BACKGROUND:Male-to-male sexual transmission continues to account for the greatest proportion of new HIV diagnoses in the United States. However, calculating population-specific surveillance metrics for HIV and other sexually transmitted infections requires regularly updated estimates of the number and proportion of men who have sex with men (MSM) in the United States, which are not collected by census surveys. OBJECTIVE:The purpose of this analysis was to estimate the number and percentage of MSM in the United States from population-based surveys. METHODS:We used data from 5 population-based surveys to calculate weighted estimates of the proportion of MSM in the United States and pooled these estimates using meta-analytic procedures. We estimated the proportion of MSM using sexual behavior-based questions (encompassing anal or oral sex) for 3 recall periods-past 12 months, past 5 years, and lifetime. In addition, we estimated the proportion of MSM using self-reported identity and attraction survey responses. The total number of MSM and non-MSM in the United States were calculated from estimates of the percentage of MSM who reported sex with another man in the past 12 months. RESULTS:The percentage of MSM varied by recall period: 3.3% (95% CI 1.7%-4.9%) indicated sex with another male in the past 12 months, 4.7% (95% CI 0.0%-33.8%) in the past 5 years, and 6.2% (95% CI 2.9%-9.5%) in their lifetime. There were comparable percentages of men who identified as gay or bisexual (3.4%, 95% CI 2.2%-4.6%) or who indicated that they are attracted to other men (4.9%, 95% CI 3.1%-6.7%) based on pooled estimates. Our estimate of the total number of MSM in the United States is 4,230,000 (95% CI 2,179,000-6,281,000) based on the history of recent sexual behavior (sex with another man in the past 12 months). CONCLUSIONS:We calculated the pooled percentage and number of MSM in the United States from a meta-analysis of population-based surveys collected from 2017 to 2021. These estimates update and expand upon those derived from the Centers for Disease Control and Prevention in 2012 by including estimates of the percentage of MSM based on sexual identity and sexual attraction. The percentage and number of MSM in the United States is an important indicator for calculating population-specific disease rates and eligibility for preventive interventions such as pre-exposure prophylaxis.

Importance:Hospital engagement networks supported by the US Centers for Medicare & Medicaid Services Partnership for Patients program have reported significant reductions in hospital-acquired harm, but methodological limitations and lack of peer review have led to persistent questions about the effectiveness of this approach.Objective:To evaluate associations between membership in Children's Hospitals' Solutions for Patient Safety (SPS), a federally funded hospital engagement network, and hospital-acquired harm using standardized definitions and secular trend adjustment.Design, Setting, and Participants:This prospective hospital cohort study included 99 children's hospitals. Using interrupted time series analyses with staggered intervention introduction, immediate and postimplementation changes in hospital-acquired harm rates were analyzed, with adjustment for preexisting secular trends. Outcomes were further evaluated by early-adopting (n = 73) and late-adopting (n = 26) cohorts.Exposures:Hospitals implemented harm prevention bundles, reported outcomes and bundle compliance using standard definitions to the network monthly, participated in learning events, and implemented a broad safety culture program. Hospitals received regular reports on their comparative performance.Main Outcomes and Measures:Outcomes for 8 hospital-acquired conditions were evaluated over 1 year before and 3 years after intervention.Results:In total, 99 hospitals met the inclusion criteria and were included in the analysis. A total of 73 were considered part of the early-adopting cohort (joined between 2012-2013) and 26 were considered part of the late-adopting cohort (joined between 2014-2016). A total of 42 hospitals were freestanding children's hospitals, and 57 were children's hospitals within hospital or health systems. The implementation of SPS was associated with an improvement in hospital-acquired condition rates in 3 of the 8 conditions after accounting for secular trends. Membership in the SPS was associated with an immediate reduction in central catheter-associated bloodstream infections (coefficient = -0.152; 95% CI, -0.213 to -0.019) and falls of moderate or greater severity (coefficient = -0.331; 95% CI, -0.594 to -0.069). The implementation of the SPS was associated with a reduction in the monthly rate of adverse drug events (coefficient = -0.021; 95% CI, -0.034 to -0.008) in the post-SPS period. The study team observed larger decreases for the early-adopting cohort compared with the late-adopting cohort.Conclusions and Relevance:Through the application of rigorous methods (standard definitions and longitudinal time series analysis with adjustment for secular trends), this study provides a more thorough analysis of the association between the Partnership for Patients hospital engagement network model and reductions in hospital-acquired conditions. These findings strengthen previous claims of an association between this model and improvement. However, inconsistent observations across hospital-acquired conditions when adjusted for secular trends suggests that some caution regarding attributing all effects observed to this model is warranted.

Abstract: Over the past decade, national initiatives in the United States (U.S.) have focused HIV prevention and care programs and research to optimize the delivery of HIV prevention and treatment through implementation research. Although existing biomedical and behavioral prevention tools could end HIV in the U.S., the implementation of these tools has been uneven because of many factors, including organizational capacity, insufficient uptake by key populations, lack of success with prioritizing by geography or population growth, and inadequate scaling. To address these challenges, the federal government has funded programs, research, and evaluation projects aimed at improving health outcomes among people with HIV and people vulnerable to HIV acquisition. Increasingly, several special federal efforts are being conducted under the umbrella of “implementation science and research” that are essential components to scaling up evidence-based HIV prevention and treatment interventions in the U.S. This paper describes federal collaborations that have supported this increased focus on implementation from the perspective of 3 agencies in the U.S. Department of Health and Human Services; the Centers for Disease Control and Prevention, the National Institutes of Health, and the Health Resources and Services Administration. These federal collaborations have resulted in improved communication and coordination of efforts in the shaping and alignment of priorities in research and service delivery, increased implementation research conducted in real-world community and clinical settings and provided a feedback loop to expedite action in response to emerging evidence from such projects.

Background: A goal of the US Department of Health and Human Services' Ending the HIV Epidemic (EHE) in the United States initiative is to reduce the annual number of incident HIV infections in the United States by 75% within 5 years and by 90% within 10 years. We developed a resource allocation analysis to understand how these goals might be met. Methods: We estimated the current annual societal funding [$2.8 billion (B)/yr] for 14 interventions to prevent HIV and facilitate treatment of infected persons. These interventions included HIV testing for different transmission groups, HIV care continuum interventions, pre-exposure prophylaxis, and syringe services programs. We developed scenarios optimizing or reallocating this funding to minimize new infections, and we analyzed the impact of additional EHE funding over the period 2021-2030. Results: With constant current annual societal funding of $2.8 B/yr for 10 years starting in 2021, we estimated the annual incidence of 36,000 new cases in 2030. When we added annual EHE funding of $500 million (M)/yr for 2021-2022, $1.5 B/yr for 2023-2025, and $2.5 B/yr for 2026-2030, the annual incidence of infections decreased to 7600 cases (no optimization), 2900 cases (optimization beginning in 2026), and 2200 cases (optimization beginning in 2023) in 2030. Conclusions: Even without optimization, significant increases in resources could lead to an 80% decrease in the annual HIV incidence in 10 years. However, to reach both EHE targets, optimization of prevention funding early in the EHE period is necessary. Implementing these efficient allocations would require flexibility of funding across agencies, which might be difficult to achieve.

Forty years after the Centers for Disease Control and Prevention's (CDC's) June 1981 Morbidity and Mortality Weekly Report about five gay men with a syndrome that came to be called AIDS, both the impact of HIV and the legal landscape in the United States for the most affected population have changed dramatically. Laws, policies, and how they are enforced reflect the values and prejudices of society, and laws can help or hinder public health efforts, regardless of intent. From the outset, HIV aroused widespread fear and new stigmatizing laws and policies, and the crisis revealed injustices in existing laws that compounded stigma and health disparities among the most affected groups. In the 1980s, HIV engulfed already stigmatized communities of gay and bisexual men and other men who have sex with men (MSM) and people who inject drugs. The CDC's HIV surveillance reports show that, throughout the epidemic, MSM have constituted the majority of annual and prevalent cases, and the burden on racial or ethnic minority MSM has increased disproportionately since the early 1990s.1 It is timely to reflect on the intertwining of HIV, laws, stigma, and inequity in the United States and their intersection with the lives of gay and bisexual men (both cisgender and transgender). (Am J Public Health. Published online ahead of print June 10, 2021: e1-e3. https://doi.org/10.2105/AJPH.2021.306335).

Objectives. To optimize combined public and private spending on HIV prevention to achieve maximum reductions in incidence. Methods. We used a national HIV model to estimate new infections from 2018 to 2027 in the United States. We estimated current spending on HIV screening, interventions that move persons with diagnosed HIV along the HIV care continuum, pre-exposure prophylaxis, and syringe services programs. We compared the current funding allocation with 2 optimal scenarios: (1) a limited-reach scenario with expanded efforts to serve eligible persons and (2) an ideal, unlimited-reach scenario in which all eligible persons could be served. Results. A continuation of the current allocation projects 331 000 new HIV cases over the next 10 years. The limited-reach scenario reduces that number by 69%, and the unlimited reach scenario by 94%. The most efficient funding allocations resulted in prompt diagnosis and sustained viral suppression through improved screening of high-risk persons and treatment adherence support for those infected. Conclusions. Optimal allocations of public and private funds for HIV prevention can achieve substantial reductions in new infections. Achieving reductions of more than 90% under current funding will require that virtually all infected receive sustained treatment.

Importance:Undiagnosed HIV infection results in delayed access to treatment and increased transmission. Self-tests for HIV may increase awareness of infection among men who have sex with men (MSM). Objective:To evaluate the effect of providing HIV self-tests on frequency of testing, diagnoses of HIV infection, and sexual risk behaviors. Design, Setting, and Participants:This 12-month longitudinal, 2-group randomized clinical trial recruited MSM through online banner advertisements from March through August 2015. Those recruited were at least 18 years of age, reported engaging in anal sex with men in the past year, never tested positive for HIV, and were US residents with mailing addresses. Participants completed quarterly online surveys. Telephone call notes and laboratory test results were included in the analysis, which was completed from August 2017 through December 2018. Interventions:All participants had access to online web-based HIV testing resources and telephone counseling on request. Participants were randomized in a 1:1 ratio to the control group or a self-testing (ST) group, which received 4 HIV self-tests after completing the baseline survey with the option to replenish self-tests after completing quarterly surveys. At study completion, all participants were offered 2 self-tests and 1 dried blood spot collection kit. Main Outcomes and Measures:Primary outcomes were HIV testing frequency (tested ≥3 times during the trial) and number of newly identified HIV infections among participants in both groups and social network members who used the study HIV self-tests. Secondary outcomes included sex behaviors (eg, anal sex, serosorting). Results:Of 2665 participants, the mean (SD) age was 30 (9.6) years, 1540 (57.8%) were white, and 443 (16.6%) had never tested for HIV before enrollment. Retention rates at each time point were more than 54%, and 1991 (74.7%) participants initiated 1 or more follow-up surveys. More ST participants reported testing 3 or more times during the trial than control participants (777 of 1014 [76.6%] vs 215 of 977 [22.0%]; P < .01). The cumulative number of newly identified infections during the trial was twice as high in the ST participants as the control participants (25 of 1325 [1.9%] vs 11 of 1340 [0.8%]; P = .02), with the largest difference in HIV infections identified in the first 3 months (12 of 1325 [0.9%] vs 2 of 1340 [0.1%]; P < .01). The ST participants reported 34 newly identified infections among social network members who used the self-tests. Conclusions and Relevance:Distribution of HIV self-tests provides a worthwhile mechanism to increase awareness of HIV infection and prevent transmission among MSM. Trial Registration:ClinicalTrials.gov identifier: NCT02067039.

BACKGROUND:The vision of learning healthcare systems (LHSs) is attractive as a more effective model for health care services, but achieving the vision is complex. There is limited literature describing the processes needed to construct such multicomponent systems or to assess development.METHODS:We used the concept of a capability maturity matrix to describe the maturation of necessary infrastructure and processes to create learning networks (LNs), multisite collaborative LHSs that use an actor-oriented network organizational architecture. We developed a network maturity grid (NMG) assessment tool by incorporating information from literature review, content theory from existing networks, and expert opinion to establish domains and components. We refined the maturity grid in response to feedback from network leadership teams. We followed NMG scores over time for nine LNs and plotted scores for each domain component with respect to SD for one participating network. We sought subjective feedback on the experience of applying the NMG to individual networks.RESULTS:LN leaders evaluated the scope, depth, and applicability of the NMG to their networks. Qualitative feedback from network leaders indicated that changes in NMG scores over time aligned with leaders' reports about growth in specific domains; changes in scores were consistent with network efforts to improve in various areas. Scores over time showed differences in maturation in the individual domains of each network. Scoring patterns, and SD for domain component scores, indicated consistency among LN leaders in some but not all aspects of network maturity. A case example from a participating network highlighted the value of the NMG in prompting strategic discussions about network development and demonstrated that the process of using the tool was itself valuable.CONCLUSIONS:The capability maturity grid proposed here provides a framework to help those interested in creating Learning Health Networks plan and develop them over time.

Purpose: The challenges of producing adequate estimates of HIV prevalence among men who have sex with men (MSM) are well known. No one, to our knowledge, has published annual estimates of HIV prevalence among MSM over an extended period and across a wide range of geographic areas. Methods: This article applies multilevel modeling to data integrated from numerous sources to estimate and validate trajectories of HIV prevalence among MSM from 1992 to 2013 for 86 of the largest metropolitan statistical areas in the United States. Results: Our estimates indicate that HIV prevalence among MSM increased, from an across-metropolitan statistical area mean of 11% in 1992 to 20% in 2013 (S.D. = 3.5%). Our estimates by racial/ethnic subgroups of MSM suggest higher mean HIV prevalence among black and Hispanic/Latino MSM than among white MSM across all years and geographic regions. Conclusions: The increases found in HIV prevalence among all MSM are likely primarily attributable to decreases in mortality and perhaps also to increasing HIV incidence among racial/ethnic minority MSM. Future research is needed to confirm this. If true, health care initiatives should focus on targeted HIV prevention efforts among racial/ethnic minority MSM and on training providers to address cross-cutting health challenges of increased longevity among HIV-positive MSM. (C) 2020 Elsevier Inc. All rights reserved.

In the United States, the all-cause mortality rate among persons living with diagnosed HIV infection (PLWH) is almost twice as high as among the general population. We aimed to identify amendable factors that state public health programs can influence to reduce mortality among PLWH. Using generalized estimating equations (GEE), we estimated age–group-specific models (24–34, 35–54, ≥ 55 years) to assess the association between state-level mortality rates among PLWH during 2010–2014 (National HIV Surveillance System) and amendable factors (percentage of Ryan White HIV/AIDS Program (RWHAP) clients with viral suppression, percentage of residents with healthcare coverage, state-enacted anti-discrimination laws index) while controlling for sociodemographic nonamendable factors. Controlling for nonamendable factors, states with 5% higher viral suppression among RWHAP clients had a 3–5% lower mortality rates across all age groups [adjusted Risk Ratio (aRR): 0.95, 95% Confidence Interval (CI): 0.92–0.99 for 24–34 years, aRR: 0.97, 95%CI: 0.94–0.99 for 35–54 years, aRR: 0.96, 95%CI: 0.94–0.99 for ≥ 55 years]; states with 5% higher health care coverage had 4–11% lower mortality rate among older age groups (aRR: 0.96, 95%CI: 0.93–0.99 for 34–54 years; aRR: 0.89, 95%CI: 0.81–0.97 for ≥ 55 years); and having laws that address one additional area of anti-discrimination was associated with a 2–3% lower mortality rate among older age groups (aRR: 0.98, 95%CI: 0.95–1.00 for 34–54 years; aRR: 0.97, 95%CI: 0.94–0.99 for ≥ 55 years). The mortality rate among PLWH was lower in states with higher levels of residents with healthcare coverage, anti-discrimination laws, and viral suppression among RWHAP clients. States can influence these factors through programs and policies.

BACKGROUND:In 2016, an estimated 1.1 million persons had human immunodeficiency virus (HIV) infection in the United States; 38,700 were new infections. Knowledge of HIV infection status, behavior change, and antiretroviral therapy (ART) all prevent HIV transmission. Persons who achieve and maintain viral suppression (achieved by most persons within 6 months of starting ART) can live long, healthy lives and pose effectively no risk of HIV transmission to their sexual partners.METHODS:A model was used to estimate transmission rates in 2016 along the HIV continuum of care. Data for sexual and needle-sharing behaviors were obtained from National HIV Behavioral Surveillance. Estimated HIV prevalence, incidence, receipt of care, and viral suppression were obtained from National HIV Surveillance System data.RESULTS:Overall, the HIV transmission rate was 3.5 per 100 person-years in 2016. Along the HIV continuum of care, the transmission rates from persons who were 1) acutely infected and unaware of their infection, 2) non-acutely infected and unaware, 3) aware of HIV infection but not in care, 4) receiving HIV care but not virally suppressed, and 5) taking ART and virally suppressed were 16.1, 8.4, 6.6, 6.1, and 0 per 100 person-years, respectively. The percentages of all transmissions generated by each group were 4.0%, 33.6%, 42.6%, 19.8%, and 0%, respectively.CONCLUSION:Approximately 80% of new HIV transmissions are from persons who do not know they have HIV infection or are not receiving regular care. Going forward, increasing the percentage of persons with HIV infection who have achieved viral suppression and do not transmit HIV will be critical for ending the HIV epidemic in the United States.

This paper describes the development of a formula to determine which evidence-based behavioral interventions (EBIs) targeting HIV-negative persons would be cost-saving in comparison to the lifetime cost of HIV treatment and the process by which this formula was used to prioritize those with greatest potential impact for continued dissemination. We developed a prevention benefit index (PBI) to rank risk-reduction EBIs for HIV-negative persons based on their estimated cost for achieving the behavior change per one would-be incident infection of HIV. Inputs for calculating the PBI included the mean estimated cost-per-client served, EBI effect size for the behavior change, and the HIV incidence per 100,000 persons in the target population. EBIs for which the PBI was ≤ $402,000, the estimated lifetime cost of HIV care, were considered cost-saving. We were able to calculate a PBI for 35 EBI and target population combinations. Ten EBIs were cost-saving having a PBI below $402,000. One EBI did not move forward for dissemination due to high start-up dissemination costs. DHAP now supports the dissemination of 9 unique EBIs targeting 13 populations of HIV-negative persons. The application of a process, such as the PBI, may assist other health-field policymakers when making decisions about how to select and fund implementation of EBIs.

Background: Calculating national rates of HIV diagnosis, incidence, and prevalence can quantify disease burden, and is important for planning and evaluating programs. We calculated HIV rates among MSM, persons who inject drugs (PWID), and heterosexuals in 2010 and 2015. Methods: We used proportion estimates of the US population classified as MSM, PWID, and heterosexuals along with census data to calculate the population sizes which were used as the denominators for calculating HIV rates. The numerators (HIV diagnosis, incidence, and prevalence) were based on data submitted to the National HIV Surveillance System through June 2017. Results: The estimated HIV diagnosis and incidence rates in 2015 were 574.7 and 583.6 per 100 000 MSM; 34.3 and 32.7 per 100 000 PWID; and 4.1 and 3.8 per 100 000 heterosexuals. The estimated HIV prevalence in 2015 was 12 372.9 per 100 000 MSM; 1937.2 per 100 000 PWID; and 126.7 per 100 000 heterosexuals. The HIV diagnosis rates decreased from 2010 to 2015 in all three transmission categories. Black individuals had the highest HIV diagnosis rates at both time points. The HIV incidence rates decreased among white MSM, MSM aged 13-24 years, PWID overall, and male and female heterosexual individuals; however, it increased among MSM aged 25-34 years. Conclusions: The estimated HIV diagnosis and HIV infection rates decreased for several transmission categories, and also race/ethnicity and age subgroups. MSM continue to be disproportionately affected. Disparities remain and have widened for some groups. Efforts are needed to strengthen prevention, care, and supportive services for all persons with HIV infection. Copyright (C) 2018 Wolters Kluwer Health, Inc. All rights reserved.

Objectives. To describe disparities in HIV infection and syphilis among gay, bisexual, and other men who have sex with men (MSM) in US states through ratio-based measures and graphical depictions of disparities. Methods. We used state-level surveillance data of reported HIV and syphilis cases in 2015 and 2016, and estimates of MSM population sizes to estimate HIV and syphilis prevalence by race/ethnicity and rate ratios (RRs) and to visually display patterns of disparity and prevalence among US states. Results. State-specific rates of new HIV diagnoses were higher for Black than for White MSM(RR range = 2.35 [Rhode Island] to 10.12 [Wisconsin]) and for Hispanic than for White MSM (RR range = 1.50 [Tennessee] to 5.78 [Pennsylvania]). Rates of syphilis diagnoses were higher for Black than for White MSM in 42 of 44 states (state RR range = 0.89 [Hawaii] to 17.11 [Alaska]). Scatterplots of HIV diagnosis rates by race showed heterogeneity in epidemic scenarios, even in states with similar ratio-based disparity measures. Conclusions. There is a widely disparate impact of HIV and syphilis among Black and Hispanic MSM compared with White MSM. Between-state variation suggests that states should tailor and focus their prevention responses to best address state data.

Purpose: Men who have sex with men (MSM) bear a disproportionate burden of new and existing HIV infections in the United States, with black and Hispanic MSM facing the highest rates. A lack of data on MSM population sizes has precluded the understanding of state-level variations in these rates. Methods: Using a recently developed model for estimating state-level population sizes of MSM by race that synthesizes data from the American Community Survey and the National Health and Nutrition Examination Survey, in conjunction with Centers for Disease Control and Prevention-based HIV diagnosis data, we estimated rates of living with an HIV diagnosis (2013) and new diagnosis among MSM (2014) by state and race. Results: Nationally, state-level median prevalence of living with an HIV diagnosis was 10.6%. White MSM had lower prevalence in all but five states; black MSM were higher in all but three. Hispanic MSM had highest concentrations in Northeast and Mississippi Delta states. Patterns were similar for new diagnoses rates. Conclusions: Results suggest that racial disparities in HIV infection among MSM are more prominent than geographic ones. Interventions should be differentially tailored to areas of high proportionate and absolute burden. Continued efforts to understand and address racial differences in HIV infection are needed. (C) 2018 Elsevier Inc. All rights reserved.

Abstract Background Men who have sex with men (MSM) in the United States experience a disproportionate rate of diagnosis of HIV. Surveillance data demonstrate age-based disparities among MSM, with higher rates of diagnosis among MSM age ≤34 years nationally. Population size estimates within age group at the state level have not been available to determine rates for each state. We estimated the size of the MSM population in 5 age groups in each state and estimated the rate of prevalent HIV diagnoses in 2013 and new HIV diagnoses in 2014. Methods We used data from the General Social Survey, American Community Survey, and previously published estimates from the National Health and Nutrition Examination Survey to estimate the population of MSM in 5 age groups at the state level. We combined these estimates with surveillance data to estimate age-stratified rates of prevalent diagnoses in 2013 and new diagnoses in 2014 in each state. We estimated standardized prevalence and diagnosis ratios comparing the Northeast, South, and West regions with the Midwest. Results Rates of prevalent diagnoses increased with increasing age, and rates of new diagnoses were highest among younger age groups. In the United States, the new diagnosis rate among those age 18–24 years in 2014 was 1.4 per 100 MSM without a diagnosis. The highest diagnosis rates were observed among men age ≤34 years in the South. Conclusions Age-stratified estimates of HIV prevalence and new diagnosis rates at the state level can inform public health prevention strategies and resource allocation.

Objective To estimate the optimal allocation of Centers for Disease Control and Prevention (CDC) HIV prevention funds for health departments in 52 jurisdictions, incorporating Health Resources and Services Administration (HRSA) Ryan White HIV/AIDS Program funds, to improve outcomes along the HIV care continuum and prevent infections. Methods Using surveillance data from 2010 to 2012 and budgetary data from 2012, we divided the 52 health departments into 5 groups varying by number of persons living with diagnosed HIV (PLWDH), median annual CDC HIV prevention budget, and median annual HRSA expenditures supporting linkage to care, retention in care, and adherence to antiretroviral therapy. Using an optimization and a Bernoulli process model, we solved for the optimal CDC prevention budget allocation for each health department group. The optimal allocation distributed the funds across prevention interventions and populations at risk for HIV to prevent the greatest number of new HIV cases annually. Results Both the HIV prevention interventions funded by the optimal allocation of CDC HIV prevention funds and the proportions of the budget allocated were similar across health department groups, particularly those representing the large majority of PLWDH. Consistently funded interventions included testing, partner services and linkage to care and interventions for men who have sex with men (MSM). Sensitivity analyses showed that the optimal allocation shifted when there were differences in transmission category proportions and progress along the HIV care continuum. Conclusion The robustness of the results suggests that most health departments can use these analyses to guide the investment of CDC HIV prevention funds into strategies to prevent the most new cases of HIV.