Background:We compared racial and ethnic disparities in HIV diagnosis rates among adults in census tracts with the most disadvantaged vs. the most advantaged levels of social determinants of health.Methods:In this ecologic analysis, we used the National HIV Surveillance System data from 2021 and social determinants of health data from 2017-2021 American Community Survey. We measured racial and ethnic disparities stratified by sex in the most disadvantaged quartiles and advantaged quartiles for (1) poverty, (2) education level, (3) median household income, and (4) insurance coverage. We calculated 8 relative disparity measures [Black-to-White rate ratio, Hispanic/Latino-to-White rate ratio, index of disparity (ID), population-weighted ID, mean log deviation, Theil index, population attributable proportion, Gini coefficient] and 4 absolute disparity measures (Black-to-White rate difference, Hispanic/Latino-to-White rate difference, absolute ID, and population-weighted absolute ID).Results:Comparing the most disadvantaged quartiles with the most advantaged quartiles, all 4 absolute disparity measures decreased, but 7 of the 8 relative disparity measures increased: the median percentage decreases in the absolute measures for men and women, respectively, were 38.1% and 47.6% for poverty, 12.4% and 42.6% for education level, 43.6% and 44.0% for median household income, and 44.2% and 45.4% for insurance coverage. The median percentage increases in the relative measures for men and women, respectively, were 44.3% and 61.3% for poverty, 54.9% and 95.3% for education level, 19.6% and 90.0% for median household income, and 32.8% and 46.4% for insurance coverage.Conclusions:Racial and ethnic disparities in the most disadvantaged and the most advantaged quartiles highlight the need for strategies addressing the root causes of disparities.

Purpose: We examined changes in racial/ethnic disparities in HIV diagnoses among adolescents and young adults aged 13-24 years from 2015 through 2019.Methods: We used national surveillance data for 2015-2019 from AtlasPlus to calculate 12 ab-solute and relative disparity measures for 7 racial/ethnic groups to understand HIV diagnosis trends over time. We calculated four absolute measures (Black-to-White rate difference, Hispanic -to-White rate difference, Absolute Index of Disparity [ID], population-weighted Absolute ID) and eight relative measures (Black-to-White rate ratio, Hispanic-to-White rate ratio, ID, population -weighted ID, population attributable proportion, Gini coefficient, Theil index, and mean log deviation).Results: HIV diagnosis rates decreased by 15.9% across all racial/ethnic groups combined. All the absolute disparity measures we examined indicated substantial reductions (13.5%-18.5%) in ab-solute disparities. Most of the relative disparity measures (eight of eight population-unadjusted measures and five of eight population-adjusted measures) declined as well, but the change was relatively modest and ranged from a 3.3% decrease to a 2.1% increase across the measures.Discussion: Despite progress, racial/ethnic disparities in HIV diagnoses among adolescents and young adults remain. Programs and services that are culturally relevant and tailored for this population may assist with continued progress toward reducing racial/ethnic disparities.Published by Elsevier Inc. on behalf of Society for Adolescent Health and Medicine.

Background Genital herpes (GH), caused by herpes simplex virus type 1 and type 2 (HSV-1, HSV-2), is a common sexually transmitted disease associated with adverse health outcomes. Symptoms associated with GH outbreaks can be reduced by antiviral medications, but the infection is incurable and lifelong. In this study, we estimate the long-term health impacts of GH in the United States using quality-adjusted life years (QALYs) lost. Methods We used probability trees to model the natural history of GH secondary to infection with HSV-1 and HSV-2 among people aged 18-49 years. We modelled the following outcomes to quantify the major causes of health losses following infection: symptomatic herpes outbreaks, psychosocial impacts associated with diagnosis and recurrences, urinary retention caused by sacral radiculitis, aseptic meningitis, Mollaret's meningitis, and neonatal herpes. The model was parameterized based on published literature on the natural history of GH. We summarized losses of health by computing the lifetime number of QALYs lost per genital HSV-1 and HSV-2 infection, and we combined this information with incidence estimates to compute the total lifetime number of QALYs lost due to infections acquired in 2018 in the United States. Findings We estimated 0.05 (95% uncertainty interval (UI) 0.02-0.08) lifetime QALYs lost per incident GH infection acquired in 2018, equivalent to losing 0.05 years or about 18 days of life for one person with perfect health. The average number of QALYs lost per GH infection due to genital HSV-1 and HSV-2 was 0.01 (95% UI 0.01-0.02) and 0.05 (95% UI 0.02-0.09), respectively. The burden of genital HSV-1 is higher among women, while the burden of HSV-2 is higher among men. QALYs lost per neonatal herpes infection was estimated to be 7.93 (95% UI 6.63-9.19). At the population level, the total estimated lifetime QALYs lost as a result of GH infections acquired in 2018 was 33,100 (95% UI 12,600-67,900) due to GH in adults and 3,140 (95% UI 2,260-4,140) due to neonatal herpes. Results were most sensitive to assumptions on the magnitude of the disutility associated with post -diagnosis psychosocial distress and symptomatic recurrences. Interpretation GH is associated with substantial health losses in the United States. Results from this study can be used to compare the burden of GH to other diseases, and it provides inputs that may be used in studies on the health impact and cost-effectiveness of interventions that aim to reduce the burden of GH. Funding The Center for Disease Control and Prevention Copyright (c) 2023 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Background As part of New York State's Ending the Epidemic (EtE) initiative, sexual health clinics (SHCs) in New York City invested in clinic enhancements and expanded their HIV-related services to increase access to HIV prevention interventions and treatment. The objective of this study was to estimate and describe the change in SHC operating costs related to clinic enhancements and expanded patient services implemented as part of the EtE initiative. Methods A comprehensive microcosting approach was used to collect retrospective cost information from SHCs, broken down by category and programmatic activity. Cost information was collected from 8 clinics across New York City during two 6-month time periods before (2015) and during (2018-2019) EtE. Results Eight SHCs reported comprehensive cost data. Costs increased by $800,000 on average per clinic during the 6-month EtE period. The cost per visit at an SHC increased by $120 on average to $381 (ranging from $302 to $464) during the EtE period. Personnel costs accounted for 69.9% of EtE costs, and HIV-related medications accounted for 8.9% of costs. Employment of social workers and patient navigators increased costs by approximately $150,000 on average per clinic. Postexposure prophylaxis was the costliest medication with average expenditures of $103,800 per clinic. Conclusions This study demonstrates the key drivers of cost increases when offering enhanced HIV services in SHCs. Documenting the changes in resources necessary to implement these services and their costs can inform other health departments on the viability of offering enhanced HIV services within their own clinics.

Background Network approaches can be used to study sociosexual partnerships and identify individuals at high risk of infection. Little is known about the cost structure of these services and their association with STD diagnoses. Method We collected costs associated with using a peer network strategy to recruit men who have sex with men and transwomen of color in 4 counties in North Carolina: Guilford, Forsyth, Durham, and Wake from February through October 2019. We used a comprehensive costing approach to gather detailed retrospective information on the intervention cost, broken down by category and programmatic activity. Results The sociosexual networks collected consisted of 31 initial seeds (index cases) and 49 peers of those seeds. In peers, 5 cases of human immunodeficiency virus (HIV) and 10 cases of syphilis were identified. The cost per case (HIV or syphilis) identified was $7325. Personnel costs accounted for 80% of total expenditures, followed by laboratory expenses (12%). Personnel cost was distributed between disease intervention specialist patient navigators (51%), nonclinical (37%), and management (12%) staff. General administration was the costliest programmatic activity (37%), followed by case management and field services (37%), and study activities (11%). The estimated average cost per patient tested was $2242. Conclusions Finding positive peer cases in nonclinical settings is costly but may be crucial for limiting the spread of sexually transmitted diseases. The cost of staff was the major driver. This study demonstrates that using a network strategy can be a cost-effective way to identify, test, and refer patients at high risk of syphilis and HIV infections to care.

BACKGROUND:We estimated the lifetime medical costs attributable to sexually transmitted infections (STIs) acquired in 2018, including sexually acquired human immunodeficiency virus (HIV). METHODS:We estimated the lifetime medical costs of infections acquired in 2018 in the United States for 8 STIs: chlamydia, gonorrhea, trichomoniasis, syphilis, genital herpes, human papillomavirus (HPV), hepatitis B, and HIV. We limited our analysis to lifetime medical costs incurred for treatment of STIs and for treatment of related sequelae; we did not include other costs, such as STI prevention. For each STI, except HPV, we calculated the lifetime medical cost by multiplying the estimated number of incident infections in 2018 by the estimated lifetime cost per infection. For HPV, we calculated the lifetime cost based on the projected lifetime incidence of health outcomes attributed to HPV infections acquired in 2018. Future costs were discounted at 3% annually. RESULTS:Incident STIs in 2018 imposed an estimated $15.9 billion (25th-75th percentile: $14.9-16.9 billion) in discounted, lifetime direct medical costs (2019 US dollars). Most of this cost was due to sexually acquired HIV ($13.7 billion) and HPV ($0.8 billion). STIs in women accounted for about one fourth of the cost of incident STIs when including HIV, but about three fourths when excluding HIV. STIs among 15- to 24-year-olds accounted for $4.2 billion (26%) of the cost of incident STIs. CONCLUSIONS:Incident STIs continue to impose a considerable lifetime medical cost burden in the United States. These results can inform health economic analyses to promote the use of cost-effective STI prevention interventions to reduce this burden.

We provide the first comprehensive evidence on the effects of access to legal same-sex marriage (SSM) on marriage and adult health using the full rollout of marriage equality across the United States. Using data from the CDC BRFSS from 2000 to 2017, we relate changes in outcomes for individuals in same-sex households (SSH) coincident with adoption of legal SSM in two-way fixed effects models. A substantial share of these households includes gay and lesbian couples. For men in SSH, we find robust evidence that access to legal SSM significantly increased marriage take-up, health insurance coverage, access to care, and healthcare utilization. Results for women in SSH are inconclusive apart from a clear increase in marriage take-up. Our results provide the first evidence that legal access to SSM significantly improved health for adult gay men.

BACKGROUND:The purpose of this study was to estimate the lifetime direct medical costs per incident case of genital herpes in the United States. METHODS:We used medical claims data to construct a cohort of people continuously enrolled in insurance for at least 48 consecutive months between 2010 and 2018. From this cohort, we identified initial genital herpes diagnoses as well as the cost of related clinical visits and medication during the 36 months after an initial diagnosis. Lifetime costs beyond 36 months were estimated based on treatment use patterns observed in the 36 months of follow-up. RESULTS:The present value of lifetime direct medical costs of genital herpes was estimated to be $972 per treated case or $165 per infection (2019 dollars), not including costs associated with prevention or treatment of neonatal herpes. The clinical visit at which genital herpes was first diagnosed accounted for 27% of lifetime costs. Subsequent clinical visits and medications related to genital herpes accounted for an additional 13% and 60% of lifetime costs, respectively. CONCLUSIONS:The results from this study can inform cost-effectiveness analysis of genital herpes control interventions as well as help quantify the cost burden of sexually transmitted infections in the United States.

This article provides the first large-scale evidence on transgender status, gender identity, and socioeconomic outcomes in the United States, using representative data from 35 states in the Behavioral Risk Factor Surveillance System (BRFSS), which asked identical questions about transgender status and gender identity during at least one year from 2014 to 2017. More than 2,100 respondents, aged 18 to 64 years, identified as transgender. Individuals who identify as transgender are significantly less likely to be college educated and less likely to identify as heterosexual than are individuals who do not identify as transgender. Controlling for these and other observed characteristics, transgender individuals have significantly lower employment rates, lower household incomes, higher poverty rates, and worse self-rated health compared to otherwise similar men who are not transgender.

Background: Diagnoses of HIV infection among male adults and adolescents ≥13 years with infection attributed to heterosexual contact decreased from 2014 through 2018. Racial disparities exist; HIV diagnoses are higher among Black/African American men compared with men of other races/ethnicities. In 2018, Black/African American males accounted for 61% of diagnosed HIV infections attributed to heterosexual contact among males. Setting: We used national HIV surveillance data from Atlas Plus to obtain the annual case counts of new HIV diagnoses in males with infection attributed to heterosexual contact and population size for years 2014 through 2018 for males (United States excluding territories) by the racial/ethnic group. Methods: We used an adjusted population denominator to calculate rates of diagnoses of HIV infection acquired through heterosexual contact per 100,000 males and 12 absolute and relative measures of disparity to calculate racial/ethnic disparity changes from 2014 to 2018. Results: Results from all disparity measures indicate that disparities decreased in 2018, compared with 2014. The decreases ranged from 18.8% to 34.6% among the 4 absolute disparity measures and from 5.3% to 22.7% among the 8 relative disparity measures. Conclusions: Despite the decrease, disparities remain. Tailored, effective strategies and interventions are needed to address the social and structural factors associated with HIV risk among heterosexual Black men and to promote continued progress toward reducing disparities.

Using 2013–2015 National Health Interview Survey data, we reproduce a well‐documented finding that self‐identified lesbians earn significantly more than comparable heterosexual women. These data also show — for the first time in the literature — that self‐identified gay men also earn significantly more than comparable heterosexual men, a difference on the order of 10% of annual earnings. We discuss several possible explanations for the new finding of a gay male earnings premium and suggest that reduced discrimination and changing patterns of household specialization are unlikely to be the primary mechanisms.