BACKGROUND: An estimated 166,155 individuals in the United States have undiagnosed HIV infection. We modeled the numbers of HIV-infected individuals who could be diagnosed in clinical and community settings by broadly implementing HIV screening guidelines. SETTING: United States. METHODS: We modeled testing for general population (once lifetime) and high-risk populations (annual): men who have sex with men, people who inject drugs, and high-risk heterosexuals. We used published data on HIV infections, HIV testing, engagement in clinical care, and risk status disclosure. RESULTS: In clinical settings, about 76 million never-tested low-risk and 2.6 million high-risk individuals would be tested, yielding 36,000 and 55,000 HIV diagnoses, respectively. In community settings, 30 million low-risk and 4.4 million high-risk individuals would be tested, yielding 75,000 HIV diagnoses. CONCLUSION: HIV testing in clinical and community settings diagnoses similar numbers of individuals. Lifetime and risk-based testing are both needed to substantially reduce undiagnosed HIV.

Young persons aged 13-24 years accounted for an estimated 22% of all new diagnoses of human immunodeficiency virus (HIV) infection in the United States in 2014. Most new HIV diagnoses among youths occur among males who have sex with males (MSM). Among all MSM, young black MSM accounted for the largest number of new HIV diagnoses in 2014 (1). To determine whether the prevalence of HIV-related risk behaviors among black male high school students who had sexual contact with males differed from the prevalence among white and Hispanic male students who had sexual contact with males, potentially contributing to the racial/ethnic disparities in new HIV diagnoses, CDC analyzed data from Youth Risk Behavior Surveys conducted by 17 large urban school districts during 2009-2013. Although other studies have examined HIV-related risk behaviors among MSM (2,3), less is known about MSM aged <18 years. Black male students who had sexual contact with males had a lower or similar prevalence of most HIV-related risk behaviors than did white and Hispanic male students who had sexual contact with males. These findings highlight the need to increase access to effective HIV prevention strategies for all young MSM.

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

BACKGROUND: Personal lubricant use is common during anal intercourse. Some water-based products with high osmolality and low pH can damage genital and rectal tissues, and the polymer polyquaternium 15 (PQ15) can enhance HIV replication in vitro. This has raised concerns that lubricants with such properties may increase STD/HIV infection risk, although in vivo evidence is scarce. We use a macaque model to evaluate rectal cytotoxicity and SHIV infection risk after use of a highly osmolar (>8,000 mOsm/kg) water-based lubricant with pH of 4.4, and containing PQ15. METHODS: Cytotoxicity was documented by measuring inflammatory cytokines and epithelial tissue sloughing during six weeks of repeated, non-traumatic lubricant or control buffer applications to rectum and anus. We measured susceptibility to SHIVSF162P3 infection by comparing virus doses needed for rectal infection in twenty-one macaques treated with lubricant or control buffer 30 minutes prior to virus exposure. RESULTS: Lubricant increased pro-inflammatory cytokines and tissue sloughing while control buffer (phosphate buffered saline; PBS) did not. However, the estimated AID50 (50% animal infectious dose) was not different in lubricant- and control buffer-treated macaques (p = 0.4467; logistic regression models). CONCLUSIONS: Although the test lubricant caused acute cytotoxicity in rectal tissues, it did not increase susceptibility to infection in this macaque model. Thus neither the lubricant-induced type/extent of inflammation nor the presence of PQ15 affected infection risk. This study constitutes a first step in the in vivo evaluation of lubricants with regards to HIV transmission.

In the United States, an estimated 1.2 million persons are living with human immunodeficiency virus (HIV), a serious infection that, if untreated, leads to illness and premature death. Persons living with HIV who use antiretroviral therapy (ART) and achieve very low levels of the virus (suppressed viral load) can have a nearly normal life expectancy and have very low risk for transmitting HIV to others. However, each year in the United States, nearly 50,000 persons become infected with HIV. Each step along the HIV care continuum (HIV diagnosis, prompt and sustained HIV medical care, and ART) is essential for achieving a suppressed viral load.

BACKGROUND: The number of strategies to prevent HIV transmission has increased following trials evaluating antiretroviral therapy (ART), preexposure prophylaxis (PrEP) and male circumcision. Serodiscordant couples need guidance on the effects of these strategies alone, and in combination with each other, on HIV transmission. METHODS: We estimated the sexual risk of HIV transmission over 1-year and 10-year periods among male-male and male-female serodiscordant couples. We assumed the following reductions in transmission: 80% from consistent condom use; 54% from circumcision in the negative male partner of a heterosexual couple; 73% from circumcision in the negative partner of a male-male couple; 71% from PrEP in heterosexual couples; 44% from PrEP in male-male couples; and 96% from ART use by the HIV-infected partner. FINDINGS: For couples using any single prevention strategy, a substantial cumulative risk of HIV transmission remained. For a male-female couple using only condoms, estimated risk over 10 years was 11%; for a male-male couple using only condoms, estimated risk was 76%. ART use by the HIV-infected partner was the most effective single strategy in reducing risk; among male-male couples, adding consistent condom use was necessary to keep the 10-year risk below 10%. CONCLUSION: Focusing on 1-year and longer term transmission probabilities gives couples a better understanding of risk than those illustrated by data for a single sexual act. Long-term transmission probabilities to the negative partner in serodiscordant couples can be high, though these can be substantially reduced with the strategic use of preventive methods, especially those that include ART.

We present a cost-utility analysis based on data from the Housing and Health (H&H) Study of rental assistance for homeless and unstably housed persons living with HIV in Baltimore, Chicago and Los Angeles. As-treated analyses found favorable associations of housing with HIV viral load, emergency room use, and perceived stress (an outcome that can be quantitatively linked to quality of life). We combined these outcome data with information on intervention costs to estimate the cost-per-quality-adjusted-life-year (QALY) saved. We estimate that the cost-per-QALY-saved by the HIV-related housing services is $62,493. These services compare favorably (in terms of cost-effectiveness) to other well-accepted medical and public health services.

BACKGROUND: In the wake of a national economic downturn, the state of California, in 2009-2010, implemented budget cuts that eliminated state funding of HIV prevention and testing. To mitigate the effect of these cuts remaining federal funds were redirected. This analysis estimates the impact of these budget cuts and reallocation of resources on HIV transmission and associated HIV treatment costs. METHODS AND FINDINGS: We estimated the effect of the budget cuts and reallocation for California county health departments (excluding Los Angeles and San Francisco) on the number of individuals living with or at-risk for HIV who received HIV prevention services. We used a Bernoulli model to estimate the number of new infections that would occur each year as a result of the changes, and assigned lifetime treatment costs to those new infections. We explored the effect of redirecting federal funds to more cost-effective programs, as well as the potential effect of allocating funds proportionately by transmission category. We estimated that cutting HIV prevention resulted in 55 new infections that were associated with $20 million in lifetime treatment costs. The redirection of federal funds to more cost-effective programs averted 15 HIV infections. If HIV prevention funding were allocated proportionately to transmission categories, we estimated that HIV infections could be reduced below the number that occurred annually before the state budget cuts. CONCLUSIONS: Reducing funding for HIV prevention may result in short-term savings at the expense of additional HIV infections and increased HIV treatment costs. Existing HIV prevention funds would likely have a greater impact on the epidemic if they were allocated to the more cost-effective programs and the populations most likely to acquire and transmit the infection.

In their recent article, Groves et al. (Citation2012) describe the complexity of six HIV-positive women's relationships with their male partners and the barriers to HIV disclosure to these partners that they face.Footnote The authors make the case that these challenging realities and higher rates of HIV testing among women argue against using ‘the language of morality’ in addressing HIV disclosure among women in South Africa. In presenting their research, we believe that they have inadequately represented our own and others’ research on the experiences of other people living with HIV and the role that moral agency plays in reducing HIV transmission risk and increasing HIV disclosure to sex partners. | Groves et al. quoted from our paper (O'Leary and Wolitski Citation2009) but failed to identify it as a systematic review of the literature. This paper was not an opinion piece. It was based on more than 30 qualitative and quantitative studies on the role of moral agency in HIV transmission risk behaviour and disclosure of HIV status to sex partners. Our review showed that concern about infecting others is central to the sexual decision-making of people living with HIV. It also showed that beliefs about personal responsibility and other aspects of moral agency are associated with decreased HIV transmission risk and increased HIV disclosure to sex partners. In making their case, Groves et al. have failed to adequately represent this broader literature.

Many men who have sex with men (MSM) are among those who increasingly use the internet to find sexual partners. Few studies have compared behavior by race/ethnicity in internet-based samples of MSM. We examined the association of race/ethnicity with HIV risk-related behavior among 10,979 Hispanic, black, and white MSM recruited online. Significant variations by race/ethnicity were found in: age, income level, sexual orientation, number of lifetime male and female sexual partners, and rates of unprotected anal intercourse (UAI). Black and Hispanic men were more likely to report anal intercourse during the last sexual encounter, but white men were more likely to report UAI. In multivariate analysis, UAI was associated with HIV infection and sex with a main partner. Significant risk behavior variations by race/ethnicity were found. Research is needed to better target online interventions to MSM who engage in UAI or have other risk factors for transmitting or acquiring HIV.

BACKGROUND: Over a three-year period, CDC invested $102.3 million in a large-scale HIV testing program, the Expanded HIV Testing Initiative, for populations disproportionally affected by HIV. Policy makers, who must optimize public health given a set budget, are interested in the financial return on investment (ROI) of large-scale HIV testing. METHODS: We conducted an ROI analysis using expenditure and outcome data from the program. A health system perspective was used that included all program expenditures including medical costs of treating newly diagnosed patients. We incorporated benefits of HIV transmissions averted from persons diagnosed of their infection through the Initiative compared to when, on average, those persons would have been diagnosed without the Initiative (3 years later in the base case). HIV transmissions were derived from a published mathematical model of HIV transmission. In sensitivity analysis, we tested the effect of 1 -5 year alternate testing intervals and differences in the prevalence of undiagnosed HIV infection. RESULTS: Under the Initiative, 2.7 million persons were tested for HIV, there was a newly diagnosed HIV positivity rate of 0.7%, and an estimated 3,381 HIV infections were averted. It achieved a return of $1.95 for every dollar invested. ROI ranged from $1.46 - $2.01 for alternative testing intervals of one to five years and remained above $1 (positive return on investment) with a prevalence of undiagnosed HIV infection as low as 0.12%. CONCLUSION: The Expanded Testing Initiative yielded ROI values of >$1 under a broad range of sensitivity analyses and provides further support for large-scale HIV testing programs.

The sexual health of gay, bisexual, and other men who have sex with men (MSM) in the United States is not getting better despite considerable social, political and human rights advances. Instead of improving, HIV and sexually transmitted infections (STIs) remain disproportionately high among MSM and have been increasing for almost two decades. The disproportionate and worsening burden of HIV and other STIs among MSM requires an urgent re-assessment of what we have been doing as a nation to reduce these infections, how we have been doing it, and the scale of our efforts. A sexual health approach has the potential to improve our understanding of MSM's sexual behavior and relationships, reduce HIV and STI incidence, and improve the health and well-being of MSM.

OBJECTIVES: To estimate the potential future burden of HIV in the United States under different intervention scenarios. METHODS: We modeled future HIV incidence, prevalence, and infections averted using 2006 estimates of HIV incidence (55,400 new infections per year), prevalence (1,107,000 persons living with HIV), and transmission rate (5.0 per 100 persons living with HIV). We modeled 10-year trends for 3 base-case scenarios (steady incidence, steady transmission rate, declining transmission rate based on the 2000-2006 trend) and 2 intensified HIV intervention scenarios (50% reduction in transmission rate within 10 and 5 years). RESULTS: Base-case scenarios predicted HIV prevalence increases of 24%-38% in 10 years. Reducing the transmission rate by 50% within 10 years reduces incidence by 40%; prevalence increases 20% to an estimated 1,329,000 persons living with HIV. Halving the transmission rate within 5 years reduces incidence by 46%; prevalence increases 13%, to 1,247,000. Although in year 10 incidence is similar regardless of the intervention time frame, more infections are averted when halving the transmission rate within 5 years. CONCLUSIONS: HIV prevalence will likely increase creating additional demands for health care services. These analyses are instructive for setting HIV prevention goals for the nation and assessing potential cost savings of intensified HIV prevention efforts.

HIV-related stigma negatively affects the lives of persons living with HIV/AIDS (PLWHA). Homeless/unstably housed PLWHA experience myriad challenges and may be particularly vulnerable to the effects of HIV-related stigma. Homeless/unstably housed PLWHA from 3 U.S. cities (N = 637) completed computer-assisted interviews that measured demographics, self-assessed physical and mental health, medical utilization, adherence, HIV disclosure, and risk behaviors. Internal and perceived external HIV stigma were assessed and combined for a total stigma score. Higher levels of stigma were experienced by women, homeless participants, those with a high school education or less, and those more recently diagnosed with HIV. Stigma was strongly associated with poorer self-assessed physical and mental health, and perceived external stigma was associated with recent non-adherence to HIV treatment. Perceived external stigma was associated with decreased HIV disclosure to social network members, and internal stigma was associated with drug use and non-disclosure to sex partners. Interventions are needed to reduce HIV-related stigma and its effects on the health of homeless/unstably housed PLWHA.

Some persons living with HIV/AIDS (PLWHA) engage in periods of sexual abstinence. Baseline data from a larger study of homeless/unstably housed PLWHA indicated that 20% (125/644) intentionally abstained from sex in the past 90 days. Reasons included: (1) 'not interested' (n = 78); (2) did not want to infect someone (n = 46); and (3) did not have a partner (n = 37). Abstinence was less likely among all who had a main partner. Among men who have sex with men (MSM), abstinence was less likely among those with a detectable viral load. It was more likely among heterosexual men who were experiencing current housing problems and who had at least a high school education. Among women, abstinence was less likely among African Americans and those whose social networks were more aware of their HIV status. Better understanding of motivations to abstain may improve how programs serving PLWHA address this issue.

Homelessness affects HIV risk and health, but little is known about the longitudinal effects of rental assistance on the housing status and health of homeless and unstably housed people living with HIV/AIDS. Homeless/unstably housed people living with HIV/AIDS (N = 630) were randomly assigned to immediate Housing Opportunities for People with AIDS (HOPWA) rental assistance or customary care. Self-reported data, CD4, and HIV viral load were collected at baseline, 6, 12, and 18 months. Results showed that housing status improved in both groups, with greater improvement occurring in the treatment group. At 18 months, 51% of the comparison group had their own housing, limiting statistical power. Intent-to-treat analyses demonstrated significant reductions in medical care utilization and improvements in self-reported physical and mental health; significant differential change benefiting the treatment group was observed for depression and perceived stress. Significant differences between homeless and stably housed participants were found in as-treated analyses for health care utilization, mental health, and physical health. HOPWA rental assistance improves housing status and, in some cases, health outcomes of homeless and unstably housed people living with HIV/AIDS.

In April 2008, the U.S. Centers for Disease Control and Prevention (CDC) hosted a national consultation meeting of academic researchers, public health officials, service providers, and community leaders to examine the HIV/AIDS epidemic and prevention needs of Hispanics/Latinos in the United States and its territories. The consultation engaged key stakeholders to review available information on HIV-related behavioral research and prevention efforts, describe gaps in current HIV prevention programs and research on Hispanics/Latinos, and identify community and societal-level factors that can increase vulnerability of Hispanics/Latinos for acquiring or transmitting HIV infection. Recommendations were also made to CDC for future collaboration with the Hispanic/Latino community in areas of HIV prevention research and prevention programs. This article summarizes participants' recommendations for HIV prevention research, program and capacity building, policy and planning, and partnerships and communication. These recommendations will be used by CDC to inform the development of a National Plan of Action for HIV/AIDS prevention among Hispanics/Latinos, and can provide a framework for use by other federal and non-federal agencies, academic researchers, community-based organizations, and policymakers as they seek to curtail the HIV epidemic among Hispanics/Latinos.

Among US racial/ethnic groups, Blacks are at the highest risk of acquiring HIV/AIDS. In response, the Centers for Disease Control and Prevention (CDC) has launched the Heightened National Response to Address the HIV/AIDS Crisis Among African Americans, which seeks to engage public and nonpublic partners in a synergistic effort to prevent HIV among Blacks. The CDC also recently launched Act Against AIDS, a campaign to refocus attention on the domestic HIV/AIDS crisis. Although the CDC's efforts to combat HIV/AIDS among Blacks have achieved some success, more must be done to address this crisis. New initiatives include President Obama's goal of developing a National HIV/AIDS Strategy to reduce HIV incidence, decrease HIV-related health disparities, and increase access to care, especially among Blacks and other disproportionately affected populations.

OBJECTIVE: To integrate the empirical findings on the prevalence of unprotected anal intercourse (UAI) among HIV-diagnosed men who have sex with men (MSM) in the United States. METHODS: Comprehensively searching MEDLINE, EMBASE, PsycINFO (2000-2007), hand searching bibliographic lists, and contacting researchers. Thirty US studies (n = 18,121) met selection criteria. Analyses were conducted using random-effects models and meta-regression. RESULTS: The prevalence of UAI was considerably higher with HIV-seropositive partners (30%; 95% confidence interval 25-36) than with serostatus unknown (16%; 95% confidence interval 13-21) or HIV-seronegative partners (13%; 95% confidence interval 10-16). The prevalence of UAI with either a serostatus unknown or HIV-seronegative partner was 26%. The UAI prevalence did not differ by the length of the behavioral recall window but did vary by the type of anal intercourse (insertive vs. receptive). Studies with the following features had a lower UAI prevalence: recruiting participants before 2000, MSM of color being the majority of study sample, recruiting participants from medical settings, using random or systematic sampling methods, and having interviewers administer the questionnaire. Being on antiretroviral therapy, having an undetectable viral load, and reporting more than 90% medication adherence were not associated with UAI. CONCLUSION: Most HIV-diagnosed MSM protect partners during sexual activity, but a sizeable percentage continues to engage in sexual behaviors that place others at risk for HIV infection and place themselves at risk for other sexually transmitted infections. Prevention with positives programs continues to be urgently needed for MSM in the United States.