the proportion of HIV infections attributed to injection drug use (24.9%) was greater than among those born elsewhere. Among HIV-infected Hispanic or Latino females, those born in the United States (21.2%) and Puerto Rico (20.5%) had a greater proportion of HIV infections attributed to injection drug use than those born elsewhere. Additional interventions and public health strategies to further decrease the rates of HIV among the Hispanic or Latino population are needed.

We estimated HIV prevalence and identified correlates of HIV infection among 1106 men and women aged 16-34 years residing in Kisumu, Kenya. Demographic, sexual, and other behavioural data were collected using audio computer-assisted self-interview in conjunction with a medical examination, real-time parallel rapid HIV testing, and laboratory testing for pregnancy, gonorrhoea, chlamydia, syphilis, and herpes simplex virus type 2. Multivariate logistic regression was used to identify variables associated with prevalent HIV infection by gender. Overall HIV prevalence was 12.1%. HIV prevalence among women (17.1%) was approximately two and one half times the prevalence among men (6.6%). Odds of HIV infection in men increased with age (aOR associated with one year increase in age = 1.21, CI = 1.07-1.35) and were greater among those who were uncircumcised (aOR = 4.42, CI = 1.41-13.89) and those who had an herpes simplex virus type 2 positive (aOR = 3.13, CI = 1.12-8.73) test result. Odds of prevalent HIV infection among women also increased with age (aOR associated with one year increase in age = 1.16, CI = 1.04-1.29). Women who tested herpes simplex virus type 2 positive had more than three times the odds (aOR = 3.85, CI = 1.38-10.46) of prevalent HIV infection compared with those who tested herpes simplex virus type 2 negative. Tailored sexual health interventions and programs may help mitigate HIV age and gender disparities.

The burden of HIV disease in the United States is monitored by using a comprehensive surveillance system. Data from this system are used at the federal, state, and local levels to plan, implement, and evaluate public health policies and programs. Implementation of HIV reporting has differed by area, and for the first time in early 2013, estimated data on diagnosed HIV infection were available from all 50 states, the District of Columbia, and six U.S. dependent areas. The newly available data for the entire U.S. as well as several other key changes to the surveillance system support the need to provide an updated summary of the status of the National HIV Surveillance System.

BACKGROUND: While laboratory aetiological diagnosis is considered the gold standard for diagnosis and management of sexually transmitted infections, syndromic management has been presented as a simplified and affordable approach for sexually transmitted infection management in limited resource settings. METHODS: Sexually transmitted infection signs and symptoms were collected using staff-administered computer-assisted personal interview and audio computer-assisted self-interview. Participants underwent a medical examination and laboratory testing for common sexually transmitted infections. The performance of syndromic management was assessed on the agreement between interviewing methods as well as accurate diagnosis. RESULTS: We screened 846 participants, of whom 88 (10.4%) received syndromic sexually transmitted infection diagnosis while 272 (32.2%) received an aetiological diagnosis. Agreement between syndromic and aetiological diagnoses was very poor (overall kappa = 0.09). The most prevalent sexually transmitted infection was herpes simplex virus type 2 and the percentage of persons with any sexually transmitted infection was higher among women (48.6%) than men (15.6%, p < 0.0001). Agreement between audio computer-assisted self-interview and computer-assisted personal interview interviewing methods for syndromic diagnosis of sexually transmitted infections ranged from poor to good. CONCLUSION: Our findings suggest that syndromic management of sexually transmitted infections is not a sufficient tool for sexually transmitted infection diagnosis in this setting; development and improvement of sexually transmitted infection diagnostic capabilities through laboratory confirmation is needed in resource-limited settings.

IMPORTANCE Early diagnosis of human immunodeficiency virus (HIV) infection, prompt linkage to and sustained care, and antiretroviral therapy are associated with reduced individual morbidity, mortality, and transmission of the virus. However, levels of these indicators may differ among population groups with HIV. Disparities in care and treatment may contribute to the higher incidence rates among groups with higher prevalence of HIV. OBJECTIVE To examine differences between groups of persons living with HIV by sex, age, race/ethnicity, and transmission category at essential steps in the continuum of care. DESIGN AND SETTING We obtained data from the National HIV Surveillance System of the Centers for Disease Control and Prevention to determine the number of persons living with HIV who are aware and unaware of their infection using back-calculation models. We calculated the percentage of persons linked to care within 3 months of diagnosis on the basis of CD4 level and viral load test results. We estimated the percentages of persons retained in care, prescribed antiretroviral therapy, and with viral suppression using data from the Medical Monitoring Project, a surveillance system of persons receiving HIV care in select areas representative of all such persons in the United States. PARTICIPANTS All HIV-infected persons in the United States. MAIN OUTCOMES AND MEASURES Percentage of persons living with HIV who are aware of their infection, linked to care, retained in care, receiving antiretroviral therapy, and achieving viral suppression. RESULTS Of the estimated 1 148 200 persons living with HIV in 2009 in the United States, 81.9% had been diagnosed, 65.8% were linked to care, 36.7% were retained in care, 32.7% were prescribed antiretroviral therapy, and 25.3% had a suppressed viral load (≤200 copies/mL). Overall, 857 276 persons with HIV had not achieved viral suppression, including 74.8% of male, 79.0% of black, 73.9% of Hispanic/Latino, and 70.3% of white persons. The percentage of blacks in each step of the continuum was lower than that for whites, but these differences were not statistically significant. Among persons with HIV who were 13 to 24 years of age, only 40.5% had received a diagnosis and 30.6% were linked to care. Persons aged 25 to 34, 35 to 44, and 45 to 54 years were all significantly less likely to achieve viral suppression than were persons aged 55 to 64 years. CONCLUSIONS AND RELEVANCE Significant age disparities exist at each step of the continuum of care. Additional efforts are needed to ensure that all persons with HIV receive a diagnosis and optimal care to reduce morbidity, mortality, disparities in care and treatment, and ultimately HIV transmission. Ensuring that people stay in care and receive treatment will increase the proportion of HIV-infected individuals who achieve and maintain a suppressed viral load.

OBJECTIVES: To report on indicators of the National HIV/AIDS Strategy, we analyzed data collected through the national HIV surveillance system. METHODS: We analyzed data from adults and adolescents aged 13 years or older diagnosed with HIV in 13 US jurisdictions that have laboratory reporting of CD4+ T-lymphocyte (CD4) and viral load (VL) test results and enter CD4 and VL test results into the national surveillance system. RESULTS: Of 4899 people diagnosed in 2009, 81.7% had at least 1 CD4 or VL test performed within 3 months of diagnosis. A higher proportion of Whites (86.2%) than Blacks (78.4%) and Hispanics (82.6%) had a CD4 or VL test. Of 53,642 people diagnosed through 2008 and living with HIV at the end of 2009 who had a VL test, 69.4% had a most recent VL of 200 copies per milliliter or less. The proportion of people with suppressed VLs differed among Blacks (60.2%), Hispanics (70.3%), and Whites (77.4%) and among people aged 13 to 24 years (44.3%) compared with people aged 65 years or older (84.2%). Of men who have sex with men, 74.2% had a suppressed VL. CONCLUSIONS: The findings highlight disparities in access to and success of care.

Laboratory data reported through HIV surveillance can provide information about disease severity and linkage to care; however these measures are only as accurate as the quality and completeness of data reported. Using data from five states that implemented enhanced collection of laboratory data in HIV surveillance from 2005-2006, we determined completeness of reporting, stage of disease at diagnosis, the most common opportunistic illnesses (OI) at diagnosis, and linkage to medical care. Methods to enhance laboratory reporting included increasing active surveillance efforts, identifying laboratories not reporting to HIV surveillance, increasing electronic reporting, and using laboratory results from auxiliary databases. Of 3,065 persons ≥13 years of age diagnosed with HIV, 35.5% were diagnosed with stage 3 (AIDS) and 37.7% progressed to stage 3 within 12-months after diagnosis. Overall, 78.5% were linked to care within 3 months; however, a higher proportion of persons with ≥1 CD4 or viral load test was found among whites compared with blacks/African Americans (82.1% vs 73.6%, p<0.001). Few (12.3%) had an OI within 3 months of diagnosis. The completeness of laboratory data collected through surveillance was improved with enhanced reporting and provided a more accurate picture of stage of disease and gaps in linkage to care. Additional interventions are needed to meet the goals of the National HIV/AIDS Strategy on linkage to care and the reduction of HIV-related disparities.

BACKGROUND: Monitoring immunologic and virologic response to antiretroviral therapy in HIV-1-infected patients is an important component of treatment in the United States. However, little population-based information is available on whether HIV-infected persons receive the recommended tests or continuous care. METHODS: Using data from 13 areas reporting relevant HIV-related tests to national HIV surveillance, we determined retention in care in persons >12 years old living with HIV at the end of 2009. We assessed retention in care, defined as ≥2 CD4 or viral load tests at least 3 months apart in the past year, by demographic, clinical, and risk characteristics, and calculated prevalence ratios (PR) and 95% confidence intervals (CI). We also assessed the percentage established in care within 12 months after HIV diagnosis in 2008 (≥2 tests, ≥3 months apart). RESULTS: Among 100,375 persons living with HIV, 45% had ≥2 tests at least 3 months apart. A higher percentage of whites was retained in care (50%) compared with blacks/African Americans (41%, PR 0.83, 95% CI 0.82, 0.84) and Hispanics/Latinos (40%, PR 0.90, 95% CI 0.87, 0.92). Compared with heterosexual women (50%), fewer men who have sex with men (48%), heterosexual males (45%), and male (37%) and female (43%) injection-drug users had ≥2 tests. About 64% established care within 12 months of diagnosis. CONCLUSIONS: Less than half of persons living with HIV had laboratory evidence of ongoing clinical care and only two-thirds established care after diagnosis. Further assessments determining modifiable barriers to accessing care could assist with achieving public health targets.