The Role of Government-Funded Assistance Programs on HIV Testing Among Poor U.S. Adults

Government-funded assistance program enrollment may play an important role in the overall increase of HIV testing among low-income U.S. adults. We pooled data from the 2016-2018 National Health Interview Survey and limited analyses to respondents aged 18 to 64 years with incomes less than 100% of the U.S. poverty threshold (N = 9,497). The outcome of interest was ever testing for HIV. Prevalence ratios were used to assess the likelihood of ever testing for HIV and were adjusted for sociodemographic covariates including whether the respondent was a beneficiary of any government-funded assistance programs (e.g., Medicaid; job-placement/training/human services; or Temporary Assistance for Needy Families). After adjusting for significant sociodemographic covariates, government-funded assistance beneficiaries were significantly more likely to ever test for HIV (adjusted prevalence ratio = 1.3; 95% CI = [1.2, 1.4], p < .0001) than adults with incomes less than 100% of the U.S. poverty threshold who did not receive government assistance. Beneficiaries of government-funded assistance programs are more likely to test for HIV.

Prevalence of risk behaviors and correlates of SARS-CoV-2 positivity among in-school contacts of confirmed cases in a Georgia school district in the pre-vaccine era, December 2020-January 2021

BACKGROUND

There is a continuing risk for COVID-19 transmission in school settings while transmission is ongoing in the community, particularly among unvaccinated populations. To ensure that schools continue to operate safely and to inform implementation of prevention strategies, it is imperative to gain better understanding of the risk behaviors of staff and students. This secondary analysis describes the prevalence of COVID-19 risk behaviors in an exposed population of students and school staff in the pre-vaccine era and identifies associations between these behaviors and testing positive for SARS-CoV-2.

METHODS

From December 2020-January 2021, school staff and students exposed to confirmed COVID-19 cases in a Georgia school district were tested for SARS-CoV-2 and surveyed regarding risk behaviors in and out of school. Prevalence of risk behaviors was described by age group and school level, and associations with SARS-CoV-2 positivity were identified using chi squared tests.

RESULTS

Overall, 717 students and 79 school staff participated in the investigation; SARS-CoV-2 positivity was 9.2%. In the 2 weeks prior to COVID-19 exposure, 24% of participants reported unmasked indoor time at school, 40% attended social gatherings with non-household members, and 71% visited out-of-school indoor locations, including 19% who ate indoors in restaurants. Frequencies of risk behaviors increased by age. Among students, 17% participated in school sports, of whom 86% participated without a mask. SARS-CoV-2 positivity was significantly associated with school sports and unmasked time in sports. Among K-5 students, positivity was associated with exposure to a teacher index case.

CONCLUSIONS

This analysis highlights the high prevalence of risk behaviors in an unvaccinated population exposed to COVID-19 in school and identifies an association between student sports participation and SARS-CoV-2 positivity. These findings illustrate the importance of school-level prevention measures to reduce SARS-CoV-2 transmission, including limiting close-contact indoor sports and promoting consistent mask use in unvaccinated individuals. Future research could explore the role of community vaccination programs as a strategy to reduce COVID-19 transmission and introductions into school settings.

Is Symptom Screening Useful for Identifying COVID-19 Infection in School Settings? Georgia, USA

This study's goal was to characterize the utility of symptom screening in staff and students for COVID-19 identification and control of transmission in a school setting. We conducted a secondary analysis of cross-sectional data for staff, students and associated household members in a Georgia school district exposed to COVID-19 cases who received RT-PCR testing and symptom monitoring. Among positive contacts, 30/49 (61%) of students and 1/6 (17%) of staff reported no symptoms consistent with COVID-19. Symptom sensitivity was 30% in elementary students and 42% in middle/high students. Fifty-three percent (10/19) of symptomatic positive contacts had at least one household member test positive for SARS-CoV-2 compared with 50% (10/20) of asymptomatic positive contacts. The absence of symptoms in children is not indicative of a lack of SARS-CoV-2 infection or reduced risk of infection for associated household members. Testing all close contacts of people with COVID-19 in schools is needed to interrupt transmission networks.

SARS-CoV-2 transmission in a Georgia school district - United States, December 2020-January 2021

BACKGROUND

To inform prevention strategies, we assessed the extent of SARS-CoV-2 transmission and settings in which transmission occurred in a Georgia public school district.

METHODS

During December 1, 2020-January 22, 2021, SARS-CoV-2-infected index cases and their close contacts in schools were identified by school and public health officials. For in-school contacts, we assessed symptoms and offered SARS-CoV-2 RT-PCR testing; performed epidemiologic investigations and whole-genome sequencing to identify in-school transmission; and calculated secondary attack rate (SAR) by school setting (e.g., sports, elementary school classroom), index case role (i.e., staff, student), and index case symptomatic status.

RESULTS

We identified 86 index cases and 1,119 contacts, 688 (63.1%) of whom received testing. Fifty-nine (8.7%) of 679 contacts tested positive; 15 (17.4%) of 86 index cases resulted in ≥2 positive contacts. Among 55 persons testing positive with available symptom data, 31 (56.4%) were asymptomatic. Highest SAR were in indoor, high-contact sports settings (23.8%, 95% confidence interval [CI] 12.7, 33.3), staff meetings/lunches (18.2%, CI 4.5-31.8), and elementary school classrooms (9.5%, CI 6.5-12.5). SAR was higher for staff (13.1%, CI 9.0-17.2) versus student index cases (5.8%, CI 3.6-8.0) and for symptomatic (10.9%, CI 8.1-13.9) versus asymptomatic index cases (3.0%, CI 1.0-5.5).

CONCLUSIONS

Indoor sports may pose a risk to the safe operation of in-person learning. Preventing infection in staff members, through measures that include COVID-19 vaccination, is critical to reducing in-school transmission. Because many positive contacts were asymptomatic, contact tracing should be paired with testing, regardless of symptoms.

Correlates of HIV-related risk behaviors among self-identified heterosexual men who have sex with men (HMSM): national survey of family growth (2002, 2006-2010, and 2011-2017)

Self-identified heterosexual men who have sex with men (HMSM) have unique sexual behaviors that may increase their risk of HIV infection. We assessed the correlates of recent sex with other men and HIV-related risk behaviors among HMSM by sex of their sex partners. We analyzed data from the 2002 and 2006-2017 National Survey of Family Growth limited to men who self-identified as heterosexual and reported any anal/oral sex with another man (N = 787). Prevalence ratios based on logistic regression models determined the association between sociodemographic and behavior variables with reporting a same-sex partner or at least one HIV-related risk behavior with a female sex partner in the last 12 months. Approximately 17.7% and 42.5% of HMSM with recent same-sex partners reported HIV-related risk behaviors with male and female sex partners, respectively. HMSM who reported a recent same-sex partner and an HIV-related risk behavior reported more annual male (Ave = 2.6:95%CI;1.6-3.7) and female (Ave = 5.0:95%CI;3.3-6.8) sex partners than HMSM with a recent same-sex partner who did not report an HIV-related risk behavior [male (Ave = 1.7:95%CI;1.2-2.1) and female (Ave = 1.6:95%CI;1.1-2.1)]. HMSM with recent same-sex partners may engage in HIV-related risk behaviors with men and women concurrently. Further studies should assess gender-specific risk of infection.

Evaluation of the performance of the Cepheid Xpert HIV-1 Viral Load Assay for quantitative and diagnostic uses

BACKGROUND

Cepheid's Xpert HIV-1 Viral Load (Xpert VL), a simplified, automated, single-use quantitative assay used with the GeneXpert System, is not FDA approved.

OBJECTIVES

Using stored plasma, we conducted a study to assess the ability of Xpert VL to quantify viral load relative to the Roche COBAS AmpliPrep/COBAS TaqMan HIV-1 (Cobas VL) and to examine the use of the Xpert VL as a qualitative diagnostic test.

STUDY DESIGN

Following HIV-1 viral stock dilutions, we conducted a probit analysis to identify the concentration where 95 % of specimens had quantified VLs. We also examined Xpert and Cobas log VL correlation in linearity panels; compared the proportion of 220 seroconverter specimens with virus detected using McNemar's test; and tested specimens from persons with untreated, established HIV-1 infection (n=149) and uninfected persons (n=497). Furthermore, we examined Xpert VL as a qualitative test in seroconverter specimens with early (n=20) and later (n=68) acute infections.

RESULTS

At 1.80 log10 copies/mL, 95 % of specimens had quantifiable virus using Xpert VL. Xpert and Cobas VLs were highly correlated (R2=0.994). The proportion of seroconverter specimens with virus detected using Cobas and with Xpert VL was not statistically different (p=0.0578). Xpert VL detected 97.9 % of established infections, and specificity was 99.80 % (95 % CI 98.87%-99.99%). Xpert VL detected 90 % and 98.5 % of early and later acute infections, respectively.

CONCLUSIONS

If approved, Xpert VL could allow U.S. laboratories that cannot bring on large, complex testing platforms to conduct HIV monitoring. An approval for diagnostic use may provide timely identification of HIV infections.

Prevalence and correlates of condom use among sexually active men who have sex with men in the United States: findings from the National Survey of Family Growth, 2002, 2006-10 and 2011-13

BACKGROUND

Men who have sex with men (MSM) are disproportionately at risk of contracting HIV and other sexually transmissible infections (STIs). Correct and consistent condom use is the most effective method to prevent HIV and other STIs among sexually active MSM.

METHODS

Using data from the 2002, 2006-10, 2011-13 cycles of the National Survey of Family Growth (NSFG), the overall prevalence of condom use at last sex and by sexual risk behaviours (sex with ≥2 same-sex partners, sex with ≥2 opposite sex partners, sex with a person who injects drugs, sex with an HIV-positive person and exchanged sex for money or drugs) among sexually active MSM (reported oral or anal sex with a male in the preceding 12 months) was estimated. The association between condom use at last sex and demographic and sexual behaviour variables was also evaluated.

RESULTS

Approximately 31% of all respondents (n=618; weighted n=1596702) reported condom use at last sex. Among MSM who reported ≥1 sexual risk behaviour in the past year, prevalence of condom use at last sex ranged from 30 to 38%. After adjusting for covariates, Hispanic MSM [adjusted prevalence ratio (APR)=1.81, 95%CI=1.27-2.58] were more likely than White MSM to report condom use at last sex; MSM with a recently diagnosed STI (APR=1.71, 95%CI=1.04-2.80) were more likely than MSM without a recently diagnosed STI to report condom use at last sex; and married or cohabitating MSM (APR=0.29, 95%CI=0.13-0.66) were less likely than unmarried and not cohabitating MSM to report condom use at last sex. There was no difference in temporal trends in condom use at last sex across the three NSFG cycles [2002 (33.8%); 2006-10 (25.6%); 2011-13 (40.6%), P=0.926].

CONCLUSIONS

This study data suggest that prevalence of condom use among MSM is low, even among MSM who report sexual risk behaviours. The continued promotion of consistent condom use as an effective primary HIV/STI risk-reduction strategy is important because it mitigates HIV and STI risk and also complements the effectiveness of newer HIV prevention approaches such as pre-exposure prophylaxis.

A cross-sectional examination of US gun ownership and support for gun control measures: Sociodemographic, geographic, and political associations explored

Public opinion regarding gun ownership and control coincide with deep political and sociodemographic divisions in the US population. The study objective was to analyze the prevalence and predictors of gun ownership and support for gun control policy using a national representative sample of US adults. Nationally representative data from the General Social Survey (2010 to 2016) were used to examine sociodemographic, geographic, and attitudinal differences in gun ownership and views towards laws requiring police permits before gun purchases (N = 6184). Prevalence ratios and 95% CIs were calculated using logistic regression models. Among US adults, 22.1% reported owning a gun (n = 1358) and 72.5% favored presale gun permit laws (n = 4445). Adults who were aged 65+, male, non-Hispanic white, and politically conservative; earned $35,000+ annually; and did not reside in the Northeast region of the US were significantly more likely to own guns (p < 0.05). Adults who were aged 65+, female, non-Hispanic blacks/other or Hispanics, college graduates, politically liberal, and resided in the Northeast were significantly more likely to favor presale gun permit laws than their counterparts (p < 0.05). Gun safety and prevention efforts must address political and sociodemographic divisions that have stymied the passage of meaningful legislation.

Men Who Have Sex with Men (MSM) Who Have Not Previously Tested for HIV: Results from the MSM Testing Initiative, United States (2012-2015)

The Centers for Disease Control and Prevention recommends annual HIV tests for men who have sex with men (MSM), yet some have never tested. We analyzed data from the MSM Testing Initiative. Of 68,185 HIV tests, 8% were with MSM who never previously tested ("first-time testers"). Among tests with first-time testers, 70.7% were with MSM from racial or ethnic minorities; 66.5% were with MSM younger than 30 years. Tests with MSM who reported female partners only during the past year (compared to male partners only) or were recruited for at-home testing (compared to venue-based recruitment) were 4 times (prevalence ratio [PR] 3.62, 95% CI 3.15-4.15) and 5 times as likely (PR 4.69, 95% CI 4.22-5.21) to be associated with first-time testing. At-home testing and focusing on MSM who have sex with women may be effective methods for reaching MSM who are first-time testers.

HIV Testing Among Foreign-Born Men and Women in the United States: Results from a Nationally Representative Cross-Sectional Survey

HIV disproportionately affects the foreign-born population in the United States. This analysis describes the prevalence of ever-testing for HIV among foreign-born individuals residing in the United States. Data from a national health survey of the civilian, non-institutionalized population was used to describe prevalence of ever-testing for HIV among foreign-born individuals by birth place. Multivariate logistic-regression procedures were used to determine factors associated with ever-testing for HIV among foreign-born men and women. The prevalence of ever-testing for HIV among foreign-born individuals varied by region of birth ranging from 31 to 67%. Factors related to ever-testing for HIV varied by gender. Efforts need to continue in order to improve HIV testing rates among Asian foreign-born individuals, lower educated foreign-born and foreign-born gay/bisexual men. Health care providers can play an important role by counseling new arrivals regarding the importance of testing for HIV and practicing HIV risk reduction activities.

Interval Since Last HIV Test for Men and Women with Recent Risk for HIV Infection - United States, 2006-2016

Since 2006, CDC has recommended routine screening of all persons aged 13-64 years for human immunodeficiency virus (HIV) and at least annual rescreening of persons at higher risk (1). However, national surveillance data indicate that many persons at higher risk for HIV infection are not screened annually, and delays in diagnosis persist (2). CDC analyzed 2006-2016 data from the General Social Survey (GSS)* and estimated that only 39.6% of noninstitutionalized U.S. adults had ever tested for HIV. Among persons ever tested, the estimated median interval since last test was 1,080 days or almost 3 years. Only 62.2% of persons who reported HIV-related risk behaviors in the past 12 months were ever tested for HIV, and the median interval since last test in this group was 512 days (1.4 years). The percentage of persons ever tested and the interval since last test remained largely unchanged during 2006-2016. More frequent screening of persons with ongoing HIV risk is needed to achieve full implementation of CDC's screening recommendations and to prevent new infections. Integration of routine screening as standard clinical practice through existing strategies, such as electronic medical record prompts (3), or through new, innovative strategies might be needed to increase repeat screening of persons with ongoing risk.

Too old to test? Prevalence and correlates of HIV testing among sexually active older adults

Older adults account for 17% of new HIV diagnoses in the US and are more likely to be diagnosed with HIV later in the course of the disease compared to younger people. We calculated the prevalence and associated factors of having ever been tested for HIV among sexually active older adults. We analyzed data from the 2008-2016 General Social Survey Limited to respondents ≥65 years of age who reported more than one sex partner(s) in past 12 months (n = 757). HIV testing prevalence, prevalence ratios, and 95% confidence intervals were calculated by demographic variables and HIV-related risk behaviors. An estimated 16.3% of sexually active older adults have tested for HIV, and 15.9% were at increased risk for HIV infection (reported injection drug and/or crack-cocaine use, exchanging money for sex, more than three sex partners in the past year, or men who reported having sex with another man). In the adjusted model, adults aged 65-70, not married, self-identified as gay/bisexual, and at increased risk for HIV infection were more likely to have tested for HIV. An estimated 83.7% of sexually active older adults never tested for HIV. Strategies are needed to increase HIV awareness and testing among potentially high-risk older adults.

How well are U.S. primary care providers assessing whether their male patients have male sex partners?

Identifying patients at-risk for HIV infection, such as men who have sex with men (MSM), is an important step in providing HIV testing and prevention interventions. It is unknown how primary care providers (PCPs) assess MSM status and related HIV-risk factors. We analyzed data from a panel-derived web-based survey for healthcare providers conducted in 2014 to describe how PCPs in the U.S. determined their patients' MSM status. We calculated adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) to describe PCP characteristics associated with systematically determining MSM status (i.e., PCP used "a patient-completed questionnaire" or "routine verbal review of sex history"). Among the 1008 PCPs, 56% determined MSM status by routine verbal review of sexual history; 41% by patient disclosure; 39% by questions driven by symptoms/history; 23% by using a patient-completed questionnaire, and 9% didn't determine MSM status. PCPs who systematically determined MSM status (n=665; 66%) were more likely to be female (aPR=1.16, CI=1.06-1.26), to be affiliated with a teaching hospital (aPR=1.15, CI=1.06-1.25), to routinely screen all patients aged 13-64 for HIV (aPR=1.29, CI=1.18-1.41), and to estimate that 6% or more of their male patients are MSM (aPR=1.14, CI=1.01-1.30). The majority of PCPs assessed MSM status and HIV risk factors through routine verbal reviews of sexual history. Implementing a systematic approach to identify MSM status and assess risk may allow PCPs to identify more patients needing frequent HIV testing and other preventive services, while mitigating socio-cultural barriers to obtaining such information.

Sexual Risk and Protective Behaviors Among Reproductive-Aged Women in the United States

BACKGROUND

In 2014, women represented 19% of HIV diagnoses in the United States. Of these, 78% were among black women and Latinas. Sexual risk behaviors-for example concurrent sex partnerships, nonmonogamous sex partners, and inconsistent condom use-are associated with increased HIV transmission and prevalence; these behaviors have been understudied, collectively, in women.

METHODS

To examine HIV-related sexual risk behaviors among sexually active women aged 18-44 years by race/ethnicity and over time, we used data from the 2006-2008, 2008-2010, and 2011-2013 cycles of the National Survey of Family Growth. We estimated weighted percentages and performed logistic regression to measure adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) for associations between selected behaviors and sociodemographic covariates.

RESULTS

Among 13,588 women, 1.1% reported concurrent sex partnerships, 10.3% reported male partners whom they perceived were nonmonogamous, and 21.1% reported using a condom at either last vaginal or anal sex. Black women (aPR = 1.52; CI = 1.36-1.71) and Latinas (aPR = 1.29; CI = 1.14-1.47) were more likely to report condom use at either last vaginal or anal sex compared with white women. However, black women were also more likely to report concurrent opposite-sex partnerships (aPR = 2.44; CI = 1.57-3.78) and perceived nonmonogamous sex partners (aPR = 1.33; CI = 1.14-1.56) compared with white women.

CONCLUSIONS

Improved HIV behavioral risk-reduction strategies are needed for women. Black women could benefit from interventions that address partnership concurrency. For black women and Latinas, who are more likely to use condoms, further examination of broader social and structural factors as contributors to racial/ethnic gaps are warranted and vital for understanding and decreasing HIV-related disparities.

Correlates of Never Testing for HIV Among Non-Hispanic Black Men in the United States: National Survey of Family Growth, 2011-2013

Currently, the Centers for Disease Control and Prevention recommends that persons between 15 and 64 years get tested for human immunodeficiency virus (HIV) at least once in their lifetime and persons with HIV risk factors get tested more frequently. There is limited research examining factors associated with never testing for HIV among non-Hispanic Black men in the United States. The purpose of this study was to examine the prevalence of never testing for HIV, reasons for never testing for HIV, and correlates of never testing for HIV. We analyzed 2011-2013 National Survey of Family Growth data and restricted analyses to male respondents aged 15-44 years who self-identified as being non-Hispanic Black. Logistic regression models estimated adjusted prevalence ratios (APR) assessing the association between socio-demographic and behavioral factors and never testing for HIV. An estimated 31.2 % of non-Hispanic Black males aged 15-44 years have never been tested for HIV. Non-Hispanic Black men aged 15-17 years (APR 4.45; 95 % CI 2.88-6.87) or 18-24 years (APR 1.94; 95 % CI 1.21-3.13), who did not visit a doctor or healthcare provider (APR 1.43; 95 % CI 1.10-1.86), or did not report any sexual risk behaviors in the past 12 months (APR 1.83; 95 % CI 1.34-2.51) were more likely to never test for HIV compared to their respective counterparts. Continued expansion of HIV testing initiatives and prevention programs that focus on non-Hispanic Black men is critical to addressing HIV-related health disparities and the public health burden of HIV in this population.

Association between parent-adolescent communication about sex-related topics and HIV testing, United States. 2006-2013

Adolescents need information about sex-related topics in order to reduce risk behavior and engage in healthy sexual decision-making. Parents have the potential to be an important source of this information. Using the 2006-2010 and 2011-2013 National Survey of Family Growth, we examined associations between parent-adolescent communication before age 18 about sex-related topics and HIV testing among respondents aged 18-24 that ever had sexual intercourse (women = 3893; men = 3359). Analyses showed that for both men and women, discussing how to prevent HIV/AIDS and how to use a condom with a parent before age 18 were positively associated with HIV testing. Among women only, discussions about methods of birth control, where to get birth control, and STDs were positively associated with HIV testing. Developing strategies and interventions to facilitate parent-adolescent communication about sex-related topics, particularly HIV prevention and condom use, may be important to increase HIV testing among young women and men.

Young Sexual Minority Males in the United States: Sociodemographic Characteristics And Sexual Attraction, Identity and Behavior

CONTEXT

HIV incidence is increasing among 13-24-year-old U.S. men who have sex with men, yet limited research is available to guide HIV prevention efforts for this population.

METHODS

National Survey of Family Growth data collected in 2002, in 2006-2010 and in 2011-2013 from 8,068 males aged 15-24 were analyzed to describe the population of U.S. young sexual minority males (i.e., males reporting same-sex attraction, identity or behavior). Correlates of sexual minority classification were assessed in logistic regression models.

RESULTS

An estimated 10% of young males, representing a population of 2.1 million, were sexual minorities. Males had an elevated likelihood of being sexual minorities if they were aged 18-19 or 20-24, rather than 15-17 (prevalence ratio, 1.7 for each); belonged to nonblack, non-Hispanic racial or ethnic minority groups (1.6); had no religious affiliation, rather than considering religion very important (1.9); or lived below the federal poverty level (1.3). They had a reduced likelihood of being sexual minorities if they lived in metropolitan areas outside of central cities (0.7). Among young sexual minority males, 44% were 15-19 years old, 29% were poor and 59% resided outside central cities. Forty-seven percent had engaged in same-sex behavior. Of those with data on all measured dimensions of sexuality, 24% reported same-sex attraction, identity and behavior; 22% considered themselves heterosexual, yet had had a male sex partner.

CONCLUSION

Future investigations can further explore subpopulations of young sexual minority males and assess sexual trajectories, resilience and HIV risk.

Factors Associated with Time Since Last HIV Test Among Persons at High Risk for HIV Infection, National Survey of Family Growth, 2006-2010

The Centers for Disease Control and Prevention (CDC) recommends annual HIV screening for persons at high risk for HIV infection. We assessed the testing history and factors associated with recent testing (tested in the last 12 months) among persons at high risk for HIV infection. We analyzed 2006-2010 National Survey of Family Growth data and classified respondents aged 15-44 who reported a sexual or drug-use risk behavior in the past year as 'high-risk'. Logistic regression models estimated prevalence ratios assessing the association between demographic and health-related factors and having been recently tested for HIV compared with never been tested. Among high-risk men, 29.3% had recently tested for HIV, 30.7% tested more than 12 months ago, and 40.0% had never been tested. Among high-risk women, 38.0% had recently tested, 36.9% tested more than 12 months ago, and 26.1% had never been tested. Compared with men who were aged 15-19, white, heterosexual, and had not recently visited a doctor, men who were aged 40-44, black/African American, homosexual/gay or bisexual, and had visited a doctor in the past year were more likely to have recently tested. Compared with women who were white, had not recently visited a doctor, and had never been pregnant, women more likely to have recently tested were black/African American, had visited a doctor in the past year, and had been pregnant. Approximately two-thirds of high-risk men and women had not been recently tested for HIV. CDC recommendations for annual screening are not being implemented for the majority of persons at risk.

Estimating the Number of Heterosexual Persons in the United States to Calculate National Rates of HIV Infection

Background

This study estimated the proportions and numbers of heterosexuals in the United States (U.S.) to calculate rates of heterosexually acquired human immunodeficiency virus (HIV) infection. Quantifying the burden of disease can inform effective prevention planning and resource allocation.

Methods

Heterosexuals were defined as males and females who ever had sex with an opposite-sex partner and excluded those with other HIV risks: persons who ever injected drugs and males who ever had sex with another man. We conducted meta-analysis using data from 3 national probability surveys that measured lifetime (ever) sexual activity and injection drug use among persons aged 15 years and older to estimate the proportion of heterosexuals in the United States population. We then applied the proportion of heterosexual persons to census data to produce population size estimates. National HIV infection rates among heterosexuals were calculated using surveillance data (cases attributable to heterosexual contact) in the numerators and the heterosexual population size estimates in the denominators.

Results

Adult and adolescent heterosexuals comprised an estimated 86.7% (95% confidence interval: 84.1%-89.3%) of the U.S. population. The estimate for males was 84.1% (CI: 81.2%-86.9%) and for females was 89.4% (95% CI: 86.9%-91.8%). The HIV diagnosis rate for 2013 was 5.2 per 100,000 heterosexuals and the rate of persons living with diagnosed HIV infection in 2012was 104 per 100,000 heterosexuals aged 13 years or older. Rates of HIV infection were >20 times as high among black heterosexuals compared to white heterosexuals, indicating considerable disparity. Rates among heterosexual men demonstrated higher disparities than overall population rates for men.

Conclusions

The best available data must be used to guide decision-making for HIV prevention. HIV rates among heterosexuals in the U.S. are important additions to cost effectiveness and other data used to make critical decisions about resources for prevention of HIV infection.

Rapid HIV testing at gay pride events to reach previously untested MSM: U.S., 2009-2010

We offered rapid HIV testing at social events frequented by young men who have sex with men (MSM), a group disproportionately affected by the HIV epidemic. We tested 1,312 MSM; of those MSM, 1,072 (81.7%) reported HIV testing history. Of those reporting HIV testing history, 550 (51.3%) were non-Hispanic black and 404 (37.7%) were aged <25 years. One hundred twenty-eight (11.9%) had never tested for HIV; 77 (7.2%) were preliminarily positive, with 15 (19.5%) being first-time testers. Factors associated with no previous HIV test included young age (13-24 years) (adjusted odds ratio [AOR] = 3.5, 95% confidence interval [CI] 1.9, 6.5) and non-Hispanic black (AOR=3.2, 95% CI 1.6, 6.4) or Hispanic (AOR=2.8, 95% CI 1.2, 6.3) race/ethnicity. HIV testing at Gay Pride events reaches young, previously untested MSM. This venue-based HIV testing approach at nonclinical sociocultural events is an additional strategy for HIV prevention goals to increase the number of people aware of their HIV infection with subsequent linkage to HIV care.

Racial and ethnic disparities in future testing intentions for HIV: United States, 2007-2010: results from the National Health Interview Survey

This study examined racial/ethnic differences in rationale for intending to test for HIV. Data were analyzed from 98,971 adults from the 2007-2010 National Health Interview Survey. An estimated 38.5 % of respondents previously tested for HIV. Testing as part of a medical checkup or procedure was the most common reason for being tested among studied racial/ethnic groups. Non-Hispanic whites (80.7 %) and non-Hispanic Asians (71.2 %) had higher proportions (p < 0.001) of respondents that have not been tested for HIV due to believing they were unlikely exposed. Non-Hispanic blacks (ARR: 2.55; 95 % CI 2.39-2.72) and Hispanics (ARR: 1.81; 95 % CI 1.68-1.95) who ever tested for HIV were significantly more likely to report positive future testing intentions compared to non-Hispanic whites. Additional efforts to increase the availability of HIV tests by making HIV testing a routine part of medical care and increasing knowledge of HIV transmission, risk-perception, and treatment may reduce racial/ethnic disparities in HIV testing.

A multisite study of the prevalence of HIV with rapid testing in mental health settings

OBJECTIVES

We estimated HIV prevalence and risk factors among persons receiving mental health treatment in Philadelphia, Pennsylvania, and Baltimore, Maryland, January 2009 to August 2011.

METHODS

We used a multisite, cross-sectional design stratified by clinical setting. We tested 1061 individuals for HIV in university-based inpatient psychiatric units (n = 287), intensive case-management programs (n = 273), and community mental health centers (n = 501).

RESULTS

Fifty-one individuals (4.8%) were HIV-infected. Confirmed positive HIV tests were 5.9% (95% confidence interval [CI] = 3.7%, 9.4%) for inpatient units, 5.1% (95% CI = 3.1%, 8.5%) for intensive case-management programs, and 4.0% (95% CI = 2.6%, 6.1%) for community mental health centers. Characteristics associated with HIV included Black race, homosexual or bisexual identity, and HCV infection.

CONCLUSIONS

HIV prevalence for individuals receiving mental health services was about 4 times as high as in the general population. We found a positive association between psychiatric symptom severity and HIV infection, indicating that engaging persons with mental illness in appropriate mental health treatment may be important to HIV prevention. These findings reinforce recommendations for routine HIV testing in all clinical settings to ensure that HIV-infected persons receiving mental health services are identified and referred to timely infectious disease care.

Association between birthplace and current asthma: the role of environment and acculturation

OBJECTIVES

We evaluated associations between current asthma and birthplace among major racial/ethnic groups in the United States.

METHODS

We used multivariate logistic regression methods to analyze data on 102,524 children and adolescents and 255,156 adults in the National Health Interview Survey (2001-2009).

RESULTS

We found significantly higher prevalence (P < .05) of current asthma among children and adolescents (9.3% vs 5.1%) and adults (7.6% vs 4.7%) born in the 50 states and Washington, DC (US-born), than among those born elsewhere. These differences were among all age groups of non-Hispanic Whites, non-Hispanic Blacks, and Hispanics (excluding Puerto Ricans) and among Chinese adults. Non-US-born adults with 10 or more years of residency in the United States had higher odds of current asthma (odds ratio = 1.55; 95% confidence interval = 1.25, 1.93) than did those who arrived more recently. Findings suggested a similar trend among non-US-born children.

CONCLUSIONS

Current asthma status was positively associated with being born in the United States and with duration of residency in the United States. Among other contributing factors, changes in environment and acculturation may explain some of the differences in asthma prevalence.

Racial and ethnic disparities in current asthma and emergency department visits: findings from the National Health Interview Survey, 2001-2010

OBJECTIVES

Racial/ethnic disparities in current asthma prevalence and medical care are a major public health concern. We examined the differences in asthma prevalence and morbidity among major racial/ethnic populations in the US.

METHODS

We analyzed data from the 2001-2010 National Health Interview Survey for adults (≥18 years) and children and adolescents (<18 years). Outcome variables were current asthma prevalence, at least one attack in the past 12 months, and at least one asthma-related emergency department/urgent care center (ED/UCC) visit in the past 12 months. We used multivariate logistic regression to calculate the model-adjusted prevalence and risk ratios (ARR).

RESULTS

In our study, 9.0% of the children and 7.2% of the adults had current asthma. Non-Hispanic black and Puerto Rican children were more likely to have current asthma (ARR 1.46, 1.66, respectively) and to visit the ED/UCC (ARR 1.61, 1.67, respectively) than non-Hispanic whites. American Indian/Alaskan Native children were more likely to have current asthma (ARR 1.76) than non-Hispanic whites. Mexican/Mexican American children and adults had lower prevalence of current asthma but higher ED/UCC use (adults only) than non-Hispanic whites. Among adults, Puerto Ricans and American Indian/Alaskan Natives were more likely to have current asthma (ARR 1.60, 1.39, respectively) than non-Hispanic whites, and all the studied racial/ethnic groups except Asians were more likely to have visited the ED/UCC than non-Hispanic whites. Adults and children who received emergency care for asthma in the past 12 months more frequently received multiple components of asthma management and control (e.g., taking long-term medication, having an asthma management plan) compared to those without emergency care.

CONCLUSIONS

Racial/ethnic differences in current asthma prevalence, asthma attacks, and increased utilization of emergency room visits for asthma among minorities persist among children and adults. Appropriate and effective asthma management and education may lead to better asthma control and reduce emergency care utilization.

Asthma prevalence among US elderly by age groups: age still matters

OBJECTIVE

For over three decades, the greatest burden of asthma deaths has occurred among persons aged 65 years and older. This study analyzed the association between increasing age and asthma prevalence among age groups within the US elderly population.

METHODS

We analyzed aggregated data on 54,485 civilian, noninstitutionalized US adults aged 65 years and older from the 2001-2010 National Health Interview Survey (NHIS). We estimated the prevalence of current asthma, lifetime asthma, and chronic obstructive pulmonary disease (COPD) among US elderly by 5-year age groups and age stages ("young elderly" aged 65-84 years and "oldest old" aged ≥85 years). We calculated adjusted odds ratios (AOR) and 95% confidence intervals (CI) to identify asthma prevalence patterns among elderly populations.

RESULTS

From 2001 to 2010, the estimated average annual prevalence of current asthma among US elderly was 7.0%. Estimates of lifetime asthma, COPD, and co-occurring current asthma and COPD were 9.9%, 9.7%, and 3.0%, respectively. Prevalence of asthma decreased with advancing age while prevalence of COPD increased with advancing age. When controlling for study variables and significant interactions (p = .05) with COPD, the odds of reporting current asthma decreased with advancing age: 0.87 (95% CI, 0.76-1.01) for 70- to 74-year-olds; 0.76 (95% CI, 0.66-0.87) for 75- to 79-year-olds; 0.62 (95% CI, 0.51-0.75) for 80- to 84-year-olds; and 0.45 (95% CI, 0.36-0.55) for ≥85-year-olds, as compared to 65- to 69-year-olds.

CONCLUSIONS

Asthma continues to affect a substantial proportion of the US elderly population. Increased diagnosis of COPD may overshadow correct diagnosis and treatment in populations with advancing age. Treatment guidelines should focus on preventable risk behaviors to increase the quality of life within this population.

Partner Referral by HIV-Infected Persons to Partner Counseling and Referral Services (PCRS) - Results from a Demonstration Project

Objective:

The objectives of this article are to determine factors associated with refusal and agreement to provide partner information, and evaluate the effectiveness of referral approaches in offering PCRS.

Methods:

Index clients from 5 sites that used 3 different PCRS approaches were interviewed to obtain demographic and risk characteristics and choice of partner referral method for PCRS. Logistic regression was used to assess factors associated with providing partner information.

Results:

The percentage of index clients who refused to provide partner information varied by site (7% to 88%). Controlling for PCRS approach, index clients who were older than 25 years, male, or reported having male-male sex in the past 12 months were more likely (p <0.01) to refuse to provide partner information. Overall, 72% of named partners referred by index clients were located and offered PCRS. The proportion of partners who were located and offered PCRS differed by referral approach used, ranging from 38% using contract referral (index clients agree to notify their partners within a certain timeframe, else a disease intervention specialist or health care provider will notify them) to 98% using dual referral (index clients notify their partners with a disease intervention specialist or provider present).

Conclusion:

Success in obtaining partner information varied by the PCRS approach used and effectiveness in locating and notifying partners varied by the referral approach selected. These results provide valuable insights for enhancing partner services.

Complementary and alternative medicine (CAM) use among children with current asthma

OBJECTIVE

To estimate the prevalence of complementary and alternative medicine (CAM) use among children with current asthma.

DESIGN

We analyzed data from the Asthma Call Back Survey (ACBS) 2006-2008. ACBS is a follow-up to the state-based Behavioral Risk Factor Surveillance System (BRFSS) survey that collects information on asthma and related factors including CAM use for asthma. The survey is administered to the parents who report in a subset of BRFSS states that their children have asthma. 5435 children had current asthma and were included in this analysis.

RESULTS

Overall, 26.7% (95% confidence interval [CI]=24.5-29.0) of children with current asthma reported CAM use in the previous 12 months. Among them, the three most commonly used therapies were breathing techniques (58.5%; 95% CI=53.6-63.5), vitamins (27.3%; 95% CI=23.0-31.5), and herbal products (12.8%; 95% CI=9.2-16.4). Multivariate analysis of CAM use revealed higher adjusted odds ratios (aOR) among children who experienced cost barriers to conventional health care compared with children with no cost barrier (aOR=1.8; 95% CI=1.2-2.8). Children with poorly controlled asthma were most likely to use all types of CAM when compared to their counterpart with well-controlled asthma: aOR=2.3 (95% CI=1.6-3.3) for any CAM; aOR=1.7 (95% CI=1.2-2.6) for self-care based CAM; and aOR=4.4 (95% CI=1.6-9.3) for practitioner-based CAM.

CONCLUSIONS

Children with poorly controlled asthma are more likely to use CAM; this likelihood persists after controlling for other factors (including parent's education, barriers to conventional health care, and controller medication use). CAM is also more commonly used by children who experienced cost barriers to conventional asthma care. CAM use could be a marker to identify patients who need patient/family education and support thus facilitate improved asthma control.

The role of income in reducing racial and ethnic disparities in emergency room and urgent care center visits for asthma-United States, 2001-2009

OBJECTIVE

To examine racial/ethnic disparities and associated factors in asthma-related emergency room (ER) and urgent care center (UCC) visits among US adults and determine whether disparities vary across increasing income strata.

METHODS

We analyzed data from 238,678 adult respondents from the 2001 to 2009 National Health Interview Survey and calculated the weighted annual prevalence of an ER/UCC visit for persons with current asthma. We used logistic regression to calculate adjusted odds ratios (AORs) for asthma-related ER/UCC visits by race/ethnicity and income, adjusting for demographics, socioeconomic, and other health-related factors.

RESULTS

The average annual prevalence of asthma-related ER/UCC visits among adults with current asthma was highest for Puerto Ricans (24.8%, 95% confidence interval [CI]: 20.3-29.9) followed by non-Hispanic American Indian/Alaskan Natives (22.1%, 95% CI: 14.4-32.4), non-Hispanic blacks (20.4%, 95% CI: 18.5-22.4), other Hispanics (17.3%, 95% CI: 15.0-19.9), Asians (11.0%, 95% CI: 7.8-15.4), and non-Hispanic whites (10.1%, 95% CI: 9.4-10.9). Puerto Ricans (AOR: 2.01; 95% CI: 1.54-2.62), non-Hispanic blacks (AOR: 1.72; 95% CI: 1.46-2.03), and other Hispanics (AOR: 1.55; 95% CI: 1.25-1.92) with current asthma had significantly higher odds of an asthma-related ER/UCC visit than non-Hispanic whites. Lower socioeconomic status, obesity, and serious psychological distress were also associated with higher odds of asthma-related ER/UCC visits. Puerto Ricans with the lowest income (AOR: 3.52; 95% CI: 2.27-5.47), non-Hispanic American Indian/Alaskan Natives with the highest income (AOR: 5.71; 95% CI: 1.48-22.13), and non-Hispanic blacks in every income stratum had significantly higher odds of asthma-related ER/UCC visits compared to non-Hispanic whites in the highest income stratum.

CONCLUSIONS

Racial/ethnic disparities in asthma-related ER/UCC visits persist after accounting for income and other socioeconomic factors. Further research is needed to identify modifiable risk factors directly associated to race/ethnicity to decrease the asthma burden on minority populations.

Asthma and serious psychological distress: prevalence and risk factors among US adults, 2001-2007

BACKGROUND

For millions of adults, effective control of asthma requires a regimen of care that may be compromised by psychological factors, such as anxiety and depression. This study estimated the prevalence and risk factors for serious psychological distress (SPD) and explored their relationship to health-related quality of life (HRQOL) among adults with asthma in the United States.

METHODS

We analyzed data from 186,738 adult respondents from the 2001-2007 US National Health Interview Survey. We calculated weighted average prevalence estimates of current asthma and SPD by demographic characteristics and health-related factors. We used logistic regression analysis to calculate odds ratios for factors that may have predicted asthma, SPD, and HRQOL.

RESULTS

From 2001 to 2007, the average annual prevalence of current asthma was 7.0% and the average prevalence of SPD was 3.0%. Among adults with asthma, the prevalence of SPD was 7.5% (95% CI, 7.0%-8.1%). A negative association between HRQOL and SPD was found for all adults, independent of asthma status. A similar pattern of risk factors predicted SPD and the co-occurrence of SPD and asthma, although adults with asthma who reported lower socioeconomic status, a history of smoking or alcohol use, and more comorbid chronic conditions had significantly higher odds of SPD.

CONCLUSION

This research suggests the importance of mental health screening for persons with asthma and the need for clinical and community-based interventions to target modifiable lifestyle factors that contribute to psychological distress and make asthma worse.