BACKGROUND: Limited data exist in the United States on the prevalence of HIV among women who exchange sex. SETTING: We estimate HIV prevalence of women who exchange sex from a 2016 survey in Chicago, Detroit, Houston, and Seattle and compare it with the prevalence of HIV among women of low socioeconomic status (SES), who did not exchange sex, and women in the general population. METHODS: Women who exchange sex were recruited via respondent-driven sampling among some cities participating in National HIV Behavioral Surveillance, interviewed, and offered HIV testing. We estimate HIV prevalence and, using prevalence ratios, compare it with the prevalence among women of low SES who did not exchange sex in the 2013 National HIV Behavioral Surveillance cycle, and to women in the general population estimated using 2015 National HIV Surveillance data. RESULTS: One thousand four hundred forty women reported exchange sex in 2016. Aggregated HIV prevalence was 4.9% [95% confidence interval (CI): 2.7 to 7.1] among women who exchanged sex, 1.6% (95% CI: 0.3 to 2.8) among women of low SES who did not exchange sex, and 0.6% (95% CI: 0.5% to 0.6%) among women in the general population. HIV prevalence among women who exchanged sex was 3.1 times (95% CI: 1.6 to 5.9) as high as among women of low SES who did not exchange sex, and 8.8 times (95% CI: 7.0 to 11.1) as high as among women in the general population. CONCLUSION: HIV prevalence was significantly higher among women who exchanged sex compared with women in the general population and women of low SES who did not exchange sex.

AIMS: To examine the cost-effectiveness of hepatitis C (HCV) treatment of people who inject drugs (PWID), combined with medication-assisted treatment (MAT) and syringe-service programs (SSP), to tackle the increasing HCV epidemic in the United States. DESIGN: HCV-transmission and disease progression models with cost-effectiveness analysis using a health care perspective. SETTING: Rural Perry County, Kentucky (PC), and urban San Francisco, California (SF),USA. Compared with PC, SF has a greater proportion of PWID with access to MAT or SSP. HCV treatment of PWID is negligible in both settings. PARTICIPANTS: PWID, data collected between 1998 and 2015 from Social Networks Among Appalachian People, U Find Out, Urban Health Study, and National HIV Behavioral Surveillance System studies. INTERVENTIONS AND COMPARATOR: Three intervention scenarios modeled: baseline-existing SSP and MAT coverage with HCV screening and treatment with direct-acting antiviral for ex-injectors only as per standard of care; Intervention 1-scale-up of SSP and MAT without changes to treatment; and Intervention 2-scale-up as Intervention 1 combined with HCV screening and treatment for current PWID. MEASUREMENTS: Incremental cost-effectiveness ratios (ICERs) and uncertainty using cost-effectiveness acceptability curves. Benefits were measured in quality-adjusted life-years (QALYs). FINDINGS: For both settings, Intervention 2 is preferred to Intervention 1 and the appropriate comparator for Intervention 2 is the baseline scenario. Relative to baseline, for PC Intervention 2 averts 1,852 more HCV infections, increases QALYS by 3,095, costs $21.6 million more, and has an ICER of $6,975/QALY. For SF, Intervention 2 averts 36,473 more HCV infections, increases QALYs by 78,93, costs $ 872 million more, and has an ICER of $11,044/QALY. The cost-effectiveness of Intervention 2 was robust to several sensitivity analysis. CONCLUSIONS: Hepatitis C screening and treatment for people who inject drugs, combined with medication-assisted treatment and syringe-service programs, is a cost-effective strategy for reducing hepatitis C burden in the United States.

In the U.S. Hepatitis C virus (HCV) transmission is increasing among people who inject drugs (PWID). Many regions have insufficient prevention intervention coverage. Using modelling, we investigate the impact of scaling-up prevention and treatment interventions on HCV transmission among PWID in Perry County, Kentucky (PC), and San Francisco, California (SF), where HCV sero-prevalence among PWID is >50%. A greater proportion of PWID access medication-assisted treatment (MAT) or syringe service programs (SSP) in urban SF (established community) than rural PC (young, expanding community). We model the proportion of HCV-infected PWID needing HCV-treatment annually to reduce HCV-incidence by 90% by 2030, with and without MAT scale-up (50% coverage, both settings) and SSP scale-up (PC only) from 2017. With current MAT&SSP coverage during 2017-2030, HCV-incidence will increase in PC (21.3 to 22.6 per 100 person-years (/100pyrs)) and decrease in SF (12.9 to 11.9/100pyrs). With concurrent MAT&SSP scale-up, 5%/year of HCV-infected PWID need HCV-treatment in PC to achieve incidence targets; 13%/year without MAT&SSP scale-up. In SF, a similar proportion need HCV-treatment (10%/year) irrespective of MAT scale-up. Reaching the same impact by 2025 requires increases in treatment rates of 45-82%. Achievable provision of HCV-treatment, alongside MAT&SSP scale-up (PC) and MAT scale-up (SF), could reduce HCV-incidence.

BACKGROUND AND AIMS: Men who have sex with men (MSM) and inject drugs are at risk for HIV infection. Although research exists on non-injection methamphetamine (meth) use and sexual risk among MSM, less is known about meth injection and its association with HIV infection among MSM who inject drugs. METHODS: We analyzed data from men aged >/=18 years who reported injecting drugs and male-to-male sexual contact. Men were recruited using respondent-driven sampling, interviewed, and tested for HIV during the 2012 and 2015 cycles of National HIV Behavioral Surveillance among persons who inject drugs. We included data from 8 cities where >/=10 MSM reported meth as the primary drug injected. We assessed differences in demographic characteristics, past 12 months risk behaviors, and HIV infection between MSM who primarily injected meth and those who primarily injected another drug. RESULTS: Among 961 MSM, 33.7% reported meth as the drug they injected most often. Compared to MSM who primarily injected other drugs, MSM who primarily injected meth were more likely to have had >/=5 condomless anal sex partners, have been diagnosed with syphilis, and were less likely to report sharing syringes. In multivariable analysis, injecting meth was associated with being HIV-positive (adjusted prevalence ratio 1.48; 95% confidence interval 1.08-2.03). Including number of condomless anal sex partners in mediation analysis rendered this association no longer significant. CONCLUSIONS: HIV prevalence among MSM who primarily injected meth was almost 50% higher than among MSM who primarily injected other drugs, and this association was mediated by sexual risk.

Many studies of persons who exchange sex for money or drugs have focused on their HIV acquisition risk, and are often limited to select populations and/or geographical locations. National estimates of exchange sex among people living with HIV (PLWH) who are in medical care, and its correlates, are lacking. To address these gaps, we analyzed data from the Medical Monitoring Project, a surveillance system that produces nationally representative estimates of behavioral and clinical characteristics of PLWH receiving medical care in the United States, to estimate the weighted prevalence of exchange sex overall, and by selected socio-demographic, behavioral and clinical characteristics. We found 3.6% of sexually active adults reported exchange sex in the past 12 months. We found a higher prevalence of exchange sex among transgender persons, those who experienced homelessness, and those with unmet needs for social and medical services. Persons who exchanged sex were more likely to report depression and substance use than those who did not exchange sex. We found a higher prevalence of sexual behaviors that increase the risk of HIV transmission and lower viral suppression among persons who exchanged sex. PLWH who exchanged sex had a higher prevalence of not being prescribed ART, and not being ART adherent than those who did not exchange sex. We identify several areas for intervention, including: provision of or referral to services for unmet needs (such as housing or shelter), enhanced delivery of mental health and substance abuse screening and treatment, risk-reduction counseling, and ART prescription and adherence support services.

BACKGROUND: Women who inject drugs and who also exchange sex are at increased risk for HIV infection, but data on this population in the United States remain sparse. METHODS: This study assessed the prevalence of exchanging sex for money or drugs among women who inject drugs using data from the 2009 US National HIV Behavioral Surveillance (NHBS) system. Prevalence of being HIV-positive (testing positive in NHBS), HIV-positive-unaware (reporting being HIV-negative or unknown status but testing positive in NHBS), and risk behaviors and use of services were compared between women who did and did not exchange sex. The association between exchange sex and being HIV-positive-unaware of the infection was examined using multivariate Poisson models with robust standard errors. RESULTS: Among 2305 women who inject drugs, 39% reported receiving things like money or drugs from ≥1 male partners in exchange for oral, vaginal, or anal sex in the previous 12 months. Women who exchanged sex were more likely to be unemployed, homeless, lack health insurance, have multiple condomless vaginal or anal sex partners, and receptively share syringes. In multivariate analysis, exchange sex was associated with being HIV-positive-unaware (adjusted prevalence ratio 1.97, 95% confidence intervals: 1.31 to 2.97). CONCLUSIONS: Prevalence of exchange sex was high in this population. Women who exchange sex were more likely to be socially disadvantaged, report sexual and injection risk, and be HIV-positive-unaware. They represent an important group to reach with HIV prevention, testing, and care services.

BACKGROUND: Women involved in the criminal justice system experience multiple risk factors that increase the likelihood of acquiring HIV infection. We evaluated the prevalence of incarceration and compared behaviors among women with and without an incarceration history. METHODS: We use the 2013 National HIV Behavioral Surveillance data, which uses respondent-driven sampling. We evaluate the association between incarceration and the following past 12 months outcomes: exchange sex, multiple casual sex partners (≥3), multiple condomless sex partners (≥3), HIV test, and sexually transmitted infection diagnoses. Log-linked Poisson regression models, adjusted for demographics and clustered on city, with generalized estimating equations were used to estimate adjusted prevalence ratios (aPRs) and 95% confidence intervals. RESULTS: Of 5154 women, 11% were incarcerated within the previous year, 36% were ever incarcerated but not in the past 12 months, and 53% were never incarcerated. Prevalence of exchange sex (aPR 1.32, 1.20-1.46), multiple casual partners (aPR 1.59, 1.2-2.1), multiple casual condomless partners (aPR 1.47, 1.07-2.03), and sexually transmitted infection diagnosis (aPR 1.61, 1.34-1.93) were all higher among recently incarcerated women compared with those never incarcerated. We also found higher prevalence of recent HIV testing among women recently incarcerated (aPR 1.30, 1.18-1.43). DISCUSSION: Nearly half of women in our study had been incarcerated. Recent incarceration was associated with several factors that increase the risk of HIV acquisition. HIV prevention, testing, and early treatment among women with a history of incarceration can maximize the effectiveness of the public health response to the HIV epidemic.

BACKGROUND: In Iraq, where Islamic State of Iraq and Syria (ISIS) and other groups have contributed to escalating violence in recent years, understanding the epidemiology of intentional firearm-related fatalities is essential for public health action. METHODS: The Iraqi Ministry of Health (MoH; Baghdad, Iraq) compiles surveillance of fatal injuries in eight of Iraq's 18 governorates (Baghdad, Al-Anbar, Basrah, Erbil, Kerbala, Maysan, Ninevah, and Al-Sulaimaniya). Information is collected from coroner's reports and interviews with family members. Analysis was performed on intentional firearm-related injuries, excluding injuries from intentional self-harm or negligent discharges, that occurred during 2010-2013, a subset of all fatal injuries, and compared to previously published explosive-related fatalities. RESULTS: Overall, the dataset included 7,985 firearm-related fatalities. Yearly fatalities were: 2010=1,706; 2011=1,642; 2012=1,662; and 2013=2,975. Among fatalities, 86.0% were men and 13.7% women; 83.4% were adults and 6.2% children <18 years of age. Where age and sex were both known, men aged 20-39 years accounted for 56.3% of fatalities. Three "high-burden" governorates had the highest fatality rate per 100,000 population-Baghdad (12.9), Ninevah (17.0), and Al-Anbar (14.6)-accounting for 85.9% of fatalities recorded in the eight governorates. Most fatalities occurred in the street (56.3%), followed by workplace (12.2%), home (11.3%), and farm/countryside (8.4%). Comparing the ratio of firearm-related fatalities to explosives-related fatalities revealed an overall ratio of 2.8:1. The ratio in Baghdad more than doubled from 2.9 in 2010 to 6.1 in 2013; the highest ratios were seen outside the high-burden governorates. CONCLUSIONS: Firearm-related fatalities remained relatively stable throughout 2010-2012, and almost doubled in 2013, correlating with increased ISIS activity. Three governorates contributed the majority of fatalities and experienced the highest fatality rates; these saw high levels of conflict. Firearm-related fatalities disproportionately affected younger men, who historically are over-represented as victims and perpetrators of violence. More than one-half of fatalities occurred in the street, indicating this as a common environment for conflict involving firearms. Firearms appear to account for more fatalities in Iraq than explosives and largely accounted for escalating violence in Baghdad during the study period. The high ratio observed outside the high-burden governorates is reflective of very low numbers of explosives-related fatalities; thus, violence in these governorates is likely non-conflict-related. These observations provide valuable public health information for targeted intervention to prevent violence. Nerlander MP , Leidman E , Hassan A , Sultan ASS , Hussain SJ , Browne LB , Bilukha OO . Fatalities from firearm-related injuries in selected governorates of Iraq, 2010-2013. Prehosp Disaster Med. 2017;32(5):1-8.

To aid decision-making during CDC's response to the 2014-2016 Ebola virus disease (Ebola) epidemic in West Africa, CDC activated a Modeling Task Force to generate estimates on various topics related to the response in West Africa and the risk for importation of cases into the United States. Analysis of eight Ebola response modeling projects conducted during August 2014-July 2015 provided insight into the types of questions addressed by modeling, the impact of the estimates generated, and the difficulties encountered during the modeling. This time frame was selected to cover the three phases of the West African epidemic curve. Questions posed to the Modeling Task Force changed as the epidemic progressed. Initially, the task force was asked to estimate the number of cases that might occur if no interventions were implemented compared with cases that might occur if interventions were implemented; however, at the peak of the epidemic, the focus shifted to estimating resource needs for Ebola treatment units. Then, as the epidemic decelerated, requests for modeling changed to generating estimates of the potential number of sexually transmitted Ebola cases. Modeling to provide information for decision-making during the CDC Ebola response involved limited data, a short turnaround time, and difficulty communicating the modeling process, including assumptions and interpretation of results. Despite these challenges, modeling yielded estimates and projections that public health officials used to make key decisions regarding response strategy and resources required. The impact of modeling during the Ebola response demonstrates the usefulness of modeling in future responses, particularly in the early stages and when data are scarce. Future modeling can be enhanced by planning ahead for data needs and data sharing, and by open communication among modelers, scientists, and others to ensure that modeling and its limitations are more clearly understood. The activities summarized in this report would not have been possible without collaboration with many U.S. and international partners (http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/partners.html).

This study assessed the prevalence of exchanging sex for money or drugs among men who have sex with men (MSM) in the 2011 US National HIV Behavioral Surveillance system. Prevalence of HIV, being HIV-positive but unaware (HIV-positive-unaware), risk behaviors and use of services were compared between MSM who did and did not receive money or drugs from one or more casual male partners in exchange for oral or anal sex in the past 12 months. Among 8411 MSM, 7.0 % exchanged sex. MSM who exchanged sex were more likely to be non-Hispanic black, live in poverty, have injected drugs, have multiple condomless anal sex partners, be HIV-positive and be HIV-positive-unaware. In multivariable analysis, exchange sex was associated with being HIV-positive-unaware (aPR 1.34, 95 % CI 1.05-1.69) after adjusting for race/ethnicity, age, education, poverty, and injecting drugs. MSM who exchange sex represent an important group to reach with HIV prevention, testing, and care services as they were more likely to report behavioral risk factors that put them at risk of HIV.

BACKGROUND: Pre-exposure prophylaxis (PrEP) is an effective prevention tool for people at substantial risk of acquiring HIV. To 1) monitor the current state of PrEP use among men who have sex with men (MSM), we report on willingness to use PrEP and PrEP utilization, and 2) assess whether the MSM sub-populations at highest risk for infection have indications for PrEP according to the 2014 clinical guidelines, we estimated indications for PrEP for MSM by demographics. METHODS: We analyzed data from the 2014 cycle of the National HIV Behavioral Surveillance system among MSM who tested HIV-negative in NHBS and were currently sexually active. Adjusted prevalence ratios and 95% confidence intervals were estimated from log-linked Poisson regression with generalized estimating equations to explore differences in willingness to take PrEP, PrEP use, and indications for PrEP. RESULTS: Whereas over half of MSM said they were willing to take PrEP, only about 4% reported using PrEP. There was no difference in willingness to take PrEP between black and white MSM. PrEP use was higher among white compared to black MSM and among those with greater education and income levels. Young, black MSM were less likely to have indications for PrEP compared to young MSM of other races/ethnicities. CONCLUSIONS: Young, black MSM, despite being at high risk of HIV acquisition, may not have indications for PrEP under the current guidelines. Clinicians may need to consider other factors besides risk behaviors such as HIV incidence and prevalence in sub-groups of their communities when considering prescribing PrEP.

BACKGROUND: Little is known about the extent to which HIV-infected street youth (living part or full time on the streets) exhibit behaviors associated with HIV transmission in their interactions with youth not living on the streets ("non-street youth"). We aimed to determine prevalences and predictors of such "bridging behaviors": inconsistent condom use and needle sharing between HIV-positive street youth and non-street youth. METHODS: A total of 171 street youth in 3 Ukrainian cites were identified as HIV infected after testing of eligible participants aged 15 to 24 years after random selection of venues. Using data from these youth, we calculated prevalence estimates of bridging behaviors and assessed predictors using logistic regression. RESULTS: Overall, two-thirds of HIV-infected street youth exhibited bridging behaviors; subgroups with high prevalences of bridging included females (78.3%) and those involved in transactional sex (84.2%). In multivariable analysis, inconsistent condom use with non-street youth was associated with being female (adjusted prevalence ratio [aPR], 1.2; 95% confidence interval [CI], 1.1-1.4), working (aPR, 1.2; 95% CI, 1.03-1.4), multiple partners (aPR, 1.4; 95% CI, 1.2-1.6), and "never" (aPR, 1.4; 95% CI, 1.1-1.6) or "sometimes" (aPR, 1.3; 95% CI, 1.02-1.8) versus "always" sleeping on the street. Needle sharing with non-street youth was associated with being male (aPR, 1.4; 95% CI, 1.02-2.0), orphaned (aPR, 2.3; 95% CI, 1.8-3.0), and 2 years or less living on the streets (aPR, 1.8; 95% CI, 1.5-2.1). CONCLUSIONS: Bridging behaviors between HIV-infected street youth and non-street youth are common. Addressing the comprehensive needs of street and other at-risk youth is a critical prevention strategy.

In the United States, an estimated 7% of new diagnoses of human immunodeficiency virus (HIV) infection in 2012 were attributed to injection drug use, and an additional 3% to male-to-male sexual contact and injection drug use. To monitor HIV prevalence and behaviors associated with HIV risk and prevention among persons who inject drugs (PWID), CDC's National HIV Behavioral Surveillance (NHBS) system conducts interviews and HIV testing in selected cities. This report summarizes HIV prevalence and behaviors among PWID interviewed and tested in 20 cities in 2012. Of the 10,002 PWID tested, 11% had a positive HIV test result. Among 9,425 PWID included in the behavioral analysis, 30% receptively shared syringes, 70% had vaginal sex without a condom, 25% had heterosexual anal sex without a condom, and 5% of males had male-to-male sexual contact without a condom in the previous 12 months. Fifty-one percent of PWID included in the behavioral analysis had been tested for HIV, 25% participated in an HIV behavioral intervention, and 39% participated in substance abuse treatment in the previous 12 months. Additional efforts are needed to reduce risk behaviors and increase access to HIV testing, drug treatment, and other HIV prevention programs to further reduce HIV infections among PWID.

A short interpregnancy interval (IPI) is a risk factor for preterm delivery among women of reproductive age. As limited data exist concerning adolescents, we aimed to examine the association between short IPIs and preterm birth among adolescents using a majority of US births. Using 2007-2008 US natality data, we assessed the relationship between IPIs <3, 3-5, 6-11, and 12-17 months and moderately (32-36 weeks) and very (<32 weeks) preterm singleton live births among mothers <20 years, relative to IPIs 18-23 months. Adjusted odds ratios (aORs) and 95 % confidence intervals (95 % CIs) adjusted for maternal race, age, previous preterm deliveries, marital status, smoking and prenatal care were determined from a multivariable multinomial logistic regression model. In 2007-2008, there were 85,077 singleton live births to women aged <20 who had one previous live birth, 69 % of which followed IPIs ≤18 months. Compared with IPIs 18-23 months, short IPIs were associated with moderately preterm birth for IPIs <3 months (aOR 1.89, 95 % CI 1.70-2.10), 3-5 months (aOR 1.33, 95 % CI 1.22-1.47), and 6-12 months (aOR 1.11, 95 % CI 1.02-1.21). IPIs <3 and <6 months were also associated with very preterm birth, with aORs of 2.52 (95 % CI 1.98-3.22) and 1.68 (95 % CI 1.35-2.10) respectively. Many adolescent mothers with repeat births have short IPIs, and shorter IPIs are associated with preterm birth in a dose-dependent fashion. Increasing adolescent mothers' use of effective contraception postpartum can address both unintended adolescent births and preterm birth.