The USA has initiated plans to reduce HIV incidence by 90% over the next 10 years through the Ending the HIV Epidemic Initiative. To succeed, the nation will need to not only overcome the scientific and programmatic barriers to testing, treatment, and prevention, but also to address the legal obstacles, racial discrimination, economic disadvantage, and homophobia that underpin many of the disparities that are prevalent in the HIV epidemic. These social barriers directly prevent access to services and indirectly impede efforts to change HIV from an exceptional, stigmatised disease to a preventable and treatable infection. One area that continues to cause concern for some people with HIV, activists, and public health officials are HIV criminalisation laws 1 Harsono D Galletly CL O'Keefe E Lazzarini Z Criminalization of HIV exposure: a review of empirical studies in the United States. AIDS Behav. 2017; 21: 27-50 Crossref PubMed Scopus (27) Google Scholar —legislation passed with the intent of reducing HIV transmission and sanctioning individuals whose behaviour potentially exposed people to HIV. Seeing the people in the percentagesThe UNAIDS 90-90-90 targets have provided clear targets to the global HIV community. Since their inception in 2014, when only 37% of people living with HIV were receiving antiretrovial therapy (ART) and tools such as pre-exposure prophylaxis (PrEP) and knowledge of U=U (undetectable=untransmissible) were in their infancy, there has been substantial progress. However, despite these gains, the 90-90-90 targets for 2020 will not be met. Although we await the final numbers the most recent estimates , from 2019, suggest that among all people living with HIV 81% were aware of their status, 67% were accessing ART, and 59% were virally suppressed. Full-Text PDF Time to end discriminatory laws against people with HIVThis World AIDS Day, UNAIDS calls for an end to the inequalities that affect people with HIV, which threaten the target to end AIDS by 2030. Countries continue to use laws to discriminate against people on the basis of their HIV status, some of which are related to travel. Restrictions can include prohibition of short-term and long-term stays, HIV testing or disclosure for entry, study, work, or residence permits, and deportation of non-nationals. In October, the New Zealand Government announced it had removed a major legal restriction on travel. Full-Text PDF

A new initiative aims to reduce new infections by 75% within five years.

The US South accounted for 51% of annual new HIV infections, 50% of undiagnosed infections and 45% of persons with HIV infection in 2016 while comprising 38% of the population. Myriad structural and contextual factors are associated with HIV-related disparities. This paper describes initiatives and strategies conducted by the Centers for Disease Control and Prevention and Health Resources and Services Administration to identify opportunities and activities addressing the disparity of HIV diagnoses in the South. Targeted HIV prevention and care efforts can change the trajectory of outcomes along the HIV care continuum and reduce HIV-related disparities in the South.

Background: During 2008–2015, the estimated annual HIV incidence rate in the United States decreased for each transmission risk category, except for men who have sex with men (MSM). Racial/ethnic disparities exist, with higher incidence rates for Black and Hispanic/Latino MSM. Setting: This analysis examines changes, 2010–2015, in disparities of HIV incidence among Black, Hispanic/Latino and White MSM. Methods: We compared results from the rate ratio, rate difference, weighted and unweighted index of disparity, and population attributable proportion. We calculated incidence rates for MSM using HIV surveillance data and published estimates of the MSM population in the United States. We generated 95% confidence intervals for each measure and used the Z statistic and associated P values to assess statistical significance. Findings: Results from all but one measure, Black-to-White rate difference, indicate that racial/ethnic disparities increased during 2010–2015; not all results were statistically significant. There were statistically significant increases in the Hispanic/Latino-to-White MSM incidence rate ratio (29%, P < 0.05), weighted index of disparity with the rate for White MSM as the referent group (9%, P < 0.05), and the population attributable proportion index (10%, P < 0.05). If racial/ethnic disparities among MSM had been eliminated, a range of 55%–61% decrease in overall MSM HIV incidence would have been achieved during 2010–2015. Conclusions: A large reduction in overall annual HIV incidence among MSM can be achieved by eliminating racial/ethnic disparities among MSM. Removing social and structural causes of racial/ethnic disparities among MSM can be effective in reducing overall annual HIV incidence among MSM.

Infection with HIV, as well as its burden, is a major health issue for the United States. Each year, about 40000 persons receive an HIV diagnosis, and more than 1 million are living with the virus (1, 2). Testing for HIV, linkage to and engagement in care, and receipt of antiretroviral therapy are critical to prevent disease progression. Persons who are aware of their HIV infection also may reduce risk behavior and, with successful treatment, achieve viral suppression, which greatly reduces the risk for transmitting the virus (35). Some successes of treatment and prevention efforts are reflected in recent decreases in HIV diagnoses among women and persons who inject drugs (2). However, progress in reducing infections among men who have sex with men (MSM) has been limited. National goals include increasing the percentage of persons who are aware of their HIV infection and reducing the number of new infections. To meet these objectives, targets must be met for all high-risk populations in the United States, particularly gay, bisexual, and other MSM of all racial/ethnic groups (6). Although MSM represent approximately 2% of the U.S. population, they made up 67% of persons who received an HIV diagnosis in 2015 (2, 7). Assessing HIV outcomes nationally as well as among MSM is important for guiding prevention efforts and monitoring progress toward national goals. We updated and extended our model estimating HIV incidence and prevalence and the percentage of undiagnosed HIV infections (8) for additional years2008 to 2015for sex and transmission categories, and for MSM by race/ethnicity and age. Methods Using data from the National HIV Surveillance System (NHSS) of the Centers for Disease Control and Prevention (CDC) on the first CD4 value after HIV diagnosis, we modeled HIV incidence and prevalence and the percentage of undiagnosed HIV infections from 2008 through 2015 for persons aged 13 years and older (812). We used information on persons living with diagnosed HIV infection by the end of 2007 to estimate HIV prevalence and the percentage of undiagnosed HIV infections. All states, the District of Columbia, and 6 U.S. territories report cases of HIV infection and associated demographic and clinical information to the CDC without personal identifiers. Although cases of stage 3 HIV infectionthat is, AIDShave been reportable in all jurisdictions since the early 1980s, implementation of confidential, name-based HIV reporting was staggered over time, with all jurisdictions reporting by 2008. The first CD4 test result after an HIV diagnosis is a required data element on the HIV case report form. In addition, as of December 2016, all but 6 states had implemented mandatory laboratory reporting of all CD4 values, and 37 states and the District of Columbia reported complete data to the NHSS, representing 72% of persons living with an HIV diagnosis in the United States (1). Cases are routinely deduplicated within and between jurisdictions (13). Deaths are ascertained by linking HIV surveillance data to vital records. Death ascertainment for a given year of death typically is completed within 12 to 18 months; therefore, we used data that allowed at least 18 months for reporting each diagnosed case. Using the first CD4 value after HIV diagnosis, we first estimated the time from HIV infection to diagnosis at the individual level on the basis of a well-characterized CD4 depletion model commonly used in the literature (9, 10): where t is the duration of infection at the date of the CD4 test and ai and bi are model parameters specific to the U.S. HIV population groups (sex, age, and transmission category) in which most HIV infections are subtype B (8). The t estimates among persons in an HIV population group may be used to estimate the distribution of diagnosis delay (time from HIV infection to diagnosis) in the group. These estimates in turn may be used to approximate HIV incidence and prevalence and the percentage of undiagnosed HIV infections (812). Because not everyone with an HIV diagnosis had a CD4 test administered or reported, persons with a CD4 test result were assigned a weight to account for those without a result. This weight is the inverse of the probability that a person with an HIV diagnosis has a CD4 test after diagnosis. This probability is estimated by using the proportion of cases with a CD4 test result reported to the NHSS. Considering the heterogeneity in the availability of CD4 data, the population is stratified on the basis of the year of HIV diagnosis, sex, race/ethnicity, transmission category, age at diagnosis, and disease status at the end of the study periodthat is, whether the person had HIV infection never classified as AIDS, died without the infection ever having been classified as AIDS, or had infection that progressed to AIDS. Because we report results for persons aged 13 years and older, if a person had an estimated date of infection before age 13, the date of infection was set to the date the person reached 13 years of age. The distribution of diagnosis delay (time from HIV infection to diagnosis) was then used to estimate annual HIV incidence, which represents persons with diagnosed or undiagnosed HIV infection. The prevalence of HIV, which represents the number of persons with diagnosed or undiagnosed HIV infection who were alive at the end of a given year, was estimated by subtracting the cumulative number of deaths from the cumulative number of infections. The number of persons with undiagnosed HIV infection was estimated by subtracting the cumulative number of diagnoses from the cumulative number of infections. The proportion of undiagnosed HIV infections was estimated by dividing the number of undiagnosed infections by the total HIV prevalence for each year. More details are provided in the Appendix. All analyses were carried out by using SAS/STAT, version 9.4 (SAS Institute). Approximately 30% of HIV infection cases are reported to the CDC without an identified risk factor (2). To provide case counts by transmission categorya summary classification of the single risk factor most likely to have been responsible for transmissionmultiple imputation was used to handle missing values (14). Multiple imputation is a statistical approach in which each missing transmission category is replaced with a set of plausible values that represent the uncertainty about the true, but missing, value. Variables in the imputation model included age at HIV diagnosis, race/ethnicity, birth country origin, stage of disease at HIV diagnosis, type of HIV diagnosis facility, year of HIV diagnosis, and delay between HIV diagnosis and reporting of the case. Multiple imputation was performed separately for males and females because each sex had different numbers of transmission categories. Ten imputation values were generated to achieve a 95% relative efficiency based on the proportion of missing data. Several data sets with imputed values were analyzed by using standard statistical procedures, and the results were combined (15, 16). To account for model uncertainty, results were rounded to the nearest hundred for estimates greater than 1000 and the nearest ten for those less than or equal to 1000. We examined trends during 2008 to 2015 by using the estimated annual percentage change (EAPC) and its associated 95% CIs. We used Poisson regression with a log link function to calculate EAPC. The EAPC for diagnosed proportions was calculated by using the logarithm of the estimated prevalence that served as offset in the Poisson regression model (17). We compared incidence estimates for 2014 and 2015 by using a simple Z test. Rates per 100000 population were calculated for estimates of HIV incidence and prevalence (18). Rates for transmission categories were calculated by using published population size estimates as denominators (7, 19, 20). Role of the Funding Source This study used data collected as part of routine public health surveillance and was not funded. Results United States HIV Incidence In the United States, the estimated annual number of HIV infections, or HIV incidence, decreased 14.8%, from 45200 infections in 2008 to 38500 in 2015 (EAPC, 2.6% [95% CI, 3.2% to 2.1%]) (Figure; for all years, 2008 to 2015, see Appendix Table 1). The incidence of HIV attributed to heterosexual contact, injection drug use, and male-to-male sexual contact and injection drug use decreased by 6.3% (CI, 7.4% to 5.2%), 10.7% (CI, 12.8% to 8.6%), and 4.3% (CI, 6.9% to 1.6%) per year, respectively. The decreasing trend for persons who inject drugs may have been leveling off since 2014, with stable incidence in 2014 and 2015 (P= 0.22). The incidence decreased among both male and female adults and adolescents with infection attributed to heterosexual contact or injection drug use, with the reduction potentially leveling off among both males and females who inject drugs after 2014 (stable incidence in 2014 and 2015; P= 0.32 and P= 0.47, respectively) (Appendix Table 1). The incidence of HIV among MSM remained relatively stable, with 26700 infections in 2008 and 26200 in 2015. Men who have sex with men had the highest annual rates of HIV incidence each year, with a 2015 rate (513.7 [CI, 443.7 to 583.7] per 100000) 16 times that of persons with infection attributed to injection drug use (32.1 [CI, 20.3 to 43.8] per 100000) and 135 times that of persons with infection attributed to heterosexual contact (3.8 [CI, 3.3 to 4.2] per 100000) (Table 1). Figure. Estimated HIV incidence among persons aged 13 years or older, by transmission category (adjusted for missing transmission category), United States, 2008 to 2015. Shown are the estimated annual percentage changes and associated 95% CIs. Appendix Table 1. Estimated HIV Incidence Among Persons Aged 13 Years, by Sex and Transmission Category*United States, 20082015 Table 1. Estimated HIV Incidence and Prevalence and the Percentage of Undiagnosed HIV Infections Among Persons Aged 13 Years or Older, b

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.

The National HIV Behavioral Surveillance system was designed to monitor risk factors for HIV infection and HIV prevalence among individuals at higher risk for HIV infection, that is, sexually active men who have sex with men who attend venues, persons who recently injected drugs, and heterosexuals of low socioeconomic status living in urban areas. These groups were selected as priorities for behavioral surveillance because they represent the major HIV transmission routes and the populations with the highest HIV burden. Accurate data on the behaviors in these populations are critical for understanding trends in HIV infections and planning and evaluating effective HIV prevention activities. The articles in this supplement illustrate how National HIV Behavioral Surveillance data can be used to assess HIV risk behaviors, prevalence, and service utilization of the populations most affected by HIV in the United States and guide local and national high-impact prevention strategies to meet national HIV prevention goals.

The article discusses the role of antiretroviral therapy (ART) in HIV infection prevention in the U.S. Topics include the High-Impact Prevention strategy used by the U.S. Centers for Disease Control and Prevention (CDC) Division of HIV/AIDS Prevention (DHAP), the use of pre-exposure prophylaxis (PrEP), and the role of health communication to prevent HIV transmission.

The article discusses the role of antiretroviral therapy (ART) in HIV infection prevention in the U.S. Topics include the High-Impact Prevention strategy used by the U.S. Centers for Disease Control and Prevention (CDC) Division of HIV/AIDS Prevention (DHAP), the use of pre-exposure prophylaxis (PrEP), and the role of health communication to prevent HIV transmission.

Objective: A recent HIV outbreak in a rural network of persons who inject drugs (PWID) underscored the intersection of the expanding epidemics of opioid abuse, unsterile injection drug use (IDU), and associated increases in hepatitis C virus (HCV) infections. We sought to identify US communities potentially vulnerable to rapid spread of HIV, if introduced, and new or continuing high rates of HCV infections among PWID. Design: We conducted a multistep analysis to identify indicator variables highly associated with IDU. We then used these indicator values to calculate vulnerability scores for each county to identify which were most vulnerable. Methods: We used confirmed cases of acute HCV infection reported to the National Notifiable Disease Surveillance System, 2012–2013, as a proxy outcome for IDU, and 15 county-level indicators available nationally in Poisson regression models to identify indicators associated with higher county acute HCV infection rates. Using these indicators, we calculated composite index scores to rank each county's vulnerability. Results: A parsimonious set of 6 indicators were associated with acute HCV infection rates (proxy for IDU): drug-overdose deaths, prescription opioid sales, per capita income, white, non-Hispanic race/ethnicity, unemployment, and buprenorphine prescribing potential by waiver. Based on these indicators, we identified 220 counties in 26 states within the 95th percentile of most vulnerable. Conclusions: Our analysis highlights US counties potentially vulnerable to HIV and HCV infections among PWID in the context of the national opioid epidemic. State and local health departments will need to further explore vulnerability and target interventions to prevent transmission.

Recent advances in science, program, and policy could better position the nation to achieve its vision of the USA as a place where new HIV infections are rare. Among these developments, passage of the Patient Protection and Affordable Care Act (ACA) in 2010 may prove particularly important, as the health system transformations it has launched offer a supportive foundation for realizing the potential of other advances, both within and beyond the clinical arena. This article summarizes opportunities to expand access to high-impact HIV prevention interventions under the ACA, examines whether available evidence indicates that these opportunities are being realized, and considers potential challenges to further gains for HIV prevention in an era of health reform. This article also highlights the new roles that HIV prevention programs and providers may assume in a health system no longer defined by fragmentation among public health, medical care, and community service providers.

New York, NY †Department of Psychiatry, Columbia University Medical Center, New York, NY ‡San Diego State University/ University of California, San Diego, Joint Doctoral Program in Epidemiology, San Diego, CA §Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY kDepartment of Epidemiology and Biostatistics, School of Public Health, University at Albany, State University of New York, Rensselaer, NY ¶School of Public Health, Boston University, Boston, MA #Division of Epidemiology, School of Public Health, University of California, Berkeley, CA **Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY

Background: Commentary -- no abstract Objective: Commentary Methods: Commentary Results: Commentary Conclusions: Commentary Clinical Trial: N/A [JMIR Public Health Surveill 2016;2(1):e26]

OBJECTIVE:We validated cases of active tuberculosis (TB) recorded in the Indian Health Service (IHS) National Patient Information Reporting System (NPIRS) and evaluated the completeness of TB case reporting from IHS facilities to state health departments.METHODS:We reviewed the medical records of American Indian/Alaska Native (AI/AN) patients at IHS health facilities who were classified as having active TB using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic codes from 2006 to 2009 for clinical and laboratory evidence of TB disease. Individuals were reclassified as having active TB disease; recent latent TB infection (LTBI); past positive tuberculin skin test (TST) only; or as having no evidence of TB, LTBI, or a past positive TST. We compared validated active TB cases with corresponding state records to determine if they were reported.RESULTS:The study included 596 patients with active TB as per ICD-9-CM codes. Based on chart review, 111 (18.6%) had active TB; 156 (26.2%) had LTBI; 104 (17.4%) had a past positive TST; and 221 (37.1%) had no evidence of TB disease, LTBI, or a past positive TST. Of the 111 confirmed cases of active TB, 89 (80.2%) resided in participating states; 81 of 89 (91.2%) were verified as reported TB cases.CONCLUSIONS:ICD-9-CM codes for active TB disease in the IHS NPIRS do not accurately reflect the burden of TB among AI/ANs. Most confirmed active TB cases in the IHS health system were reported to the state; the national TB surveillance system may accurately represent the burden of TB in the AI/AN population.

OBJECTIVES:We examined trends and epidemiology of tuberculosis (TB) across racial/ethnic groups to better understand TB disparities in the United States, with particular focus on American Indians/Alaska Natives (AI/ANs) and Native Hawaiians/other Pacific Islanders (NH/PIs). METHODS:We analyzed cases in the U.S. National Tuberculosis Surveillance System and calculated TB case rates among all racial/ethnic groups from 2003 to 2008. Socioeconomic and health indicators for counties in which TB cases were reported came from the Health Resources and Services Administration Area Resource File. RESULTS:Among the 82,836 TB cases, 914 (1.1%) were in AI/ANs and 362 (0.4%) were in NH/PIs. In 2008, TB case rates for AI/ANs and NH/PIs were 5.9 and 14.7 per 100,000 population, respectively, rates that were more than five and 13 times greater than for non-Hispanic white people (1.1 per 100,000 population). From 2003 to 2008, AI/ANs had the largest percentage decline in TB case rates (-27.4%) for any racial/ethnic group, but NH/PIs had the smallest percentage decline (-3.5%). AI/ANs were more likely than other racial/ethnic groups to be homeless, excessively use alcohol, receive totally directly observed therapy, and come from counties with a greater proportion of people living in poverty and without health insurance. A greater proportion of NH/PIs had extrapulmonary disease and came from counties with a higher proportion of people with a high school diploma. CONCLUSIONS:There is a need to develop flexible TB-control strategies that address the social determinants of health and that are tailored to the specific needs of AI/ANs and NH/PIs in the U.S.

HIV/AIDS is one of the most devastating diseases that humanity has ever faced. Since the first clinical evidence of HIV/AIDS was reported in 1981, more than 60 million people have been infected with the virus and more than 20 million have died of AIDS. This article provides an overview of the global HIV/AIDS epidemic with a focus on its impact on sub-Saharan Africa and people of African descent in the United States.

SETTING Kiboga District, a rural district in central Uganda. OBJECTIVE As part of routine tuberculosis control programme operations, to measure the effectiveness and acceptability of community-based tuberculosis (TB) care using the directly observed treatment, short-course (DOTS) strategy for TB control. The implementation of the DOTS strategy with active participation of local communities in providing the option of treatment supervision in the community is known in Uganda as community-based DOTS (CB-DOTS). DESIGN Effectiveness was measured by comparing TB case-finding and treatment outcomes before and after the introduction of CB-DOTS in 1998. Acceptability was measured by administering a knowledge, attitudes and beliefs questionnaire to community members, health care workers and TB patients before and after the intervention. RESULTS A total of 540 TB patients were registered in the control period (1995-1997) before the introduction of CB-DOTS, and 450 were registered in the intervention period (1998-1999) after the implementation of CB-DOTS. Following the implementation of CB-DOTS, treatment success among new smear-positive pulmonary TB cases increased from 56% to 74% (RR 1.3, 95%CI 1.2-1.5, P < 0.001) and treatment interruption decreased from 23% to 1% (RR 16.5, 95%CI 6.1-44.7, P < 0.001). There was no significant difference in the proportion of deaths before and after the implementation of CB-DOTS (15% vs. 14% for new smear-positive pulmonary, and 38% vs. 29% for new smear-negative and extra-pulmonary TB cases). The acceptability of CB-DOTS was very high among those interviewed, mainly because CB-DOTS improved access to TB care, decreased costs and enabled patients to stay with their families. CONCLUSIONS In enabling patients to choose TB treatment supervision in the community, CB-DOTS provided a highly effective and acceptable additional option to conventional TB care. Efforts are underway to address the high case fatality rates in both study groups before and after the introduction of CB-DOTS. CB-DOTS is an example of shared responsibility between health services and communities in tackling a major public health priority.

SETTING:Foreign-born persons in the United States represent a growing proportion of the nation's tuberculosis (TB) cases.OBJECTIVE:To characterize drug resistance patterns in foreign-born TB patients from the three most common birth countries.DESIGN:A descriptive analysis of national TB surveillance data for 1993-1997. TB case reports for foreign-born persons who were at least 15 years old and born either in Mexico (6221), the Philippines (3624), or Vietnam (3351) were included.RESULTS:Among those with no prior history of TB, the proportions with isoniazid-resistant TB and MDR-TB (resistance to at least isoniazid and rifampin) were 9.2% and 1.6% for persons from Mexico, 13.7% and 1.4% for those from the Philippines, and 17.8% and 1.4% for those from Vietnam. Levels of isoniazid resistance and MDR-TB did not change during the 5-year study period. Levels of isoniazid resistance decreased with older age for persons with no prior TB from all three countries; however, rates of MDR-TB did not vary with age. Persons with <1 year of residence in the US were more likely to have MDR-TB; however, duration of residence in the US was not associated with isoniazid resistance.CONCLUSION:Increased drug resistance in younger and more recent arrivals suggests that vigorous efforts to prevent further development of MDR-TB in the three countries are essential.