Last data update: Dec 09, 2024. (Total: 48320 publications since 2009)
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Query Trace: Purcell D[original query] |
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Population percentage and population size of men who have sex with men in the United States, 2017-2021: Meta-analysis of 5 population-based surveys
Bennett BW , DuBose S , Huang YA , Johnson CH , Hoover KW , Wiener J , Purcell DW , Sullivan PS . JMIR Public Health Surveill 2024 10 e56643 BACKGROUND: Male-to-male sexual transmission continues to account for the greatest proportion of new HIV diagnoses in the United States. However, calculating population-specific surveillance metrics for HIV and other sexually transmitted infections requires regularly updated estimates of the number and proportion of men who have sex with men (MSM) in the United States, which are not collected by census surveys. OBJECTIVE: The purpose of this analysis was to estimate the number and percentage of MSM in the United States from population-based surveys. METHODS: We used data from 5 population-based surveys to calculate weighted estimates of the proportion of MSM in the United States and pooled these estimates using meta-analytic procedures. We estimated the proportion of MSM using sexual behavior-based questions (encompassing anal or oral sex) for 3 recall periods-past 12 months, past 5 years, and lifetime. In addition, we estimated the proportion of MSM using self-reported identity and attraction survey responses. The total number of MSM and non-MSM in the United States were calculated from estimates of the percentage of MSM who reported sex with another man in the past 12 months. RESULTS: The percentage of MSM varied by recall period: 3.3% (95% CI 1.7%-4.9%) indicated sex with another male in the past 12 months, 4.7% (95% CI 0.0%-33.8%) in the past 5 years, and 6.2% (95% CI 2.9%-9.5%) in their lifetime. There were comparable percentages of men who identified as gay or bisexual (3.4%, 95% CI 2.2%-4.6%) or who indicated that they are attracted to other men (4.9%, 95% CI 3.1%-6.7%) based on pooled estimates. Our estimate of the total number of MSM in the United States is 4,230,000 (95% CI 2,179,000-6,281,000) based on the history of recent sexual behavior (sex with another man in the past 12 months). CONCLUSIONS: We calculated the pooled percentage and number of MSM in the United States from a meta-analysis of population-based surveys collected from 2017 to 2021. These estimates update and expand upon those derived from the Centers for Disease Control and Prevention in 2012 by including estimates of the percentage of MSM based on sexual identity and sexual attraction. The percentage and number of MSM in the United States is an important indicator for calculating population-specific disease rates and eligibility for preventive interventions such as pre-exposure prophylaxis. |
Enhanced federal collaborations in implementation science and research of HIV prevention and treatment
Purcell DW , Namkung Lee A , Dempsey A , Gordon C . J Acquir Immune Defic Syndr 2022 90 S17-s22 Over the past decade, national initiatives in the United States (U.S.) have focused HIV prevention and care programs and research to optimize the delivery of HIV prevention and treatment through implementation research. Although existing biomedical and behavioral prevention tools could end HIV in the U.S., the implementation of these tools has been uneven because of many factors, including organizational capacity, insufficient uptake by key populations, lack of success with prioritizing by geography or population growth, and inadequate scaling. To address these challenges, the federal government has funded programs, research, and evaluation projects aimed at improving health outcomes among people with HIV and people vulnerable to HIV acquisition. Increasingly, several special federal efforts are being conducted under the umbrella of "implementation science and research" that are essential components to scaling up evidence-based HIV prevention and treatment interventions in the U.S. This paper describes federal collaborations that have supported this increased focus on implementation from the perspective of 3 agencies in the U.S. Department of Health and Human Services; the Centers for Disease Control and Prevention, the National Institutes of Health, and the Health Resources and Services Administration. These federal collaborations have resulted in improved communication and coordination of efforts in the shaping and alignment of priorities in research and service delivery, increased implementation research conducted in real-world community and clinical settings and provided a feedback loop to expedite action in response to emerging evidence from such projects. |
Optimizing HIV prevention efforts to achieve EHE incidence targets
Jacobson EU , Hicks KA , Carrico J , Purcell DW , Green TA , Mermin JH , Farnham PG . J Acquir Immune Defic Syndr 2022 89 (4) 374-380 BACKGROUND: A goal of the US Department of Health and Human Services' Ending the HIV Epidemic (EHE) in the United States initiative is to reduce the annual number of incident HIV infections in the United States by 75% within 5 years and by 90% within 10 years. We developed a resource allocation analysis to understand how these goals might be met. METHODS: We estimated the current annual societal funding [$2.8 billion (B)/yr] for 14 interventions to prevent HIV and facilitate treatment of infected persons. These interventions included HIV testing for different transmission groups, HIV care continuum interventions, pre-exposure prophylaxis, and syringe services programs. We developed scenarios optimizing or reallocating this funding to minimize new infections, and we analyzed the impact of additional EHE funding over the period 2021-2030. RESULTS: With constant current annual societal funding of $2.8 B/yr for 10 years starting in 2021, we estimated the annual incidence of 36,000 new cases in 2030. When we added annual EHE funding of $500 million (M)/yr for 2021-2022, $1.5 B/yr for 2023-2025, and $2.5 B/yr for 2026-2030, the annual incidence of infections decreased to 7600 cases (no optimization), 2900 cases (optimization beginning in 2026), and 2200 cases (optimization beginning in 2023) in 2030. CONCLUSIONS: Even without optimization, significant increases in resources could lead to an 80% decrease in the annual HIV incidence in 10 years. However, to reach both EHE targets, optimization of prevention funding early in the EHE period is necessary. Implementing these efficient allocations would require flexibility of funding across agencies, which might be difficult to achieve. |
Notes from the Field: Multistate Outbreak of Escherichia coli O26 Infections Linked to Raw Flour - United States, 2019
Vasser M , Barkley J , Miller A , Gee E , Purcell K , Schroeder MN , Basler C , Neil KP . MMWR Morb Mortal Wkly Rep 2021 70 (16) 600-601 On February 20, 2019, PulseNet, the molecular subtyping network for foodborne disease surveillance, identified six Shiga toxin–producing Escherichia coli (STEC) O26:H11 infections with the same pulsed-field gel electrophoresis (PFGE) pattern combination. This PFGE pattern combination matched that of infections from a July 2018 outbreak that was associated with ground beef. In response, CDC initiated an investigation with federal, state, and local partners to identify the outbreak source and implement prevention measures. | | CDC defined a case as STEC O26 infection with an isolate matching the outbreak strain by PFGE or related by core genome multilocus sequence typing scheme (cgMLST), with dates of illness onset during December 11, 2018–May 21, 2019. Investigators initially hypothesized that ground beef was the outbreak cause because of the PFGE match to the July 2018 outbreak and because in early interviews, patients commonly reported eating ground beef and leafy greens. Investigators used cgMLST to compare the genetic sequences of isolates from both outbreaks and determined that they fell into separate genetic clades (differing by 6–11 alleles), suggesting that something other than ground beef caused the illness in 2019. CDC noted that one patient consumed raw cookie dough and that most patients were young adult females, similar to demographic distributions of past flour-associated STEC outbreaks (1–3). Investigators developed a supplemental questionnaire focusing on beef, leafy greens, and flour exposures. |
Optimal allocation of societal HIV prevention resources to reduce HIV incidence in the United States
Sansom SL , Hicks KA , Carrico J , Jacobson EU , Shrestha RK , Green TA , Purcell DW . Am J Public Health 2020 111 (1) e1-e8 Objectives. To optimize combined public and private spending on HIV prevention to achieve maximum reductions in incidence.Methods. We used a national HIV model to estimate new infections from 2018 to 2027 in the United States. We estimated current spending on HIV screening, interventions that move persons with diagnosed HIV along the HIV care continuum, pre-exposure prophylaxis, and syringe services programs. We compared the current funding allocation with 2 optimal scenarios: (1) a limited-reach scenario with expanded efforts to serve eligible persons and (2) an ideal, unlimited-reach scenario in which all eligible persons could be served.Results. A continuation of the current allocation projects 331 000 new HIV cases over the next 10 years. The limited-reach scenario reduces that number by 69%, and the unlimited reach scenario by 94%. The most efficient funding allocations resulted in prompt diagnosis and sustained viral suppression through improved screening of high-risk persons and treatment adherence support for those infected.Conclusions. Optimal allocations of public and private funds for HIV prevention can achieve substantial reductions in new infections. Achieving reductions of more than 90% under current funding will require that virtually all infected receive sustained treatment. (Am J Public Health. Published online ahead of print November 19, 2020: e1-e8. https://doi.org/10.2105/AJPH.2020.305965). |
Trajectories of and disparities in HIV prevalence among Black, white, and Hispanic/Latino men who have sex with men in 86 large U.S. Metropolitan Statistical Areas, 1992-2013
Williams LD , Stall R , Tempalski B , Jefferson K , Smith J , Ibragimov U , Hall HI , Satcher Johnson A , Wang G , Purcell DW , Cooper HLF , Friedman SR . Ann Epidemiol 2020 54 52-63 The challenges of producing adequate estimates of HIV prevalence among men who have sex with men (MSM) are well known. Among them are accurately estimating MSM population size and obtaining HIV testing data from unbiased samples. Previous research has produced rigorous estimates of HIV prevalence among MSM in specific geographic locations (e.g., large cities with large populations of MSM), or for a broader range of locations, but only over a relatively short period of time (e.g., one year). No one, to our knowledge, has published annual estimates of HIV prevalence among MSM over an extended period of time and across a wide range of geographic areas. This is an important gap in the literature, given that this information is needed to identify multi-level predictors of change over time in HIV prevalence among MSM and to help target resources to high-need areas - a national priority. This paper integrates data from numerous sources: Centers for Disease Control and Prevention's (CDC) National HIV Surveillance System and National HIV Prevention Monitoring and Evaluation data; estimates of 1992 MSM population size and HIV prevalence and incidence among MSM by Holmberg, 1997; and estimates of HIV among MSM from published literature using 1992-2013 data. It applies multilevel modeling to these data to estimate and validate trajectories of HIV prevalence among MSM from 1992-2013 for 86 of the largest metropolitan statistical areas (MSAs) in the United States. Our estimates indicate that, consistently, HIV prevalence among MSM increased during this time period in each MSA, from an across-MSA mean of 11% in 1992 to 20% in 2013 (with slightly smaller increases among MSAs with the initially-largest HIV burden among MSM; S.D. across all years = 3.5%). Our estimates by racial/ethnic subgroups of MSM suggest higher mean HIV prevalence among minority (Black and Hispanic/Latino) MSM than among white MSM across all years and geographic regions. The consistent increases found in HIV prevalence among all MSM are likely primarily attributable to decreases in mortality among HIV-positive MSM, and are likely secondarily attributable to increasing HIV incidence among racial/ethnic minority subpopulations of MSM. Future research is needed to confirm that these are in fact the factors driving the increases in HIV prevalence observed in our estimates. If so, without detracting from HIV prevention efforts targeting MSM, new healthcare initiatives may be needed which focus on targeted HIV prevention efforts among racial/ethnic minority MSM and on training healthcare providers to address cross-cutting health challenges of increased longevity among HIV-positive MSM populations. |
Policy and public health: Reducing the burden of infectious diseases
Burton DC , Burris S , Mermin JH , Purcell DW , Zeigler SC , Bull-Otterson L , Dean HD . Public Health Rep 2020 135 5s-9s The Centers for Disease Control and Prevention (CDC) works for a future free of HIV/AIDS, viral hepatitis, sexually transmitted diseases (STDs), and tuberculosis (TB). Policy can have powerful effects on the complex, multisectoral factors that influence the population-level morbidity, mortality, and health disparities of these and other diseases.1-4 Public health policy approaches comprise laws, regulations, incentive systems, or other standardized procedures and practices aimed at influencing institutional and individual behavior to improve health and health equity.5,6 Laws and policies that were not designed to achieve health-related objectives also can have important, albeit unintended, health effects. A systematic study of the association between policies and population health is needed to guide the development and implementation of health-promoting policy strategies that are feasible and effective and that minimize harms. This supplemental issue of Public Health Reports provides timely research on policy interventions that have the potential to reduce the incidence, morbidity, or mortality of HIV/AIDS, viral hepatitis, STDs, and TB. Furthermore, the articles in this supplement demonstrate a typology of public health law and policy research that supports vital and comprehensive examination of the evidence on which policy interventions can be based. We summarize the proposed research typology, apply it to the diversity of articles included in this supplement, and discuss future directions for this important field of research. |
Effect of internet-distributed HIV self-tests on HIV diagnosis and behavioral outcomes in men who have sex with men: A randomized clinical trial
MacGowan RJ , Chavez PR , Borkowf CB , Owen SM , Purcell DW , Mermin JH , Sullivan PS . JAMA Intern Med 2019 180 (1) 117-125 Importance: Undiagnosed HIV infection results in delayed access to treatment and increased transmission. Self-tests for HIV may increase awareness of infection among men who have sex with men (MSM). Objective: To evaluate the effect of providing HIV self-tests on frequency of testing, diagnoses of HIV infection, and sexual risk behaviors. Design, Setting, and Participants: This 12-month longitudinal, 2-group randomized clinical trial recruited MSM through online banner advertisements from March through August 2015. Those recruited were at least 18 years of age, reported engaging in anal sex with men in the past year, never tested positive for HIV, and were US residents with mailing addresses. Participants completed quarterly online surveys. Telephone call notes and laboratory test results were included in the analysis, which was completed from August 2017 through December 2018. Interventions: All participants had access to online web-based HIV testing resources and telephone counseling on request. Participants were randomized in a 1:1 ratio to the control group or a self-testing (ST) group, which received 4 HIV self-tests after completing the baseline survey with the option to replenish self-tests after completing quarterly surveys. At study completion, all participants were offered 2 self-tests and 1 dried blood spot collection kit. Main Outcomes and Measures: Primary outcomes were HIV testing frequency (tested >/=3 times during the trial) and number of newly identified HIV infections among participants in both groups and social network members who used the study HIV self-tests. Secondary outcomes included sex behaviors (eg, anal sex, serosorting). Results: Of 2665 participants, the mean (SD) age was 30 (9.6) years, 1540 (57.8%) were white, and 443 (16.6%) had never tested for HIV before enrollment. Retention rates at each time point were more than 54%, and 1991 (74.7%) participants initiated 1 or more follow-up surveys. More ST participants reported testing 3 or more times during the trial than control participants (777 of 1014 [76.6%] vs 215 of 977 [22.0%]; P < .01). The cumulative number of newly identified infections during the trial was twice as high in the ST participants as the control participants (25 of 1325 [1.9%] vs 11 of 1340 [0.8%]; P = .02), with the largest difference in HIV infections identified in the first 3 months (12 of 1325 [0.9%] vs 2 of 1340 [0.1%]; P < .01). The ST participants reported 34 newly identified infections among social network members who used the self-tests. Conclusions and Relevance: Distribution of HIV self-tests provides a worthwhile mechanism to increase awareness of HIV infection and prevent transmission among MSM. Trial Registration: ClinicalTrials.gov identifier: NCT02067039. |
Preparing communities to evacuate for major hurricanes
Kruger J , Avchen RN , Purcell P . Am J Public Health 2019 109 S279-s280 Evacuation plans can be activated to take lifesaving measures. Emergency evacuation is often recommended when authorities determine that moving people away from an area that contains an imminent threat will likely reduce morbidity and mortality related to the pending disaster (e.g., hurricanes, floods). This editorial offers that public health could be more effectively leveraged to promote evacuation recommendations in the face of an impending disaster. |
Factors associated with state variation in mortality among persons living with diagnosed HIV infection
Krueger AL , Van Handel M , Dietz PM , Williams WO , Satcher Johnson A , Klein PW , Cohen S , Mandsager P , Cheever LW , Rhodes P , Purcell DW . J Community Health 2019 44 (5) 963-973 In the United States, the all-cause mortality rate among persons living with diagnosed HIV infection (PLWH) is almost twice as high as among the general population. We aimed to identify amendable factors that state public health programs can influence to reduce mortality among PLWH. Using generalized estimating equations (GEE), we estimated age-group-specific models (24-34, 35-54, >/= 55 years) to assess the association between state-level mortality rates among PLWH during 2010-2014 (National HIV Surveillance System) and amendable factors (percentage of Ryan White HIV/AIDS Program (RWHAP) clients with viral suppression, percentage of residents with healthcare coverage, state-enacted anti-discrimination laws index) while controlling for sociodemographic nonamendable factors. Controlling for nonamendable factors, states with 5% higher viral suppression among RWHAP clients had a 3-5% lower mortality rates across all age groups [adjusted Risk Ratio (aRR): 0.95, 95% Confidence Interval (CI): 0.92-0.99 for 24-34 years, aRR: 0.97, 95%CI: 0.94-0.99 for 35-54 years, aRR: 0.96, 95%CI: 0.94-0.99 for >/= 55 years]; states with 5% higher health care coverage had 4-11% lower mortality rate among older age groups (aRR: 0.96, 95%CI: 0.93-0.99 for 34-54 years; aRR: 0.89, 95%CI: 0.81-0.97 for >/= 55 years); and having laws that address one additional area of anti-discrimination was associated with a 2-3% lower mortality rate among older age groups (aRR: 0.98, 95%CI: 0.95-1.00 for 34-54 years; aRR: 0.97, 95%CI: 0.94-0.99 for >/= 55 years). The mortality rate among PLWH was lower in states with higher levels of residents with healthcare coverage, anti-discrimination laws, and viral suppression among RWHAP clients. States can influence these factors through programs and policies. |
Vital signs: HIV transmission along the continuum of care - United States, 2016
Li Z , Purcell DW , Sansom SL , Hayes D , Hall HI . MMWR Morb Mortal Wkly Rep 2018 68 (11) 267-272 BACKGROUND: In 2016, an estimated 1.1 million persons had human immunodeficiency virus (HIV) infection in the United States; 38,700 were new infections. Knowledge of HIV infection status, behavior change, and antiretroviral therapy (ART) all prevent HIV transmission. Persons who achieve and maintain viral suppression (achieved by most persons within 6 months of starting ART) can live long, healthy lives and pose effectively no risk of HIV transmission to their sexual partners. METHODS: A model was used to estimate transmission rates in 2016 along the HIV continuum of care. Data for sexual and needle-sharing behaviors were obtained from National HIV Behavioral Surveillance. Estimated HIV prevalence, incidence, receipt of care, and viral suppression were obtained from National HIV Surveillance System data. RESULTS: Overall, the HIV transmission rate was 3.5 per 100 person-years in 2016. Along the HIV continuum of care, the transmission rates from persons who were 1) acutely infected and unaware of their infection, 2) non-acutely infected and unaware, 3) aware of HIV infection but not in care, 4) receiving HIV care but not virally suppressed, and 5) taking ART and virally suppressed were 16.1, 8.4, 6.6, 6.1, and 0 per 100 person-years, respectively. The percentages of all transmissions generated by each group were 4.0%, 33.6%, 42.6%, 19.8%, and 0%, respectively. CONCLUSION: Approximately 80% of new HIV transmissions are from persons who do not know they have HIV infection or are not receiving regular care. Going forward, increasing the percentage of persons with HIV infection who have achieved viral suppression and do not transmit HIV will be critical for ending the HIV epidemic in the United States. |
Selecting evidence-based HIV prevention behavioral interventions for HIV-negative persons for national dissemination
Collins CB Jr , Baack BN , Tomlinson H , Lyles C , Cleveland JC , Purcell DW , Ortiz-Ricard A , Mermin J . AIDS Behav 2019 23 (9) 2226-2237 This paper describes the development of a formula to determine which evidence-based behavioral interventions (EBIs) targeting HIV-negative persons would be cost-saving in comparison to the lifetime cost of HIV treatment and the process by which this formula was used to prioritize those with greatest potential impact for continued dissemination. We developed a prevention benefit index (PBI) to rank risk-reduction EBIs for HIV-negative persons based on their estimated cost for achieving the behavior change per one would-be incident infection of HIV. Inputs for calculating the PBI included the mean estimated cost-per-client served, EBI effect size for the behavior change, and the HIV incidence per 100,000 persons in the target population. EBIs for which the PBI was </= $402,000, the estimated lifetime cost of HIV care, were considered cost-saving. We were able to calculate a PBI for 35 EBI and target population combinations. Ten EBIs were cost-saving having a PBI below $402,000. One EBI did not move forward for dissemination due to high start-up dissemination costs. DHAP now supports the dissemination of 9 unique EBIs targeting 13 populations of HIV-negative persons. The application of a process, such as the PBI, may assist other health-field policymakers when making decisions about how to select and fund implementation of EBIs. |
Estimating prevalent diagnoses and rates of new diagnoses of HIV at the state level by age group among men who have sex with men in the United States
Jones J , Grey JA , Purcell DW , Bernstein KT , Sullivan PS , Rosenberg ES . Open Forum Infect Dis 2018 5 (6) ofy124 Background: Men who have sex with men (MSM) in the United States experience a disproportionate rate of diagnosis of HIV. Surveillance data demonstrate age-based disparities among MSM, with higher rates of diagnosis among MSM age </=34 years nationally. Population size estimates within age group at the state level have not been available to determine rates for each state. We estimated the size of the MSM population in 5 age groups in each state and estimated the rate of prevalent HIV diagnoses in 2013 and new HIV diagnoses in 2014. Methods: We used data from the General Social Survey, American Community Survey, and previously published estimates from the National Health and Nutrition Examination Survey to estimate the population of MSM in 5 age groups at the state level. We combined these estimates with surveillance data to estimate age-stratified rates of prevalent diagnoses in 2013 and new diagnoses in 2014 in each state. We estimated standardized prevalence and diagnosis ratios comparing the Northeast, South, and West regions with the Midwest. Results: Rates of prevalent diagnoses increased with increasing age, and rates of new diagnoses were highest among younger age groups. In the United States, the new diagnosis rate among those age 18-24 years in 2014 was 1.4 per 100 MSM without a diagnosis. The highest diagnosis rates were observed among men age </=34 years in the South. Conclusions: Age-stratified estimates of HIV prevalence and new diagnosis rates at the state level can inform public health prevention strategies and resource allocation. |
Estimating national rates of HIV infection among men who have sex with men, persons who inject drugs and heterosexuals in the United States
Crepaz N , Hess KL , Purcell DW , Hall HI . AIDS 2018 33 (4) 701-708 BACKGROUND: Calculating national rates of HIV diagnosis, incidence, and prevalence can quantify disease burden and is important for planning and evaluating programs. We calculated HIV rates among men who have sex with men (MSM), persons who inject drugs (PWID), and heterosexuals in 2010 and 2015. METHODS: We used proportion estimates of the United States population classified as MSM, PWID, and heterosexuals along with census data to calculate the population sizes which were used as the denominators for calculating HIV rates. The numerators (HIV diagnosis, incidence, and prevalence) were based on data submitted to the National HIV Surveillance System through June 2017. RESULTS: The estimated HIV diagnosis and incidence rates in 2015 were 574.7 and 583.6 per 100,000 MSM; 34.3 and 32.7 per 100,000 PWID; and 4.1 and 3.8 per 100,000 heterosexuals. The estimated HIV prevalence in 2015 was 12,372.9 per 100,000 MSM; 1,937.2 per 100,000 PWID; and 126.7 per 100,000 heterosexuals. The HIV diagnosis rates decreased from 2010 to 2015 in all three transmission categories. Blacks had the highest HIV diagnosis rates at both time points. The HIV incidence rates decreased among white MSM, MSM aged 13-24 years, PWID overall, and male and female heterosexuals; however, it increased among MSM aged 25-34 years. CONCLUSIONS: The estimated HIV diagnosis and HIV infection rates decreased for several transmission categories as well as race/ethnicity and age subgroups. MSM continue to be disproportionately affected. Disparities remain and have widened for some groups. Efforts are needed to strengthen prevention, care, and supportive services for all persons with HIV infection. |
Enhancing HIV prevention and care through CAPUS and other demonstration projects aimed at achieving National HIV/AIDS Strategy Goals, 2010-2018
Purcell DW , Flores SA , Koenig LJ , Cleveland JC , Mermin J . Public Health Rep 2018 133 6s-9s Despite advances in HIV prevention and treatment during the past decade, more than 39 000 HIV diagnoses were made in the United States in 2016.1 In addition, persistent disparities in HIV acquisition and care, particularly among men who have sex with men (MSM) and racial/ethnic minority groups, make it difficult to end HIV. To focus our nation’s efforts toward this goal, the first comprehensive National HIV/AIDS Strategy for the United States was released in July 2010 with 4 goals: (1) reduce new HIV infections, (2) increase access to care and improve health outcomes for people with HIV, (3) reduce HIV-related disparities and health inequities, and (4) achieve a more coordinated national response within the federal government and between the federal government and state, local, territorial, and tribal governments.2 In 2015, the National HIV/AIDS Strategy was updated and extended to 2020.3 During the past 8 years, the National HIV/AIDS Strategy has helped focus HIV prevention and care research, programs, and community advocacy. This supplemental issue of Public Health Reports focuses on demonstration projects led or co-led by the Centers for Disease Control and Prevention’s (CDC’s) Division of HIV/AIDS Prevention and funded by the US Department of Health and Human Services (HHS) Secretary’s Minority AIDS Initiative Fund (SMAIF). These projects targeted HIV prevention and improving health outcomes among racial/ethnic minority populations disproportionately affected by HIV. |
Patterns of racial/ethnic disparities and prevalence in HIV and syphilis diagnoses among men who have sex with men, 2016: A novel data visualization
Sullivan PS , Purcell DW , Grey JA , Bernstein KT , Gift TL , Wimbly TA , Hall E , Rosenberg ES . Am J Public Health 2018 108 S266-s273 OBJECTIVES: To describe disparities in HIV infection and syphilis among gay, bisexual, and other men who have sex with men (MSM) in US states through ratio-based measures and graphical depictions of disparities. METHODS: We used state-level surveillance data of reported HIV and syphilis cases in 2015 and 2016, and estimates of MSM population sizes to estimate HIV and syphilis prevalence by race/ethnicity and rate ratios (RRs) and to visually display patterns of disparity and prevalence among US states. RESULTS: State-specific rates of new HIV diagnoses were higher for Black than for White MSM (RR range = 2.35 [Rhode Island] to 10.12 [Wisconsin]) and for Hispanic than for White MSM (RR range = 1.50 [Tennessee] to 5.78 [Pennsylvania]). Rates of syphilis diagnoses were higher for Black than for White MSM in 42 of 44 states (state RR range = 0.89 [Hawaii] to 17.11 [Alaska]). Scatterplots of HIV diagnosis rates by race showed heterogeneity in epidemic scenarios, even in states with similar ratio-based disparity measures. CONCLUSIONS: There is a widely disparate impact of HIV and syphilis among Black and Hispanic MSM compared with White MSM. Between-state variation suggests that states should tailor and focus their prevention responses to best address state data. |
Optimal allocation of HIV prevention funds for state health departments
Yaylali E , Farnham PG , Cohen S , Purcell DW , Hauck H , Sansom SL . PLoS One 2018 13 (5) e0197421 OBJECTIVE: To estimate the optimal allocation of Centers for Disease Control and Prevention (CDC) HIV prevention funds for health departments in 52 jurisdictions, incorporating Health Resources and Services Administration (HRSA) Ryan White HIV/AIDS Program funds, to improve outcomes along the HIV care continuum and prevent infections. METHODS: Using surveillance data from 2010 to 2012 and budgetary data from 2012, we divided the 52 health departments into 5 groups varying by number of persons living with diagnosed HIV (PLWDH), median annual CDC HIV prevention budget, and median annual HRSA expenditures supporting linkage to care, retention in care, and adherence to antiretroviral therapy. Using an optimization and a Bernoulli process model, we solved for the optimal CDC prevention budget allocation for each health department group. The optimal allocation distributed the funds across prevention interventions and populations at risk for HIV to prevent the greatest number of new HIV cases annually. RESULTS: Both the HIV prevention interventions funded by the optimal allocation of CDC HIV prevention funds and the proportions of the budget allocated were similar across health department groups, particularly those representing the large majority of PLWDH. Consistently funded interventions included testing, partner services and linkage to care and interventions for men who have sex with men (MSM). Sensitivity analyses showed that the optimal allocation shifted when there were differences in transmission category proportions and progress along the HIV care continuum. CONCLUSION: The robustness of the results suggests that most health departments can use these analyses to guide the investment of CDC HIV prevention funds into strategies to prevent the most new cases of HIV. |
Rates of prevalent and new HIV diagnoses by race and ethnicity among men who have sex with men, U.S. states, 2013-2014
Rosenberg ES , Purcell DW , Grey JA , Hankin-Wei A , Hall E , Sullivan PS . Ann Epidemiol 2018 28 (12) 865-873 PURPOSE: Men who have sex with men (MSM) bear a disproportionate burden of new and existing HIV infections in the United States, with black and Hispanic MSM facing the highest rates. A lack of data on MSM population sizes has precluded the understanding of state-level variations in these rates. METHODS: Using a recently developed model for estimating state-level population sizes of MSM by race that synthesizes data from the American Community Survey and the National Health and Nutrition Examination Survey, in conjunction with Centers for Disease Control and Prevention-based HIV diagnosis data, we estimated rates of living with an HIV diagnosis (2013) and new diagnosis among MSM (2014) by state and race. RESULTS: Nationally, state-level median prevalence of living with an HIV diagnosis was 10.6%. White MSM had lower prevalence in all but five states; black MSM were higher in all but three. Hispanic MSM had highest concentrations in Northeast and Mississippi Delta states. Patterns were similar for new diagnoses rates. CONCLUSIONS: Results suggest that racial disparities in HIV infection among MSM are more prominent than geographic ones. Interventions should be differentially tailored to areas of high proportionate and absolute burden. Continued efforts to understand and address racial differences in HIV infection are needed. |
Swipe right: Dating website and app use among men who have sex with men
Badal HJ , Stryker JE , DeLuca N , Purcell DW . AIDS Behav 2017 22 (4) 1265-1272 This study explored the frequency of dating website and app usage among MSM to understand sub-group differences in use. Web-based survey data (N = 3105) were analyzed to assess the use of dating websites and apps. More than half (55.7%) of MSM in this sample were frequent users of dating websites and apps. Two-thirds (66.7%) of frequent users had casual partners only in the past 12 months and reported a high average number of casual sexual partners in the past 12 months (Mdn = 5.0) compared to never users (Mdn = 0.0; chi 2(2) = 734.94, adj. p < .001). The most frequently used dating website or app was Grindr, with 60.2% of the sample reporting some or frequent use. Adam4Adam (23.5%), Jack'd (18.9%) and Scruff (18.7%) were also frequently used. Dating websites and apps may be effective channels to reach a diverse group of MSM with HIV prevention messages. |
Antiretroviral drugs as the linchpin for prevention of HIV infections in the United States
Samandari T , Harris N , Cleveland JC , Purcell DW , McCray E . Am J Public Health 2017 107 (10) 1577-1579 Recent advances in the use of antiretroviral drugs for the prevention of HIV infection present a historic opportunity to better control the spread of the disease. Despite an estimated 18% decline in the number of annual HIV infections between 2008 and 2014 (http://bit.ly/2ftovat), there were approximately 38 000 new infections in 2014, 70% of which were among men who have sex with men (MSM). As a consequence of improved survival with antiretroviral therapy (ART), the number of persons living with HIV has increased to 1.1 million. However, all of these persons are a potential source of new infections to their partners, particularly the 15% who do not know that they are infected, as well as those who know their HIV status but have not achieved a suppressed viral load (i.e., as a result of ART). Each infected person incurs $402 000 in discounted lifetime costs.1 |
Trends in internet use among men who have sex with men in the United States
Paz-Bailey G , Hoots BE , Xia M , Finlayson T , Prejean J , Purcell DW . J Acquir Immune Defic Syndr 2017 75 Suppl 3 S288-s295 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. |
Quantifying the harms and benefits from serosorting among HIV-negative gay and bisexual men: A systematic review and meta-analysis
Purcell DW , Higa D , Mizuno Y , Lyles C . AIDS Behav 2017 21 (10) 2835-2843 We conducted a systematic review and meta-analysis of the association between serosorting and HIV infection among HIV-negative men who have sex with men (MSM). Compared to no condomless anal sex (i.e., consistent condom use or no anal sex), serosorting was associated with increased HIV risk (RR = 1.64, 95% CI 1.37-1.96). Compared to condomless discordant anal sex, serosorting was associated with reduced HIV risk (RR = 0.46, 95% CI 0.33-0.65). Serosorting may be an important harm reduction strategy when condoms are not consistently used, but can be harmful if HIV-negative MSM who consistently use condoms shift to using serosorting as their primary prevention strategy. The protective effects of serosorting and ways in which MSM are operationalizing serosorting are becoming more complex as additional factors affecting risk are considered (e.g., durable viral load suppression, PrEP). Understanding the potential risk and benefit of serosorting continues to be important, particularly within the context of other prevention strategies. |
Increasing availability of prevention to communities disproportionately affected by HIV
McCree DH , Purcell DW , Cleveland JC , Brooks JT . Am J Public Health 2017 107 (7) 1027-1028 Advances in HIV testing, treatment, and prevention produced a decline in the number of new HIV diagnoses in the United States over the past 10 years, with the largest declines seen in mother-to-child transmission and among women and people who inject drugs. However, diagnoses have only stabilized among gay, bisexual, and other men who have sex with men (MSM) in the past five years, and increases continue among Hispanic/Latino MSM.1 Furthermore, disparities persist; MSM, transgender persons, African Americans and Hispanics/Latinos, and persons residing in the Southern United States are the most disproportionately affected subpopulations.1 | The disparities in HIV diagnoses are associated with myriad social, contextual, and structural factors. The National HIV/AIDS Strategy for the United States (NHAS), originally released in 2010 and updated to 2020,2 describes principles, priorities, and actions federal agencies should use to guide a collective national response that will reduce new HIV infections, increase access to care, improve outcomes for persons living with HIV, and reduce disparities. To achieve the NHAS goals, the Centers for Disease Control and Prevention (CDC) adopted a high-impact prevention (HIP) approach3 that targets the best combinations of scientifically proven, cost-effective, and scalable interventions to the right populations in the right geographic areas. Following up Nunn et al.,4 we discuss CDC’s HIV research and programmatic efforts under the HIP approach. |
Trends in sexual behavior among men who have sex with men (MSM) in high-income countries, 1990-2013: A systematic review
Hess KL , Crepaz N , Rose C , Purcell D , Paz-Bailey G . AIDS Behav 2017 21 (10) 2811-2834 HIV diagnoses among men who have sex with men (MSM) have been increasing in several high-income countries. A better understanding of the sexual behavior trends among MSM can be useful for informing HIV prevention. We conducted a systematic review of studies that examined behavioral trends (1990-2013) in any condomless anal sex, condomless anal sex with an HIV-discordant partner, and number of partners. Studies included come from the United States, Europe, and Australia. We found increasing trends in condomless anal sex and condomless anal sex with an HIV-discordant partner, and a decreasing trend in number of partners. The increase in condomless anal sex may help to explain the increase in HIV infections. More explanatory research is needed to provide insight into factors that contribute to these behavior trends. Continuous monitoring of HIV, risk behaviors, and use of prevention and treatment is needed to evaluate prevention efforts and monitor HIV transmission risk. |
Association of HIV diagnosis rates and laws criminalizing HIV exposure in the United States
Sweeney P , Gray SC , Purcell DW , Sewell J , Babu AS , Tarver BA , Prejean J , Mermin J . AIDS 2017 31 (10) 1483-1488 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. |
Assessing HIV acquisition risks among men who have sex with men in the United States of America
Shrestha RK , Sansom SL , Purcell DW . Rev Panam Salud Publica 2016 40 (6) 474-478 Men who have sex with men (MSM) can reduce their risk of acquiring human immunodeficiency virus (HIV) by using various prevention strategies and by understanding the effectiveness of each option over the short- and long-term. Strategies examined were: circumcision; insertive anal sex only; consistent, 100% self-reported condom use; and pre-exposure prophylaxis (PrEP). PrEP efficacy was based on three levels of adherence. The cumulative HIV acquisition risk among MSM over periods of 1 year and 10 years were estimated with and without single and combinations of prevention strategies. A Bernoulli process model was used to estimate risk. In the base case with no prevention strategies, the 1-year risk of HIV acquisition among MSM was 8.8%. In contrast, the 1-year risk associated with circumcision alone was 6.9%; with insertive sex only, 5.5%; with 100% self-reported condom use, 2.7%; and with average, high, and very high PrEP adherence, 5.1%, 2.5%, and 0.7%, respectively. The 10-year risk of HIV acquisition among MSM with no prevention strategy was 60.3%. In contrast, that associated with circumcision alone was 51.1%; with insertive sex only, 43.1%; with 100% self-reported condom use, 24.0%; and with average, high, and very high PrEP adherence, 40.5%, 22.2%, and 7.2%, respectively. While MSM face substantial risk of HIV, there are now a number of prevention strategies that reduce risk. Very high adherence to PrEP alone or with other strategies appears to be the most powerful tool for HIV prevention. |
Molecular characterization of a novel orthomyxovirus from rainbow and steelhead trout (Oncorhynchus mykiss).
Batts WN , LaPatra SE , Katona R , Leis E , Ng TF , Brieuc MS , Breyta RB , Purcell MK , Conway CM , Waltzek TB , Delwart E , Winton JR . Virus Res 2017 230 38-49 A novel virus, rainbow trout orthomyxovirus (RbtOV), was isolated in 1997 and again in 2000 from commercially-reared rainbow trout (Oncorhynchus mykiss) in Idaho, USA. The virus grew optimally in the CHSE-214 cell line at 15 degrees C producing a diffuse cytopathic effect; however, juvenile rainbow trout exposed to cell culture-grown virus showed no mortality or gross pathology. Electron microscopy of preparations from infected cell cultures revealed the presence of typical orthomyxovirus particles. The complete genome of RbtOV is comprised of eight linear segments of single-stranded, negative-sense RNA having highly conserved 5' and 3'-terminal nucleotide sequences. Another virus isolated in 2014 from steelhead trout (also O. mykiss) in Wisconsin, USA, and designated SttOV was found to have eight genome segments with high amino acid sequence identities (89-99%) to the corresponding genes of RbtOV, suggesting these new viruses are isolates of the same virus species and may be more widespread than currently realized. The new isolates had the same genome segment order and the closest pairwise amino acid sequence identities of 16-42% with Infectious salmon anemia virus (ISAV), the type species and currently only member of the genus Isavirus in the family Orthomyxoviridae. However, pairwise comparisons of the predicted amino acid sequences of the 10 RbtOV and SttOV proteins with orthologs from representatives of the established orthomyxoviral genera and a phylogenetic analysis using the PB1 protein showed that while RbtOV and SttOV clustered most closely with ISAV, they diverged sufficiently to merit consideration as representatives of a novel genus. A set of PCR primers was designed using conserved regions of the PB1 gene to produce amplicons that may be sequenced for identification of similar fish orthomyxoviruses in the future. |
Promotion of research on the HIV continuum of care in the United States: The CFAR HIV Continuum of Care/ECHPP Working Group
Greenberg AE , Gordon CM , Purcell DW . J Acquir Immune Defic Syndr 2017 74 Suppl 2 S75-s80 Addressing the challenges of the HIV care continuum remains a major public health priority in the United States. This is exemplified by the July 2013 Executive Order from the White House which established the HIV Care Continuum Initiative to “mobilize and coordinate Federal efforts in response to recent advances regarding how to prevent and treat HIV infection.”1 This third and final supplemental issue developed by the CFAR HIV Continuum of Care (CoC)/Enhanced Comprehensive HIV Prevention Planning Project (ECHPP) Working Group2 for the Journal of Acquired Immune Deficiency Syndrome (JAIDS) highlights the work of academic investigators from seven cities, four of which include co-authors from local public health departments, to conduct research on the HIV continuum of care. This supplemental issue describes the third series of studies to emerge from an initiative supported by the National Institutes of Health (NIH) Centers for AIDS Research (CFAR) Program designed to stimulate research among the CFARs around the HIV prevention and care continuum. | The present introductory article begins with a brief overview of the CFAR CoC/ECHPP Working Group; continues with synopses of NIH funding opportunities and current CDC programs that have been developed to address the continuum of care; and concludes with a synthesis of the seven articles that are included in this supplement. |
The importance of population denominators for high-impact public health for marginalized populations
Purcell DW , Hall HI , Bernstein KL , Gift TL , McCray E , Mermin J . JMIR Public Health Surveill 2016 2 (1) e26 The lack of consistent methods to enumerate population-level denominators for hidden populations has made it difficult for public health to articulate some of the most pressing disparities in America. For example, since the first cases of AIDS in the United States struck gay and bisexual men, injection drug users, and transgender persons, calculating rates of disease to compare impact across populations and geographic areas to highlight disparities and target resources has been challenging. While routine census data have allowed the Centers for Disease Control and Prevention (CDC) to calculate disease rates by sex, age, race/ethnicity, and geographic area [1], the census does not collect information on sexual orientation or same-sex sexual behavior, persons who inject drugs or injection behaviors, heterosexuals who are at higher risk of HIV infection, or transgender persons. This lack of information is nowhere more evident than among gay, bisexual, and other men who have sex with men (MSM), who comprise 67% of estimated number of persons with HIV diagnosed in 2014 (70% when MSM who also inject drugs are included) [1]. Among youth ages 13 to 24, 80% of diagnoses in 2014 were among MSM or MSM who also inject drugs [1]. The impact of HIV on MSM has made them a key focus of the National HIV/AIDS Strategy (NHAS) [2,3]; yet, proportions alone cannot accurately describe disparities, because the size of population denominators vary. | Over the past 5 years, CDC has tried to fill the gap in national, population-wide denominators by using various analytic techniques to estimate the US population size of MSM [4], persons who inject drugs [5], and high-risk heterosexuals [6], and to estimate the population size of MSM and persons who inject drugs by urbanicity and region [7]. Other groups have tried to estimate the size of the population of transgender adults [8] and youth [9]. These national estimates have allowed for the calculation of disease rates for these populations for HIV and other sexually transmitted diseases, which in turn has allowed for national disparities to be highlighted and for federal resources to be better targeted to maximize health impact and increase equity. MSM, who constitute 4% of men in the United States [4], have HIV prevalence and diagnosis rates at least 40 times as great, and syphilis rates at least 60 times as great as for women and other men [4]. However, national estimates may not be applicable to state or local areas because the proportion of the population that is MSM may differ greatly between and within states. Therefore, more refined information is necessary for accurate local information to help plan local programs and allocate resources. |
Estimating the population sizes of men who have sex with men in US states and counties using data from the American Community Survey
Grey JA , Bernstein KT , Sullivan PS , Purcell DW , Chesson HW , Gift TL , Rosenberg ES . JMIR Public Health Surveill 2016 2 (1) e14 BACKGROUND: In the United States, male-to-male sexual transmission accounts for the greatest number of new human immunodeficiency virus (HIV) diagnoses and a substantial number of sexually transmitted infections (STI) annually. However, the prevalence and annual incidence of HIV and other STIs among men who have sex with men (MSM) cannot be estimated in local contexts because demographic data on sexual behavior, particularly same-sex behavior, are not routinely collected by large-scale surveys that allow analysis at state, county, or finer levels, such as the US decennial census or the American Community Survey (ACS). Therefore, techniques for indirectly estimating population sizes of MSM are necessary to supply denominators for rates at various geographic levels. OBJECTIVE: Our objectives were to indirectly estimate MSM population sizes at the county level to incorporate recent data estimates and to aggregate county-level estimates to states and core-based statistical areas (CBSAs). METHODS: We used data from the ACS to calculate a weight for each county in the United States based on its relative proportion of households that were headed by a male who lived with a male partner, compared with the overall proportion among counties at the same level of urbanicity (ie, large central metropolitan county, large fringe metropolitan county, medium/small metropolitan county, or nonmetropolitan county). We then used this weight to adjust the urbanicity-stratified percentage of adult men who had sex with a man in the past year, according to estimates derived from the National Health and Nutrition Examination Survey (NHANES), for each county. We multiplied the weighted percentages by the number of adult men in each county to estimate its number of MSM, summing county-level estimates to create state- and CBSA-level estimates. Finally, we scaled our estimated MSM population sizes to a meta-analytic estimate of the percentage of US MSM in the past 5 years (3.9%). RESULTS: We found that the percentage of MSM among adult men ranged from 1.5% (Wyoming) to 6.0% (Rhode Island) among states. Over one-quarter of MSM in the United States resided in 1 of 13 counties. Among counties with over 300,000 residents, the five highest county-level percentages of MSM were San Francisco County, California at 18.5% (66,586/359,566); New York County, New York at 13.8% (87,556/635,847); Denver County, Colorado at 10.5% (25,465/243,002); Multnomah County, Oregon at 9.9% (28,949/292,450); and Suffolk County, Massachusetts at 9.1% (26,338/289,634). Although California (n=792,750) and Los Angeles County (n=251,521) had the largest MSM populations of states and counties, respectively, the New York City-Newark-Jersey City CBSA had the most MSM of all CBSAs (n=397,399). CONCLUSIONS: We used a new method to generate small-area estimates of MSM populations, incorporating prior work, recent data, and urbanicity-specific parameters. We also used an imputation approach to estimate MSM in rural areas, where same-sex sexual behavior may be underreported. Our approach yielded estimates of MSM population sizes within states, counties, and metropolitan areas in the United States, which provide denominators for calculation of HIV and STI prevalence and incidence at those geographic levels. |
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