BACKGROUND: We compared HIV care outcomes by HIV provider type to inform efforts to strengthen the HIV provider workforce. SETTING: U.S. METHODS: We analyzed data from CDC's Medical Monitoring Project collected during 6/2019-5/2021 from 6,323 adults receiving HIV medical care. Provider types were infectious disease physicians only (ID physicians), non-ID physicians only (non-ID physicians), nurse practitioners only (NPs), physician assistants only (PAs), and ID physicians plus NPs and/or PAs (mixed providers). We measured patient characteristics, social determinants of health (SDOH), and clinical outcomes including retention in care; antiretroviral therapy prescription; antiretroviral therapy adherence; viral suppression; gonorrhea, chlamydia, and syphilis testing; satisfaction with HIV care; and HIV provider trust. RESULTS: Compared with patients of ID physicians, higher percentages of patients of other provider types had characteristics and SDOH associated with poor health outcomes and received HIV care at Ryan White HIV/AIDS Program-funded facilities. After accounting for these differences, most outcomes were not meaningfully different, however higher percentages of patients of non-ID physicians, NPs, and mixed providers were retained in care (6.5, 5.6, and 12.7 percentage points, respectively) and had STI testing in the past 12 months, if sexually active (6.9, 7.4, and 13.5 percentage points, respectively). CONCLUSION: Most HIV outcomes were equivalent across provider types. However, patients of non-ID physicians, NPs, and mixed providers were more likely to be retained in care and have recommended STI testing. Increasing delivery of comprehensive primary care by ID physicians and including primary care providers in ID practices could improve HIV primary care outcomes.

INTRODUCTION: E-cigarettes emerged in the U.S. market in the late 2000s. In 2017, E-cigarette use among U.S. adults was 2.8%, with higher use among some population groups. Limited studies have assessed E-cigarette use among persons with diagnosed HIV. The purpose of this study is to describe the national prevalence estimates of E-cigarette use among persons with diagnosed HIV by selected sociodemographic, behavioral, and clinical characteristics. METHODS: Data were collected between June 2018 and May 2019 as part of the Medical Monitoring Project, an annual cross-sectional survey that produces nationally representative estimates of behavioral and clinical characteristics of persons with diagnosed HIV in the U.S. Statistically significant differences (p<0.05) were determined using chi-square tests. Data were analyzed in 2021. RESULTS: Among persons with diagnosed HIV, 5.9% reported currently using E-cigarettes, 27.1% had ever used them but were not using them currently, and 72.9% had never used them. Current use of E-cigarettes was highest among persons with diagnosed HIV who currently smoke conventional cigarettes (11.1%), those with major depression (10.8%), those aged 25-34 years (10.5%), those who reported injectable and noninjectable drug use in the past 12 months (9.7%), those diagnosed <5 years ago (9.5%), those who self-reported sexual orientation as other (9.2%), and non-Hispanic White people (8.4%). CONCLUSIONS: Overall, findings suggest that a greater proportion of persons with diagnosed HIV used E-cigarettes than the overall U.S. adult population and that higher rates were observed among certain subgroups, including those who currently smoke cigarettes. E-cigarette use among persons with diagnosed HIV warrants continued attention because of its potential impact on HIV-related morbidity and mortality.

Wiewel et al. suggest that misclassification may account for differences between Medical Monitoring Project (MMP) estimates of the proportion of US transgender HIV patients that are transgender men and HIV case surveillance estimates of this proportion among persons living with diagnosed HIV in New York City and California. The risk of misclassification attributable to data entry is reduced by MMP’s electronic data collection, which has programmed logic checks based on responses to questions about sex at birth and gender to prevent errors. Furthermore, in certain sections of the interview, transgender persons are asked interview questions that would not pertain to cisgender persons, providing additional protection against data entry errors. We attribute the differences Wiewel et al. note to the method of measurement used to calculate estimates and substantial differences in populations.

OBJECTIVE: To estimate trends in the proportion of sexually active U.S. adults with HIV (PWH) reporting an HIV-discordant sexual partner taking preexposure prophylaxis (PrEP) and proportion of partners taking PrEP. DESIGN: The Medical Monitoring Project is a complex sample survey of U.S. adults with diagnosed HIV. METHODS: We used annual cross-sectional data collected during June 2015-May 2020 to estimate the annual percentage change (EAPC), overall and by selected characteristics, in reported partner PrEP use among PWH with HIV-discordant partners (N = 8707) and reported PrEP use among these partners (N = 15 844). RESULTS: The proportion of PWH reporting PrEP use by one or more HIV-discordant sex partner rose 19.5% annually (11.3 to 24.4%). The prevalence rose from 6.0 to 17.4% (EAPC, 25.8%) among Black PWH, 10.1 to 26.0% (EAPC, 19.5%) among Hispanic/Latino PWH, and 20.8 to 34.6% (EAPC, 16.3%) among White PWH. Among MSM with HIV, the prevalence increased from 9.6 to 32.6% (EAPC, 28.2%) among Black MSM, 16.6 to 36.0% (EAPC, 15.6%) among Hispanic/Latino MSM, and 24.9 to 44.1% (EAPC, 17.9%) among White MSM. Among HIV-discordant sex partners, the proportion reported to be taking PrEP increased 21.1% annually (7.8 to 18.8%). Reported PrEP use rose from 4.9 to 14.2% (EAPC, 29.9%) among Black partners, 6.5 to 16.8% (EAPC, 20.3%) among Hispanic/Latino partners, and 12.7 to 26.1% (EAPC, 17.0%) among White partners. CONCLUSIONS: One in five HIV-discordant sexual partners of PWH was reported to be taking PrEP. PrEP use rose among all examined populations, although the increases did not eliminate disparities in PrEP use.

OBJECTIVES: Assess concordance of assigned transmission category between National HIV Surveillance System (NHSS) and Medical Monitoring Project (MMP); assess persistence of behaviors by comparing transmission category to current behavior. DESIGN: Retrospective analysis of HIV surveillance data. METHODS: For 4034 participants in the 2016 MMP cycle, transmission category was assigned in NHSS and MMP by applying a hierarchy to acquisition risk behaviors and selecting the most likely risk behavior that led to HIV acquisition. We assessed concordance of transmission category between systems, the number of persons with an updated transmission category in NHSS after incorporating MMP data, and concordance of transmission category and current behavior. RESULTS: Concordance of transmission category between NHSS and MMP was 87% for men with evidence of male-to-male sexual contact and ranged from 27% to 62% in persons with other transmission categories. Transmission category in NHSS was updated for 9% of persons after incorporating MMP data, mostly affecting those with no identified risk in NHSS. Current behavior aligned with updated NHSS transmission category in 56% of men with a transmission category of male-to-male sexual contact. However, only 8% of men and 5% of women with a transmission category of injection drug use had recently injected drugs. CONCLUSION: HIV surveillance systems can better inform prevention efforts with more complete risk information. Sexual behaviors are more persistent over time than injection drug use. In addition to promoting viral suppression, routinely assessing risk and tailoring prevention activities accordingly can improve health outcomes.

Objectives. To assess geographic differences in reaching national targets for viral suppression, homelessness, and HIV-related stigma among people with HIV and key factors associated with these targets. Methods. We used data from the Medical Monitoring Project (2017-2020) and the National HIV Surveillance System (2019) to report estimates nationally and for 17 US jurisdictions. Results. Viral suppression (range = 55.3%-74.7%) and estimates for homelessness (range = 3.6%-11.9%) and HIV-related stigma (range for median score = 27.5-34.4) varied widely by jurisdiction. No jurisdiction met any of the national 2025 targets, except for Puerto Rico, which exceeded the target for homelessness (3.6% vs 4.6%). Viral suppression and antiretroviral therapy dose adherence were lowest, and certain social determinants of health (i.e., housing instability, HIV-related stigma, and HIV health care discrimination) were highest in Midwestern states. Conclusions. Jurisdictions have room for improvement in reaching the national 2025 targets for ending the HIV epidemic and in addressing other measures associated with adverse HIV outcomes-especially in the Midwest. Working with local partners will help jurisdictions determine a tailored approach for addressing barriers to meeting national targets. (Am J Public Health. Published online ahead of print June 2, 2022: e1-e9. https://doi.org/10.2105/AJPH.2022.306843).

HIV stigma is a barrier to achieving the goals of the US Ending the HIV Epidemic initiative. We analyzed data from the Medical Monitoring Project (MMP) collected during 6/2018-5/2019 from 4050 US adults with diagnosed HIV. We reported national estimates of HIV stigma and assessed their associations with sociodemographic and clinical characteristics. Disclosure concerns and stigma related to negative public attitudes were common. Stigma was higher among younger age groups, women and transgender people, Black and Hispanic/Latino men and women, and Black and Hispanic/Latino men who have sex with men. Stigma was associated with lower antiretroviral therapy use and adherence, missed HIV care visits, and symptoms of depression or anxiety. The estimates presented provide a benchmark from which the nation can monitor its progress. The findings suggest the need for enhanced stigma-reduction efforts among specific groups and the importance of addressing stigma around disclosure and community attitudes.

INTRODUCTION: Intimate partner violence is associated with adverse health consequences among people with diagnosed HIV, which could have implications for disease progression and transmission. However, nationally representative estimates of intimate partner violence among people with diagnosed HIV are lacking. Investigators used nationally representative data to estimate the prevalence of physical violence by an intimate partner among adults with diagnosed HIV and examine the differences by selected characteristics. METHODS: This analysis included interview and medical record data from the 2015-2017 cycles of the Medical Monitoring Project, analyzed in 2019. Weighted percentages and 95% CIs were used to report the prevalence of intimate partner violence among people with diagnosed HIV (N=11,768). Bivariate and multivariate differences in intimate partner violence by sociodemographic, behavioral, and clinical characteristics were examined using Rao-Scott chi-square tests (p<0.05). RESULTS: Among people with diagnosed HIV, 26.3% reported having ever experienced intimate partner violence, and 4.4% reported having experienced intimate partner violence in the past 12 months. The prevalence of intimate partner violence differed by gender and gender/sexual identity. People who experienced intimate partner violence in the past 12 months were more likely to engage in behaviors associated with elevated HIV transmission risk and have unmet needs for supportive services. People who recently experienced intimate partner violence were less likely to be engaged in routine HIV care but were more likely to seek emergency care services and have poor HIV clinical outcomes. CONCLUSIONS: This study's findings support the need for screening people with diagnosed HIV for intimate partner violence and offering linkage to supportive services. Screening for intimate partner violence among people with diagnosed HIV, coupled with supportive services and counseling, may lead to improved safety and HIV clinical outcomes and decreased need for emergency and inpatient medical services.

The year 2020 marked 30 years since passage of the Ryan White CARE Act in the United States. Named for Ryan White—a child with HIV who endured discrimination and emerged as a spokesperson for HIV education and understanding before dying of AIDS in 1990 at age 18—the CARE Act established the Ryan White HIV/AIDS Program (RWHAP) within the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services. The RWHAP provides a comprehensive system of HIV primary medical care, medication, and essential support services to about half of people with diagnosed HIV (PWH) in the United States. The RWHAP has demonstrated rising levels of viral suppression among PWH who had at least one outpatient visit at a RWHAP-funded facility; in 2018, 87.1% of PWH receiving care at RWHAP-funded facilities were virally suppressed (HRSA, 2019). Today, the RWHAP is a key part of Ending the HIV Epidemic: A Plan for America—an initiative that aims to reduce new HIV infections in the United States by 90% by 2030.

BACKGROUND: Health inequities among people with HIV may be compounded by disparities in the prevalence of comorbidities associated with increased risk of severe illness from COVID-19. SETTING: Complex sample survey designed to produce nationally representative estimates of behavioral and clinical characteristics of adults with diagnosed HIV in the United States. METHODS: We estimated prevalence of having ≥1 diagnosed comorbidity associated with severe illness from COVID-19 and prevalence differences (PD) by race/ethnicity, income level, and type of health insurance. We considered PDs ≥5 percentage points to be meaningful from a public health perspective. RESULTS: An estimated 37.9% (95% CI, 36.6 to 39.2) of adults receiving HIV care had ≥1 diagnosed comorbidity associated with severe illness from COVID-19. Compared with non-Hispanic Whites, non-Hispanic Blacks or African Americans were more likely (adjusted prevalence difference [APD], 7.8 percentage points [95% CI, 5.7 to 10.0]) and non-Hispanic Asians were less likely (APD, -13.7 percentage points [95% CI, -22.3 to -5.0]) to have ≥1 diagnosed comorbidity after adjusting for age differences. There were no meaningful differences between non-Hispanic Whites and adults in other racial/ethnic groups. Those with low income, were more likely to have ≥1 diagnosed comorbidity (PD, 7.3 percentage points [95% CI, 5.1 to 9.4]). CONCLUSIONS: Among adults receiving HIV care, non-Hispanic Blacks and those with low income were more likely to have ≥1 diagnosed comorbidity associated with severe COVID-19. Building health equity among people with HIV during the COVID-19 pandemic may require reducing the impact of comorbidities in heavily affected communities.

OBJECTIVES: The Medical Monitoring Project (MMP) is a public health surveillance system that provides representative estimates of the experiences and behaviors of adults with diagnosed HIV in the United States. In 2015, the sample design and frame of MMP changed from a system that only included HIV patients to one that captures the experiences of persons receiving and not receiving HIV care. We describe methods investigated for calculating survey weights, the approach chosen, and the benefits of using a dynamic surveillance registry as a sampling frame. METHODS: MMP samples adults with diagnosed HIV from the National HIV Surveillance System, the HIV case surveillance registry for the United States. In the methodological study presented in this manuscript, we compared methods that account for sample design and nonresponse, including weighting class adjustment vs. propensity weighting and a single-stage nonresponse adjustment vs. sequential adjustments for noncontact and nonresponse. We investigated how best to adjust for non-coverage using surveillance data to post-stratify estimates. RESULTS: After assessing these methods, we chose as our preferred procedure weighting class adjustments and a single-stage nonresponse adjustment. Classes were constructed using variables associated with respondents' characteristics and important survey outcomes, chief among them laboratory results available from surveillance that served as a proxy for medical care. CONCLUSIONS: MMPs weighting procedures reduced sample bias by leveraging auxiliary information on medical care available from the surveillance registry sampling frame. Expanding MMPs population of focus provides important information on characteristics of persons with diagnosed HIV that complement the information provided by the surveillance registry. MMP methods can be applied to other disease registries or population-monitoring systems when more detailed information is needed for a population, with the detailed information obtained efficiently from a representative sample of the population covered by the registry.

Comparison of social determinants of health and clinical outcomes between HIV-positive persons who inject drugs (PWID) and HIV-positive persons who do not inject drugs is essential to understanding disparities and informing HIV prevention and care efforts; however, nationally representative estimates are lacking. Interview and medical record data were collected for the Medical Monitoring Project during 2015-2018 among U.S. adults with diagnosed HIV. Among HIV-positive PWID (N=340) and HIV-positive persons who do not inject drugs (N=11,475), we reported weighted percentages and prevalence ratios with predicted marginal means to compare differences between groups (P<.05). Associations with clinical outcomes were adjusted for age, race/ethnicity, and gender. HIV-positive PWID were more likely to be homeless (29.1% vs. 8.1%) and incarcerated (18.3% vs. 4.9%). HIV-positive PWID were less likely to be retained in HIV care (aPR: 0.85 [95% CI: 0.77-0.94]), and were more likely to have poor HIV outcomes, have unmet needs for care services (aPR: 1.50 [1.39-1.61]), seek non-routine care, and experience healthcare discrimination (aPR: 1.42 [1.17-1.73]). Strengthening interventions supporting (1) continuity of care given high levels of incarceration and housing instability, (2) early ART initiation and adherence support, and (3) drug treatment and harm reduction programs to limit transmission risk may improve outcomes among HIV-positive PWID.

Objectives. Health utility estimates from the current era of HIV treatment, critical for cost-effectiveness analyses (CEA) informing HIV health policy, are limited. We examined peer-reviewed literature to assess the appropriateness of commonly referenced utilities, present previously unreported quality-of-life data from two studies, and discuss future implications for HIV-related CEA. Methods. We searched a database of cost-effectiveness analyses specific to HIV prevention efforts from 1999 to 2016 to identify the most commonly referenced sources for health utilities and to examine practices around using and reporting health utility data. Additionally, we present new utility estimates from the Centers of Disease Control and Prevention's Medical Monitoring Project (MMP) and the INSIGHT Strategies for Management of Anti-Retroviral Therapy (SMART) trial. We compare data collection time frames, sample characteristics, assessment methods, and key estimates. Results. Data collection for the most frequently cited utility estimates ranged from 1985 to 1997, predating modern HIV treatment. Reporting practices around utility weights are poor and lack details on participant characteristics, which may be important stratifying factors for CEA. More recent utility estimates derived from MMP and SMART were similar across CD4+ count strata and had a narrower range than pre-antiretroviral therapy (ART) utilities. Conclusions. Despite the widespread use of ART, cost-effectiveness analysis of HIV prevention interventions frequently apply pre-ART health utility weights. Use of utility weights reflecting the current state of the US epidemic are needed to best inform HIV research and public policy decisions. Improved practices around the selection, application, and reporting of health utility data used in HIV prevention CEA are needed to improve transparency.

BACKGROUND: Understanding sexual partnerships of HIV-positive persons, particularly at the dyad level, can help in quantifying HIV transmission risk. We described sexual partnerships among HIV-positive men who have sex with men (MSM), including partnerships with a high risk for sexual HIV transmission. SETTING: The Medical Monitoring Project is an annual, cross-sectional study that reports representative estimates on U.S. HIV-positive adults. METHODS: During 2015-2019, we assessed sexual behaviors by interview, and viral load results from medical records. Among sexually active HIV-positive MSM (n = 4923), we described prevalence of high-risk sex, defined as: (1) not having sustained viral suppression, and (2) having condomless sex with an HIV-negative partner not known to be taking pre-exposure prophylaxis or an HIV-unknown partner. We described sexual partnerships among HIV-positive MSM (n = 13,024 partnerships among 4923 MSM). For HIV-discordant partnerships (n = 7768), we reported the proportion involved in high-risk sex, and associations with high-risk sex using prevalence ratios with predicted marginal means, controlling for age of the HIV-positive partner (P < 0.05). RESULTS: More than half (66%) of sexually active HIV-positive MSM had condomless sex; 11% had high-risk sex. Blacks were more likely to have detectable viral loads, but less likely to have condomless sex, making prevalence of high-risk sex comparable between racial/ethnic groups. Dyad-level analyses among HIV-discordant partnerships indicated that prevalence of high-risk sex was higher among partnerships with HIV-positive white MSM, which was not observed using person-level data alone. CONCLUSIONS: In the context of ending the HIV epidemic, behavioral and clinical surveillance data can help monitor HIV transmission risk and target prevention efforts to reduce transmission among populations at disproportionate risk.

People with HIV (PWH) who contract hepatitis A may have higher level and prolonged hepatitis A viremia with an increased potential to transmit hepatitis A.1,2 Many PWH have risk factors for which hepatitis A vaccination is recommended, including male-to-male sexual contact, injection and noninjection drug use, homelessness, and chronic liver disease.3,4 However, in February 2020, the U.S. Advisory Committee on Immunization Practices (ACIP) recommended that all PWH age $ 1 year be routinely vaccinated for hepatitis A (https://www.cdc.gov/vaccines/schedules/index.html). The number of additional adults receiving HIV care who have an indication for vaccination based on the 2020 ACIP update is unknown and could inform public health practice and resource allocation.

Reported cases of bacterial sexually transmitted diseases (STDs) have steadily increased during the past 10 years, with disproportionate increases among men who have sex with men (MSM), particularly those with HIV (1). Bacterial STDs can increase genital HIV shedding and potentially facilitate HIV transmission (2), challenging efforts to end the HIV epidemic. In addition, although hepatitis C is not generally transmitted by sex, sexual transmission among HIV-positive MSM has been identified as an emerging challenge to its elimination (3).

BACKGROUND: Guidelines recommend that sexually active men who have sex with men (MSM) including human immunodeficiency virus (HIV)-positive MSM be tested at least annually for syphilis, with testing every 3-6 months for MSM at elevated risk. We examined the proportion of HIV-positive MSM tested for syphilis in the past 3, 6, and 12 months by their HIV care provider during 2013-2014. METHODS: Using data from the Medical Monitoring Project, a population-based HIV surveillance system, we evaluated the proportion of MSM who had documentation of being tested for syphilis by their HIV care provider in the past 3, 6, and 12 months. RESULTS: During 2013-2014, 71% (95% confidence interval [CI]: 69%-73%) of sexually active HIV-positive MSM were tested for syphilis in the past year. This proportion was higher among MSM reporting condomless sex: (75%; 95% CI: 72%-78%), and among MSM reporting >/= 2 sex partners (77%; 95% CI: 74%-79%), in the past 12 months. Among MSM reporting condomless sex, 49% (95% CI: 45%-53%) were tested in the past 6 months, and 26% (95% CI: 22%-30%) in the past 3 months. Among MSM reporting >/= 2 sex partners, 49% (95% CI: 44%-54%) were tested in the past 6 months and 26% (95% CI: 22%-29%) in the past 3 months. CONCLUSIONS: Nearly one-third of sexually active HIV-positive MSM were not tested annually, and many at increased risk were not tested at recommended frequencies. Efforts to improve compliance with screening guidelines for high-risk HIV-positive MSM are warranted.

OBJECTIVE: To estimate the proportion of U.S. HIV-positive men who report a male HIV-negative/unknown status (HIV-discordant) sexual partner taking PrEP, and the use of multiple HIV prevention strategies within partnerships. DESIGN: The Medical Monitoring Project is a complex sample survey of U.S. adults with diagnosed HIV. METHODS: We used data collected during June 2016-May 2018 among sexually-active HIV-positive men who had >/=1 HIV-discordant male partner (N = 1,871) to estimate the weighted prevalence of reporting >/=1 partner taking PrEP. Among HIV-discordant partnerships (N = 4,029), we estimated PrEP use, viral suppression among HIV-positive partners, and condomless anal sex. We evaluated significant (p < 0.05) differences between groups using prevalence ratios with predicted marginal means. RESULTS: Twenty-eight percent of sexually-active HIV-positive MSM reported >/= 1 HIV-discordant male partner taking PrEP. Twenty percent of HIV-discordant partners were reported to be taking PrEP; 73% were taking PrEP or the HIV-positive partner was virally suppressed. PrEP use was lower among black and Hispanic partners compared with white partners (12% and 19% vs. 27%). Fewer black than white MSM were in partnerships in which PrEP was used or the HIV-positive partner had sustained viral suppression (69% vs. 77%). Condomless anal intercourse was more prevalent in partnerships involving PrEP use and in partnerships involving either PrEP use or sustained viral suppression among the HIV-positive partner. CONCLUSIONS: PrEP use was reported among 1 in 5 partners, with disparities between black and white partners. Increasing PrEP use and decreasing racial/ethnic disparities could reduce disparities in HIV incidence and help end the U.S. HIV epidemic.

People with HIV (PWH) who are unaware of their infection are estimated to account for the majority of HIV transmission due to unsuppressed viral load and ongoing HIV exposure risk activities with their sex or needle-sharing partners.1,2 The Centers for Disease Control and Prevention (CDC) guidelines for HIV prevention have long recommended the provision of partner services (PS) for all persons with a new HIV diagnosis3 to identify and notify exposed persons and offer them HIV testing and prevention services. Prior reports suggest that PS are underutilized and not delivered as prescribed by guidelines, with only approximately half of people in the United States with a new HIV diagnosis interviewed to elicit partner names and contact information.4,5 Although surveys have attempted to examine the scope and effectiveness of PS,5,6 national estimates are lacking.

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 United States spends more per capita on prescription drugs than do other high-income countries (1). In 2017, patients paid 14% of this cost out of pocket (2). Prescription drug cost-saving strategies, including nonadherence to medications due to cost concerns, have been documented among U.S. adults (3) and can negatively affect morbidity and, in the case of persons with human immunodeficiency virus (HIV) infection, can increase transmission risk (4,5). However, population-based data on prescription drug cost-saving strategies among U.S. persons with HIV are lacking. CDC's Medical Monitoring Project* analyzed cross-sectional, nationally representative, surveillance data on behaviors, medical care, and clinical outcomes among adults with HIV infection. During 2016-2017, 14% of persons with HIV infection used a prescription drug cost-saving strategy for any prescribed medication, and 7% had cost saving-related nonadherence. Nonadherence due to prescription drug costs was associated with reporting an unmet need for medications from the Ryan White AIDS Drug Assistance Program (ADAP), not having Medicaid coverage, and having private insurance. Persons who were nonadherent because of cost concerns were more likely to have visited an emergency department, have been hospitalized, and not be virally suppressed. Reducing barriers to ADAP and Medicaid coverage, in addition to reducing medication costs for persons with private insurance, might help to decrease nonadherence due to cost concerns and, thus contribute to improved viral suppression rates and other health outcomes among persons with HIV infection.

We analyzed nationally representative medical record data from the Medical Monitoring Project (MMP) to estimate prevalence of antiretroviral (ARV) agents prescribed for US adults with diagnosed HIV and to examine recent changes in prescribing practices. The MMP uses a multi-stage sample survey methodology to produce nationally representative annual estimates of characteristics of adults with diagnosed HIV in the US and Puerto Rico. We compared weighted prevalence of most recent ARV prescriptions from 3368 adults interviewed during June 2015–May 2016 and from 3717 adults interviewed during June 2016–May 2017. We also compared weighted prevalence of the first ARV prescriptions among those who initiated ART during these time periods. Among patients initiating antiretroviral therapy (ART), prescription of non-nucleoside reverse transcriptase inhibitors (NNRTIs) as part of initial regimen decreased across the time periods from 38.5% to 26.6% (P = 0.01). Prescription of protease inhibitors (PI) did not change (17.0% and 14.5%). Prescription of integrase strand transfer inhibitors (INSTIs) increased (54.7 to 70.2%, P = 0.004) due mostly to increased prescription of dolutegravir (13.9% to 32.5%). Among all patients, prescription of NNRTIs remained stable across (44.5% and 43.2%). Prescriptions of PIs decreased significantly, from 36.5% to 32.4% (P = 0.006), as did prescription of individual PIs except darunavir. In contrast, prescription of INSTIs increased from 43.4% to 50.7% (P < 0.001), due mostly to increased prescription of dolutegravir and elvitegravir. ART prescribing practices changed rapidly across the examined time periods. Following guidelines, INSTI prescription increased significantly among all U.S adults with diagnosed HIV, including adults initiating ART. © The Author(s) 2019.

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

BACKGROUND: Data to care (D2C) is a public health strategy that uses HIV surveillance and other data to identify persons in need of HIV medical care. The Medical Monitoring Project (MMP), which uses similar methods to contact and recruit HIV-positive persons, may inform predictors of successful contact for D2C programs. SETTING: MMP is a Centers for Disease Control and Prevention-funded surveillance system that collects nationally representative data on adults with diagnosed HIV in the United States and Puerto Rico. METHODS: Using MMP's 2016 data collection cycle, we present contact rates (ie, proportion of HIV-positive persons successfully contacted for MMP) by the age of contact information and age of laboratory test results available from HIV surveillance data. RESULTS: Nationally, 27.6% of eligible persons did not have a recorded laboratory test performed within the past year (project area range: 10.8%-54.6%). The national contact rate among persons with laboratory tests older than 1 year was 37.0% (project area range: 16.5%-67.1%). Higher contact rates were found among persons with more recent laboratory tests. Similar results were found by the age of contact information. Nationally, the most common reason for MMP ineligibility was that the person was deceased; the most common reason for not being contacted was lack of correct contact information. CONCLUSIONS: MMP findings suggest that D2C programs would benefit from efforts to improve the quality of HIV surveillance data and local surveillance practices-in particular, death ascertainment, the completeness of laboratory reporting, and the routine updating of contact information. Strengthening collaboration and integration with existing MMP programs may be beneficial.

BACKGROUND: "Data to Care" (D2C) is a public health strategy that uses surveillance and other data to improve continuity of HIV care for persons with HIV (PWH) by identifying those who are in need of medical care or other services and facilitating linkage to these services. The primary goal of D2C is to increase the number of PWH who are engaged in care and virally suppressed. METHODS: Data to Care can be implemented using several approaches. Surveillance-based D2C is usually initiated by health departments, using HIV surveillance and other data to identify those not in care. Health care providers may also initiate D2C by identifying patients who may have fallen out of care and working collaboratively with health departments to investigate, locate, and relink the patients to medical care or other needed services. RESULTS: Although D2C is a relatively new strategy, health department D2C programs have reported both promising results (eg, improved surveillance data quality and successful linkage to or re-engagement in care for PWH) and challenges (eg, incomplete or inaccurate data in surveillance systems, barriers to data sharing, and limitations of existing data systems). CONCLUSIONS: Data to Care is expected to enable health departments to move closer toward achieving national HIV prevention goals. However, additional information on appropriate implementation practices at each step of the D2C process is needed. This JAIDS Special Supplement explores how CDC funding to state health departments (eg, technical assistance and demonstration projects), and partnerships across federal agencies, are advancing our knowledge of D2C.

During 2016, 6% of persons in the United States who received a diagnosis of human immunodeficiency virus (HIV) infection had their HIV infection attributed to injection drug use (1). Injection practices and sexual behaviors among HIV-positive persons who inject drugs, such as injection equipment sharing and condomless sex, can increase HIV transmission risk; nationally representative estimates of the prevalences of these behaviors are lacking. The Medical Monitoring Project (MMP) is an annual, cross-sectional survey that reports nationally representative estimates of clinical and behavioral characteristics among U.S. adults with diagnosed HIV (2). CDC used MMP data to assess high-risk injection practices and sexual behaviors among HIV-positive persons who injected drugs during the preceding 12 months and compared their HIV transmission risk behaviors with those of HIV-positive persons who did not inject drugs. During 2015-2017, approximately 10% (weighted percentage estimate) of HIV-positive persons who injected drugs engaged in distributive injection equipment sharing (giving used equipment to another person for use); nonsterile syringe acquisition and unsafe disposal methods were common. Overall, among HIV-positive persons who injected drugs, 80% received no treatment, and 57% self-reported needing drug or alcohol treatment. Compared with HIV-positive persons who did not inject drugs, those who injected drugs were more likely to have a detectable viral load (48% versus 35%; p = 0.008) and engage in high-risk sexual behaviors (p<0.001). Focusing on interventions that reduce high-risk injection practices and sexual behaviors and increase rates of viral suppression might decrease HIV transmission risk among HIV-positive persons who inject drugs. Successful substance use treatment could also lower risk for transmission and overdose through reduced injection.

OBJECTIVE: To describe delivery of recommended HIV care and work satisfaction among infectious disease (ID) physicians, non-ID physicians, nurse practitioners (NPs), and physician assistants (PAs). DATA SOURCES: Medical Monitoring Project 2013-2014 HIV Provider Survey. STUDY DESIGN: Population-based complex sample survey. DATA COLLECTION/ANALYSIS METHODS: We surveyed 2208 HIV care providers at 505 US HIV care facilities and computed weighted percentages of provider characteristics, stratified by provider type. Rao-Scott chi-square tests and logistic regression used to compare characteristics of ID physicians with each other provider type. PRINCIPAL FINDINGS: The adjusted provider response rate was 64 percent. Among US HIV care providers, 45 percent were ID physicians, 35 percent non-ID physicians, 15 percent NPs, and 5 percent PAs. Satisfaction with administrative burden was lowest among non-ID physicians (27 percent). Compared with ID physicians, satisfaction with remuneration was lower among non-ID physicians and higher among NPs (37, 28, and 51 percent, respectively). NPs were more likely than ID physicians to report performing four of six services that are key to providing comprehensive HIV care, but more NPs planned to leave clinical practice within 5 years (19 vs 7 percent). CONCLUSION: Addressing physician dissatisfaction with remuneration and administrative burden could help prevent a provider shortage. Strengthening the role of NPs may help sustain a high-quality workforce.

OBJECTIVE: To estimate the prevalence of Generalized Anxiety Disorder (GAD) symptoms among adults with diagnosed HIV (PWH) in the United States in order to inform effective HIV prevention and care efforts. DESIGN: The Medical Monitoring Project (MMP) is a complex sample survey of adults with diagnosed HIV in the United States. METHODS: We used MMP data collected during 6/2015-5/2016 to calculate the weighted prevalence of GAD symptoms among PWH (N = 3654) and prevalence ratios with predicted marginal means to evaluate significant differences between groups. RESULTS: The estimated prevalence of GAD symptoms among PWH was 19%. GAD symptoms were associated with significantly lower antiretroviral therapy prescription and adherence, medical HIV care engagement, and sustained viral suppression. Persons with GAD symptoms were over 3 times as likely to have an unmet need for mental health services (23% vs. 7%) and had significantly more emergency room visits and hospitalizations than those without these symptoms. GAD symptoms were associated with significantly higher prevalence of condomless sex while not sustainably virally suppressed with a person not known to be taking preexposure prophylaxis (9% vs. 6%). CONCLUSIONS: GAD symptom prevalence among PWH was considerably higher than among the U.S. general adult population, indicating an excess burden of anxiety among PWH. Outcomes along the HIV care continuum were poorer, and risk for HIV transmission was higher, among persons with symptoms. Incorporating routine screening for GAD in HIV clinical settings may help improve health outcomes, reduce HIV transmission, and save healthcare costs.

BACKGROUND: More than one-quarter of 2016 HIV diagnoses among blacks in the U.S. occurred among persons aged 15-24 years, and three-quarters were among men. Although the prevalence of viral suppression at all tests in the past 12 months (durable viral suppression) among persons receiving HIV care increased from 58% to 68% during 2009-2013, we do not know whether this same improvement was seen among young black men receiving care. METHODS: We analyzed 2009-2014 Medical Monitoring Project (MMP) data collected from 336 black men aged 18-24 years. We estimated the proportion of young black men receiving HIV care who were prescribed antiretroviral therapy (ART), adherent to ART, and durably virally suppressed. We assessed changes in clinical outcomes over time and their association with patient characteristics, health behaviors, and depression. RESULTS: During 2009-2014, 80% of young black men receiving HIV care were prescribed ART, 73% were adherent to ART, and 36% had durable viral suppression. There was no significant change in viral suppression over this period. ART prescription and durable viral suppression were significantly higher among those receiving Ryan White HIV/AIDS Program assistance compared with those did not. Durable viral suppression was significantly lower among those who used drugs compared with those who did not. CONCLUSIONS: Viral suppression among young black men during 2009-2014 was lower than among the overall population receiving HIV care in 2013 (36% vs. 68%). Increasing viral suppression is essential to improve health and reduce HIV transmissions in this key population.

The rate of diagnosis of human immunodeficiency virus (HIV) infection among American Indians and Alaska Natives (AI/ANs) in 2016 (10.2 per 100,000 population) was the fourth highest among seven racial/ethnic groups in the United States (1); the number of diagnoses of HIV infection among AI/AN persons increased by 70%, from 143 in 2011 to 243 in 2016 (1). However, little has been published about the sociodemographic, behavioral, and clinical characteristics of AI/AN patients with HIV infection in care because small sample sizes have led to infrequent analysis of AI/AN-specific estimates (2) and because of underestimation of AI/AN race/ethnicity in surveillance and other data sources (3). CDC analyzed data from the Medical Monitoring Project (MMP), a surveillance system that collects information about the experiences and needs of persons with diagnosed HIV infection, collected during 2011-2015 among AI/AN adults receiving HIV medical care. The results indicated that 64% of AI/AN patients with HIV infection in care achieved sustained viral suppression, and 76% achieved viral suppression at their most recent viral load test within the past 12 months, which is below the national HIV prevention goal of 80%, but comparable to or better than some other racial/ethnic groups (4). Based on self-report, 51% of AI/AN patients with HIV infection had incomes at or below the U.S. Department of Health and Human Services' (HHS) annual poverty limit, 27% had symptoms of depression, 78% reported internalized HIV-related stigma, and 20% reported binge drinking in the past 30 days. To improve the health of AI/AN patients with HIV infection, it is important that health care providers, tribal organizations, and state and local health departments consider the sociodemographic and behavioral barriers to AI/AN patients with HIV infection achieving viral suppression and design care plans that seek to eliminate those barriers.