Janet M. Blair

Trends in AIDS incidence and survival among racial/ethnic minority men who have sex with men, United States, 1990-1999.

Objectives: We describe trends in AIDS incidence, survival, and deaths among racial/ethnic minority men who have sex with men (MSM). Methods: We examined AIDS surveillance data for men diagnosed with AIDS from 1990 through 1999, survival trends from 1993 through 1997, and trends in AIDS incidence and deaths from 1996 to 1999, when highly active antiretroviral therapy (HAART) was introduced. Results: The percentage of racial/ethnic minority MSM with AIDS increased from 33% of 26.930 men in 1990 to 54% of 17,162 men in 1999. From 1996 through 1998, declines in AIDS incidence were smallest among black MSM (25%, from 66.2 to 49.5 per 100,000) and Hispanic MSM (29%, from 39.3 to 27.8), compared with white MSM (41%, from 17.9 to 10.5). Declines in deaths of MSM with AIDS were also smallest among black MSM (53%, from 39.7 to 18.6 deaths per 100.000) and Hispanic MSM (61%, 21.6 to 8.4), compared with white MSM (63%, 12.3 to 4.5). Survival improved each year for all racial/ethnic groups but was poorest for black MSM in all years. Conclusions: Since the introduction of HAART, a combination of factors that include relatively higher infection rates in more recent years and differences in survival following AIDS diagnosis contribute to observed differences in trends in AIDS incidence and deaths among racial/ethnic minority MSM. Increased development of culturally sensitive HIV prevention services, and improved access to testing and care early in the course of disease are needed to further reduce HIV‐related morbidity in racial/ethnic minority MSM.

Trends in pregnancy rates among women with human immunodeficiency virus

OBJECTIVE: To describe factors associated with pregnancy and trends in pregnancy rates among women with human immunodeficiency virus (HIV) before and after the release of U.S. Public Health Service Guidelines for the Use of Zidovudine and the Increased Availability of Highly Active Antiretroviral Therapy. METHODS: Human immunodeficiency virus (HIV)–infected women aged 15 to 44 years who were enrolled in the Adult/Adolescent Spectrum of HIV Disease Project, a medical records cohort study of HIV-infected persons conducted in more than 100 U.S. health care facilities. RESULTS: Among 8,857 women, there were 1,185 incident pregnancies during 21,617 person-years of follow-up from 1992 through 2001. Pregnancy rate at enrollment was 16%; thereafter, an average of 5.5% of women became pregnant annually. Pregnancies were more likely to occur in women aged 15 to 24 years (adjusted rate ratio [RR] 9.2; 95% confidence interval [CI] 7.4, 11.3) and 25 to 34 years (adjusted RR 4.0; 95% CI 3.3, 4.9) than in women aged 35 to 44 years. Pregnancies were less likely to occur in women with a history of acquired immunodeficiency syndrome (AIDS)–opportunistic illness (adjusted RR 0.4; 95% CI 0.3, 0.5) or a CD4 count below 200 cells/μL and no opportunistic illness (adjusted RR 0.6; 95% CI 0.5, 0.7) than in women with HIV but not AIDS. Higher rates of pregnancy were observed for women prescribed highly active antiretroviral therapy (adjusted RR 1.3; 95% CI 1.0, 1.6) than women prescribed other regimens of antiretroviral therapy. There were significantly higher rates of pregnancy during 1997 through 2001. CONCLUSION: The increase in pregnancy rates during the era of widespread use of highly active antiretroviral therapy illustrates the continued need for comprehensive prevention and treatment services. LEVEL OF EVIDENCE: II-2

Estimated number of infants born to HIV-infected women in the United States and five dependent areas, 2006.

Objective:Although perinatal HIV infections are declining in the United States, there is no single source of nationally representative data available to estimate the number of infants born to HIV-infected women in the United States and its dependencies. This study determines the total number of births to HIV-positive women in the United States and 5 dependent areas in 2006. Study Design:Diagnosed stage 1 or 2 HIV disease in the United States were based on reported data from 39 areas that conducted confidential name-based HIV case reporting and stage 3 HIV from all areas in the United States. A zero-inflated Poisson model was used to estimate the number of women aged 13-44 years living with diagnosed stage 1 or 2 HIV disease in the United States. The number of undiagnosed HIV-infected women (stage 1 or 2) of childbearing age was estimated from the number of reported Stage 3 HIV (ie, AIDS) cases using a back-calculation method. Results:An estimated 115,200 women aged 13-44 years were living with stage 1 or 2 HIV disease in 2006. A total of 56,200 women were living with diagnosed stage 3 disease. The estimated number of births to all women living with HIV disease (diagnosed or undiagnosed) was 8700 [95% Confidence Interval (CI): 8400 to 8800] in 2006. Conclusions:The number of infants born to HIV-infected women in 2006 was approximately 30% greater than the number of such births (6075-6422) in 2000. This increase highlights the need to continue and strengthen efforts to prevent perinatal HIV transmission in the United States.

Prevalence of cervical cancer screening of HIV-infected women in the United States.

Background:HIV-infected women are at increased risk of cervical cytologic abnormalities. HIV treatment guidelines recommend annual Papanicolaou (Pap) tests for HIV-infected women. We assessed screening prevalence and associated factors among HIV-infected women. Methods:We used data collected during 2000-2004 in an interview study of HIV-infected persons in 18 states. We performed logistic regression to describe factors associated with not having an annual Pap test. Results:Of 2417 women, 556 (23.0%) did not report receiving a Pap test during the past year. Not having a Pap test was associated with increasing age [adjusted odds ratio (AOR) = 1.3 per 10 years, 95% confidence interval (CI): 1.1 to 1.4] and most recent CD4 count of <200 cells per microliter (AOR = 1.6, CI: 1.1 to 2.1) or unknown (AOR = 1.4, CI: 1.1 to 1.7; both vs. CD4 count of ≥200 cells/μL). Odds of a missed Pap test increased for women whose most recent pelvic exam was not performed at their usual source of HIV care (AOR = 2.6, CI: 2.1 to 3.2). Conclusions:Nearly 1 in 4 women did not receive an annual Pap test. HIV care providers should ensure that HIV-infected women receive annual Pap tests, recognizing that missed Pap tests are more likely among older women and women with low CD4 cell counts. Integrating HIV and gynecologic care and educating clinicians about recommendations may increase screening.

The National Violent Death Reporting System: overview and future directions.

Objective To describe the National Violent Death Reporting System (NVDRS). This is a surveillance system for monitoring the occurrence of homicides, suicides, unintentional firearm deaths, deaths of undetermined intent, and deaths from legal intervention (excluding legal executions) in the US. Design This report provides information about the history, scope, data variables, processes, utility, limitations, and future directions of the NVDRS. Results The NVDRS currently operates in 32 states, with the goal of future expansion to all 50 states, the District of Columbia, and US territories. The system uses existing primary data sources (death certificates, coroner/medical examiner reports, and law enforcement reports), and links them together to provide a comprehensive picture of the circumstances surrounding violent deaths. Conclusions This report provides an overview of the NVDRS including a description of the system, discussion of its expanded capability, the use of new technologies as the system has evolved, how the data are being used for violence prevention efforts, and future directions.

Routine HIV Testing among Providers of HIV Care in the United States, 2009

In 2006, CDC recommended HIV screening as part of routine medical care for all persons aged 13–64 years. We examined adherence to the recommendations among a sample of HIV care providers in the US to determine if known providers of HIV care are offering routine HIV testing in outpatient settings. Data were from the CDCs Medical Monitoring Project Provider Survey, administered to physicians, nurse practitioners and physician assistants from June-September 2009. We assessed bivariate associations between testing behaviors and provider and practice characteristics and used multivariate regression to determine factors associated with offering HIV screening to all patients aged 13–64 years. Sixty percent of providers reported offering HIV screening to all patients 13 to 64 years of age. Being a nurse practitioner (aOR = 5.6, 95% CI = 2.6–11.9) compared to physician, age<39 (aOR = 1.9, 95% CI = 1.0–3.5) or 39–49 (aOR = 2.1, 95% CI = 1.4–3.3) compared with ≥50 years, and black race (aOR = 2.6, 95% CI = 1.2–6.0) compared with white race was associated with offering testing to all patients. Providers with low (aOR = 0.2, 95% CI = 0.1–0.3) or medium (aOR = 0.4, 95% CI = 0.2–0.6) HIV-infected patient loads were less likely to offer HIV testing to all patients compared with providers with high patient loads. Many providers of HIV care are still conducting risk-based rather than routine testing. We found that provider profession, age, race, and HIV-infected patient load were associated with offering HIV testing. Health care providers should use patient encounters as an opportunity to offer routine HIV testing to patients as outlined in CDCs revised recommendations for HIV testing in health care settings.

Racial and Ethnic Differences in Homicides of Adult Women and the Role of Intimate Partner Violence — United States, 2003–2014

Homicide is one of the leading causes of death for women aged ≤44 years.* In 2015, homicide caused the death of 3,519 girls and women in the United States. Rates of female homicide vary by race/ethnicity (1), and nearly half of victims are killed by a current or former male intimate partner (2). To inform homicide and intimate partner violence (IPV) prevention efforts, CDC analyzed homicide data from the National Violent Death Reporting System (NVDRS) among 10,018 women aged ≥18 years in 18 states during 2003-2014. The frequency of homicide by race/ethnicity and precipitating circumstances of homicides associated with and without IPV were examined. Non-Hispanic black and American Indian/Alaska Native women experienced the highest rates of homicide (4.4 and 4.3 per 100,000 population, respectively). Over half of all homicides (55.3%) were IPV-related; 11.2% of victims of IPV-related homicide experienced some form of violence in the month preceding their deaths, and argument and jealousy were common precipitating circumstances. Targeted IPV prevention programs for populations at disproportionate risk and enhanced access to intervention services for persons experiencing IPV are needed to reduce homicides among women.

Surveillance for Violent Deaths - National Violent Death Reporting System, 17 States, 2013.

PROBLEM/CONDITION In 2013, more than 57,000 persons died in the United States as a result of violence-related injuries. This report summarizes data from CDCs National Violent Death Reporting System (NVDRS) regarding violent deaths from 17 U.S. states for 2013. Results are reported by sex, age group, race/ethnicity, marital status, location of injury, method of injury, circumstances of injury, and other selected characteristics. REPORTING PERIOD COVERED 2013. DESCRIPTION OF SYSTEM NVDRS collects data from participating states regarding violent deaths obtained from death certificates, coroner/medical examiner reports, law enforcement reports, and secondary sources (e.g., child fatality review team data, supplemental homicide reports, hospital data, and crime laboratory data). This report includes data from 17 states that collected statewide data for 2013 (Alaska, Colorado, Georgia, Kentucky, Maryland, Massachusetts, North Carolina, New Jersey, New Mexico, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Virginia, and Wisconsin). NVDRS collates documents for each death and links deaths that are related (e.g., multiple homicides, a homicide followed by a suicide, or multiple suicides) from a single incident. RESULTS For 2013, a total of 18,765 fatal incidents involving 19,251 deaths were captured by NVDRS in the 17 states included in this report. The majority (66.2%) of deaths were suicides, followed by homicides (23.2%), deaths of undetermined intent (8.8%), deaths involving legal intervention (1.2%) (i.e., deaths caused by law enforcement and other persons with legal authority to use deadly force, excluding legal executions), and unintentional firearm deaths (<1%). (The term legal intervention is a classification incorporated into the International Classification of Diseases, Tenth Revision [ICD-10] and does not denote the lawfulness or legality of the circumstances surrounding a death caused by law enforcement.) Suicides occurred at higher rates among males, non-Hispanic whites, American Indian/Alaska Natives, persons aged 45-64 years, and males aged ≥75 years. Suicides were preceded primarily by a mental health, intimate partner, or physical health problem or a crisis during the previous or upcoming 2 weeks. Homicide rates were higher among males and persons aged 15-44 years; rates were highest among non-Hispanic black males. Homicides primarily were precipitated by arguments and interpersonal conflicts, occurrence in conjunction with another crime, or were related to intimate partner violence (particularly for females). A known relationship between a homicide victim and a suspected perpetrator was most likely either that of an acquaintance or friend or an intimate partner. Legal intervention death rates were highest among males and persons aged 20-24 years and 30-34 years; rates were highest among non-Hispanic black males. Precipitating factors for the majority of legal intervention deaths were another crime, a mental health problem, or a recent crisis. Deaths of undetermined intent occurred at the highest rates among males and persons aged <1 year and 45-54 years. Substance abuse and mental or physical health problems were the most common circumstances preceding deaths of undetermined intent. Unintentional firearm death rates were higher among males, non-Hispanic whites, and persons aged persons aged 15-19 and 55-64 years; these deaths were most often precipitated by a person unintentionally pulling the trigger while playing with a firearm or while hunting. INTERPRETATION This report provides a detailed summary of data from NVDRS for 2013. The results indicate that violent deaths resulting from self-inflicted or interpersonal violence disproportionately affected persons aged <65 years, males, and certain minority populations. For homicides and suicides, intimate partner problems, interpersonal conflicts, mental health problems, and recent crises were primary precipitating factors. PUBLIC HEALTH ACTION NVDRS data are used to monitor the occurrence of violence-related fatal injuries and assist public health authorities in the development, implementation, and evaluation of programs and policies to reduce and prevent violent deaths. For example, Utah Violent Death Reporting System (VDRS) data were used to develop policies that support children of intimate partner homicide victims, Colorado VDRS data to develop a web-based suicide prevention program targeting middle-aged men, and Rhode Island VDRS data to help guide suicide prevention efforts at workplaces. The continued development and expansion of NVDRS to include all U.S. states, territories, and the District of Columbia are essential to public health efforts to reduce the impact of violence.

Screening for Cervical Cancer and Sexually Transmitted Diseases Among HIV-Infected Women

BACKGROUND Women living with HIV infection are at higher risk for cervical cancer, an AIDS-defining diagnosis. We examined the prevalence of cervical cancer and sexually transmitted disease (STD) screening among human immunodeficiency virus (HIV)-infected women and factors associated with the receipt of Papanicolaou (Pap) tests. METHODS We did a cross-sectional analysis of weighted data from a sample of HIV-infected adults receiving outpatient medical care. We used matched interview (report of Pap test) and medical record data (STD screenings) from HIV-infected women. We performed logistic regression to compute adjusted prevalence ratios and 95% confidence intervals for the association between demographic, behavioral, and clinical factors and receipt of Pap tests among HIV-infected women. RESULTS Data were available for 2,270 women, who represent 112,894 HIV-infected women; 62% were African American, 17% were Hispanic/Latina, and 18% were white. Most (78%) reported having a Pap test in the past year. Among sexually active women (n = 1234), 20% reported sex without condoms, 27% were screened for gonorrhea, and 29% were screened for chlamydia. Being screened for STDs was less likely among women who did not have a Pap test in the past year (adjusted prevalence ratios 0.82, 95% confidence interval 0.77-0.87). Women who were ≥50 years of age and reported income above federal poverty level, no sexual activity, depression, no HIV care from an obstetrician/gynecologist, and no documented STD tests, were less likely to report a Pap test (p < 0.05). CONCLUSIONS Screening for cervical cancer and STDs among HIV-infected women is suboptimal. Clinical visits for Pap tests are an important opportunity for HIV-infected sexually active women to also receive STD screenings and counseling regarding condoms.

Prevention counseling practices of HIV care providers with patients new to HIV medical care: medical monitoring project provider survey, 2009.

Objectives: To determine the prevalence of prevention counseling discussions between HIV care providers and their patients who are newly linked to care and to assess factors that facilitate such discussions. Methods: In 2009, a probability sample of HIV care providers in 582 outpatient settings in the United States and Puerto Rico was surveyed regarding provider’s HIV prevention discussions with HIV-infected patients newly linked to HIV medical care. Results: A majority of providers reported consistently discussing HIV transmission risk reduction (76%), sexually transmitted disease risk (66%), and adherence to antiretroviral regimens (87%). Only 35% of providers reported consistently discussing partner counseling services. Conclusion: The proportion of providers engaged in HIV prevention counseling with patients newly linked to HIV care is generally high, but more work is needed to encourage providers to fully participate as partners in prevention, which is central to preventing onward transmission of HIV.