The status of the National HIV Surveillance System, United States, 2013

Health policy counterpublics: Enacting collective resistances to US molecular HIV surveillance and cluster detection and response programs

Health policies and the problems they constitute are deeply shaped by multiple publics. In this article we conceptualize health policy counterpublics: temporally bounded socio-political forms that aim to cultivate particular modes of conduct, generally to resist trajectories set by arms of the state. These counterpublics often emerge from existing social movements and involve varied forms of activism and advocacy. We examine a health policy counterpublic that has arisen in response to new forms of HIV public health surveillance by drawing on public documents and interview data from 2021 with 26 stakeholders who were critical of key policy developments. Since 2018, the national rollout of molecular HIV surveillance (MHS) and cluster detection and response (CDR) programs in the United States has produced sustained controversies among HIV stakeholders, including among organized networks of people living with HIV. This article focuses on how a health policy counterpublic formed around MHS/CDR and how constituents problematized the policy agenda set in motion by federal health agencies, including in relation to data ethics, the meaningful involvement of affected communities, informed consent, the digitization of health systems, and HIV criminalization. Although familiar problems in HIV policymaking, concerns about these issues have been reconfigured in response to the new sociotechnical milieu proffered by MHS/CDR, generating new critical positions aiming to remake public health. Critical attention to the scenes within which health policy controversies play out ought to consider how (counter)publics are made, how problems are constituted, and the broader social movement dynamics and activist resources drawn upon to contest and reimagine policymaking in public life.

Enhancements to the National HIV Surveillance System, United States, 2013-2023

HIV infection is monitored through the National HIV Surveillance System (NHSS) to help improve the health of people with HIV and reduce transmission. NHSS data are routinely used at federal, state, and local levels to monitor the distribution and transmission of HIV, plan and evaluate prevention and care programs, allocate resources, inform policy development, and identify and respond to rapid transmission in the United States. We describe the expanded use of HIV surveillance data since the 2013 NHSS status update, during which time the Centers for Disease Control and Prevention (CDC) coordinated to revise the HIV surveillance case definition to support the detection of early infection and reporting of laboratory data, expanded data collection to include information on sexual orientation and gender identity, enhanced data deduplication processes to improve quality, and expanded reporting to include social determinants of health and health equity measures. CDC maximized the effects of federal funding by integrating funding for HIV prevention and surveillance into a single program; the integration of program funding has expanded the use of HIV surveillance data and strengthened surveillance, resulting in enhanced cluster response capacity and intensified data-to-care activities to ensure sustained viral suppression. NHSS data serve as the primary source for monitoring HIV trends and progress toward achieving national initiatives, including the US Department of Health and Human Services' Ending the HIV Epidemic in the United States initiative, the White House's National HIV/AIDS Strategy (2022-2025), and Healthy People 2030. The NHSS will continue to modernize, adapt, and broaden its scope as the need for high-quality HIV surveillance data remains.

Misclassification of Loss to Care Among Persons With Human Immunodeficiency Virus: Improved Capture of Silent Transfers Through Surveillance Linkage Using Statewide Mandatorily Reported Laboratory Measures

Human Immunodeficiency Virus (HIV)-positive individuals lost to follow-up from particular clinics may not be lost to care (LTC). After linking Vanderbilt's Comprehensive Care Clinic cohort to Tennessee's statewide HIV surveillance database, LTC decreased from 48.4% to 35.0% at 10 years. Routine surveillance linkage by domestic HIV clinics would improve LTC and retention measure accuracy.

Joint modeling HIV and HPV using a new hybrid agent-based network and compartmental simulation technique

Persons living with human immunodeficiency virus (HIV) have a disproportionately higher burden of human papillomavirus infection (HPV)-related cancers. Causal factors include both behavioral and biological. While pharmaceutical and care support interventions help address biological risk of coinfection, as social conditions are common drivers of behaviors, structural interventions are key part of behavioral interventions. Our objective is to develop a joint HIV-HPV model to evaluate the contribution of each factor, to subsequently inform intervention analyses. While compartmental modeling is sufficient for faster spreading HPV, network modeling is suitable for slower spreading HIV. However, using network modeling for jointly modeling HIV and HPV can generate computational complexities given their vastly varying disease epidemiology and disease burden across sub-population groups. We applied a recently developed mixed agent-based compartmental (MAC) simulation technique, which simulates persons with at least one slower spreading disease and their immediate contacts as agents in a network, and all other persons including those with faster spreading diseases in a compartmental model, with an evolving contact network algorithm maintaining the dynamics between the two models. We simulated HIV and HPV in the U.S. among heterosexual female, heterosexual male, and men who have sex with men (men only and men and women) (MSM), sub-populations that mix but have varying HIV burden, and cervical cancer among women. We conducted numerical analyses to evaluate the contribution of behavioral and biological factors to risk of cervical cancer among women with HIV. The model outputs for HIV, HPV, and cervical cancer compared well with surveillance estimates. Model estimates for relative prevalence of HPV (1.67 times) and relative incidence of cervical cancer (3.6 times), among women with HIV compared to women without, were also similar to that reported in observational studies in the literature. The fraction attributed to biological factors ranged from 22-38% for increased HPV prevalence and 80% for increased cervical cancer incidence, the remaining attributed to behavioral. The attribution of both behavioral and biological factors to increased HPV prevalence and cervical cancer incidence suggest the need for behavioral, structural, and pharmaceutical interventions. Validity of model results related to both individual and joint disease metrics serves as proof-of-concept of the MAC simulation technique. Understanding the contribution of behavioral and biological factors of risk helps inform interventions. Future work can expand the model to simulate sexual and care behaviors as functions of social conditions to jointly evaluate behavioral, structural, and pharmaceutical interventions for HIV and cervical cancer prevention.

Enhancing the ATra Black Box Matching Algorithm: Use of All Names for Deduplication Across Jurisdictions

OBJECTIVES

Achieving accurate, timely, and complete HIV surveillance data is complicated in the United States by migration and care seeking across jurisdictional boundaries. To address these issues, public health entities use the ATra Black Box-a secure, electronic, privacy-assuring system developed by Georgetown University-to identify and confirm potential duplicate case records, exchange data, and perform other analytics to improve the quality of data in the Enhanced HIV/AIDS Reporting System (eHARS). We aimed to evaluate the ability of 2 ATra software algorithms to identify potential duplicate case-pairs across 6 jurisdictions for people living with diagnosed HIV.

METHODS

We implemented 2 matching algorithms for identifying potential duplicate case-pairs in ATra software. The Single Name Matching Algorithm examines only 1 name for a person, whereas the All Names Matching Algorithm examines all names in eHARS for a person. Six public health jurisdictions used the algorithms. We compared outputs for the overall number of potential matches and changes in matching level.

RESULTS

The All Names Matching Algorithm found more matches than the Single Name Matching Algorithm and increased levels of match. The All Names Matching Algorithm identified 9070 (4.5%) more duplicate matches than the Single Name Matching Algorithm (n = 198 828) and increased the total number of matches at the exact through high levels by 15.4% (from 167 156 to 192 932; n = 25 776).

CONCLUSIONS

HIV data quality across multiple jurisdictions can be improved by using all known first and last names of people living with diagnosed HIV that match with eHARS rather than using only 1 first and last name.

Linkage to HIV Medical Care and Social Determinants of Health Among Adults With Diagnosed HIV Infection in 41 States and the District of Columbia, 2017

OBJECTIVES

To reduce the number of new HIV infections and improve HIV health care outcomes, the social conditions in which people live and work should be assessed. The objective of this study was to describe linkage to HIV medical care by selected demographic characteristics and social determinants of health (SDH) among US adults with HIV at the county level.

METHODS

We used National HIV Surveillance System data from 42 US jurisdictions and data from the American Community Survey to describe differences in linkage to HIV medical care among adults aged ≥18 with HIV infection diagnosed in 2017. We categorized SDH variables into higher or lower levels of poverty (where <13% or ≥13% of the population lived below the federal poverty level), education (where <13% or ≥13% of the population had

RESULTS

Of 33 204 adults with HIV infection diagnosed in 2017, 78.4% were linked to HIV medical care ≤1 month after diagnosis. Overall, rates of linkage to care were significantly lower among men and women living in counties with higher versus lower poverty (PR = 0.96; 95% CI, 0.94-0.97), with lower versus higher health insurance coverage (PR = 0.93; 95% CI, 0.92-0.94), and with lower versus higher education levels (PR = 0.97; 95% CI, 0.96-0.98).

CONCLUSIONS

Increasing health insurance coverage and addressing economic and educational disparities would likely lead to better HIV care outcomes in these areas.

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Key Words

• HIV health care outcomes
• health disparity
• human immunodeficiency virus
• linkage to HIV medical care
• social determinants of health

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MESH Headings

• Adult
• District of Columbia
• Female
• HIV Infections/diagnosis
• HIV Infections/epidemiology
• HIV Infections/therapy
• Humans
• Insurance, Health
• Male
• Poverty
• Social Determinants of Health
• United States/epidemiology

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Affiliation(s)

Myrline Gillot Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA
Zanetta Gant Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
Xiaohong Hu Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
Anna Satcher Johnson Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA

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Do partner services linked to molecular clusters yield people with viremia or new HIV?

OBJECTIVES

We examined whether molecular cluster membership was associated with public health identification of HIV transmission potential among named partners in Chicago.

DESIGN

Historical cohort study.

METHODS

We matched and analyzed HIV surveillance and partner services data from HIV diagnoses (2012-2016) prior to implementation of cluster detection and response interventions. We constructed molecular clusters using HIV-TRACE at a pairwise genetic distance threshold of 0.5% and identified clusters exhibiting recent and rapid growth according to the Centers for Disease Control and Prevention definition (three new cases diagnosed in past year). Factors associated with identification of partners with HIV transmission potential were examined using multivariable Poisson regression.

RESULTS

There were 5208 newly diagnosed index clients over this time period. Average age of index clients in clusters was 28; 47% were Black, 29% Latinx/Hispanic, 6% female and 89% MSM. Of the 537 named partners, 191 (35.6%) were linked to index cases in a cluster and of those 16% were either new diagnoses or viremic. There was no statistically significant difference in the probability of identifying partners with HIV transmission potential among index clients in a rapidly growing cluster versus those not in a cluster [adjusted relative risk 1.82, (0.81-4.06)].

CONCLUSION

Partner services that were initiated from index clients in a molecular cluster yielded similar new HIV case finding or identification of those with viremia as did interviews with index clients not in clusters. It remains unclear whether these findings are due to temporal disconnects between diagnoses and cluster identification, unobserved cluster members, or challenges with partner services implementation.

Practical issues in operationalizing the design and outcome evaluation of cluster randomized trials

Trial designs using cluster-level randomization are necessary when interventions have intended effects that cannot be measured with individual randomization. When an intervention is intrinsically only able to be delivered to a cluster or when implementation of an individual level intervention is only feasibly implemented at a cluster level, cluster-level randomization is required. In designing the strategy for evaluation of the primary outcome of a cluster randomized trial, there are a multitude of important decisions to consider. While these decisions are guided primarily by the intervention-who benefits, what is the intended effect and when will it be achieved-there are important detailed choices that affect potential bias and statistical power, and implementation considerations that require compromise for considerations of feasibility and practicality. Through the lens of three large completed cluster randomized trials in HIV prevention, we present specific choices made for the overall evaluation plan, together with some of the detailed considerations, compromises and modifications that occurred during trial implementation.

America's HIV Epidemic Analysis Dashboard: Protocol for a Data Resource to Support Ending the HIV Epidemic in the United States

Background

The Ending the HIV Epidemic (EHE) plan aims to end the HIV epidemic in the United States by 2030. Having timely and accessible data to assess progress toward EHE goals at the local level is a critical resource to achieve this goal.

Objective

The aim of this paper was to introduce America’s HIV Epidemic Analysis Dashboard (AHEAD), a data visualization tool that displays relevant data on the 6 HIV indicators provided by the Centers for Disease Control and Prevention. AHEAD can be used to monitor progress toward ending the HIV epidemic in local communities across the United States. Its objective is to make data available to stakeholders, which can be used to measure national and local progress toward 2025 and 2030 EHE goals and to help jurisdictions make local decisions that are grounded in high-quality data.

Methods

AHEAD displays data from public health data systems (eg, surveillance systems and census data), organized around the 6 EHE indicators (HIV incidence, knowledge of HIV status, HIV diagnoses, linkage to HIV medical care, viral HIV suppression, and preexposure prophylaxis coverage). Data are displayed for each of the EHE priority areas (48 counties in Washington, District of Columbia, and San Juan, Puerto Rico) which accounted for more than 50% of all US HIV diagnoses in 2016 and 2017 and 7 primarily southern states with high rates of HIV in rural communities. AHEAD also displays data for the 43 remaining states for which data are available. Data features prioritize interactive data visualization tools that allow users to compare indicator data stratified by sex at birth, race or ethnicity, age, and transmission category within a jurisdiction (when available) or compare data on EHE indicators between jurisdictions.

Results

AHEAD was launched on August 14, 2020. In the 11 months since its launch, the Dashboard has been visited 26,591 times by 17,600 unique users. About one-quarter of all users returned to the Dashboard at least once. On average, users engaged with 2.4 pages during their visit to the Dashboard, indicating that the average user goes beyond the informational landing page to engage with 1 or more pages of data and content. The most frequently visited content pages are the jurisdiction webpages.

Conclusions

The Ending the HIV Epidemic plan is described as a “whole of society” effort. Societal public health initiatives require objective indicators and require that all societal stakeholders have transparent access to indicator data at the level of the health jurisdictions responsible for meeting the goals of the plan. Data transparency empowers local stakeholders to track movement toward EHE goals, identify areas with needs for improvement, and make data-informed adjustments to deploy the expertise and resources required to locally tailor and implement strategies to end the HIV epidemic in their jurisdiction.

Identification and Reporting of Gender Identity in HIV Surveillance Data in the Deep South

Introduction

Although studies have identified high prevalence of HIV among individuals who are transgender, HIV surveillance data regarding gender identity is incomplete, resulting in uncertainty regarding the gender identity, including transgender and other diverse gender identities, of individuals diagnosed with HIV. This information is critical to planning strategies for HIV prevention and care.

Methods

From August 2018 to March 2019, interviews were conducted with HIV surveillance leadership (including Surveillance Directors, Epidemiologists, and HIV/STI Prevention Staff) at offices of epidemiology from eight US Deep South states regarding their practices related to gender identity documentation in HIV surveillance data and the barriers encountered in these documentation processes as well as their recommendations for improving gender identity data collection.

Results

Interview findings indicated significant barriers to collection of accurate gender identity information in HIV surveillance data including lack of standardized data systems for collecting gender identity; difficulty obtaining gender identity information from HIV testing sites, laboratories, and medical databases; and need for enhanced cultural sensitivity and gender identity knowledge at all levels of the data collection process. Recommendations from the state HIV surveillance staff, leaders, and epidemiologists are included in the findings.

Conclusions and Policy Implications

Effective, well-coordinated strategies are needed to improve gender identity information in HIV surveillance reporting. Recommendations include standardizing and enhancing data collection strategies, providing cultural sensitivity training at all levels of HIV testing/reporting, and developing formal guidance and providing technical assistance that targets and educates laboratories and medical organizations to implement systems of data collection that routinely and safely capture gender identity data.

Sorting by Race/Ethnicity Across HIV Genetic Transmission Networks in Three Major Metropolitan Areas in the United States

An important component underlying the disparity in HIV risk between race/ethnic groups is the preferential transmission between individuals in the same group. We sought to quantify transmission between different race/ethnicity groups and measure racial assortativity in HIV transmission networks in major metropolitan areas in the United States. We reconstructed HIV molecular transmission networks from viral sequences collected as part of HIV surveillance in New York City, Los Angeles County, and Cook County, Illinois. We calculated assortativity (the tendency for individuals to link to others with similar characteristics) across the network for three candidate characteristics: transmission risk, age at diagnosis, and race/ethnicity. We then compared assortativity between race/ethnicity groups. Finally, for each race/ethnicity pair, we performed network permutations to test whether the number of links observed differed from that expected if individuals were sorting at random. Transmission networks in all three jurisdictions were more assortative by race/ethnicity than by transmission risk or age at diagnosis. Despite the different race/ethnicity proportions in each metropolitan area and lower proportions of clustering among African Americans than other race/ethnicities, African Americans were the group most likely to have transmission partners of the same race/ethnicity. This high level of assortativity should be considered in the design of HIV intervention and prevention strategies.

Progression and transmission of HIV (PATH 4.0)-A new agent-based evolving network simulation for modeling HIV transmission clusters

We present the Progression and Transmission of HIV (PATH 4.0), a simulation tool for analyses of cluster detection and intervention strategies. Molecular clusters are groups of HIV infections that are genetically similar, indicating rapid HIV transmission where HIV prevention resources are needed to improve health outcomes and prevent new infections. PATH 4.0 was constructed using a newly developed agent-based evolving network modeling (ABENM) technique and evolving contact network algorithm (ECNA) for generating scale-free networks. ABENM and ECNA were developed to facilitate simulation of transmission networks for low-prevalence diseases, such as HIV, which creates computational challenges for current network simulation techniques. Simulating transmission networks is essential for studying network dynamics, including clusters. We validated PATH 4.0 by comparing simulated projections of HIV diagnoses with estimates from the National HIV Surveillance System (NHSS) for 2010-2017. We also applied a cluster generation algorithm to PATH 4.0 to estimate cluster features, including the distribution of persons with diagnosed HIV infection by cluster status and size and the size distribution of clusters. Simulated features matched well with NHSS estimates, which used molecular methods to detect clusters among HIV nucleotide sequences of persons with HIV diagnosed during 2015-2017. Cluster detection and response is a component of the U.S. Ending the HIV Epidemic strategy. While surveillance is critical for detecting clusters, a model in conjunction with surveillance can allow us to refine cluster detection methods, understand factors associated with cluster growth, and assess interventions to inform effective response strategies. As surveillance data are only available for cases that are diagnosed and reported, a model is a critical tool to understand the true size of clusters and assess key questions, such as the relative contributions of clusters to onward transmissions. We believe PATH 4.0 is the first modeling tool available to assess cluster detection and response at the national-level and could help inform the national strategic plan.

Reassessing the Ethics of Molecular HIV Surveillance in the Era of Cluster Detection and Response: Toward HIV Data Justice

In the United States, clinical HIV data reported to surveillance systems operated by jurisdictional departments of public health are re-used for epidemiology and prevention. In 2018, all jurisdictions began using HIV genetic sequence data from clinical drug resistance tests to identify people living with HIV in "clusters" of others with genetically similar strains. This is called "molecular HIV surveillance" (MHS). In 2019, "cluster detection and response" (CDR) programs that re-use MHS data became the "fourth pillar" of the national HIV strategy. Public health re-uses of HIV data are done without consent and are a source of concern among stakeholders. This article presents three cases that illuminate bioethical challenges associated with re-uses of clinical HIV data for public health. We focus on evidence-base, risk-benefit ratio, determining directionality of HIV transmission, consent, and ethical re-use. The conclusion offers strategies for "HIV data justice." The essay contributes to a "bioethics of the oppressed."

Identification and characterization of tweets related to the 2015 Indiana HIV outbreak: A retrospective infoveillance study

INTRODUCTION

From late 2014 through 2015, Scott County, Indiana faced an HIV outbreak triggered by opioid abuse and transition to injection drug use. Investigating the origins, risk factors, and responses related to this outbreak is critical to inform future surveillance, interventions, and policymaking. In response, this retrospective infoveillance study identifies and characterizes user-generated messages related to opioid abuse, heroin injection drug use, and HIV status using natural language processing (NLP) among Twitter users in Indiana during the period of this HIV outbreak.

MATERIALS AND METHODS

Our study consisted of two phases: data collection and processing, and data analysis. We collected Indiana geolocated tweets from the public Twitter API using Amazon Web Services EC2 instances filtered for geocoded messages in the immediate pre and post period of the outbreak. In the data analysis phase we applied an unsupervised machine learning approach using NLP called the Biterm Topic Model (BTM) to identify tweets related to opioid, heroin/injection, and HIV behavior and then examined these messages for HIV risk-related topics that could be associated with the outbreak.

RESULTS

More than 10 million geocoded tweets occurring in Indiana during the immediate pre and post period of the outbreak were collected for analysis. Using BTM, we identified 1350 tweets thought to be relevant to the outbreak and then confirmed 358 tweets using human annotation. The most prevalent themes identified were tweets related to self-reported abuse of illicit and prescription drugs, opioid use disorder, self-reported HIV status, and public sentiment regarding the outbreak. Geospatial analysis found that these messages clustered in population dense areas outside of the outbreak, including Indianapolis and neighboring Clark County.

DISCUSSION

This infoveillance study characterized the social media conversations of communities in Indiana in the pre and post period of the 2015 HIV outbreak. Behavioral themes detected reflect discussion about risk factors related to HIV transmission stemming from opioid and heroin abuse for priority populations, and also help identify community attitudes that could have motivated or detracted the use of HIV prevention methods, along with helping identify factors that can impede access to prevention services.

CONCLUSIONS

Infoveillance approaches, such as the analysis conducted in this study, represent a possibly strategy to detect "signal" of the emergence of risk factors associated with an outbreak though may be limited in their scope and generalizability. Our results, in conjunction with other forms of public health surveillance, can leverage the growing ubiquity of social media platforms to better detect opioid-related HIV risk knowledge, attitudes and behavior, as well as inform future prevention efforts.

County-level factors affecting Latino HIV disparities in the United States

OBJECTIVE

To determine which county-level social, economic, demographic, epidemiologic and access to care factors are associated with Latino/non-Latino White disparities in prevalence of diagnosed HIV infection.

METHODS AND FINDINGS

We used 2016 county-level prevalence rates of diagnosed HIV infection rates for Latinos and non-Latino Whites obtained from the National HIV Surveillance System and factors obtained from multiple publicly available datasets. We used mixed effects Poisson modeling of observed HIV prevalence at the county-level to identify county-level factors that explained homogeneous effects across race/ethnicity and differential effects for Latinos and NL-Whites. Overall, the median Latinos disparity in HIV prevalence is 2.4; 94% of the counties have higher rates for Latinos than non-Latinos, and one-quarter of the counties' disparities exceeded 10. Of the 41 county-level factors examined, 24 showed significant effect modification when examined individually. In multi-variable modeling, 11 county-level factors were found that significantly affected disparities. Factors that increased disparity with higher, compared to lower values included proportion of HIV diagnoses due to injection drug use, percent Latino living in poverty, percent not English proficient, and percent Puerto Rican. Latino disparities increased with decreasing percent severe housing, drug overdose mortality rate, percent rural, female prevalence rate, social association rate, percent change in Latino population, and Latino to NL-White proportion of the population. These factors while significant had minimal effects on diminishing disparity, but did substantially reduce the variance in disparity rates.

CONCLUSIONS

Large differences in HIV prevalence rates persist across almost all counties even after controlling for county-level factors. Counties that are more rural, have fewer Latinos, or have lower NL-White prevalence rates tend to have higher disparities. There is also higher disparity when community risk is low.

Methods to include persons living with HIV not receiving HIV care in the Medical Monitoring Project

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

The "No Wrong Door" Approach to HIV Testing: Results From a Statewide Retail Pharmacy-Based HIV Testing Program in Virginia, 2014-2016

OBJECTIVE

As part of the Care and Prevention in the United States Demonstration Project (2012-2016), which aimed to reduce HIV-related morbidity and mortality among racial/ethnic minority groups in 8 states, the Virginia Department of Health (VDH) funded Walgreens to provide HIV testing in retail pharmacies in areas with large racial/ethnic minority communities and high rates of poverty. We describe this program and summarize its outcomes. We hypothesized that (1) offering walk-in HIV testing outside of traditional business hours and alongside other point-of-care tests in retail pharmacies would increase rates of first-time testers and (2) using data on social determinants of health associated with higher rates of HIV infection to locate test sites would increase the identification of people who were previously undiagnosed.

METHODS

Using 2010 US Census data and 2007-2011 five-year population estimates from the American Community Survey, VDH selected 32 Walgreens stores located in census tracts where at least 30% of the population was black and/or Hispanic/Latino and/or where at least 20% of the population was living at or below the federal poverty level. Pharmacists administered the INSTI HIV-1/HIV-2 Rapid Antibody Test. Clients with a reactive test result were linked to confirmatory testing and medical care.

RESULTS

Between June 1, 2014, and September 29, 2016, Walgreens pharmacists performed HIV tests on 3630 clients, of whom 1668 (46.0%) had either never been tested or were unsure if they had been tested. Of all clients tested, 30 (0.8%) had a reactive test result. Of 26 clients who also had positive confirmatory testing, 22 (84.6%) were linked to care. The mean cost per person tested was $41.79, and the mean cost per reactive result was $5057.

CONCLUSIONS

Retail pharmacies may be an effective venue for those who have never been tested for HIV to access HIV testing, particularly if the pharmacies are located in priority areas or where community-based organizations are unable to operate.

Implementing a Data to Care Strategy to Improve Health Outcomes for People With HIV: A Report From the Care and Prevention in the United States Demonstration Project

OBJECTIVES

The Care and Prevention in the United States Demonstration Project included implementation of a Data to Care strategy using surveillance and other data to (1) identify people with HIV infection in need of HIV medical care or other services and (2) facilitate linkages to those services to improve health outcomes. We present the experiences of 4 state health departments: Illinois, Louisiana, Tennessee, and Virginia.

METHODS

The 4 state health departments used multiple databases to generate listings of people with diagnosed HIV infection (PWH) who were presumed not to be in HIV medical care or who had difficulty maintaining viral suppression from October 1, 2013, through September 29, 2016. Each health department prioritized the listings (eg, by length of time not in care, by viral load), reviewed them for accuracy, and then disseminated the listings to staff members to link PWH to HIV care and services.

RESULTS

Of 16 391 PWH presumed not to be in HIV medical care, 9852 (60.1%) were selected for follow-up; of those, 4164 (42.3%) were contacted, and of those, 1479 (35.5%) were confirmed to be not in care. Of 794 (53.7%) PWH who accepted services, 694 (87.4%) were linked to HIV medical care. The Louisiana Department of Health also identified 1559 PWH as not virally suppressed, 764 (49.0%) of whom were eligible for follow-up. Of the 764 PWH who were eligible for follow-up, 434 (56.8%) were contacted, of whom 269 (62.0%) had treatment adherence issues. Of 153 PWH who received treatment adherence services, 104 (68.0%) showed substantial improvement in viral suppression.

CONCLUSIONS

The 4 health departments established procedures for using surveillance and other data to improve linkage to HIV medical care and health outcomes for PWH. To be effective, health departments had to enhance coordination among surveillance, care programs, and providers; develop mechanisms to share data; and address limitations in data systems and data quality.

HIV Prevention Practices and Non-Federal Funding Among U.S. States and Non-State Regions: A Survey of HIV/AIDS Directors

We surveyed U.S. HIV/AIDS directors or designees in states and non-state regions, regarding factors influencing HIV viral suppression: (1) non-federal prevention funding; (2) contacting newly reported patients and providers, for care linkage and partner services; (3) follow-up of non-received viral load reports, to identify untreated patients; and (4) genotype/phenotype surveillance, to monitor drug resistance. The survey was conducted April-July 2015; 50 (87.7%) participated. Eighty percent of jurisdictions contacted all newly reported patients; 60% contacted all providers. HIV resistance tests were reportable in 38%; 66% contacted providers and/or patients about missed viral loads. Non-federal funding was significantly associated with annual diagnoses (p = .0001) and population (p = .0002), but not with other factors studied. Many jurisdictions lacked non-federal funding (28%), or experienced unrestored reductions since 2008 (33%). Jurisdictions' funding and preventive practices varied greatly. HIV viral suppression could be enhanced by restoring (or establishing) non-federal prevention funding, and by more standardized surveillance/outreach practices.

Generalizing the per-protocol treatment effect: The case of ACTG A5095

BACKGROUND

Intention-to-treat comparisons of randomized trials provide asymptotically consistent estimators of the effect of treatment assignment, without regard to compliance. However, decision makers often wish to know the effect of a per-protocol comparison. Moreover, decision makers may also wish to know the effect of treatment assignment or treatment protocol in a user-specified target population other than the sample in which the trial was fielded. Here, we aimed to generalize results from the ACTG A5095 trial to the US recently HIV-diagnosed target population.

METHODS

We first replicated the published conventional intention-to-treat estimate (2-year risk difference and hazard ratio) comparing a four-drug antiretroviral regimen to a three-drug regimen in the A5095 trial. We then estimated the intention-to-treat effect that accounted for informative dropout and the per-protocol effect that additionally accounted for protocol deviations by constructing inverse probability weights. Furthermore, we employed inverse odds of sampling weights to generalize both intention-to-treat and per-protocol effects to a target population comprising US individuals with HIV diagnosed during 2008-2014.

RESULTS

Of 761 subjects in the analysis, 82 dropouts (36 in the three-drug arm and 46 in the four-drug arm) and 59 protocol deviations (25 in the three-drug arm and 34 in the four-drug arm) occurred during the first 2 years of follow-up. A total of 169 subjects incurred virologic failure or death. The 2-year risks were similar both in the trial and in the US HIV-diagnosed target population for estimates from the conventional intention-to-treat, dropout-weighted intention-to-treat, and per-protocol analyses. In the US target population, the 2-year conventional intention-to-treat risk difference (unit: %) for virologic failure or death comparing the four-drug arm to the three-drug arm was -0.4 (95% confidence interval: -6.2, 5.1), while the hazard ratio was 0.97 (95% confidence interval: 0.70, 1.34); the 2-year risk difference was -0.9 (95% confidence interval: -6.9, 5.3) for the dropout-weighted intention-to-treat comparison (hazard ratio = 0.95, 95% confidence interval: 0.68, 1.32) and -0.7 (95% confidence interval: -6.7, 5.5) for the per-protocol comparison (hazard ratio = 0.96, 95% confidence interval: 0.69, 1.34).

CONCLUSION

No benefit of four-drug antiretroviral regimen over three-drug regimen was found from the conventional intention-to-treat, dropout-weighted intention-to-treat or per-protocol estimates in the trial sample or target population.

Evaluating the Completeness of HIV Surveillance Using Capture-Recapture Models, Alameda County, California

HIV prevalence in Alameda County (including Oakland) is among the highest in California, yet the case registry may under-appreciate the full burden of disease. Using lists from health care facilities serving socioeconomically diverse populations and the HIV surveillance list, we applied capture-recapture methods to evaluate the completeness of the surveillance system by estimating the number of diagnosed people living with HIV and seeking care in Alameda County in 2013. Of the 5376 unique individuals reported from the lists, 397 were missing from the surveillance list. Models projected the total population size to be 5720 (95% CI 5587-6190), estimating the surveillance system as 87% complete. Subgroup analyses identified groups facing a disproportionate burden of HIV as more likely to be detected by the surveillance list. The Alameda County HIV surveillance system reports a high proportion of persons diagnosed with HIV within the jurisdiction. Capture-recapture analysis can help track progress towards maximizing engagement in HIV care.

Locating People Diagnosed With HIV for Public Health Action: Utility of HIV Case Surveillance and Other Data Sources

INTRODUCTION

Human immunodeficiency virus (HIV) case surveillance and other health care databases are increasingly being used for public health action, which has the potential to optimize the health outcomes of people living with HIV (PLWH). However, often PLWH cannot be located based on the contact information available in these data sources. We assessed the accuracy of contact information for PLWH in HIV case surveillance and additional data sources and whether time since diagnosis was associated with accurate contact information in HIV case surveillance and successful contact.

MATERIALS AND METHODS

The Case Surveillance-Based Sampling (CSBS) project was a pilot HIV surveillance system that selected a random population-based sample of people diagnosed with HIV from HIV case surveillance registries in 5 state and metropolitan areas. From November 2012 through June 2014, CSBS staff members attempted to locate and interview 1800 sampled people and used 22 data sources to search for contact information.

RESULTS

Among 1063 contacted PLWH, HIV case surveillance data provided accurate telephone number, address, or HIV care facility information for 239 (22%), 412 (39%), and 827 (78%) sampled people, respectively. CSBS staff members used additional data sources, such as support services and commercial people-search databases, to locate and contact PLWH with insufficient contact information in HIV case surveillance. PLWH diagnosed <1 year ago were more likely to have accurate contact information in HIV case surveillance than were PLWH diagnosed ≥1 year ago ( P = .002), and the benefit from using additional data sources was greater for PLWH with more longstanding HIV infection ( P < .001).

PRACTICE IMPLICATIONS

When HIV case surveillance cannot provide accurate contact information, health departments can prioritize searching additional data sources, especially for people with more longstanding HIV infection.

Virologic suppression and CD4+ cell count recovery after initiation of raltegravir or efavirenz-containing HIV treatment regimens

OBJECTIVE

To explore the effectiveness of raltegravir-based antiretroviral therapy (ART) on treatment response among ART-naive patients seeking routine clinical care.

DESIGN

Cohort study of adults enrolled in HIV care in the United States.

METHODS

We compared virologic suppression and CD4 cell count recovery over a 2.5 year period after initiation of an ART regimen containing raltegravir or efavirenz using observational data from a US clinical cohort, generalized to the US population of people with diagnosed HIV. We accounted for nonrandom treatment assignment, informative censoring, and nonrandom selection from the US target population using inverse probability weights.

RESULTS

Of the 2843 patients included in the study, 2476 initiated the efavirenz-containing regimen and 367 initiated the raltegravir-containing regimen. In the weighted intent-to-treat analysis, patients spent an average of 74 (95% confidence interval: 41, 106) additional days alive with a suppressed viral load on the raltegravir regimen than on the efavirenz regimen over the 2.5-year study period. CD4 cell count recovery was also superior under the raltegravir regimen.

CONCLUSION

Patients receiving raltegravir spent more time alive and suppressed than patients receiving efavirenz, but the probability of viral suppression by 2.5 years after treatment was similar between groups. Optimizing the amount of time spent in a state of viral suppression is important to improve survival among people living with HIV and to reduce onward transmission.

Country of Birth of Children With Diagnosed HIV Infection in the United States, 2008-2014

BACKGROUND

Diagnoses of HIV infection among children in the United States have been declining; however, a notable percentage of diagnoses are among those born outside the United States. The impact of foreign birth among children with diagnosed infections has not been examined in the United States.

METHODS

Using the Centers for Disease Control and Prevention National HIV Surveillance System, we analyzed data for children aged <13 years with diagnosed HIV infection ("children") in the United States (reported from 50 states and the District of Columbia) during 2008-2014, by place of birth and selected characteristics.

RESULTS

There were 1516 children [726 US born (47.9%) and 676 foreign born (44.6%)]. US-born children accounted for 70.0% in 2008, declining to 32.3% in 2013, and 40.9% in 2014. Foreign-born children have exceeded US-born children in number since 2011. Age at diagnosis was younger for US-born than foreign-born children (0-18 months: 72.6% vs. 9.8%; 5-12 years: 16.9% vs. 60.3%). HIV diagnoses in mothers of US-born children were made more often before pregnancy (49.7% vs. 21.4%), or during pregnancy (16.6% vs. 13.9%), and less often after birth (23.7% vs. 41%). Custodians of US-born children were more often biological parents (71.9% vs. 43.2%) and less likely to be foster or nonrelated adoptive parents (10.4% vs. 55.1%). Of 676 foreign-born children with known place of birth, 65.5% were born in sub-Saharan Africa and 14.3% in Eastern Europe. The top countries of birth were Ethiopia, Ukraine, Uganda, Haiti, and Russia.

CONCLUSIONS

The increasing number of foreign-born children with diagnosed HIV infection in the United States requires specific considerations for care and treatment.

Estimated HIV Incidence, Prevalence, and Undiagnosed Infections in US States and Washington, DC, 2010-2014

INTRODUCTION

The burden of HIV infection and health outcomes for people living with HIV varies across the United States. New methods allow for estimating national and state-level HIV incidence, prevalence, and undiagnosed infections using surveillance data and CD4 values.

METHODS

HIV surveillance data reported to the Centers for Disease Control and Prevention and the first CD4 value after diagnosis were used to estimate the distribution of delay from infection to diagnosis based on a well-characterized CD4 depletion model. This distribution was used to estimate HIV incidence, prevalence, and undiagnosed infections during 2010-2014. Estimated annual percentage changes (EAPCs) were calculated to assess trends.

RESULTS

During 2010-2014, HIV incidence decreased 10.3% (EAPC = -3.1%) and the percentage of undiagnosed infection decreased from 17.1% to 15.0% (EAPC = -3.3%) in the United States; HIV prevalence increased 9.1% (EAPC = 2.2%). Among 36 jurisdictions with sufficient data to produce stable estimates, HIV incidence decreased in 3 jurisdictions (Georgia, New York, and District of Columbia) and the percentage of undiagnosed HIV infections decreased in 2 states (Texas and Georgia). HIV prevalence increased in 4 states (California, Florida, Georgia, and Texas). In 2014, southern states accounted for 50% of both new HIV infections and undiagnosed infections.

CONCLUSION

HIV incidence and undiagnosed infection decreased in the United States during 2010-2014; however, outcomes varied by state and region. Progress in national HIV prevention is encouraging but intensified efforts for testing and treatment are needed in the South and states with high percentages of undiagnosed infection.

Financial Incentives for Linkage to Care and Viral Suppression Among HIV-Positive Patients: A Randomized Clinical Trial (HPTN 065)

IMPORTANCE

Achieving linkage to care and viral suppression in human immunodeficiency virus (HIV)-positive patients improves their well-being and prevents new infections. Current gaps in the HIV care continuum substantially limit such benefits.

OBJECTIVE

To evaluate the effectiveness of financial incentives on linkage to care and viral suppression in HIV-positive patients.

DESIGN, SETTING, AND PARTICIPANTS

A large community-based clinical trial that randomized 37 HIV test and 39 HIV care sites in the Bronx, New York, and Washington, DC, to financial incentives or standard of care.

INTERVENTIONS

Participants at financial incentive test sites who had positive test results for HIV received coupons redeemable for $125 cash-equivalent gift cards upon linkage to care. HIV-positive patients receiving antiretroviral therapy at financial incentive care sites received $70 gift cards quarterly, if virally suppressed.

MAIN OUTCOMES AND MEASURES

Linkage to care: proportion of HIV-positive persons at the test site who linked to care within 3 months, as indicated by CD4+ and/or viral load test results done at a care site. Viral suppression: proportion of established patients at HIV care sites with suppressed viral load (<400 copies/mL), assessed at each calendar quarter. Outcomes assessed through laboratory test results reported to the National HIV Surveillance System.

RESULTS

A total of 1061 coupons were dispensed for linkage to care at 18 financial incentive test sites and 39 359 gift cards were dispensed to 9641 HIV-positive patients eligible for gift cards at 17 financial incentive care sites. Financial incentives did not increase linkage to care (adjusted odds ratio, 1.10; 95% CI, 0.73-1.67; P = .65). However, financial incentives significantly increased viral suppression. The overall proportion of patients with viral suppression was 3.8% higher (95% CI, 0.7%-6.8%; P = .01) at financial incentive sites compared with standard of care sites. Among patients not previously consistently virally suppressed, the proportion virally suppressed was 4.9% higher (95% CI, 1.4%-8.5%; P = .007) at financial incentive sites. In addition, continuity in care was 8.7% higher (95% CI, 4.2%-13.2%; P < .001) at financial incentive sites.

CONCLUSIONS AND RELEVANCE

Financial incentives, as used in this study (HPTN 065), significantly increased viral suppression and regular clinic attendance among HIV-positive patients in care. No effect was noted on linkage to care. Financial incentives offer promise for improving adherence to treatment and viral suppression among HIV-positive patients.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01152918.

Feasibility of Establishing HIV Case-Based Surveillance to Measure Progress Along the Health Sector Cascade: Situational Assessments in Tanzania, South Africa, and Kenya

BACKGROUND

To track the HIV epidemic and responses to it, the World Health Organization recommends 10 global indicators to collect information along the HIV care cascade. Patient diagnosis and medical record data, harnessed through case-based surveillance (CBS), can be used to measure 8 of these. While many high burden countries have well-established systems for monitoring patients on HIV treatment, few have formally adopted CBS.

OBJECTIVE

In response to the need for improved strategic HIV information and to facilitate the development of CBS in resource-limited countries, we aimed to conduct situational assessments of existing data collection systems in Tanzania, South Africa, and Kenya.

METHODS

We developed a standardized protocol and a modularized data collection tool to be adapted for the particular focus of the assessments within each country. The three countries were selected based on their stage of readiness for CBS. The assessment included three parts: a desk review of relevant materials on HIV surveillance and program monitoring, stakeholder meetings, and site visits.

RESULTS

In all three countries, routine HIV program monitoring is conducted, and information on new HIV diagnoses and persons accessing HIV care and treatment services is collected. Key findings from the assessments included substantial stakeholder support for the development of CBS, significant challenges in linking data within and between systems, data quality, the ability to obtain data from multiple sources, and information technology infrastructure. Viral load testing capacity varied by country, and vital registry data were not routinely linked to health systems to update medical records.

CONCLUSIONS

Our findings support the development of CBS systems to systematically capture routinely collected health data to measure and monitor HIV epidemics and guide responses. Although there were wide variations in the systems examined, some of the current program and patient monitoring systems can be adapted to function effectively for CBS, especially if supported by an improved patient registration system with shared unique health identifiers.

HIV Strategic Information in Non-European Union Countries in the World Health Organization European Region: Capacity Development Needs

BACKGROUND

Capacity building of the national HIV strategic information system is a core component of the response to the HIV epidemic as it enables understanding of the evolving nature of the epidemic, which is critical for program planning and identification of the gaps and deficiencies in HIV programs.

OBJECTIVE

The study aims to describe the results of the assessment of the needs for further development of capacities in HIV strategic information systems in the non-European Union (EU) countries in the World Health Organization European Region (EUR).

METHODS

Self-administered questionnaires were distributed to national AIDS programs. The first questionnaire was sent to all countries (N=18) to find out, among other issues, the priority level for strengthening a range of HIV surveillance areas and their key gaps and weaknesses. The second questionnaire was sent to 15 countries to more specifically determine capacities for the analysis of the HIV care cascade.

RESULTS

Responses to the first questionnaire were received from 10 countries, whereas 13 countries responded to the second questionnaire. Areas that were most frequently marked as being of high to moderate priority for strengthening were national electronic patient monitoring systems, evaluation of HIV interventions and impact analysis, implementation science, and data analysis. Key weaknesseses were lack of electronic reporting of HIV cases, problems with timeliness and completeness of reporting in HIV cases, under-estimates of the reported number of HIV-related deaths, and limited CD4 count testing at the time of HIV diagnosis. Migrant populations, internally displaced persons, and refugees were most commonly mentioned as groups not covered by surveillance, followed by clients of sex workers and men who have sex with men. The majority of countries reported that they were able to provide the number of people diagnosed with HIV who know their HIV status, which is important for the analysis of cross-sectional and longitudinal HIV care cascades. Ability to report on some of the key impact indicators of HIV programs-viral load suppression and mortality-should be considerably strengthened.

CONCLUSIONS

The assessment found a substantial need to invest in surveillance capacities, which is a cornerstone in the development of an evidence-informed response to HIV epidemics.

Design of the HPTN 065 (TLC-Plus) study: A study to evaluate the feasibility of an enhanced test, link-to-care, plus treat approach for HIV prevention in the United States

Background/Aims

HIV continues to be a major public health threat in the United States, and mathematical modeling has demonstrated that the universal effective use of antiretroviral therapy among all HIV-positive individuals (i.e. the “test and treat” approach) has the potential to control HIV. However, to accomplish this, all the steps that define the HIV care continuum must be achieved at high levels, including HIV testing and diagnosis, linkage to and retention in clinical care, antiretroviral medication initiation, and adherence to achieve and maintain viral suppression. The HPTN 065 (Test, Link-to-Care Plus Treat [TLC-Plus]) study was designed to determine the feasibility of the “test and treat” approach in the United States.

Methods

HPTN 065 was conducted in two intervention communities, Bronx, NY, and Washington, DC, along with four non-intervention communities, Chicago, IL; Houston, TX; Miami, FL; and Philadelphia, PA. The study consisted of five components: (1) exploring the feasibility of expanded HIV testing via social mobilization and the universal offer of testing in hospital settings, (2) evaluating the effectiveness of financial incentives to increase linkage to care, (3) evaluating the effectiveness of financial incentives to increase viral suppression, (4) evaluating the effectiveness of a computer-delivered intervention to decrease risk behavior in HIV-positive patients in healthcare settings, and (5) administering provider and patient surveys to assess knowledge and attitudes regarding the use of antiretroviral therapy for prevention and the use of financial incentives to improve health outcomes. The study used observational cohorts, cluster and individual randomization, and made novel use of the existing national HIV surveillance data infrastructure. All components were developed with input from a community advisory board, and pragmatic methods were used to implement and assess the outcomes for each study component.

Results

A total of 76 sites in Washington, DC, and the Bronx, NY, participated in the study: 37 HIV test sites, including 16 hospitals, and 39 HIV care sites. Between September 2010 and December 2014, all study components were successfully implemented at these sites and resulted in valid outcomes. Our pragmatic approach to the study design, implementation, and the assessment of study outcomes allowed the study to be conducted within established programmatic structures and processes. In addition, it was successfully layered on the ongoing standard of care and existing data infrastructure without disrupting health services.

Conclusion

The HPTN 065 study demonstrated the feasibility of implementing and evaluating a multi-component “test and treat” trial that included a large number of community sites and involved pragmatic approaches to study implementation and evaluation.

Using CD4 Data to Estimate HIV Incidence, Prevalence, and Percent of Undiagnosed Infections in the United States

INTRODUCTION

The incidence and prevalence of HIV infection are important measures of HIV trends; however, they are difficult to estimate because of the long incubation period between infection and symptom development and the relative infrequency of HIV screening. A new method is introduced to estimate HIV incidence, prevalence, and the number of undiagnosed infections in the United States using data from the HIV case surveillance system and CD4 test results.

METHODS

Persons with HIV diagnosed during 2006-2013 and their CD4 test results were used to estimate the distribution of diagnosis delay from HIV infection to diagnosis based on a well-characterized CD4 depletion model. This distribution was then used to estimate HIV incidence, prevalence, and the number of undiagnosed infections.

RESULTS

Applying this method, we estimated that the annual number of new HIV infections decreased after 2007, from 48,300 (95% confidence interval [CI]: 47,300 to 49,400) to 39,000 (95% CI: 36,600 to 41,400) in 2013. Prevalence increased from 923,200 (95% CI: 914,500 to 931,800) in 2006 to 1,104,600 (95% CI: 1,084,300 to 1,124,900) in 2013, whereas the proportion of undiagnosed infections decreased from 21.0% in 2006 (95% CI: 20.2% to 21.7%) to 16.4% (95% CI: 15.7% to 17.2%) in 2013.

CONCLUSIONS

HIV incidence, prevalence, and undiagnosed infections can be estimated using HIV case surveillance data and information on first CD4 test result after diagnosis. Similar to earlier findings, the decreases in incidence and undiagnosed infections are encouraging but intensified efforts for HIV testing and treatment are needed to meet the goals of the National HIV/AIDS Strategy.

Increasing HIV-1 subtype diversity in seven states, United States, 2006-2013

PURPOSE

The aim of the analysis was to explore HIV-1 subtype diversity in the United States and understand differences in prevalence of non-B subtypes and circulating recombinant forms (CRFs) between demographic/risk groups and over time.

METHODS

We included HIV-1 polymerase sequences reported to the National HIV Surveillance System for HIV infections diagnosed during 2006-2013 in seven states. We assigned subtype or CRF using the automated subtyping tool COMET, assessed subtype/CRF prevalence by demographic characteristics and country of birth, and determined changes in subtype/CRF by HIV diagnosis year.

RESULTS

Of 32,968 sequences, 30,757 (93.3%) were subtype B. The most common non-B subtypes and CRFs were C (1.6%), CRF02_AG (1.4%), A (0.6%), CRF01_AE (0.5%), and G (0.3%). Elevated percentages of non-B infections occurred among persons aged <13 years at diagnosis (40.9%), Asians (32.1%), persons born outside the United States (22.6%), and persons with infection attributable to heterosexual contact (12.0%-15.0%). Prevalence of non-B infections increased from 5.9% in 2006 to 8.5% in 2013.

CONCLUSIONS

Subtype B continues to predominate in the United States. However, the percentage of non-B infections has grown in recent years, and numerous demographic subgroups have much higher prevalence. Subgroups and areas with high prevalence of non-B infections might represent sub-epidemics meriting further investigation.

HIV Trends in the United States: Diagnoses and Estimated Incidence

Background

The best indicator of the impact of human immunodeficiency virus (HIV) prevention programs is the incidence of infection; however, HIV is a chronic infection and HIV diagnoses may include infections that occurred years before diagnosis. Alternative methods to estimate incidence use diagnoses, stage of disease, and laboratory assays of infection recency. Using a consistent, accurate method would allow for timely interpretation of HIV trends.

Objective

The objective of our study was to assess the recent progress toward reducing HIV infections in the United States overall and among selected population segments with available incidence estimation methods.

Methods

Data on cases of HIV infection reported to national surveillance for 2008-2013 were used to compare trends in HIV diagnoses, unadjusted and adjusted for reporting delay, and model-based incidence for the US population aged ≥13 years. Incidence was estimated using a biomarker for recency of infection (stratified extrapolation approach) and 2 back-calculation models (CD4 and Bayesian hierarchical models). HIV testing trends were determined from behavioral surveys for persons aged ≥18 years. Analyses were stratified by sex, race or ethnicity (black, Hispanic or Latino, and white), and transmission category (men who have sex with men, MSM).

Results

On average, HIV diagnoses decreased 4.0% per year from 48,309 in 2008 to 39,270 in 2013 (P<.001). Adjusting for reporting delays, diagnoses decreased 3.1% per year (P<.001). The CD4 model estimated an annual decrease in incidence of 4.6% (P<.001) and the Bayesian hierarchical model 2.6% (P<.001); the stratified extrapolation approach estimated a stable incidence. During these years, overall, the percentage of persons who ever had received an HIV test or had had a test within the past year remained stable; among MSM testing increased. For women, all 3 incidence models corroborated the decreasing trend in HIV diagnoses, and HIV diagnoses and 2 incidence models indicated decreases among blacks and whites. The CD4 and Bayesian hierarchical models, but not the stratified extrapolation approach, indicated decreases in incidence among MSM.

Conclusions

HIV diagnoses and CD4 and Bayesian hierarchical model estimates indicated decreases in HIV incidence overall, among both sexes and all race or ethnicity groups. Further progress depends on effectively reducing HIV incidence among MSM, among whom the majority of new infections occur.

Clinical Data Systems to Support Public Health Practice: A National Survey of Software and Storage Systems Among Local Health Departments

CONTEXT

Numerous software and data storage systems are employed by local health departments (LHDs) to manage clinical and nonclinical data needs. Leveraging electronic systems may yield improvements in public health practice. However, information is lacking regarding current usage patterns among LHDs.

OBJECTIVE

To analyze clinical and nonclinical data storage and software types by LHDs.

DESIGN

Data came from the 2015 Informatics Capacity and Needs Assessment Survey, conducted by Georgia Southern University in collaboration with the National Association of County and City Health Officials.

PARTICIPANTS

A total of 324 LHDs from all 50 states completed the survey (response rate: 50%).

MAIN OUTCOME MEASURES

Outcome measures included LHD's primary clinical service data system, nonclinical data system(s) used, and plans to adopt electronic clinical data system (if not already in use). Predictors of interest included jurisdiction size and governance type, and other informatics capacities within the LHD. Bivariate analyses were performed using χ and t tests.

RESULTS

Up to 38.4% of LHDs reported using an electronic health record (EHR). Usage was common especially among LHDs that provide primary care and/or dental services. LHDs serving smaller populations and those with state-level governance were both less likely to use an EHR. Paper records were a common data storage approach for both clinical data (28.9%) and nonclinical data (59.4%). Among LHDs without an EHR, 84.7% reported implementation plans.

CONCLUSIONS

Our findings suggest that LHDs are increasingly using EHRs as a clinical data storage solution and that more LHDs are likely to adopt EHRs in the foreseeable future. Yet use of paper records remains common. Correlates of electronic system usage emerged across a range of factors. Program- or system-specific needs may be barriers or facilitators to EHR adoption. Policy makers can tailor resources to address barriers specific to LHD size, governance, service portfolio, existing informatics capabilities, and other pertinent characteristics.

Trends in HIV Infection Among Persons Who Inject Drugs: United States and Puerto Rico, 2008-2013

OBJECTIVES

To describe trends in HIV diagnoses and prevalence among persons who inject drugs (PWID), and trend variations by jurisdiction.

METHODS

We used National HIV Surveillance System data to estimate the number of HIV diagnoses made during 2008 through 2013, and measured trends by estimated annual percent change; and persons living with diagnosed HIV infection at year-end 2008 to 2012, and measured trends in prevalence by the 2012-2008 arithmetic difference.

RESULTS

During 2008 through 2013, the number of HIV diagnoses was stable among all persons (< 2% per year), and decreased among PWID (> 10% per year) overall and in 10 jurisdictions. The Black-to-White PWID diagnosis ratio was 2 to 1. During 2008 through 2012, the number of persons living with diagnosed HIV infection increased overall, was stable among PWID, and decreased in 14 jurisdictions.

CONCLUSIONS

Had the rate of decrease in diagnoses of HIV infection among PWID equaled that of all persons, an additional 1500 diagnoses would have occurred between 2008 and 2013. Prevalence was stable among PWID, and increased overall among all persons living with HIV infection. Pronounced racial inequities persist, particularly for Blacks, and appear to be diminishing.

Increased antiretroviral therapy prescription and HIV viral suppression among persons receiving clinical care for HIV infection

OBJECTIVE

To assess trends during 2009-2013 in antiretroviral therapy (ART) prescription and viral suppression among adults receiving HIV clinical care in the United States.

DESIGN

We used data from the Medical Monitoring Project, a surveillance system producing national estimates of characteristics of HIV-infected adults receiving clinical care in the United States.

METHODS

We estimated weighted proportions of persons receiving HIV medical care who were prescribed ART and achieved HIV viral suppression (<200 copies/ml) at both last test and at all tests in the previous 12 months during 2009-2013. We assessed trends overall and by gender, age, race/ethnicity, and sexual behavior/orientation.

RESULTS

ART prescription and viral suppression increased significantly during 2009-2013, overall and in subgroups. ART prescription increased from 89 to 94% (P for trend <0.01). Viral suppression at last measurement increased from 72 to 80% (P for trend <0.01). The largest increases were among 18-29 year olds (56-68%), 30-39 year olds (62-75%), and non-Hispanic blacks (64-76%). Sustained viral suppression increased from 58 to 68% (P for trend <0.01). The largest increases were among 18-29 year olds (32-51%), 30-39 year olds (47-63%), and non-Hispanic blacks (49-61%).

CONCLUSION

Adults receiving HIV medical care are increasingly likely to be prescribed ART and achieve viral suppression. Recent efforts to promote early antiretroviral therapy use may have contributed to these increases, bringing us closer to realizing key goals of the National HIV/AIDS Strategy.

The discovery of allyltyrosine based tripeptides as selective inhibitors of the HIV-1 integrase strand-transfer reaction

From library screening of synthetic antimicrobial peptides, an O-allyltyrosine-based tripeptide was identified to possess inhibitory activity against HIV-1 integrase (IN) exhibiting an IC50 value of 17.5 μM in a combination 3'-processing and strand transfer microtitre plate assay. The tripeptide was subjected to structure-activity relationship (SAR) studies with 28 peptides, incorporating an array of natural and non-natural amino acids. Resulting SAR analysis revealed the allyltyrosine residue was a key feature for IN inhibitory activity whilst incorporation of a lysine residue and extended hydrophilic chains bearing a terminal methyl ester was advantageous. Addition of hydrophobic aromatic moieties to the N-terminal of the scaffold afforded compounds with improved inhibitory activity. Consolidation of these functionalities lead to the development of the tripeptide 96 which specifically inhibited the IN strand-transfer reaction with an IC50 value of 2.5 μM.

The International Dimension of the U.S. HIV Transmission Network and Onward Transmission of HIV Recently Imported into the United States

The majority of HIV infections in the United States can be traced back to a single introduction in late 1960s or early 1970s. However, it remains unclear whether subsequent introductions of HIV into the United States have given rise to onward transmission. Genetic transmission networks can aid in understanding HIV transmission. We constructed a genetic distance-based transmission network using HIV-1 pol sequences reported to the U.S. National HIV Surveillance System (n = 41,539) and all publicly available non-U.S. HIV-1 pol sequences (n = 86,215). Of the 13,145 U.S. persons clustered in the network, 457 (3.5%) were genetically linked to a potential transmission partner outside the United States. For internationally connected persons residing in but born outside the United States, 61% had a connection to their country of birth or to another country that shared a language with their country of birth. Bayesian molecular clock phylogenetic analyses indicate that introduced nonsubtype B infections have resulted in onward transmission within the United States.