Importance:Long-acting injectable (LAI) pre-exposure prophylaxis (PrEP) has superior efficacy vs oral PrEP, and higher LAI-cabotegravir (CAB) persistence may optimize its HIV prevention impact. Objective:To characterize individuals using LAI-CAB compared with oral PrEP, to describe changes in national LAI-CAB vs oral PrEP use over time, and to examine longitudinal persistence among LAI-CAB users. Design, Setting, and Participants:This retrospective cohort study used pharmacy and medical claims from a database that covered a majority of all claims in the US from 2022 to 2024. Participants included persons with 1 or more claim for any PrEP drugs (oral or injectable). Exposure:PrEP use during the study period. Main Outcomes and Measures:Study outcomes were LAI-CAB use and persistence in care. LAI-CAB use was defined as at least 1 claim, and LAI-CAB yearly persistence was defined as at least 2 LAI-CAB claims for each of 2 biannual periods. Yearly persistence in any type of PrEP (PrEP persistence) was defined as at least 2 claims for PrEP medications (oral or injectable) for each of 2 biannual periods among LAI-CAB users. Multivariable logistic regression models were used to assess variables associated with LAI-CAB use compared with oral PrEP. Results:From 2022 to 2024, there were 24 194 LAI-CAB users, representing 3% of all 781 040 PrEP users. LAI-CAB users were young (mean [SD] age, 37.1 [11.4] years) and predominantly male (20 642 users [85%]); 656 (3%) were Asian, 4531 (19%) were Black, 4380 (19%) were Hispanic, 13 696 (58%) were White, and 414 (2%) were of other races and ethnicities. Most had commercial insurance (16 334 users [68%]) and had no copayment (13 507 users [82%]). LAI-CAB users were more likely than oral PrEP users to be covered by Medicaid (6256 of 24 194 users [26%] vs 108 589 of 770 833 users [14%]). In the most recent evaluated period (July to December 2024), LAI-CAB accounted for 4% (16 557 of 390 816 users) of PrEP users. Among users with sufficient data, LAI-CAB persistence was 50% (6020 of 12 118 users) at 1 year and 23% (785 of 3381 users) at 2 years. Overall PrEP persistence among LAI-CAB users, including transitions to oral PrEP, was 57% (6879 of 12 118 users) at 1 year and 30% (1019 of 3381 users) at 2 years. A greater proportion of female users initiated LAI-CAB (3551 users [15%]) than oral PrEP (83 274 users [11%]), but 2-year LAI-CAB persistence was lower among female users (61 users [13%]) than among male users (724 users [25%]). Conclusions and Relevance:In this national prescription claims cohort study, LAI-CAB use was a small share of overall PrEP use from 2022 to 2024. Approximately one-half of users were persistent in LAI-CAB or in PrEP at year 1, declining to about one-quarter and one-third, respectively, by year 2. The implementation of more effective new PrEP modalities alone is unlikely to substantially alter PrEP use in the US. Instead, structural supports and behavioral interventions are needed to facilitate scale-up of new, highly efficacious modalities.

BACKGROUND:People who inject drugs (PWID) have high risk for overdose, but there are no current estimates of overdose rates in this population. We aimed to estimate rates of non-fatal and fatal overdose among PWID living in the United States (US) and comparator countries (Canada, Mexico, United Kingdom, Australia), and ratios of non-fatal to fatal overdose rates, using literature published 01/01/2010 - 09/29/2023. METHODS:PubMed, PsycINFO, Embase, and ProQuest databases were systematically searched to identify publications reporting prevalence or rates of recent non-fatal and fatal overdose among PWID. Non-fatal and fatal overdose rates were meta-analyzed using random effects models. Risk of bias was assessed using a quality assessment tool, and heterogeneity was explored using sensitivity analyses. RESULTS:Our review included 143 studies, with 58 contributing unique data to the meta-analysis. Non-fatal and fatal overdose rates among PWID in the US were 32.9 per 100 person-years (PY) (95% CI: 26.4-40.9) and 1.7 per 100 PY (95% CI: 0.9-3.2), respectively. Post-2016 data yielded a non-fatal overdose rate of 41.0 per 100 PY (95% CI: 32.1-52.5) and a fatal overdose rate of 2.5 per 100 PY (95% CI: 1.4-4.3) in the US. An estimated 5% of overdoses among PWID in the US and Canada resulted in death during 2010-2023, compared to 6% in the UK and 2% in Australia. CONCLUSION:Findings demonstrate substantial burden of non-fatal and fatal overdose among PWID in the US and some comparator countries. Scale-up of interventions to prevent overdose mortality are urgently needed.

Importance:Universal administration of hepatitis B (HepB) vaccine at birth is a cornerstone for hepatitis B virus (HBV) elimination efforts in the US. In 2025, the Advisory Committee on Immunization Practices (ACIP) recommended delaying HepB vaccine initiation among infants born to birth parents who tested negative for hepatitis B surface antigen (HBsAg). Objective:To evaluate the health and economic impact of delaying HepB vaccination among US infants. Design, Setting, and Participants:A Markov model of HBV infections was acquired among a cohort infants, born in 2025, up to age 18 years. The model incorporated HBsAg prevalence among birthing parents, HBsAg testing during pregnancy or delivery, vertical or perinatal and household or community HBV transmission among children, and sequalae from chronic infection. This study was conducted in the US. Exposures:Eight scenarios in which the first HepB dose was delayed at intervals between 2 months and 12 years, applied either only to infants born to birth parents who tested negative for HBsAg or to parents who either tested negative for HBsAg or had unknown HBsAg status. All delayed vaccination scenarios were compared with administering first HepB dose at birth. Scenarios were modeled with perfect and imperfect adherence to recommendations. Main Outcomes and Measures:Outcomes included acute and chronic HBV infections acquired until age 18 years, additional associated lifetime HBV-related morbidity and mortality, and health care costs (2025 US dollars). Results:The health and economic outcomes of 3 628 934 infants were modeled in this analysis. All delayed vaccination scenarios resulted in more infections, worse health outcomes, and higher costs than administering first HepB dose at birth. Under perfect adherence, delaying HepB vaccination by 2 months for infants of parents negative for HBsAg led to an additional 90 acute infections (range, 16-107), 76 chronic infections (range, 14-97), 29 HBV-related deaths (range, 6-53), with $16.4 million in added costs for infants born during 1 year. Delaying to 12 years resulted in an additional 190 acute infections (range, 61-233), 50 deaths (range, 15-83), and nearly $30 million in added costs. Delaying HepB vaccination among infants of parents with unknown HBsAg status or imperfect adherence to the vaccination schedule amplified all negative outcomes. Conclusions and Relevance:Results of this economic evaluation quantified the potential impact of changing ACIP recommendations. Even brief delays in HepB vaccine initiation were associated with a substantial increase in HBV infections, adverse health outcomes, and health care costs.

Background Accurate estimates of the population sizes of men who have sex with men (MSM) are essential for evaluating HIV-related interventions. We aimed to estimate MSM populations at county and state levels using recent data from the decennial census and the National Health and Nutrition Examination Survey.Methods We used 2020 Decennial Census data to calculate a weight for each U.S. county, reflecting the proportion of male-male partner households relative to counties of similar urbanicity based on the 2013 National Center for Health Statistics Urban-Rural Classification Scheme. We applied these weights to urbanicity-stratified estimates of the prevalence of adult men who reported sex with a man in the past 12 months, derived from National Health and Nutrition Examination Survey (2015-2020). Multiplying these percentages by adult male populations produced county estimates, which were aggregated to state levels.Results We estimated approximately 2.1 million MSM in the United States, representing 1.7% of adult males. State-level estimates ranged from 0.3% in Wyoming (n = 675) to 3.7% in the District of Columbia (n = 9709). California had the largest MSM population (n = 318 612; 2.1%), followed by Florida (n = 191 199; 2.3%) and Texas (n = 173 751; 1.6%). At the county level, Los Angeles County, CA, had the largest MSM population (n = 82 513; 2.1%), followed by Cook County, IL (n = 39 580; 2.0%), and Broward County, FL (n = 34 321; 4.7%). Broward County, FL (4.7%), and San Francisco County, CA (4.6%), had the highest proportions relative to their male populations.Conclusions County- and state-level MSM estimates provide crucial denominators for calculating disease rates and informing public health interventions.

BACKGROUND:The prioritization of US health care personnel (HCP) for early receipt of messenger RNA (mRNA) vaccines against SARS-CoV-2 allowed for the evaluation of the effectiveness of these vaccines in a real-world setting among a high-risk population. This study aimed to summarize the sociodemographic characteristics of eligible HCP in Oregon and estimate vaccine effectiveness (VE) of a mRNA COVID-19 vaccine booster dose. METHODS:Using a case-control design, we compared HCP with positive antigen or nucleic acid amplification test SARS-CoV-2 test results (cases) to those with negative results (controls) and matched by site and test date. Using conditional logistic regression adjusted for age, sex, race and ethnicity, educational level, underlying conditions, and exposure to COVID-19, we estimated VE for a third COVID-19 vaccine booster dose using the screening method as 1-odds ratio × 100%. RESULTS:VE of a mRNA booster dose was 62.6% (95% CI: 37.6%, 77.6%), compared with 2-dose primary mRNA vaccination. Additionally, HCP with a college degree (vs no degree), private insurance (vs government), and an income level $200K+ (vs < $50K) were more likely to have received the booster vaccine. CONCLUSIONS:The mRNA COVID-19 booster vaccine conferred approximately 63% protection against COVID-19 among Oregon HCP. These findings encourage remaining up-to-date with subsequent COVID-19 vaccines.

Children who acquire hepatitis B virus (HBV) infection in early childhood through perinatal, household or community exposures are at highest risk of all age groups for experiencing chronic infection and premature death. Universal administration of hepatitis B (HepB) vaccine for all infants <24 hours of birth and completing the childhood series remains the cornerstone for HBV elimination efforts in the United States. We evaluated the health and economic impact of delaying HepB vaccination among U.S. infants. We constructed a Markov model to simulate lifetime health outcomes and costs for the 3,628,934 infants born in the United States in 2024 for HBV infections acquired up to age 18 years. The model incorporated hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg) prevalence among birthing parents, percentage of pregnant parents tested for HBsAg during pregnancy or at delivery, vertical/perinatal and household/community HBV infection risks among children, and resulting sequalae from chronic infection. Eight delayed vaccination scenarios were evaluated in which the first HepB dose was given at 2 months, 7 months, 4 years, or 12 years, applied either only to infants born to HBsAg-negative birth parent or to both HBsAg-negative and HBsAg-unknown birthing parents. Outcomes included acute and chronic HBV infections, cirrhosis, hepatocellular carcinoma, HBV-related deaths, quality-adjusted life-years (QALYs), life-years, and total healthcare costs from the healthcare system perspective. We modeled scenarios with perfect and imperfect adherence to the HepB vaccination schedule, and scenarios with or without additional HBV screening costs for those with delayed receipt of HepB vaccine. All delayed vaccination scenarios resulted in more infections, worse health outcomes, and higher costs than the current universal birth dose recommendation. Under perfect adherence, delaying HepB vaccination by 2 months for infants of HBsAg-negative parents led to an additional 90 acute infections, 75 chronic infections, 29 HBV-related deaths, with $16.4 million in added costs for infants born during one year. Delaying to 12 years resulted in an additional 190 acute infections, 50 deaths, and nearly $30 million in added costs. Delaying HepB vaccination to 12 years for infants of both HBsAg-negative and HBsAg-unknown parents resulted in an additional 2,351 acute infections, 744 deaths, and $368 million in excess costs. Imperfect adherence to the vaccination schedule amplified all negative outcomes substantially. Incorporating pre-vaccination serologic screening for delayed schedules markedly increased total costs. Even brief delays in HepB vaccine initiation substantially increase HBV infections, adverse health outcomes, and health system costs. Our results quantify and demonstrate the importance of the universal HepB birth dose in preventing perinatal and early childhood HBV transmission in the United States. We constructed a Markov model to evaluate health and economic outcomes for the 3.6 million infants born in 2024 under eight scenarios that delayed the first hepatitis B (HepB) vaccine dose to 2 months, 7 months, 4 years, or 12 years. All delayed schedules increased acute and chronic infections, HBV-related deaths, and healthcare costs compared with the current universal HepB birth-dose policy. For a single year of delaying the HepB birth dose to 2 months among infants whose birth parents are not known to be living with hepatitis B, we estimate 1,437 preventable hepatitis B infections among children, 304 cases of liver cancer, 482 HBV-related deaths, and over $222 million in excess healthcare costs. For a single year of delaying the HepB birth dose to 12 years among infants whose birth parents are not known to be living with hepatitis B, we estimate 2,726 preventable hepatitis B infections among children, 503 cases of liver cancer, 788 HBV-related deaths, and over $313 million in excess healthcare costs. Our results demonstrate and quantify the critical role of timely universal HepB birth dose vaccination in preventing childhood HBV transmission.

Objectives. To estimate the population size of people who inject drugs (PWID) in the United States in 2022. Methods. We constructed a hybrid estimator, which applied the ratio of nonfatal to fatal overdose among PWID to convert estimated injection-involved overdose deaths to the number of nonfatal overdoses. We divided the number of nonfatal overdose events by the prevalence of nonfatal overdose to generate PWID population size estimates. Results. There were an estimated 2 392 100 (95% confidence interval = 1 323 300, 4 648 100) PWID in 2022, which was 35% lower than the 2018 estimate. Most PWID were male and non-Hispanic White. The US South had the highest number of PWID. Conclusions. Reduced PWID population size may reflect improved data inputs or a true decline in the number of PWID because of high levels of overdose fatality or shifts in routes of drug consumption. These data are essential for determining needs for prevention services and rates of morbidity and mortality among PWID. (Am J Public Health. 2026;116(3):376-379. https://doi.org/10.2105/AJPH.2025.308310).

Background Diagnosis of infection with hepatitis C virus (HCV) is the first step to accessing curative treatment, yet many infected adults in the United States are unaware of their infection. Viral-first HCV testing strategies may improve diagnosis. We assessed the cost-effectiveness of several hepatitis C testing strategies compared with the currently recommended testing algorithm. Methods We used a decision tree framework with a Markov model of hepatitis C disease progression, to model a cohort representative of US adults at average risk. We modeled 4 strategies: anti-HCV test with automatic nucleic acid test (NAT) for HCV RNA when the anti-HCV result is reactive (comparator); anti-HCV test with automatic hepatitis C core antigen (HCVcAg) test when the anti-HCV result is reactive, followed by NAT for HCV RNA when the HCVcAg result is not reactive (intervention 1); concurrent anti-HCV and HCVcAg tests with automatic NAT for HCV RNA for discordant anti-HCV and HCVcAg results (intervention 2); and NAT for HCV RNA (intervention 3). We compared costs (in 2023 US dollars), quality-adjusted life-years (QALYs) and epidemiologic outcomes for the lifetime of the cohort. Results Relative to the comparator, intervention 1 resulted in the same number of HCV diagnoses and subsequent health outcomes, with cost savings of $0.26 per person. Interventions 2 and 3 had increased costs per person ($8.60 2 and $21.48, respectively) and resulted in an increase in diagnosed infections, treated infections, and QALYs. Conclusions Compared with the current HCV testing approach, viral-first HCV testing approaches are potentially cost-effective strategies that resulted in gains in diagnoses and health outcomes.

Background and Aims: The National Health and Nutrition Examination Survey (NHANES) underestimates the true prevalence of HCV infection. By accounting for populations inadequately represented in NHANES, we created 2 models to estimate the national hepatitis C prevalence among US adults during 2017-2020. Approach and Results: The first approach (NHANES+) replicated previous methodology by supplementing hepatitis C prevalence estimates among the US noninstitutionalized civilian population with a literature review and meta-analysis of hepatitis C prevalence among populations not included in the NHANES sampling frame. In the second approach (persons who injected drugs [PWID] adjustment), we developed a model to account for the underrepresentation of PWID in NHANES by incorporating the estimated number of adult PWID in the United States and applying PWID-specific hepatitis C prevalence estimates. Using the NHANES+ model, we estimated HCV RNA prevalence of 1.0% (95% CI: 0.5%-1.4%) among US adults in 2017-2020, corresponding to 2,463,700 (95% CI: 1,321,700-3,629,400) current HCV infections. Using the PWID adjustment model, we estimated HCV RNA prevalence of 1.6% (95% CI: 0.9%-2.2%), corresponding to 4,043,200 (95% CI: 2,401,800-5,607,100) current HCV infections. Conclusions: Despite years of an effective cure, the estimated prevalence of hepatitis C in 2017-2020 remains unchanged from 2013 to 2016 when using a comparable methodology. When accounting for increased injection drug use, the estimated prevalence of hepatitis C is substantially higher than previously reported. National action is urgently needed to expand testing, increase access to treatment, and improve surveillance, especially among medically underserved populations, to support hepatitis C elimination goals.

BackgroundIn the United States, both drug overdose mortality and injection-involved drug overdose mortality have increased nationally over the past 25 years. Despite documented geographic differences in overdose mortality and substances implicated in overdose mortality trends, injection-involved overdose mortality has not been summarized at a subnational level. ObjectiveWe aimed to estimate the annual number of injection-involved overdose deaths in each US state from 2000 to 2020. MethodsWe conducted a stratified analysis that used data from drug treatment admissions (Treatment Episodes Data Set–Admissions; TEDS-A) and the National Vital Statistics System (NVSS) to estimate state-specific percentages of reported drug overdose deaths that were injection-involved from 2000 to 2020. TEDS-A collects data on the route of administration and the type of substance used upon treatment admission. We used these data to calculate the percentage of reported injections for each drug type by demographic group (race or ethnicity, sex, and age group), year, and state. Additionally, using NVSS mortality data, the annual number of overdose deaths involving selected drug types was identified by the following specific multiple-cause-of-death codes: heroin or synthetic opioids other than methadone (T40.1, T40.4), natural or semisynthetic opioids and methadone (T40.2, T40.3), cocaine (T40.5), psychostimulants with abuse potential (T43.6), sedatives (T42.3, T42.4), and others (T36-T59.0). We used the probabilities of injection with the annual number of overdose deaths, by year, primary substance, and demographic groups to estimate the number of overdose deaths that were injection-involved. ResultsIn 2020, there were 91,071 overdose deaths among adults recorded in the United States, and 93.1% (84,753/91,071) occurred in the 46 jurisdictions that reported data to TEDS-A. Slightly less than half (38,253/84,753, 45.1%; 95% CI 41.1%-49.8%) of those overdose deaths were estimated to be injection-involved, translating to 38,253 (95% CI 34,839-42,181) injection-involved overdose deaths in 2020. There was large variation among states in the estimated injection-involved overdose death rate (median 14.72, range 5.45-31.77 per 100,000 people). The national injection-involved overdose death rate increased by 323% (95% CI 255%-391%) from 2010 (3.78, 95% CI 3.33-4.31) to 2020 (15.97, 95% CI 14.55-17.61). States in which the estimated injection-involved overdose death rate increased faster than the national average were disproportionately concentrated in the Northeast region. ConclusionsAlthough overdose mortality and injection-involved overdose mortality have increased dramatically across the country, these trends have been more pronounced in some regions. A better understanding of state-level trends in injection-involved mortality can inform the prioritization of public health strategies that aim to reduce overdose mortality and prevent downstream consequences of injection drug use.

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Background: Understanding characteristics of healthcare personnel (HCP) with SARS-CoV-2 infection supports the development and prioritization of interventions to protect this important workforce. We report detailed characteristics of HCP who tested positive for SARS-CoV-2 from April 20, 2020 through December 31, 2021.Methods: CDC collaborated with Emerging Infections Program sites in 10 states to interview HCP with SARS-CoV-2 infection (case-HCP) about their demographics, underlying medical conditions, healthcare roles, exposures, personal protective equipment (PPE) use, and COVID-19 vaccination status. We grouped case-HCP by healthcare role. To describe residential social vulnerability, we merged geocoded HCP residential addresses with CDC/ATSDR Social Vulnerability Index (SVI) values at the census tract level. We defined highest and lowest SVI quartiles as high and low social vulnerability, respectively.Results: Our analysis included 7,531 case-HCP. Most case-HCP with roles as certified nursing assistant (CNA) (444, 61.3%), medical assistant (252, 65.3%), or home healthcare worker (HHW) (225, 59.5%) reported their race and ethnicity as either non-Hispanic Black or Hispanic. More than one third of HHWs (166, 45.2%), CNAs (283, 41.7%), and medical assistants (138, 37.9%) reported a residential address in the high social vulnerability category. The proportion of case-HCP who reported using recommended PPE at all times when caring for patients with COVID-19 was lowest among HHWs compared with other roles.Conclusions: To mitigate SARS-CoV-2 infection risk in healthcare settings, infection prevention, and control interventions should be specific to HCP roles and educational backgrounds. Additional interventions are needed to address high social vulnerability among HHWs, CNAs, and medical assistants.

Background: People who inject drugs (PWID) have high risk for overdose, but there are no current estimates of overdose rates in this population. We estimated the rates of non-fatal and fatal overdose among PWID living in the U.S. and comparator countries (Canada, Mexico, United Kingdom, Australia), and ratios of non-fatal to fatal overdose, using literature published 01/01/2010 - 09/29/2023. Methods: PubMed, PsychInfo, Embase, and ProQuest databases were systematically searched to identify publications reporting prevalence or rates of recent (past 12 months) non-fatal and fatal overdose among PWID. Non-fatal and fatal overdose rates were meta-analyzed using random effects models. Risk of bias was assessed using an adapted quality assessment tool, and heterogeneity was explored using sensitivity analyses. Results: Our review included 143 records, with 58 contributing unique data to the meta-analysis. Non-fatal and fatal overdose rates among PWID in the U.S. were 32.9 per 100 person-years (PY) (95% CI: 26.4 - 40.9; n=28) and 1.7 per 100 PY (95% CI: 0.9 - 3.2; n=4), respectively. Limiting the analysis to data collected after 2016 yielded a non-fatal rate of 41.0 per 100 PY (95% CI: 32.1 - 52.5; n=16) and a fatal rate of 2.5 per 100 PY (95% CI: 1.4 - 4.3; n=2) in the U.S. An estimated 5% of overdoses among PWID in the U.S. result in death. Among the analyzed countries, Australia had the lowest non-fatal and fatal overdose rates and the largest ratio of non-fatal to fatal overdose. Conclusion: Findings demonstrate substantial burden of non-fatal and fatal overdose among PWID in the U.S. and comparator countries. Scale-up of interventions that prevent overdose mortality and investments in PWID health research are urgently needed. Funding: Centers for Disease Control and Prevention, National Center for National Center for HIV, Viral Hepatitis, STD, and TB Prevention and the National Institutes of Health, National Institute on Drug Abuse. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was funded by Centers for Disease Control and Prevention, National Center for National Center for HIV, Viral Hepatitis, STD, and TB Prevention and the National Institutes of Health, National Institute on Drug Abuse ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors

The COVID-19 pandemic exposed and exacerbated a public health workforce shortage and national strategies have called for the development of clear occupational pathways for students to enter the public health workforce and meaningful public health careers. In response to the immediate need for public health workers during the pandemic, several universities and academic hospitals rapidly mobilized students and employees and partnered with local or state health departments. However, many of those partnerships were based on short-term volunteer effort to support critical COVID-19 public health efforts. In this article, we document the development of Oregon’s Public Health Practice Team, a student, staff, and faculty workforce developed at the Oregon Health Science University-Portland State University (OHSU-PSU) School of Public Health in close collaboration with the Oregon Health Authority (OHA). This project contributed significant effort to several phases of Oregon’s statewide public health response to COVID-19, and over time developed into a lasting, multi-purpose, inter-agency collaborative public health practice program. Health equity has been centered at every stage of this work. We describe the phases of the partnership development, the current team structure and operations, and highlight key challenges and lessons learned. This provides a case-study of how an innovative and flexible university-government partnership can contribute to immediate pandemic response needs, and also support ongoing public health responses to emerging needs, while contributing to the development of a skilled and diverse public health workforce.

Objective To determine the optimal testing strategy to identify children with perinatally acquired hepatitis C virus (HCV) infection. Study design We used a decision-tree framework with a Markov disease progression model to conduct an economic analysis of 4 strategies, based on combinations of type and timing of test: anti-HCV with reflex to HCV RNA at 18 months among children known to be perinatally exposed (ie, baseline comparison strategy); HCV RNA testing at 2-6 months among infants known to be perinatally exposed (test strategy 1); universal anti-HCV with reflex to HCV RNA at 18 months among all children (test strategy 2); and universal HCV RNA testing at 2-6 months among all infants (test strategy 3). We estimated total cost, quality-adjusted life years, and disease sequalae for each strategy. Results Each of the 3 alternative testing strategies resulted in an increased number of children tested and improved health outcomes. HCV RNA testing at 2-6 months (test strategy 1) was cost-saving and resulted in a population-level difference in cost of $469 671. The 2 universal testing strategies resulted in an increase in quality-adjusted life years and an increase in total costs. Conclusions Testing of perinatally exposed infants at age 2-6 months with a single HCV RNA test will reduce costs and improve health outcomes, preventing morbidity and mortality associated with complications from perinatal HCV infections.

Background HIV incidence estimates are published each year for all Ending the HIV Epidemic (EHE) counties, but they are not stratified by the demographic variables highly associated with risk of infection. Regularly updated estimates of HIV incident diagnoses available at local levels are required to monitor the epidemic in the United States over time and could contribute to background incidence rate estimates for alternative clinical trial designs for new HIV prevention products. Objective We describe methods using existing, robust data sources within areas in the United States to reliably estimate longitudinal HIV incident diagnoses stratified by race and age categories among men who have sex with other men (MSM) eligible for pre-exposure prophylaxis (PrEP) but not taking it. Methods This is a secondary analysis of existing data sources to develop new estimates of incident HIV diagnoses in MSM. We reviewed past methods used to estimate incident diagnoses and explored opportunities to improve these estimates. We will use existing surveillance data sources and population sizes of HIV PrEP-eligible MSM estimated from population-based data sources (eg, US Census data and pharmaceutical prescription databases) to develop metropolitan statistical area–level estimates of new HIV diagnoses among PrEP-eligible MSM. Required parameters are number of new diagnoses among MSM, estimates of MSM with an indication for PrEP, and prevalent PrEP use including median duration of use; these parameters will be stratified by jurisdiction and age group or race or ethnicity. Preliminary outputs will be available in 2023, and updated estimates will be produced annually thereafter. Results Data to parameterize new HIV diagnoses among PrEP-eligible MSM are available with varying levels of public availability and timeliness. In early 2023, the most recent available data on new HIV diagnoses were from the 2020 HIV surveillance report, which reports 30,689 new HIV infections in 2020, and 24,724 of them occurred in an MSA with a population of ≥500,000. Updated estimates for PrEP coverage based on commercial pharmacy claims data through February 2023 will be generated. The rate of new HIV diagnoses among MSM can be estimated from new diagnoses within each demographic group (numerator) and the total person-time at risk of diagnosis for each group (denominator) by metropolitan statistical area and year. To estimate time at risk, the person-time of individuals on PrEP or person-time after incident HIV infection but before diagnosis should be removed from stratified population size estimates of the total number of person-years with indications for PrEP. Conclusions Reliable, serial, cross-sectional estimates for rates of new HIV diagnoses for MSM with PrEP indications can serve as benchmark community estimates of failures of HIV prevention and opportunities to improve services and will support public health epidemic monitoring and alternative clinical trial designs. International Registered Report Identifier (IRRID) DERR1-10.2196/42267

BACKGROUND:Public health data signal increases in the number of people who inject drugs (PWID) in the United States during the past decade. An updated PWID population size estimate is critical for informing interventions and policies aiming to reduce injection-associated infections and overdose, as well as to provide a baseline for assessments of pandemic-related changes in injection drug use. METHODS:We used a modified multiplier approach to estimate the number of adults who injected drugs in the United States in 2018. We deduced the estimated number of nonfatal overdose events among PWID from 2 of our previously published estimates: the number of injection-involved overdose deaths and the meta-analyzed ratio of nonfatal to fatal overdose. The number of nonfatal overdose events was divided by prevalence of nonfatal overdose among current PWID for a population size estimate. RESULTS:There were an estimated 3 694 500 (95% confidence interval [CI], 1 872 700-7 273 300) PWID in the United States in 2018, representing 1.46% (95% CI, .74-2.87) of the adult population. The estimated prevalence of injection drug use was highest among males (2.1%; 95% CI, 1.1-4.2), non-Hispanic Whites (1.8%; 95% CI, .9-3.6), and adults aged 18-39 years (1.8%; 95% CI, .9-3.6). CONCLUSIONS:Using transparent, replicable methods and largely publicly available data, we provide the first update to the number of people who inject drugs in the United States in nearly 10 years. Findings suggest the population size of PWID has substantially grown in the past decade and that prevention services for PWID should be proportionally increased.

BackgroundCOVID-19 mitigation behaviors, such as wearing masks, maintaining social distancing, and practicing hand hygiene, have been and will remain vital to slowing the pandemic. ObjectiveThis study aims to describe the period prevalence of consistent mask-wearing, social distancing, and hand hygiene practices during the peak of COVID-19 incidence (August-December 2020) and just before COVID-19 vaccine availability, overall and in demographic subgroups. MethodsWe used baseline survey data from a nationwide household probability sample to generate weighted estimates of mitigation behaviors: wearing masks, maintaining social distancing, and practicing hand hygiene. Weighted logistic regression explored differences in mitigation behaviors by demographics. Latent class analysis (LCA) identified patterns in mitigation behaviors. ResultsAmong 4654 participants, most (n=2727, 58.6%) were female, were non-Hispanic White (n=3063, 65.8%), were aged 55 years or older (n=2099, 45.1%), lived in the South (n=2275, 48.9%), lived in metropolitan areas (n=4186, 89.9%), had at least a bachelor’s degree (n=2547, 54.7%), had an income of US $50,000-$99,000 (n=1445, 31%), and were privately insured (n=2734, 58.7%). The period prevalence of consistent mask wearing was 71.1% (sample-weighted 95% CI 68.8-73.3); consistent social distancing, 42.9% (95% CI 40.5-45.3); frequent handwashing, 55.0% (95% CI 52.3-57.7); and frequent hand sanitizing, 21.5% (95% CI 19.4-23.8). Mitigation behaviors were more prevalent among women, older persons, Black or Hispanic persons, those who were not college graduates, and service-oriented workers. LCA identified an optimal-mitigation class that consistently practiced all behaviors (n=2656, 67% of US adults), a low-mitigation class that inconsistently practiced all behaviors (n=771, 20.6%), and a class that had optimal masking and social distancing but a high frequency of hand hygiene (n=463, 12.4%). ConclusionsDespite a high prevalence of COVID-19 mitigation behaviors, there were likely millions who did not consistently practice these behaviors during the time of the highest COVID-19 incidence. In future infectious disease outbreak responses, public health authorities should also consider addressing disparities in mitigation practices through more targeted prevention messaging.