BACKGROUND: Persons aged 13-24 years are a priority population in the National HIV/AIDS Strategy. Young adults with HIV have poorer health outcomes-including not being retained in care, antiretroviral nonadherence, and not being virally suppressed-than other persons with HIV. SETTING: Centers for Disease Control and Prevention's Medical Monitoring Project data collected June 2018 through May 2022. METHODS: We compared demographic characteristics, social determinants of health (SDOH), and mental health between persons aged 18-24 years with HIV versus persons aged ≥25 years with HIV. Among those aged 18-24 years, we analyzed total and unmet needs for ancillary services, defined as those that support care engagement, viral suppression, and overall health and well-being among people with HIV. RESULTS: Persons aged 18-24 years were more likely to have a household income <100% of the federal poverty level (48% vs. 39%), and experience unstable housing or homelessness (37% vs. 18%) or hunger/food insecurity (29% vs. 18%) than those aged ≥25 years. Persons aged 18-24 years had higher median HIV stigma scores (40 vs. 29) and were more likely to experience symptoms of generalized anxiety disorder (21% vs. 15%) than those aged ≥25 years. Of persons aged 18-24 years, 96% had a need for ≥1 ancillary service, of whom 56% had ≥1 unmet need; unmet needs were highest for subsistence services (53%) and non-HIV medical services (41%). CONCLUSIONS: Addressing unmet needs for subsistence and non-HIV medical services could help reduce disparities in SDOH and mental health that drive inequities in health outcomes among persons with HIV aged 18-24 years.

Ensuring good quality of life (QoL) among persons with diagnosed HIV (PWH) is a priority of the National HIV/AIDS Strategy (NHAS), which established 2025 goals for improving QoL. Goals are monitored through five indicators: self-rated health, unmet needs for mental health services, unemployment, hunger or food insecurity, and unstable housing or homelessness. Among the growing population of PWH aged ≥50 years, progress toward these goals has not been assessed. Data collected during the 2017-2022 cycles of the Medical Monitoring Project, an annual complex sample survey of U.S. adults with diagnosed HIV, assessed progress toward NHAS 2025 QoL goals among PWH aged ≥50 years, overall and by age group. The recent estimated annual percentage change from baseline (2017 or 2018) to 2022 was calculated for each indicator. Among PWH aged ≥50 years, the 2025 goal of 95% PWH with good or better self-rated health is 46.2% higher than the 2022 estimate. The 2025 goals of a 50% reduction in the other indicators range from 26.3% to 56.3% lower than the 2022 estimates. Decreasing hunger or food insecurity by 50% among PWH aged ≥65 was the only goal met by 2022. If recent trends continue, other NHAS QoL 2025 goals are unlikely to be met. Multisectoral strategies to improve access to housing, employment, food, and mental health will be needed to meet NHAS 2025 goals for QoL among older PWH.

BACKGROUND: Men who inject drugs who have sex with men (MWIDSM) may acquire HIV through injecting drugs or sex. Interventions to increase awareness of HIV preexposure prophylaxis (PrEP) have focused on gay/bisexual MSM and may not be reaching heterosexual-identifying men or people who inject drugs (PWID). We explored changes in PrEP awareness and use among MWIDSM from 2018 to 2022 by sexual identity. METHODS: We used data from the 2018 and 2022 National HIV Behavioral Surveillance among PWID recruited via respondent-driven sampling in 19 urban areas in the US. We examined changes in PrEP awareness and use over time by sexual identity among HIV-negative men who inject drugs and who had sex with another man in the past 12 months using log-linked Poisson regression models with robust standard errors with an interaction term between year and sexual identity. RESULTS: Among 758 HIV-negative MWIDSM (463 in 2018; 295 in 2022), nearly all sample participants were likely indicated for PrEP (94.2 and 92.9%, respectively). PrEP awareness increased from 2018 to 2022 among gay/bisexual-identifying MWIDSM [45.5-65.5%; aPR = 1.49, 95% confidence interval (95% CI) = 1.30-1.70] but remained stable for heterosexual-identifying MWIDSM (39.4-40.8%; aPR = 1.01, 95% CI 0.75-1.36). PrEP use remained low among all MWIDSM (2.5-7.7%, among heterosexually identifying; 15.3 to 10.2% among gay/bisexual-identifying). CONCLUSION: PrEP awareness increased among gay/bisexual-identifying MWIDSM but not among heterosexual-identifying. PrEP use was low for all MWIDSM. Public health initiatives catered to MWIDSM should focus on improved campaigns and expanding PrEP accessibility in existing healthcare, harm reduction, and social services.

CONTEXT: In response to the first reported mpox cases in May 2022, the US government implemented plans to bring testing, treatment, and vaccines to communities disproportionately affected by mpox-including the population of men who have sex with men (MSM) and Black/African American and Hispanic/Latino men, 2 subpopulations experiencing vaccination disparities. We describe the development and implementation of the US Mpox Vaccine Equity Pilot Program (MVEPP), characteristics of completed vaccination projects, and challenges that occurred. We also discuss opportunities for reducing vaccination disparities in future outbreaks. PROGRAM: To address reported vaccination disparities, the US government launched MVEPP in 2 phases. Phase 1 centered around public events attended by large numbers of gay, bisexual, and other MSM, such as Pride festivals. Phase 2 asked health departments to propose mpox vaccination projects specifically aimed at reducing or eliminating racial/ethnic and other demographic disparities in mpox vaccination. IMPLEMENTATION: MVEPP received 35 vaccination project proposals. We analyzed data from 22 completed projects that resulted in 25 675 doses of JYNNEOS administered. We note 3 innovative strategies that were implemented in several projects: direct collaboration with organizations providing services to MSM and transgender women; implementation of MVEPP projects in unique nonclinical community settings and at venues frequented by MSM and transgender women; and offering an array of services as part of mpox vaccination projects, rather than offering only mpox vaccination. EVALUATION: MVEPP highlighted the importance of recognizing and working to eliminate racial/ethnic and other disparities in access to medical countermeasures during a public health emergency. Jurisdictions developed and implemented innovative strategies to bring mpox vaccination and related services to communities disproportionately affected by mpox-including MSM and the subpopulations of Black/African American and Hispanic/Latino MSM. Lessons learned from MVEPP may inform efforts to reduce disparities during future public health responses.

Monkeypox (mpox) is a serious viral zoonosis endemic in west and central Africa. An unprecedented global outbreak was first detected in May 2022. CDC activated its emergency outbreak response on May 23, 2022, and the outbreak was declared a Public Health Emergency of International Concern on July 23, 2022, by the World Health Organization (WHO),* and a U.S. Public Health Emergency on August 4, 2022, by the U.S. Department of Health and Human Services.(†) A U.S. government response was initiated, and CDC coordinated activities with the White House, the U.S. Department of Health and Human Services, and many other federal, state, and local partners. CDC quickly adapted surveillance systems, diagnostic tests, vaccines, therapeutics, grants, and communication systems originally developed for U.S. smallpox preparedness and other infectious diseases to fit the unique needs of the outbreak. In 1 year, more than 30,000 U.S. mpox cases were reported, more than 140,000 specimens were tested, >1.2 million doses of vaccine were administered, and more than 6,900 patients were treated with tecovirimat, an antiviral medication with activity against orthopoxviruses such as Variola virus and Monkeypox virus. Non-Hispanic Black (Black) and Hispanic or Latino (Hispanic) persons represented 33% and 31% of mpox cases, respectively; 87% of 42 fatal cases occurred in Black persons. Sexual contact among gay, bisexual, and other men who have sex with men (MSM) was rapidly identified as the primary risk for infection, resulting in profound changes in our scientific understanding of mpox clinical presentation, pathogenesis, and transmission dynamics. This report provides an overview of the first year of the response to the U.S. mpox outbreak by CDC, reviews lessons learned to improve response and future readiness, and previews continued mpox response and prevention activities as local viral transmission continues in multiple U.S. jurisdictions (Figure).

BACKGROUND: Men who have sex with men (MSM) accounted for two thirds of new HIV infections in the United States in 2019 despite representing approximately 2% of the adult population. METHODS: CDC analyzed surveillance data to determine trends in estimated new HIV infections and to assess measures of undiagnosed infection and HIV prevention and treatment services including HIV testing, preexposure prophylaxis (PrEP) use, antiretroviral therapy (ART) adherence, and viral suppression, as well as HIV-related stigma. RESULTS: The estimated number of new HIV infections among MSM was 25,100 in 2010 and 23,100 in 2019. New infections decreased significantly among White MSM but did not decrease among Black or African American (Black) MSM and Hispanic/Latino MSM. New infections increased among MSM aged 25-34 years. During 2019, approximately 83% of Black MSM and 80% of Hispanic/Latino MSM compared with 90% of White MSM with HIV had received an HIV diagnosis. The lowest percentage of diagnosed infection was among MSM aged 13-24 years (55%). Among MSM with a likely PrEP indication, discussions about PrEP with a provider and PrEP use were lower among Black MSM (47% and 27%, respectively) and Hispanic/Latino MSM (45% and 31%) than among White MSM (59% and 42%). Among MSM with an HIV diagnosis, adherence to ART and viral suppression were lower among Black MSM (48% and 62%, respectively) and Hispanic/Latino MSM (59% and 67%) compared with White MSM (64% and 74%). Experiences of HIV-related stigma among those with an HIV diagnosis were higher among Black MSM (median = 33; scale = 0-100) and Hispanic/Latino MSM (32) compared with White MSM (26). MSM aged 18-24 years had the lowest adherence to ART (45%) and the highest median stigma score (39). CONCLUSION: Improving access to and use of HIV services for MSM, especially Black MSM, Hispanic/Latino MSM, and younger MSM, and addressing social determinants of health, such as HIV-related stigma, that contribute to unequal outcomes will be essential to end the HIV epidemic in the United States.

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

BACKGROUND: Life expectancy for persons with human immunodeficiency virus (HIV) infection who receive recommended treatment can approach that of the general population, yet HIV remains among the 10 leading causes of death among certain populations. Using surveillance data, CDC assessed progress toward reducing deaths among persons with diagnosed HIV (PWDH). METHODS: CDC analyzed National HIV Surveillance System data for persons aged ≥13 years to determine age-adjusted death rates per 1,000 PWDH during 2010-2018. Using the International Classification of Diseases, Tenth Revision, deaths with a nonmissing underlying cause were classified as HIV-related or non-HIV-related. Temporal changes in total deaths during 2010-2018 and deaths by cause during 2010-2017 (2018 excluded because of delays in reporting), by demographic characteristics, transmission category, and U.S. Census region of residence at time of death were calculated. RESULTS: During 2010-2018, rates of death decreased by 36.6% overall (from 19.4 to 12.3 per 1,000 PWDH). During 2010-2017, HIV-related death rates decreased 48.4% (from 9.1 to 4.7), whereas non-HIV-related death rates decreased 8.6% (from 9.3 to 8.5). Rates of HIV-related deaths during 2017 were highest by race/ethnicity among persons of multiple races (7.0) and Black/African American persons (5.6), followed by White persons (3.9) and Hispanic/Latino persons (3.9). The HIV-related death rate was highest in the South (6.0) and lowest in the Northeast (3.2). CONCLUSION: Early diagnosis, prompt treatment, and maintaining access to high-quality care and treatment have been successful in reducing HIV-related deaths and remain necessary for continuing reductions in HIV-related deaths.

BACKGROUND: Some persons who achieve viral suppression may later experience viral rebound, potentially putting them at risk for transmitting HIV. We estimate the prevalence of, and describe factors associated with, viral rebound among adults with diagnosed HIV in the United States who had >/=2 viral load tests in a 12-month period. SETTING: The Medical Monitoring Project (MMP) is an annual cross-sectional survey about the experiences and needs of adults with diagnosed HIV sampled from the National HIV Surveillance System (NHSS). METHODS: We analyzed interview and medical record data from three MMP cycles spanning June 2015-May 2018. We analyzed viral load results from the 12-month period before the interview among persons with >/=2 viral load tests who achieved viral suppression. Data were weighted based on known probabilities of selection, adjusted for patient nonresponse, and post-stratified to known population totals from NHSS. RESULTS: Among those with >/=2 viral load tests who achieved viral suppression, 7.5% demonstrated viral rebound. In multivariable analyses, viral rebound was higher among non-Hispanic blacks, persons ages 18-39, persons with public insurance, persons recently experiencing homelessness, persons with higher numbers of viral load tests, persons who missed HIV care appointments, and persons with sub-optimal adherence to antiretroviral therapy. CONCLUSIONS: Viral rebound varied by sociodemographic and clinical characteristics. HIV providers can monitor persons at greatest risk for viral rebound and link patients with ancillary services or evidence-based interventions to help them remain virally suppressed. Our findings can inform strategies and interventions implemented under the Ending the HIV Epidemic initiative.

The Medical Monitoring Project (MMP) is an HIV surveillance system that provides national estimates of HIV-related behaviors and clinical outcomes. When first implemented, MMP excluded persons living with HIV not receiving HIV care. This analysis will describe new case-surveillance-based methods to identify and recruit persons living with HIV who are out of care and at elevated risk for mortality and ongoing HIV transmission. Stratified random samples of all persons living with HIV were selected from the National HIV Surveillance System in five public health jurisdictions from 2012-2014. Sampled persons were located and contacted through seven different data sources and five methods of contact to collect interviews and medical record abstractions. Data were weighted for non-response and case reporting delay. The modified sampling methodology yielded 1159 interviews (adjusted response rate, 44.5%) and matching medical record abstractions for 1087 (93.8%). Of persons with both interview and medical record data, 264 (24.3%) would not have been included using prior MMP methods. Significant predictors were identified for successful contact (e.g., retention in care, adjusted Odds Ratio [aOR] 5.02; 95% Confidence Interval [CI] 1.98-12.73), interview (e.g. moving out of jurisdiction, aOR 0.24; 95% CI: 0.12-0.46) and case reporting delay (e.g. rural residence, aOR 3.18; 95% CI: 2.09-4.85). Case-surveillance-based sampling resulted in a comparable response rate to existing MMP methods while providing information on an important new population. These methods have since been adopted by the nationally representative MMP surveillance system, offering a model for public health program, research and surveillance endeavors seeking inclusion of all persons living with HIV.

In February 2019, the U.S. Department of Health and Human Services proposed a strategic initiative to end the human immunodeficiency (HIV) epidemic in the United States by reducing new HIV infections by 90% during 2020-2030* (1). Phase 1 of the Ending the HIV Epidemic initiative focuses on Washington, DC; San Juan, Puerto Rico; and 48 counties where the majority of new diagnoses of HIV infection in 2016 and 2017 were concentrated and on seven states with a disproportionate occurrence of HIV in rural areas relative to other states.(dagger) One of the four pillars in the initiative is protecting persons at risk for HIV infection using proven, comprehensive prevention approaches and treatments, such as HIV preexposure prophylaxis (PrEP), which is the use of antiretroviral medications that have proven effective at preventing infection among persons at risk for acquiring HIV. In 2014, CDC released clinical PrEP guidelines to health care providers (2) and intensified efforts to raise awareness and increase the use of PrEP among persons at risk for infection, including gay, bisexual, and other men who have sex with men (MSM), a group that accounted for an estimated 68% of new HIV infections in 2016 (3). Data from CDC's National HIV Behavioral Surveillance (NHBS) were collected in 20 U.S. urban areas in 2014 and 2017, covering 26 of the geographic areas included in Phase I of the Ending the HIV Epidemic initiative, and were compared to assess changes in PrEP awareness and use among MSM. From 2014 to 2017, PrEP awareness increased by 50% overall, with >80% of MSM in 17 of the 20 urban areas reporting PrEP awareness in 2017. Among MSM with likely indications for PrEP (e.g., sexual risk behaviors or recent bacterial sexually transmitted infection [STI]), use of PrEP increased by approximately 500% from 6% to 35%, with significant increases observed in all urban areas and in almost all demographic subgroups. Despite this progress, PrEP use among MSM, especially among black and Hispanic MSM, remains low. Continued efforts to improve coverage are needed to reach the goal of 90% reduction in HIV incidence by 2030. In addition to developing new ways of connecting black and Hispanic MSM to health care providers through demonstration projects, CDC has developed resources and tools such as the Prescribe HIV Prevention program to enable health care providers to integrate PrEP into their clinical care.( section sign) By routinely testing their patients for HIV, assessing HIV-negative patients for risk behaviors, and prescribing PrEP as needed, health care providers can play a critical role in this effort.

Since 2006, CDC has recommended universal screening for human immunodeficiency virus (HIV) infection at least once in health care settings and at least annual rescreening of persons at increased risk for infection (1,2), but data from national surveys and HIV surveillance demonstrate that these recommendations have not been fully implemented (3,4). The national Ending the HIV Epidemic initiative* is intended to reduce the number of new infections by 90% from 2020 to 2030. The initiative focuses first on 50 local jurisdictions (48 counties, the District of Columbia, and San Juan, Puerto Rico) where the majority of new diagnoses of HIV infection in 2016 and 2017 were concentrated and seven states with a disproportionate occurrence of HIV in rural areas relative to other states (i.e., states with at least 75 reported HIV diagnoses in rural areas that accounted for >/=10% of all diagnoses in the state).(dagger) This initial geographic focus will be followed by wider implementation of the initiative within the United States. An important goal of the initiative is the timely identification of all persons with HIV infection as soon as possible after infection (5). CDC analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS)( section sign) to assess the percentage of adults tested for HIV in the United States nationwide (38.9%), in the 50 local jurisdictions (46.9%), and in the seven states (35.5%). Testing percentages varied widely by jurisdiction but were suboptimal and generally low in jurisdictions with low rates of diagnosis of HIV infection. To achieve national goals and end the HIV epidemic in the United States, strategies must be tailored to meet local needs. Novel screening approaches might be needed to reach segments of the population that have never been tested for HIV.

PURPOSE: To assess sampling bias in national viral suppression (VS) estimates derived from the Medical Monitoring Project (MMP) resulting from use of an abbreviated (four-month) annual sampling period. We aimed to improve VS estimates using cohort data from the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) and a novel cohort-adjustment method. METHODS: Using full calendar years of NA-ACCORD data, we assessed timing of HIV care attendance (inside vs. exclusively outside MMP's four-month sampling period), VS status at last test (<200 vs. >/=200 copies/mL), and associated demographics. These external estimates were used to standardize MMP to NA-ACCORD data with multivariable regression models of care attendance and VS, yielding adjusted 2009-2013 VS estimates with 95% confidence intervals. RESULTS: Weighted percentages of VS among persons in HIV care were 67% in 2009 and 77% in 2013. These estimates are slightly lower than previously published MMP estimates (72% and 80% in 2009 and 2013, respectively). The number of persons receiving HIV care was previously underestimated by 20%, because patients receiving care exclusively outside the MMP sampling period did not contribute toward the weighted population estimate. CONCLUSIONS: Careful examination of national surveillance estimates using data triangulation and novel methodologies can improve the robustness of VS estimates.

This study uses National HIV Behavioral Surveillance survey data to estimate the proportion of men who have sex with men and persons who inject drugs unaware of their HIV infection who missed opportunities for testing and diagnosis in clinical settings.

Since 2006, CDC has recommended routine screening of all persons aged 13-64 years for human immunodeficiency virus (HIV) and at least annual rescreening of persons at higher risk (1). However, national surveillance data indicate that many persons at higher risk for HIV infection are not screened annually, and delays in diagnosis persist (2). CDC analyzed 2006-2016 data from the General Social Survey (GSS)* and estimated that only 39.6% of noninstitutionalized U.S. adults had ever tested for HIV. Among persons ever tested, the estimated median interval since last test was 1,080 days or almost 3 years. Only 62.2% of persons who reported HIV-related risk behaviors in the past 12 months were ever tested for HIV, and the median interval since last test in this group was 512 days (1.4 years). The percentage of persons ever tested and the interval since last test remained largely unchanged during 2006-2016. More frequent screening of persons with ongoing HIV risk is needed to achieve full implementation of CDC's screening recommendations and to prevent new infections. Integration of routine screening as standard clinical practice through existing strategies, such as electronic medical record prompts (3), or through new, innovative strategies might be needed to increase repeat screening of persons with ongoing risk.

CDC has estimated HIV viral suppression (VS) using two data sources. The National HIV Surveillance System estimate (50% of HIV-diagnosed persons in 2012) is derived from viral load reporting from a subset of jurisdictions that vary yearly. The Medical Monitoring Project (MMP) estimate (42% in 2012) is based on a sample of persons receiving HIV care during the first 4 months of each year. We developed the Cohort-adjustment Method to reconstruct VS estimates, accounting for persons receiving care later in the year. Using the HIV Outpatient Study cohort, we assessed timing of care receipt, demographics, and VS at last test (<200 vs. >/=200 copies/mL), standardizing MMP to HIV Outpatient Study data using multivariable regression models and yielding adjusted VS estimates. We estimated 52% (95% CI: 48, 56) of HIV-diagnosed persons achieved VS in 2012. Differences from previously published estimate were due to: 1) 23% underestimation of persons receiving HIV care and 2) lower VS rates among persons receiving care outside versus inside the 4-month MMP sampling period (79% vs. 88%). This methodology yielded VS estimates closer to the National HIV Surveillance System estimate than previously published. Use of more, geographically diverse cohort data may enable assessment of temporal trends.

INTRODUCTION: Human immunodeficiency virus (HIV) case surveillance and other health care databases are increasingly being used for public health action, which has the potential to optimize the health outcomes of people living with HIV (PLWH). However, often PLWH cannot be located based on the contact information available in these data sources. We assessed the accuracy of contact information for PLWH in HIV case surveillance and additional data sources and whether time since diagnosis was associated with accurate contact information in HIV case surveillance and successful contact. MATERIALS AND METHODS: The Case Surveillance-Based Sampling (CSBS) project was a pilot HIV surveillance system that selected a random population-based sample of people diagnosed with HIV from HIV case surveillance registries in 5 state and metropolitan areas. From November 2012 through June 2014, CSBS staff members attempted to locate and interview 1800 sampled people and used 22 data sources to search for contact information. RESULTS: Among 1063 contacted PLWH, HIV case surveillance data provided accurate telephone number, address, or HIV care facility information for 239 (22%), 412 (39%), and 827 (78%) sampled people, respectively. CSBS staff members used additional data sources, such as support services and commercial people-search databases, to locate and contact PLWH with insufficient contact information in HIV case surveillance. PLWH diagnosed <1 year ago were more likely to have accurate contact information in HIV case surveillance than were PLWH diagnosed >/=1 year ago ( P = .002), and the benefit from using additional data sources was greater for PLWH with more longstanding HIV infection ( P < .001). PRACTICE IMPLICATIONS: When HIV case surveillance cannot provide accurate contact information, health departments can prioritize searching additional data sources, especially for people with more longstanding HIV infection.

BACKGROUND: Persons unaware of their human immunodeficiency virus (HIV) infection account for approximately 40% of ongoing transmissions in the United States. Persons are unaware of their infection because of delayed HIV diagnoses that represent substantial missed opportunities to improve health outcomes and prevent HIV transmission. METHODS: Data from CDC's National HIV Surveillance System were used to estimate, among persons with HIV infection diagnosed in 2015, the median interval (and range) from infection to diagnosis (diagnosis delay), based on the first CD4 test after HIV diagnosis and a CD4 depletion model indicating disease progression and, among persons living with HIV in 2015, the percentage with undiagnosed infection. Data from CDC's National HIV Behavioral Surveillance were analyzed to determine the percentage of persons at increased risk for HIV infection who had tested in the past 12 months and who had missed opportunities for testing. RESULTS: An estimated 15% of persons living with HIV in 2015 were unaware of their infection. Among the 39,720 persons with HIV infection diagnosed in 2015, the estimated median diagnosis delay was 3.0 years (interquartile range = 0.7-7.8 years); diagnosis delay varied by race/ethnicity (from 2.2 years among whites to 4.2 years among Asians) and transmission category (from 2.0 years among females who inject drugs to 4.9 years among heterosexual males). Among persons interviewed through National HIV Behavioral Surveillance, 71% of men who have sex with men, 58% of persons who inject drugs, and 41% of heterosexual persons at increased risk for HIV infection reported testing in the past 12 months. In each risk group, at least two thirds of persons who did not have an HIV test had seen a health care provider in the past year. CONCLUSIONS: Delayed HIV diagnoses continue to be substantial for some population groups and prevent early entry to care to improve health outcomes and reduce HIV transmission to others. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Health care providers and others providing HIV testing can reduce HIV-related adverse health outcomes and risk for HIV transmission by implementing routine and targeted HIV testing to decrease diagnosis delays.

The Centers for Disease Control and Prevention (CDC) recommended in 2006 that sexually active gay, bisexual, and other men who have sex with men (MSM) be screened for human immunodeficiency virus (HIV) at least annually. A workgroup comprising CDC and external experts conducted a systematic review of the literature, including benefits, harms, acceptability, and feasibility of annual versus more frequent screening among MSM, to determine whether evidence was sufficient to change the current recommendation. Four consultations with managers of public and nonprofit HIV testing programs, clinics, and mathematical modeling experts were conducted to provide input on the programmatic and scientific evidence. Mathematical models predicted that more frequent than annual screening of MSM could prevent some new HIV infections and would be more cost-effective than annual screening, but this evidence was considered insufficient due to study design. Evidence supports CDC's current recommendation that sexually active MSM be screened at least annually. However, some MSM might benefit from more frequent screening. Future research should evaluate which MSM subpopulations would benefit most from more frequent HIV screening.

CDC's 2006 recommendations for human immunodeficiency virus (HIV) testing state that all persons aged 13-64 years should be screened for HIV at least once, and that persons at higher risk for HIV infection, including sexually active gay, bisexual, and other men who have sex with men (MSM), should be rescreened at least annually (1). Authors of reports published since 2006, including CDC (2), suggested that MSM, a group that is at highest risk for HIV infection, might benefit from being screened more frequently than once each year. In 2013, the U.S. Preventive Services Task Force (USPSTF) found insufficient evidence to specify an HIV rescreening interval but recommended annual screening for MSM as a reasonable approach (3). However, some HIV providers have begun to offer more frequent screening, such as once every 3 or 6 months, to some MSM. A CDC work group conducted a systematic literature review and held four expert consultations to review programmatic experience to determine whether there was sufficient evidence to change the 2006 CDC recommendation (i.e., at least annual HIV screening of MSM in clinical settings). The CDC work group concluded that the evidence remains insufficient to recommend screening more frequently than at least once each year. CDC continues to recommend that clinicians screen asymptomatic sexually active MSM at least annually. Each clinician can consider the benefits of offering more frequent screening (e.g., once every 3 or 6 months) to individual MSM at increased risk for acquiring HIV infection, weighing their patients' individual risk factors, local HIV epidemiology, and local testing policies.

BACKGROUND: Internet-based platforms are increasingly prominent interfaces for social and sexual networking among men who have sex with men (MSM). METHODS: MSM were recruited through venue-based sampling in 2008, 2011, and 2014 in 20 US cities. We examined changes in internet use (IU) to meet men and in meeting the last partner online among MSM from 2008 to 2014 using Poisson regression with generalized estimating equations to calculate adjusted prevalence ratios (APRs). We also examined factors associated with increased frequency of IU using data from 2014. IU was categorized as never, infrequent use (<once a week), and frequent use (≥once a week). RESULTS: Frequent IU increased from 21% in 2008 to 44% in 2014 (APR = 1.39, 95% confidence interval: 1.36 to 1.42), and having met the last partner online increased from 19% in 2008 to 32% in 2014 (APR = 1.30, 95% confidence interval: 1.26 to 1.34). Those who never used the internet had fewer partners (median of 2 in the past 12 months, interquartile range: 1-4) compared with infrequent (4, 2-7) and frequent users (5, 3-12). HIV testing in the past 12 months also increased with increasing IU (58%, 68%, and 71%, respectively, P < 0.0001). Among HIV-positive participants, the percent HIV-positive awareness increased as IU increased (71%, 75%, and 79%, P < 0.005). CONCLUSIONS: Both IU to meet men and meeting the last partner online increased since 2008. Although men who used the internet more frequently reported more partners in the past 12 months, they were also more likely to report testing in the past 12 months and were more likely to be HIV-positive aware.

The National HIV Behavioral Surveillance system was designed to monitor risk factors for HIV infection and HIV prevalence among individuals at higher risk for HIV infection, that is, sexually active men who have sex with men who attend venues, persons who recently injected drugs, and heterosexuals of low socioeconomic status living in urban areas. These groups were selected as priorities for behavioral surveillance because they represent the major HIV transmission routes and the populations with the highest HIV burden. Accurate data on the behaviors in these populations are critical for understanding trends in HIV infections and planning and evaluating effective HIV prevention activities. The articles in this supplement illustrate how National HIV Behavioral Surveillance data can be used to assess HIV risk behaviors, prevalence, and service utilization of the populations most affected by HIV in the United States and guide local and national high-impact prevention strategies to meet national HIV prevention goals.

OBJECTIVE: To assess whether state criminal exposure laws are associated with HIV and stage 3 (AIDS) diagnosis rates in the United States. DESIGN: We assessed the relationship between HIV and stage 3 (AIDS) diagnosis data from the National HIV Surveillance System and the presence of a state criminal exposure law as identified through WestlawNext by using generalized estimating equations. METHODS: We limited analysis to persons aged ≥13 years with diagnosed HIV infection or AIDS reported to the National HIV Surveillance System of the Centers for Disease Control and Prevention. The primary outcome measures were rates of diagnosis of HIV (2001-2010 in 33 states) and AIDS (1994-2010 in 50 states) per 100,000 individuals per year. In addition to criminal exposure laws, state-level factors evaluated for inclusion in models included income, unemployment, poverty, education, urbanicity, and race/ethnicity. RESULTS: At the end of the study period, 30 states had laws criminalizing HIV exposure. In bivariate models (P < .05), unemployment, poverty, education, urbanicity, and race/ethnicity were associated with HIV and AIDS diagnoses. In final models, proportion of adults with less than a high school education and percentage of the population living in urban areas were significantly associated with HIV and AIDS diagnoses over time; criminal exposure laws were not associated with diagnosis rates. CONCLUSIONS: We found no association between HIV or AIDS diagnosis rates and criminal exposure laws across states over time, suggesting that these laws have had no detectable HIV prevention effect.

BACKGROUND: The best indicator of the impact of human immunodeficiency virus (HIV) prevention programs is the incidence of infection; however, HIV is a chronic infection and HIV diagnoses may include infections that occurred years before diagnosis. Alternative methods to estimate incidence use diagnoses, stage of disease, and laboratory assays of infection recency. Using a consistent, accurate method would allow for timely interpretation of HIV trends. OBJECTIVE: The objective of our study was to assess the recent progress toward reducing HIV infections in the United States overall and among selected population segments with available incidence estimation methods. METHODS: Data on cases of HIV infection reported to national surveillance for 2008-2013 were used to compare trends in HIV diagnoses, unadjusted and adjusted for reporting delay, and model-based incidence for the US population aged ≥13 years. Incidence was estimated using a biomarker for recency of infection (stratified extrapolation approach) and 2 back-calculation models (CD4 and Bayesian hierarchical models). HIV testing trends were determined from behavioral surveys for persons aged ≥18 years. Analyses were stratified by sex, race or ethnicity (black, Hispanic or Latino, and white), and transmission category (men who have sex with men, MSM). RESULTS: On average, HIV diagnoses decreased 4.0% per year from 48,309 in 2008 to 39,270 in 2013 (P<.001). Adjusting for reporting delays, diagnoses decreased 3.1% per year (P<.001). The CD4 model estimated an annual decrease in incidence of 4.6% (P<.001) and the Bayesian hierarchical model 2.6% (P<.001); the stratified extrapolation approach estimated a stable incidence. During these years, overall, the percentage of persons who ever had received an HIV test or had had a test within the past year remained stable; among MSM testing increased. For women, all 3 incidence models corroborated the decreasing trend in HIV diagnoses, and HIV diagnoses and 2 incidence models indicated decreases among blacks and whites. The CD4 and Bayesian hierarchical models, but not the stratified extrapolation approach, indicated decreases in incidence among MSM. CONCLUSIONS: HIV diagnoses and CD4 and Bayesian hierarchical model estimates indicated decreases in HIV incidence overall, among both sexes and all race or ethnicity groups. Further progress depends on effectively reducing HIV incidence among MSM, among whom the majority of new infections occur.

BACKGROUND: Persons who inject drugs (PWID) are at increased risk for poor health outcomes and bloodborne infections, including human immunodeficiency virus (HIV), hepatitis C virus and hepatitis B virus infections. Although substantial progress has been made in reducing HIV infections among PWID, recent changes in drug use could challenge this success. METHODS: CDC used National HIV Surveillance System data to analyze trends in HIV diagnoses. Further, National HIV Behavioral Surveillance interviews of PWID in 22 cities were analyzed to describe risk behaviors and use of prevention services among all PWID and among PWID who first injected drugs during the 5 years before their interview (new PWID). RESULTS: During 2008-2014, HIV diagnoses among PWID declined in urban and nonurban areas, but have leveled off in recent years. Among PWID in 22 cities, during 2005-2015, syringe sharing decreased by 34% among blacks/African Americans (blacks) and by 12% among Hispanics/Latinos (Hispanics), but remained unchanged among whites. The racial composition of new PWID changed during 2005-2015: the percentage who were black decreased from 38% to 19%, the percentage who were white increased from 38% to 54%, and the percentage who were Hispanic remained stable. Among new PWID interviewed in 2015, whites engaged in riskier injection behaviors than blacks. CONCLUSIONS: Decreases in HIV diagnoses among PWID indicate success in HIV prevention. However, emerging behavioral and demographic trends could reverse this success. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Access to comprehensive prevention services is essential for all PWID. Syringe services programs reduce syringe sharing and can help PWID access prevention and treatment services for HIV and other bloodborne diseases, such as hepatitis C and hepatitis B.

We appreciate the correspondence by Kippax and Holt [1] regarding explanations for the increases in condomless sex. We agree that there may have been changes in social norms due to the effectiveness of antiretroviral therapy (ART) that are not captured by our survey. Furthermore, the measures we used for seroadaptive behaviors were based on participants’ last sex act and do not reflect the complexities of negotiations for safer sex throughout a partnership. However, we disagree with Kippax and Holt [1] who propose that the predominance of concordant condomless sex in the survey suggests an increase in seroadaptive strategies. The percentage of condomless sex partnerships that was concordant does not increase over time. Further, seroadaptive behaviors are predicated on engaging in different sexual practices according to whether partners are HIV seroconcordant or serodiscordant. The important question is not whether concordant condomless sex is more likely than discordant condomless, as suggested by Kippax and Holt [1], but whether concordant condomless sex is more likely than would be expected by chance alone. If men are consciously choosing partners of the same serostatus, there should be more positive–positive and negative– negative partnerships than would occur by chance according to the marginal probabilities dictated by HIV prevalence and the number of partnerships in our sample. Using a Z test, we compared observed and expected percentages of concordant partnerships. Among MSM reporting condomless sex at last sex using all years combined, 15% were HIV-positive, 76% were HIV-negative, and 9% had unknown HIV status. We used this distribution to compute the expected frequencies of concordant condomless sex partnerships. Among condomless sex partnerships at last sex, 52% were HIV-negative concordant and 9% were HIV-positive concordant. We found evidence suggesting that HIV-negative MSM are not serosorting; they report concordant partners less frequently than what would be expected through random mixing when they engage in condomless anal sex (52% observed vs. 57% expected, P < 0.001), possibly due to insufficient information about their partners’ HIV status. In contrast, our data suggest that HIV-positive MSM may be purposely serosorting when they engage in condomless sex (9% observed vs. 2% expected, P < 0.001). Therefore, although we found evidence to suggest that HIV-positive MSM may be serosorting, the preponderance of concordant partnerships among HIV-negative MSM is not beyond what would be expected through random mixing.

The prevalence of diagnosed human immunodeficiency virus (HIV) infection in Hispanics/Latinos in the United States is more than twice as high as the prevalence among non-Hispanic whites (1). Services that support retention in HIV medical care and assist with day-to-day living, referred to here as ancillary services, help persons living with HIV access HIV medical care, adhere to HIV treatment, and attain HIV viral suppression. The needs for these ancillary services among Hispanics/Latinos are not well described (2). To obtain nationally representative estimates of and reasons for unmet needs for such services among Hispanic/Latino adults receiving outpatient HIV medical care during 2013-2014, CDC analyzed data from the Medical Monitoring Project (MMP). The analysis found that Hispanics/Latinos in all age and sexual orientation/behavior subgroups reported substantial unmet needs, including 24% needing dental care, 21% needing eye or vision care, 15% needing food and nutrition services, and 9% needing transportation assistance. Addressing unmet needs for ancillary services among Hispanics/Latinos living with HIV might help increase access to HIV care, improve health outcomes, and reduce health disparities.

OBJECTIVE: Evaluate changes in condomless anal sex at last sex among men who have sex with men (MSM) and assess if these changes are associated with the adoption of serosorting and biomedical prevention. DESIGN: The National HIV Behavioral Surveillance is a crosssectional survey done in up to 21 cities in 2005, 2008, 2011 and 2014. METHODS: MSM were recruited through venue-based sampling. Among men reporting at least one male partner, we evaluated changes in condomless anal sex at last sex with a partner with (1) HIV-concordant (proxy for serosorting) or (2) HIV-discordant (discordant/unknown) status. We hypothesized that if concordant condomless sex was increasing while discordant was stable/declining, the increases could be driven by more men attempting to serosort. We used generalized estimating equations assuming a Poisson distribution and robust variance estimator to explore whether temporal changes in the outcomes varied by selected characteristics. We also assessed changes in condomless anal sex by antiretroviral therapy (ART) use among HIV-positive MSM. RESULTS: Among 5371 HIV-positive MSM, there were increases in concordant (19% in 2005 to 25% in 2014, P < 0.001) and discordant condomless sex (15 to 19%, P < 0.001). The increases were not different by ART use. Among 30 547 HIV-negative MSM, concordant (21 to 27%, P < 0.001) and discordant condomless sex (8 to 13%, P < 0.001) increased. CONCLUSION: Our data suggest that condom use decreased among MSM and that the trends are not explained by serosorting or ART. Promotion of condoms and increased access to preexposure prophylaxis are vital to ensure that the benefits of ART in reducing transmission of HIV are not undermined.

We describe receipt of clinical and prevention services, clinical outcomes, and sexual risk behaviors among young adult HIV patients in the United States during 2009-2013, using a sample designed to produce nationally representative estimates. Compared with older HIV patients, proportionately more young adults received provider-delivered prevention services and reported sexual risk behaviors. Young adults had similar care patterns as older HIV patients, but were less likely to have or adhere to an antiretroviral therapy prescription and achieve viral suppression. These estimates establish a national baseline from which to monitor changes in clinical outcomes and transmission behaviors among young HIV-infected adults.

BACKGROUND: In 2014, approximately 40,000 persons in the United States received a diagnosis of human immunodeficiency virus (HIV) infection. Preexposure prophylaxis (PrEP) with daily oral antiretroviral medication is a new, highly effective intervention that could reduce the number of new HIV infections. METHODS: CDC analyzed nationally representative data to estimate the percentages and numbers of persons in the United States, by transmission risk group, with indications for PrEP consistent with the 2014 U.S. Public Health Service's PrEP clinical practice guideline. RESULTS: Approximately 24.7% of sexually active adult men who have sex with men (MSM) (492,000 [95% confidence interval {CI} = 212,000-772,000]), 18.5% of persons who inject drugs (115,000 [CI = 45,000-185,000]), and 0.4% of heterosexually active adults (624,000 [CI = 404,000-846,000]), had substantial risks for acquiring HIV consistent with PrEP indications. CONCLUSIONS: Based on current guidelines, many MSM, persons who inject drugs, and heterosexually active adults have indications for PrEP. A higher percentage of MSM and persons who inject drugs have indications for PrEP than heterosexually active adults, consistent with distribution of new HIV diagnoses across these populations. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Clinical organizations, health departments, and community-based organizations should raise awareness of PrEP among persons with substantial risk for acquiring HIV infection and their health care providers. These data can be used to inform scale-up and evaluation of PrEP coverage. Increasing delivery of PrEP and other highly effective HIV prevention services could lower the number of new HIV infections occurring in the United States each year.