Undiagnosed HIV prevalence among adults and adolescents in the United States at the end of 2006.

OBJECTIVES: To describe adults/adolescents (age 13 years and older) living with undiagnosed HIV infection in the United States at the end of 2006. METHODS: HIV prevalence and percentage undiagnosed were estimated from cumulative HIV incidence using an extended back-calculation model (using both HIV and AIDS data, the time of first diagnosis with HIV, and disease severity at diagnosis) and estimated cumulative deaths. RESULTS: An estimated 1,106,400 adults/adolescents (95% confidence interval = 1,056,400-1,156,400) were living with HIV in the United States at the end of 2006; overall, 21.0% (232,700; 95% confidence interval = 221,200-244,200) were undiagnosed. Whites had the lowest percentage undiagnosed (18.8%) compared with Hispanics/Latinos (21.6%), blacks/African Americans (22.2%), American Indians/Alaska Natives (25.8%), and Asians/Pacific Islanders (29.5%; all P < 0.001). Persons with a behavioral risk of injection drug use (IDU) had the lowest percentage undiagnosed (female IDU: 13.7% and male IDU: 14.5%); men exposed through heterosexual contact had the highest (26.7%) followed by men who have sex with men (23.5%). CONCLUSIONS: Differences in undiagnosed HIV were evident across demographic and behavior groups. Effective testing programs and early access to treatment and prevention services are necessary to reduce undiagnosed HIV infections and HIV prevalence.

Housing status and HIV risk behaviors among homeless and housed persons with HIV.

OBJECTIVES: To compare drug, alcohol, and sexual HIV transmission risk behaviors of homeless and housed people living with HIV/AIDS. METHODS: Data were from 8075 respondents in a cross-sectional, multisite behavioral survey of adults recently reported to have HIV infection. RESULTS: At interview, 310 respondents (4%) were homeless. Compared with homeless respondents, housed respondents were more likely to be sexually active (past 12 months). However, sexually active homeless respondents had more sex partners (lifetime and past 12 months), greater sex exchange for money or drugs (lifetime and past 12 months), and greater unprotected vaginal or anal sex with an unknown serostatus partner. Homeless respondents were more likely to have possible alcohol abuse (lifetime), used drugs (last 12 months), and injected drugs (lifetime and past 12 months). After controlling for potential confounding variables, housing status remained a significant predictor of number of sex partners (past 12 months), sex exchange (lifetime and past 12 months), unprotected sex with unknown status partner, and all drug and alcohol use variables. CONCLUSIONS: Homeless people living with HIV/AIDS are more likely to have ever or recently engaged in substance use and HIV transmission risk behaviors. Findings underscore the need to provide HIV prevention services to homeless persons and address their housing needs.

Health status, health care use, medication use, and medication adherence among homeless and housed people living with HIV/AIDS.

OBJECTIVES: We sought to compare health status, health care use, HIV anti-retroviral medication use, and HIV medication adherence among homeless and housed people with HIV/AIDS. METHODS: Data were obtained from a cross-sectional, multisite behavioral survey of adults (N=7925) recently reported to be HIV positive. RESULTS: At the time interviews were conducted, 304 respondents (4%) were homeless. Self-ratings of mental, physical, and overall health revealed that the health status of homeless respondents was poorer than that of housed respondents. Also, homeless respondents were more likely to be uninsured, to have visited an emergency department, and to have been admitted to a hospital. Homeless respondents had lower CD4 counts, were less likely to have taken HIV anti-retroviral medications, and were less adherent to their medication regimen. Homeless respondents needed more HIV social and medical services, but nearly all respondents in both groups had received needed services. Housing status remained a significant predictor of health and medication outcomes after we controlled for potential confounding variables. CONCLUSIONS: Homeless people with HIV/AIDS are at increased risk of negative health outcomes, and housing is a potentially important mechanism for improving the health of this vulnerable group.

Patient and regimen characteristics associated with self-reported nonadherence to antiretroviral therapy.

BACKGROUND: Nonadherence to antiretroviral therapy (ARVT) is an important behavioral determinant of the success of ARVT. Nonadherence may lead to virological failure, and increases the risk of development of drug resistance. Understanding the prevalence of nonadherence and associated factors is important to inform secondary HIV prevention efforts. METHODOLOGY/PRINCIPAL FINDINGS: We used data from a cross-sectional interview study of persons with HIV conducted in 18 U.S. states from 2000-2004. We calculated the proportion of nonadherent respondents (took <95% of prescribed doses in the past 48 hours), and the proportion of doses missed. We used multivariate logistic regression to describe factors associated with nonadherence. Nine hundred and fifty-eight (16%) of 5,887 respondents reported nonadherence. Nonadherence was significantly (p<0.05) associated with black race and Hispanic ethnicity; age <40 years; alcohol or crack use in the prior 12 months; being prescribed >or=4 medications; living in a shelter or on the street; and feeling "blue" >or=14 of the past 30 days. We found weaker associations with having both male-male sex and injection drug use risks for HIV acquisition; being prescribed ARVT for >or=21 months; and being prescribed a protease inhibitor (PI)-based regimen not boosted with ritonavir. The median proportion of doses missed was 50%. The most common reasons for missing doses were forgetting and side effects. CONCLUSIONS/SIGNIFICANCE: Self-reported recent nonadherence was high in our study. Our data support increased emphasis on adherence in clinical settings, and additional research on how providers and patients can overcome barriers to adherence.

Unprotected anal intercourse among HIV-positive men who have a steady male sex partner with negative or unknown HIV serostatus.

OBJECTIVES: We sought to determine the prevalence and predictors of unprotected anal intercourse (UAI) among HIV-positive men who have a single steady male partner with negative or unknown HIV serostatus. METHODS: We analyzed behavioral surveillance data from HIV-positive men who have sex with men (MSM) interviewed in 12 states between 1995 and 2000. RESULTS: Of 970 HIV-positive MSM who had a single steady male sex partner with negative or unknown serostatus, 278 (29%) reported UAI during the previous year. In a subset of 674 men who were aware of their infection, 144 (21%) had UAI. Among the men who were aware of their infection, factors found to be predictive of UAI in multivariate modeling were heterosexual self-identification, crack cocaine use, no education beyond high school, and a partner with unknown serostatus. CONCLUSIONS: Even after learning of their infection, one fifth of HIV-positive MSM who had a single steady male partner with negative or unknown serostatus engaged in UAI, underscoring the need to expand HIV prevention interventions among these men.

HIV testing and awareness of care-related services among a group of HIV-positive Asian Americans and Pacific Islanders in the United States: findings from a supplemental HIV/AIDS surveillance project.

Compared with other racial/ethnic groups in the United States, Asian Americans and Pacific Islanders (AAPIs) are more likely to be at an advanced stage of AIDS disease and have opportunistic infections at the time of diagnosis. However, it is not clear how these two findings are related to issues such as HIV testing and access to HIV care-related services. We examined HIV testing and awareness of care-related services among a group of HIV-positive AAPIs in the United States. Data are from a multisite supplemental surveillance project, 1990-1999. Compared with Whites, a higher percentage of AAPIs cited "illness" as the main reason for HIV testing and had their tests done as a hospital inpatients--although these differences were not statistically significant. A significantly lower percentage of AAPIs than Whites were aware of their current CD4 count; AAPIs also had significantly lower awareness about a number of care-related services. Among AAPIs, educational level was positively associated with awareness of these services. Efforts are needed to promote service availability among HIV-positive AAPIs.

Self-reported health-related quality of life in persons with HIV infection: results from a multi-site interview project.

BACKGROUND: To examine demographic and behavioral associations with self-reported health-related quality of life (HRQOL) among persons with HIV infection or AIDS. METHODS: Analysis of interviews with persons > or = 18 years of age reported through routine disease surveillance with HIV infection or AIDS to nine state and local health departments from January 1995 through December 1996. Scales were constructed from validated measures of HRQOL, and mean scores were calculated (lower scores signified poorer HRQOL). Measures of HRQOL included Overall Health, Pain, Physical Functioning, Role Functioning, Social Functioning, Mental Health, Energy/Fatigue, and Cognitive Functioning. Differences in HRQOL were examined by various demographic and behavioral factors, including taking antiretroviral medication. RESULTS: HRQOL data were available for 3778 persons. Factors associated with lower HRQOL scores included older age, female sex, black or Hispanic race/ethnicity, injection drug use, lower education and income, no private health insurance, and lower CD4 count. In multivariate analysis, lower CD4 count was the factor most consistently associated with lower HRQOL. Taking antiretroviral medication was not associated with differences in HRQOL regardless of CD4 count. CONCLUSIONS: Perception of HRQOL varied in a population with HIV infection or AIDS. On most HRQOL measures, lower CD4 count was associated with lower HRQOL. Measurement of HRQOL can assist in understanding the long-term effects of disease and treatment on persons with HIV.