Health Care Access and Use Among Adults With and Without Vision Impairment: Behavioral Risk Factor Surveillance System, 2018.

INTRODUCTION: Adults with vision impairment may have unique needs when accessing health care to maintain good health. Our study examined the relationship between vision status and access to and use of health care. METHODS: We analyzed data on adults aged 18 years or older who participated in the 2018 Behavioral Risk Factor Surveillance System. Vision impairment was identified by a yes response to the question "Are you blind or do you have serious difficulty seeing, even when wearing glasses?" Survey questions assessed health care access over the past year (having health insurance coverage, a usual health care provider, or unmet health care needs because of cost) and use of health care during that period (routine checkup and dental visit). We estimated age-adjusted prevalence of our outcomes of interest and used bivariate analyses to compare estimates of the outcomes by vision impairment status. RESULTS: The prevalence of self-reported vision impairment was 5.3%. Compared with adults without impaired vision, adults with vision impairment had a lower prevalence of having health insurance coverage (80.6% vs 87.6%), a usual health care provider (71.9% vs 75.7%), or a dental visit in the past year (52.9% vs 67.2%) and a higher prevalence of having an unmet health care need in the past year because of cost (29.2% vs 12.6%). CONCLUSION: Adults with vision impairment reported lower access to and use of health care than those without. Further research can better identify and understand barriers to care to improve access to and use of health care among this population.

CDC's Community-Based Organization Behavioral Outcomes Project: Perspectives for Researchers, Implementers and Funders.

Behavioral interventions have been a crucial tool for the prevention of HIV transmission since early in the epidemic. The Centers for Disease Control and Prevention (CDC) has provided funding for evidence-based behavioral interventions (EBIs) at health departments and community-based organizations (CBOs) since 2004. From 2006 to 2015, CDC funded 25 CBOs to evaluate one or more of seven EBIs designed to prevent HIV through the Community-based Organization Behavioral Outcomes Project (CBOP) as implemented outside of a research setting. For each EBI, CBOP showed that most HIV risk behaviors improved after the intervention, and improvements were similar to those observed in research studies. Our findings show that behavioral interventions can be successfully implemented in real-world settings. Although the focus of HIV prevention has largely shifted toward biomedical interventions in recent years, successful implementation often depends on behavioral components. Lessons from CBOP can inform future efforts to develop and implement behavioral interventions for HIV and other areas of public health.

Factors Associated with HIV Antiretroviral Therapy among Men Who Have Sex with Men in 20 US Cities, 2014.

Reducing HIV among men who have sex with men (MSM) is a national goal, and early diagnosis, timely linkage to HIV medical care, and ongoing care and treatment are critical for improving health outcomes for MSM with HIV and preventing transmission to others. We assessed demographic, social, and economic factors associated with HIV antiretroviral treatment among HIV-infected MSM. Data are from the National HIV Behavioral Surveillance (NHBS) collected in 2014 among MSM. We estimated prevalence ratios and 95% confidence intervals using average marginal predictions from logistic regression. Overall, 89% of HIV-positive MSM reported currently taking antiretroviral therapy (ART). After controlling for other variables, we found that higher perceived community stigma and not having health insurance were significant risk factors for not taking ART. We also found that high socioeconomic status (SES) was associated with taking ART. Race/ethnicity was not significantly associated with taking ART in either the unadjusted or adjusted analyses. Findings suggest that to increase ART use for MSM with HIV, we need to move beyond individual-level approaches and move towards the development, dissemination, and evaluation of structural and policy interventions that respond to these important social and economic factors.

HIV Testing, Linkage to HIV Medical Care, and Interviews for Partner Services Among Black Men Who Have Sex with Men - Non-Health Care Facilities, 20 Southern U.S. Jurisdictions, 2016.

Identifying HIV-infected persons who are unaware of their human immunodeficiency virus (HIV) infection status, linking them to care, and reducing health disparities are important national HIV prevention goals (1). Gay, bisexual, and other men who have sex with men (collectively referred to as MSM) accounted for 70% of HIV infection diagnoses in the United States in 2016, despite representing only 2% of the population (2,3). African American or black (black) MSM accounted for 38% of all new diagnoses of HIV infection among MSM (2). Nearly two thirds (63%) of all U.S. black MSM with diagnosed HIV infection reside in the southern United States (2), making targeted HIV prevention activities for black MSM in this region critical. Analysis of CDC-funded HIV testing data for black MSM submitted by 20 health departments in the southern United States in 2016 revealed that although black MSM received 6% of the HIV tests provided, they accounted for 36% of the new diagnoses in non-health care facilities. Among those who received new diagnoses, 67% were linked to HIV medical care within 90 days of diagnosis, which is below the 2020 national goal of linking at least 85% of persons with newly diagnosed HIV infection to care within 30 days (1). Black MSM in the southern United States are the group most affected by HIV, but only a small percentage of CDC tests in the southern United States are provided to this group. Increasing awareness of HIV status through HIV testing, especially among black MSM in the southern United States, is essential for reducing the risk for transmission and addressing disparities. HIV testing programs in the southern United States can reach more black MSM by conducting targeted risk-based testing in non-health care settings and by routine screening in agencies that also provide health care services to black MSM.

HIV Testing, Linkage to HIV Medical Care, and Interviews for Partner Services Among Women - 61 Health Department Jurisdictions, United States, Puerto Rico, and the U.S. Virgin Islands, 2015.

Diagnoses of human immunodeficiency virus (HIV) infection among women declined 17% during 2011-2015, and a total of 7,498 women received a diagnosis of HIV infection in 2015 (1). Although black or African American (black) women accounted for only 12% of the U.S. female population, 60% of women with newly diagnosed HIV infection were black (1,2). By the end of 2014, an estimated 255,900 women were living with HIV infection (3), including approximately 12% who did not know they were infected; in addition, approximately 45% of women who had received a diagnosis had not achieved viral suppression (3). HIV testing is an important public health strategy for identifying women with HIV infection and linking them to HIV medical care. Analysis of CDC-funded program data submitted by 61 health departments in 2015 indicated that among 4,749 women tested who received a diagnosis of HIV infection, 2,951 (62%) had received a diagnosis in the past (previous diagnosis), and 1,798 (38%) were receiving a diagnosis for the first time (new diagnosis). Of those who had received a previous diagnosis, 87% were not in HIV medical care at the time of the current test. Testing and identifying women who are living with HIV infection but who are not in care (regardless of when they received their first diagnosis) and rapidly linking them to care so they can receive antiretroviral therapy and become virally suppressed are essential for reducing HIV infection among all women.

HIV testing in nonhealthcare facilities among adolescent MSM.

OBJECTIVES: To describe the extent to which Centers for Disease Control and Prevention (CDC)-funded HIV testing in nonhealthcare facilities reaches adolescent MSM, identifies new HIV infections, and links those newly diagnosed to medical care. METHODS/DESIGN: We describe HIV testing, newly diagnosed positivity, and linkage to medical care for adolescent MSM who received a CDC-funded HIV test in a nonhealthcare facility in 2015. We assess outcomes by race/ethnicity, HIV-related risk behaviors, and US geographical region. RESULTS: Of the 703 890 CDC-funded HIV testing events conducted in nonhealthcare facilities in 2015, 6848 (0.9%) were provided to adolescent MSM aged 13-19 years. Among those tested, 1.8% were newly diagnosed with HIV, compared with 0.7% among total tests provided in nonhealthcare facilities regardless of age and sex. The odds of testing positive among black adolescent MSM were nearly four times that of white adolescent MSM in multivariable analysis (odds ratio = 3.97, P < 0.001). Among adolescent MSM newly diagnosed with HIV, 67% were linked to HIV medical care. Linkage was lower among black (59%) and Hispanic/Latino adolescent MSM (71%) compared with white adolescent MSM (88%). CONCLUSION: CDC-funded nonhealthcare facilities can reach and provide HIV tests to adolescent MSM and identify new HIV infections; however, given the low rate of HIV testing overall and high engagement in HIV-related risk behaviors, there are opportunities to increase access to HIV testing and linkage to care for HIV-positive adolescent MSM. Efforts are needed to identify and address the barriers that prevent black and Hispanic/Latino adolescent MSM from being linked to HIV medical care in a timely manner.

HIV Testing, Linkage to HIV Medical Care, and Interviews for Partner Services Among Youths - 61 Health Department Jurisdictions, United States, Puerto Rico, and the U.S. Virgin Islands, 2015.

Identifying persons living with human immunodeficiency virus (HIV) who are unaware of their infection, linking them to HIV medical care, and reducing health disparities are important national goals (1). Of the 8,841 teens and young adults aged 13-24 years (collectively referred to as youths in this report) who received a diagnosis of HIV in 2014, 70% were young men who have sex with men (MSM) (2). In the same year, an estimated 52% of young MSM living with HIV were unaware of their infection compared with 15% among all persons living with HIV (3). An average of 22% of high school students who have had sexual intercourse and 33% of young adults (persons aged 18-24 years) reported ever receiving an HIV test (4). CDC recommends screening all persons aged 13-64 years, with annual rescreening for persons at high risk for HIV infection (5). Analysis of CDC-funded program data for youths submitted by 61 health departments in 2015 revealed that young MSM, who accounted for 83% of new diagnoses among all youths in non-health care facilities, received 28% of HIV tests.* The 2020 national goal is to link at least 85% of HIV-positive persons to HIV medical care within 30 days of diagnosis. In this analysis, 66% of youths who received positive test results for HIV infection were linked to care within 90 days of diagnosis. Increasing the number of youths at risk for HIV infection who are tested for HIV on a regular basis and ensuring that youths who receive positive test results for HIV are rapidly linked to and retained in appropriate medical care, including early initiation of antiretroviral therapy, are essential steps for reducing HIV infection in this vulnerable population.

HIV Testing and Service Delivery Among Black Females--61 Health Department Jurisdictions, United States, 2012-2014.

A primary goal of the national human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) Strategy is to reduce HIV-related health disparities (1). Among all HIV diagnoses among women in the United States in 2014, non-Hispanic black or African American (black) women accounted for an estimated 62% of diagnoses, despite constituting only 13% of the female population (2,3). Although HIV diagnoses continue to occur disproportionately among black women, HIV surveillance data indicate a 13.5% decrease in diagnoses from 2012 to 2014 (2,4). However, widespread HIV testing and early linkage to care are critical for persons with HIV to achieve viral suppression and improved health outcomes, and to reduce transmission of HIV to others (5). Analysis of CDC-funded program data on HIV testing services provided to black females and submitted by 61 state and local health departments during 2012-2014 revealed that the number of new HIV diagnoses among black females decreased 17% from 2,177 in 2012 to 1,806 in 2014. Among black females with newly diagnosed HIV infection, the percentage who were linked to HIV medical care within 90 days of diagnosis increased 48.2%, from 33.8% in 2012 to 50.1% in 2014. However, in 2010 the National HIV/AIDS Strategy established a goal to link 85% of persons with newly diagnosed HIV infection to HIV medical care (1). Enhanced efforts to diagnose HIV infection among black females and link them to HIV medical care are critical to address HIV infections in the United States.

Reduced Sexual Risk Behaviors Among Young Men of Color Who Have Sex with Men: Findings from the Community-Based Organization Behavioral Outcomes of Many Men, Many Voices (CBOP-3MV) Project.

In 2006, the Centers for Disease Control and Prevention (CDC) funded community-based organizations (CBOs) to deliver Many Men, Many Voices (3MV) to young men of color who have sex with men. Although 3MV, a group-level behavioral intervention designed to reduce human immunodeficiency virus (HIV) risk behaviors of black men who have sex with men (MSM), has shown effectiveness when delivered in a controlled research environment, there is limited evidence that the intervention is associated with similar outcomes in "real world" settings. For the current project, CDC funded three CBOs to conduct outcome monitoring of the 3MV intervention to determine if young MSM of color report changes in HIV risk behaviors postintervention. Using a repeated measures design, risk behaviors were collected at baseline and again at 3 and 6 months postintervention. Changes in risk behaviors were assessed using generalized estimating equations. Participants (n = 337) reported decreases in sexual risk behaviors at both follow-up time points, such as sex without a condom, sex without a condom and multiple partners, and sex without a condom with serodiscordant or status unknown partners. Results suggest that 3MV may be an effective tool for reducing HIV risk behaviors in this critical target population.

Estimating the population size of men who have sex with men in the United States to obtain HIV and syphilis rates.

BACKGROUND: CDC has not previously calculated disease rates for men who have sex with men (MSM) because there is no single comprehensive source of data on population size. To inform prevention planning, CDC developed a national population size estimate for MSM to calculate disease metrics for HIV and syphilis. METHODS: We conducted a systematic literature search and identified seven surveys that provided data on same-sex behavior in nationally representative samples. Data were pooled by three recall periods and combined using meta-analytic procedures. We applied the proportion of men reporting same-sex behavior in the past 5 years to U.S. census data to produce a population size estimate. We then calculated three disease metrics using CDC HIV and STD surveillance data and rate ratios comparing MSM to other men and to women. RESULTS: Estimates of the proportion of men who engaged in same-sex behavior differed by recall period: past year = 2.9% (95%CI, 2.6-3.2); past five years = 3.9% (3.5-4.4); ever = 6.9% (5.1-8.6). Rates on all 3 disease metrics were much higher among MSM than among either other men or women (38 to 109 times as high). CONCLUSIONS: Estimating the population size for MSM allowed us to calculate rates for disease metrics and to develop rate ratios showing dramatically higher rates among MSM than among other men or women. These data greatly improve our understanding of the disproportionate impact of these diseases among MSM in the U.S. and help with prevention planning.

Provision of HIV counseling and testing services at five community-based organizations among young men of color who have sex with men.

In the context of monitoring and improving CDC-funded HIV prevention programs, we describe HIV tests and infections, provision of results, previous HIV tests, and risk behaviors for young (aged 13-29) men of color who have sex with men who received HIV tests at five community-based organizations. Of 1,723 tests provided, 2.1% were positive and 75.7% of positives were previously unaware of their infection. The highest positivity rate was among men aged 25-29 (4.7%). Thirty-four percent of tests were provided to men who were tested for the first time. Over half the tests (53.2%) were provided to men who reported sex with a person of unknown HIV status, and 34% to men who reported sex with an anonymous partner. Continued and more focused prevention efforts are needed to reach and test young men of color who have sex with men and to identify previously undiagnosed HIV infections among this target population.

Coping strategies of adolescents living with HIV: disease-specific stressors and responses.

This study examined disease-specific stressors and coping responses employed by youth with HIV. Data were analyzed from Adolescent Impact, a multi-site study of 166 adolescents infected with HIV in three major US cities. Participants identified HIV-related stressors during a face-to-face interview. Coping strategies were measured using the adolescent version of the Kidcope. Emotional and behavioral functioning were assessed with the Youth or Adult Self Report symptom checklists. Medication-related stressors were most common (30%) and reported more often by perinatally infected youth, whereas youth infected through risk behaviors reported more disclosure-related stressors. Passive emotional regulation was perceived as the most used and most helpful coping strategy overall. Youth reporting medication adherence-related stressors used resignation most frequently. A two-factor model (Passive and Active Coping) emerged. The Passive Coping factor included strategies that do not directly approach the problem, whereas Active Coping included strategies that involve an active approach. Youth with moderately advanced disease (CD4 200-500 cells/mm(3)) used a Passive Coping style more often than healthier youth (CD4 > 500 cells/mm(3)). Additionally, Passive Coping was associated with greater emotional and behavioral problems. Youth infected with HIV may benefit from interventions promoting adaptive coping responses to HIV-specific stressors, particularly medication adherence.

Emotional and behavioral problems and mental health service utilization of youth living with HIV acquired perinatally or later in life.

This study sought to examine predictors of psychological symptoms and psychiatric service receipt among youth with HIV. Data were from the baseline assessment of Adolescent Impact, a study of 13-21-year-old youth with HIV in three US cities. Between August 2003 and February 2005, participants completed the age-appropriate youth or adult self-report symptom checklists (Achenbach system of empirically based assessment) and reported their psychiatric treatment history. Psychiatric diagnoses were abstracted from medical records. The 164 participating youth living with HIV were Black (81%), female (52%), Heterosexually identified (62%), and perinatally HIV-infected (60%). Thirty-one percentage reported levels of internalizing (i.e., self-focused/emotional), externalizing (i.e., outwardly focused/behavioral), or overall symptoms consistent with clinical psychopathology. In multivariate analyses, questioning one's sexual identity was associated with greater internalizing problems, whereas identifying as Bisexual was associated with greater externalizing problems (p<0.05). Symptoms were not associated with HIV transmission group. Participants with > or =1 composite score within the clinical range were more likely to have received > or =1 psychiatric service (Odds ratio (OR): 2.51; 95% confidence interval (CI): 1.22, 5.13) and a psychiatric diagnosis in the past year (OR: 2.16; 95% CI: 1.09, 4.27). However, 27% with clinically elevated scores had never received psychiatric care. Results suggest that among youth with HIV, those who identify as Bisexual or Questioning are at greatest risk for emotional and behavioral problems. Despite available mental health services, some youth with HIV are not receiving needed mental health care. Enhanced evaluation, referral and mental health service linkage is needed for these high-risk youth.

Characterizing social support: global and specific social support experiences of HIV-infected youth.

This study examined the nature, type, and source of social support available to a diverse group of HIV-infected adolescents and the relationship between social support and depression. Data were obtained from the baseline assessment of Adolescent Impact, a behavioral intervention conducted in 2003-2006 involving 166 HIV-infected youth, ages 13-21, in care at four urban medical centers. Youth completed the Medical Outcomes Study Social Support Survey, Beck Depression Inventory, and questions about HIV-specific social support including locus (family and friends) and type (structural, perceived, instrumental, and satisfaction). Linear regression modeling examined the relation between HIV-specific and general perceived social support, and between social support and depression. Participants were predominately minority (72% black and 20% Hispanic); perinatally infected (60% PIY), and female (53%). Most had someone to either remind them to attend (71%) or to bring them to clinic (60%), a majority family (53%) and fewer friends (4%). More youth reported being satisfied with family (64%) social support than that from friends (51%). Behaviorally infected youth (BIY) had significantly more friends who knew their serostatus than PIY (means = 4.5 and 1.7; p < 0.001), but received significantly less help from family in accessing care (p < 0.001). Satisfaction with family social support was the best predictor of general perceived social support with general perceived social support and behavioral mode of transmission the best predictors of depression. Regular screening of HIV-positive youth for social support needs, especially BIY, and identification of sources for social support should be a regular part of care.

Age differences in emotion-regulation strategies in handling everyday problems.

We examined age differences in problem-focused and emotion-regulatory problem-solving strategy use for self-generated family problems. Young, middle-aged, and older participants generated family problem situations that were high and low in emotional salience. They were asked both how they solved the problem and how they managed emotions involved in the problem. We conducted analyses on three categories of problem-solving strategies: instrumental strategies, proactive emotion regulation, and passive emotion regulation. When regulating emotions, middle-aged adults used more proactive emotion-regulation strategies than older adults, and older adults used more passive emotion-regulation strategies than middle-aged adults. These effects were driven by the high emotional salience condition.

The effects of age-stereotype priming on the memory performance of older adults.

The effects of age-stereotype priming on the memory performance of older adults were investigated through a conceptual replication and extension of Levy's (1996. Journal of Personality and Social Psychology, 71, 1092-1107) study. Sixty young and 60 older adults were subliminally primed with a positive age stereotype, a negative age stereotype, or neutral primes. Memory performance on two tasks (a photo recall task and a dot location task) was measured before and after the priming intervention. Although the study does not provide unequivocal support for Levy's (1996) findings, results did show that priming a negative age stereotype undermined memory performance for a small sample of older adults who were "unaware" of the primes. However, contrary to Levy's findings, priming a positive age stereotype did not increase older adults' memory performance. There were no significant effects of priming positive or negative age stereotypes on the memory performance of young adults.