Eliminating HIV Infections in Children and Keeping their Mothers Alive

Key interventions can reduce mother-to-child HIV transmission from 35% to <5%

• Routine HIV testing and counseling of all pregnant women.
• Provision of antiretroviral drugs (ARVs) to all HIV-positive women during pregnancy, birth, and after delivery.
• Preventive therapy with ARVs for infants born to HIV-positive mothers.
• Safe infant feeding to minimize transmission.

The transmission of HIV from mothers to their infants contributes substantially to global morbidity and mortality for children under-5 years of age. Approximately 1000 HIV-infected infants are born every day, mostly in sub-Saharan Africa, amounting to nearly 370,000 new pediatric infections annually (UNAIDS, 2010). Without treatment, over half of these children will die before the age of two (WHO, 2006). Fortunately, prevention of mother-to-child HIV transmission (PMTCT) can be accomplished by effective, accessible, and scalable interventions within existing maternal and child health services.

Preventing mother-to-child transmission of HIV

Without diagnosis and treatment, about 35% of HIV-infected pregnant women will transmit HIV to their infants. Key interventions, including those listed in the right column, have reduced mother-to-child transmission in the United States to <1% (CDC, 2007), in Botswana to 3.6% (Tlale J, 2008), and in South Africa to 3.5% (MRC South Africa, 2011) in infants 4-8 weeks of age.

A global call to action

In an effort to achieve the Millennium Development Goal 4 (MDG4) to reduce mortality of children under five years of age, the World Health Organization (WHO), UNAIDS, UNICEF and other international health partners, have called for elimination of mother-to-child transmission of HIV by 2015.

CDC’s role in preventing infant HIV infections

The US government, through the President’s Emergency Plan for AIDS Relief (PEPFAR), has been supporting the global strategy by providing technical and financial assistance to countries with a high burden of HIV infection. As the U.S. science-based public health and disease prevention agency, the Centers for Disease Control and Prevention (CDC) plays a unique and essential role in PEPFAR. CDC leverages its technical expertise in public health science and long-standing relationships with Ministries of Health to work side-by-side with countries to build strong programs and sustainable public health systems that respond effectively to the global HIV/AIDS epidemic.
Since 2004, CDC, through PEPFAR, has contributed to significant progress in implementing two essential components of comprehensive PMTCT programs, namely HIV testing and counseling of pregnant women and initiating HIV-infected pregnant women on ARVs. In high burden countries in 2010, with direct PEPFAR-support, 34% of pregnant women were tested, and 56% of those who tested HIV-positive received ARVs for PMTCT (PEPFAR, 2004-2010). These interventions have contributed to nearly 386,000 infants being born without HIV.
CDC uses a variety of approaches to support resource-constrained, high burden countries in combating mother-to-child transmission of HIV.

• Providing technical assistance and support CDC provides technical assistance to in-country US Government teams, Ministries of Health, and nongovernmental (NGO) partners to implement international recommendations and best practices.
• Translating research into practice CDC conducts program evaluations to identify bottlenecks, contributes to the development of evidence-based tools, and recommends implementation strategies to enhance scale up and improve quality of PMTCT programs.
• Contributing scientific expertise CDC collaborates with WHO and other international health partners to develop global PMTCT policies and practice guidelines.

On the path to an AIDS-free generation

On World AIDS Day 2011, President Barack Obama announced a new PMTCT goal, in addition to other HIV prevention goals: By the end of 2013, PEPFAR will reach more than 1.5 million more HIV-positive pregnant women with antiretroviral drugs to prevent them from passing the virus to their children. To achieve this goal, CDC, through PEPFAR, is supporting the rapid scale-up of high quality PMTCT services. An AIDS-free generation means that virtually no children are born infected with the HIV virus, as they become adults they are at far lower risk of becoming infected than they would be today, and if they do acquire the virus, they have access to treatment that helps prevent them from developing AIDS and passing the virus to others.

Broader benefits of PMTCT

In addition to ending HIV infections in children, PMTCT programs provide other significant benefits: they also offer an opportunity to save the lives of mothers by improving the coverage of HIV-positive women on antiretroviral drugs, and significantly decrease their risk of transmitting the virus to uninfected partners.

Citations

South Africa Medical Research Council (MRC). SA PMTCT Evaluation shows that virtual elimination of paediatric HIV is possible with intensified effort. Accessed at http://www.mrc.ac.za/pressreleases/2011/10press2011.htm (2011).
Tlale J et al. Mother to child HIV transmission in Botswana – analysis of dried blood spot (DBS) results from the national PMTCT programme. XVII International Conference on AIDS, Mexico City, Mexico (2008)

Strategy for an AIDS-Free Generation

Recent scientific advances have proven that existing HIV prevention tools can dramatically drive down the rate of new infections and virtually eliminate them in babies and children.
Progress has been particularly rapid in the last two years, due to recent scientific breakthroughs as well as accelerated targets set by President Obama, who again championed the achievable goal of an AIDS-free generation in his 2013 State of the Union address. The Administration’s Blueprint  for creating an AIDS-free generation outlines specific steps that PEPFAR is taking to uphold America’s commitment to fight this deadly disease.
As a principal implementing agency for the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), CDC is helping to implement PEPFAR’s “combination prevention” strategy, which consists of three key HIV prevention tools:

• Antiretroviral treatment of HIV-positive persons
• Prevention of mother-to-child transmission of HIV
• Voluntary medical male circumcision

When used with HIV testing and counseling, condoms, and other evidence-based and appropriately targeted prevention activities, these proven tools put us on a plausible path for eliminating new HIV infections.

Antiretroviral Treatment of HIV-Positive Persons

Treatment of HIV-positive people with antiretroviral drugs saves lives. In addition, recent science has shown that treatment is also highly effective in preventing HIV transmission to others. The research showed that treatment reduced the risk of HIV transmission from an HIV-positive woman to an uninfected male partner by up to 96%, a success rate similar to that of a vaccine.

Progress and Goal

• As of September 2012, CDC, through PEPFAR, helped support nearly 5.1 million men, women and children with antiretroviral drug treatment.
• By the end of 2013, CDC, through PEPFAR, will help support more than 6 million people on these life-saving drugs.

Preventing Mother-to-Child Transmission of HIV

An HIV-positive mother is at risk of transmitting the HIV virus to her child during pregnancy, labor, delivery, or breastfeeding. In 2012, approximately 260,000 children around the world were infected with HIV. Identifying and treating HIV-positive pregnant women with antiretroviral drugs is very effective in eliminating new infant infections.

Progress and Goal

In fiscal year 2012, CDC, through PEPFAR, directly supported

• HIV testing and counseling for more than 11 million pregnant women
• Treatment for 750,000 of these pregnant women who were HIV positive with antiretroviral drugs to prevent their transmitting the HIV virus to their babies
• Prevention of approximately 230,000 infant infections

By the end of 2013, the United States will reach more than 1.5 million HIV-positive pregnant women with antiretroviral drugs to prevent them from passing the virus to their children. To achieve this goal, CDC, through PEPFAR, is supporting the rapid scale-up of high quality services for preventing mother-to-child-transmission.

Voluntary Medical Male Circumcision

Medical male circumcision is a one-time intervention with a lifelong benefit. This low-cost procedure reduces the risk that women with HIV will transmit the HIV virus to HIV-negative men by more than 60%. HIV-negative women also benefit from the lower rate of infections among men.

Progress and Goal

• Through PEPFAR, CDC helped support medical circumcision procedures for approximately 2 million men (cumulatively through September 2012)
• By the end of 2013, CDC, through PEPFAR, will help support over 4.7 million voluntary medical male circumcisions in Eastern and Southern Africa.

Cervical Cancer and HIV in Women

Posted by CSIS Staff on Feb 10, 2013 at 12:43 pm

Blog by Janet Fleischman and Julia Nagel
Blog by Darnisah Umala Harahap


Cervical cancer kills an estimated 275,000 women every year, 85 percent of whom are in developing countries. The link between HIV and cervical cancer is direct and deadly; HIV-infected women who are also infected with specific types of human papilloma virus (HPV) are 4-5 times more susceptible to cervical cancer than HIV-negative women. This has important implications for HIV programs, especially in countries with significant HIV epidemics.
To understand the opportunities and challenges of integrating cervical cancer screening and treatment into HIV services for women, we traveled to Zambia, which has been at the forefront of integrating these services. Dr. Joan Katema, provincial coordinator for the cervical cancer screening program, explained why this integration is so critical: “Most of the attention was drawn to HIV only… But we'd still find that despite [women] accessing the ARVs and all the services that come with the ART clinic, they were still dying from cervical cancer.”
Attention to cervical cancer in Zambia has been heightened with the December 2011 launch of the Pink Ribbon Red Ribbon (PRRR) initiative, led by the George W. Bush Institute, the U.S. State Department, Susan G. Komen for the Cure, UNAIDS, and several corporate partners. PRRR is designed to build off the HIV services supported by PEPFAR to expand cervical and breast cancer prevention, screening, and treatment. Zambia is the first PRRR focus country, and President George W. Bush and Mrs. Laura Bush initially launched the program there.
The Zambian government has also been very engaged in PRRR, led by the first lady, Dr. Christine Kaseba Sata, an obstetrician and gynecologist herself. The impact of this leadership is apparent, according to a nurse supervisor with the cervical cancer program: “We've been encouraged a lot by our women leaders in this country... including the First Lady. She's been talking about cervical cancer screening and [its] importance a lot on TV, on radio, and so as a result, we've seen that a lot of women have reacted positively, received the message and have come in for screening.”
Since the start of PRRR in December 2011, the demand for screening has been growing in Zambia, sometimes overwhelming the roughly 50 health care workers who have been trained. Between September 2011 and December 2012, some 22,000 women had been screened, about a third of whom are HIV-positive. The screening itself is simple and cost-effective, involving soaking the cervix in acetic acid, such as that found in common vinegar, to check for abnormal lesions. If small lesions are found, they are removed at the clinic using cryotherapy, which is nitrous oxide. More advanced cases are referred to either Kabwe District Hospital or the University Teaching Hospital in Lusaka, but those sites are still unreachable for most women across the country.
To be sure, this is only the beginning; much more needs to be done to effectively integrate cervical cancer screening into HIV services throughout Zambia, and to build the capacity to screen, refer and treat. Ultimately, the HPV vaccine could be critically important in preventing infection with the viruses that cause cervical cancer, and a demonstration project in Zambia to evaluate the feasibility of vaccine delivery through a school-based program for adolescent girls is scheduled to begin in March 2013.  
Yet HIV-positive women in Zambia are now learning that screening and treatment for cervical cancer can save their lives.  In the words Paxina, an HIV-positive women who had been successfully treated: “Cervical cancer screening can help women living with HIV and AIDS. They will stay healthier and they will stay for a long time. Like I am. I am HIV positive. I went for cervical cancer screening and here I am today."

Pregnant Women, Infants and Children

HIV transmission from mother to child during pregnancy, labor and delivery, or breastfeeding is known as perinatal transmission and is the most common route of HIV infection in children. When HIV is diagnosed before or during pregnancy, perinatal transmission can be reduced to less than 1% if appropriate medical treatment is given, the virus becomes undetectable, and breastfeeding is avoided. Read more about prevention challenges for women and what CDC is doing to address them in HIV Among Pregnant Women, Children and Infants.

• Fact Sheets
• Campaigns
• Community Interventions

HIV Among Pregnant Women, Infants, and Children in the United States
HIV Among Women
Reducing HIV Transmission From Mother to Child: an Opt-Out Approach to HIV Screening
New HIV Infections in the United States 

All Fact Sheets

Act Against AIDS
One Test. Two Lives.
Take Charge. Take the Test.
Let's Stop HIV Together

RAPP
SIHLE
SISTA
Sister to Sister
WILLOW

All Effective Behavioral Interventions

Other Resources

Event: National Women and Girls HIV/AIDS Awareness Day
Slide set: HIV Surveillance in Women
MMWR article: HIV, Other STD, and Pregnancy Prevention Education in Public Secondary Schools — 45 States, 2008–2010
AIDS Alliance for Children, Youth, & Families
Mother to Child Transmission Resources (AIDS Education and Training Centers) ­
STDs & Pregnancy
HIV/AIDS (womenshealth.gov)
Women, Children, and HIV (University of California, San Francisco)
Cervical Cancer and HIV (SmartGlobalHealth.org)
Pregnancy and HIV, Viral Hepatitis, STD, and TB Prevention

Reducing HIV Transmission From Mother-to-Child: An Opt-Out Approach to HIV Screening 

The chance that HIV infection will be transmitted from an HIV-infected pregnant woman to her child can be reduced to 2% or less (fewer than 2 out of every 100). This is possible because better medicines are available to treat HIV. But first, the pregnant woman and her doctor must know if she is infected with HIV.
What do we know?

• Many women across the United States do not get tested for HIV during pregnancy.
• HIV-infected women who do not get tested often transmit HIV to their infants. 2005 CDC data show that among HIV-infected infants born in the 33 states which report HIV-exposed infants, 31% of the mothers of HIV-infected infants had not been tested for HIV until after delivery.
• Studies show that more women are tested when the HIV test is included in the standard group of tests that all pregnant women receive routinely, and when providers recommend HIV testing early in pregnancy to all their pregnant patients.
• Since 1995, CDC has recommended all pregnant women be tested for HIV and, if found to be infected, offered treatment for themselves to improve their health and to prevent passing the virus to their infant.

What Testing Approaches Are Available?
There are two different ways to approach pregnant women about HIV testing:

• Opt-in:
  • Pregnant women are given pre-HIV test counseling.
  • They must agree to receiving an HIV test, usually in writing.

• Opt-out:
  • Pregnant women are told that an HIV test will be included in the standard group of prenatal tests (that is to say, tests given to all pregnant women), and that they may decline the test.
  • Unless they decline, they will receive an HIV test.

Statistics published in the Nov.15, 2002, Morbidity Mortality Weekly Report (MMWR) showed that in eight states using the opt-in approach in 1998-1999, testing rates ranged from 25% to 69%. In Tennessee, which uses an opt-out approach, the testing rate was 85%. Other studies support this evidence that, of the voluntary approaches to prenatal HIV testing, more women are tested with the opt-out approach. An evaluation of opt-out testing in Birmingham, Ala. prenatal clinic showed that HIV testing increased from 75% to 88% after opt-out testing was implemented in August 1999. At the Denver Health Medical Center, 98.2% of women who delivered received HIV testing between 1998 and 2001, using opt-out testing.
For updated information about state laws in your area, please see the Compendium of State HIV Testing Laws.
Which Approach Does CDC Recommend?
In the 2006 Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Womenin Health-Care Settings, CDC recommended the opt-out approach to testing for all adult and adolescent patients in health-care settings, including pregnant women.
These recommendations emphasize:

• Universal “opt-out” HIV testing for all pregnant women early in every pregnancy;
• A second test in the third trimester in certain geographic areas or for women who are known to be at high risk of becoming infected (e.g., injection-drug users and their sex partners, women who exchange sex for money or drugs, women who are sex partners of HIV-infected persons, and women who have had a new or more than one sex partner during this pregnancy);
• Rapid HIV testing at labor and delivery for women without a prenatal test result; and
• Exploration of reasons that women decline testing.

Studies show that the opt-out approach can:

• Increase testing rates among pregnant women; thereby, increasing the number of pregnant women who know their HIV status;
• Increase the number of HIV-infected women who are offered treatment; and
• Reduce HIV transmission to their babies.

How is Opt-Out Implemented in the Health Care Setting?
Opt-out has three steps for health-care providers to follow to put this approach into practice (CDC recommends all three steps):

• Tell all pregnant women that an HIV test will be performed as part of the standard group of tests for pregnant women.
• Tell all pregnant women that they may decline this test.
• Give all pregnant women information about how to prevent HIV transmission during pregnancy and provide information about treatment for pregnant women who are HIV-positive.

Additional Information
For more detailed information on the Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings, please refer to the Morbidity and Mortality Weekly Report (MMWR) of September 22, 2006, or request a copy from the National Prevention Information Network at (800) 458-5231 or online

Morbidity and Mortality Weekly Report (MMWR)

HIV Testing and Risk Behaviors Among Gay, Bisexual, and Other Men Who Have Sex with Men — United States

Weekly

November 29, 2013 / 62(47);958-962

The burden of human immunodeficiency virus (HIV) is high among gay, bisexual, and other men who have sex with men (MSM) (1). High HIV prevalence, lack of awareness of HIV-positive status, unprotected anal sex, and increased viral load among HIV-positive MSM not on antiretroviral treatment contribute substantially to new infections among this population. CDC analyzed data from the National HIV Surveillance System (NHSS) to estimate the percentage of HIV diagnoses among MSM by area of residence and data from the National HIV Behavioral Surveillance System (NHBS) to estimate unprotected anal sex in the past 12 months among MSM in 2005, 2008, and 2011; unprotected discordant anal sex at last sex (i.e., with a partner of opposite or unknown HIV status) in 2008 and 2011; and HIV testing history and the percentage HIV-positive but unaware of their HIV status by the time since their last HIV test in 2011. This report describes the results of these analyses. In all but two states, the majority of new HIV diagnoses were among MSM in 2011. Unprotected anal sex at least once in the past 12 months increased from 48% in 2005 to 57% in 2011 (p<0.001). The percentage engaging in unprotected discordant anal sex was 13% in 2008 and 2011. In 2011, 33% of HIV-positive but unaware MSM reported unprotected discordant anal sex. Among MSM with negative or unknown HIV status, 67% had an HIV test in the past 12 months. Among those tested recently, the percentage HIV-positive but unaware of their infection was 4%, 5%, and 7% among those tested in the past ≤3, 4–6, and 7–12 months, respectively. Expanded efforts are needed to reduce HIV risk behaviors and to promote at least annual HIV testing among MSM.
Data reported through June 2012 to NHSS were used to estimate* HIV diagnoses among MSM by area of residence in 2011. Data from NHBS† were used to describe adjusted trends in unprotected anal sex§ in the past 12 months among MSM in 2005, 2008, and 2011.¶ Data from 2008 and 2011 were used to calculate the prevalence of unprotected discordant anal sex** at last sex. Chi-square tests†† were used to evaluate differences between 2008 and 2011 by HIV status, race/ethnicity, and age. Data from 2011 were used to evaluate the difference in the percentage engaging in unprotected discordant anal sex at last sex among HIV-positive aware,§§ HIV-positive unaware, and HIV-negative MSM. Adjusted¶¶ prevalence ratios (APRs) and 95% confidence intervals (CIs) are presented. Data from 2011 were used to assess HIV testing history after excluding self-reported HIV-positive MSM, and the percentage HIV-positive but unaware, by time since the last HIV test.
In 2011, MSM accounted for at least half of persons diagnosed with HIV in all but two states (Figure 1). The percentage of MSM reporting unprotected anal sex at least once in the past 12 months increased from 2005 to 2011, from 48% in 2005, to 54% in 2008, and 57% in 2011 (p<0.001). The trend was statistically significant among self-reported HIV-negative or unknown status MSM (47%, 54%, and 57%, respectively; p<0.001), but not statistically significant for self-reported HIV-positive MSM (55%, 57%, and 62%, respectively; p=0.054) (Table 1).
The percentage of MSM engaging in unprotected discordant anal sex at last sex was 13% in both 2008 and 2011 (Table 2). In 2011, 33% of HIV-positive but unaware MSM had unprotected discordant anal sex at last sex. This percentage was more than twice as high as the percentage among those who were HIV-positive aware (13%) (APR = 2.2; CI = 1.7–2.9; p<0.001) or HIV-negative (12%) (APR = 2.8; CI = 2.2–3.5; p<0.001).
Among HIV-negative or unknown status MSM, 67% reported testing for HIV in the past 12 months. A higher percentage tested in the past 3 months (31%) than in the past 4–6 months (17%) or in the past 7–12 months (19%) (Figure 2). The percentage HIV-positive but unaware was 5% among those who tested in the past 12 months: 4%, 5%, and 7% among those tested ≤3, 4–6, and 7–12 months ago, respectively (Figure 3).

Reported by

Gabriela Paz-Bailey, MD, PhD, H. Irene Hall, PhD, Richard J. Wolitski, PhD, Joseph Prejean, PhD, Michelle M. Van Handel, MPH, Binh Le, MD, Michael LaFlam, Linda J. Koenig, PhD, Maria Corazon Bueno Mendoza, PhD, Charles Rose, PhD, Linda A. Valleroy, PhD, Div of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC. Corresponding contributor: Gabriela Paz-Bailey, gmb5@cdc.gov, 404-639-4451.

Editorial Note

Although MSM are a small proportion of the population, they represent the majority of persons diagnosed with HIV in nearly every U.S. state. Unprotected anal sex in the last 12 months increased nearly 20% among MSM from 2005 to 2011. MSM unaware of their HIV-positive status were more than twice as likely to have unprotected discordant anal sex at last sex as MSM who were either HIV-negative or HIV-positive aware. Only 67% of MSM had tested for HIV in the past 12 months.
Unprotected anal sex is a high-risk practice for HIV infection, with receptive anal sex having the highest risk (2). Unprotected anal sex also places MSM at risk for other sexually transmitted infections such as syphilis, chlamydia, and gonorrhea. Although condoms can reduce the risk for HIV transmission, they do not eliminate risk and often are not used consistently (3). Some MSM attempt to decrease their HIV risk by engaging in unprotected sex only with partners perceived to have the same HIV status as their own. However, this practice is risky, especially for HIV-negative MSM, because MSM with HIV might not know or disclose that they are infected and men's assumptions about the HIV status of their partners can be wrong (2).
The reasons for the increase in unprotected anal sex are not fully known but might partially reflect the adoption of presumed risk-reduction strategies, such as engaging in unprotected sex only with partners perceived to have the same HIV status as one's own (4). The fact that the same percentage of MSM engaged in unprotected discordant anal sex at last sex in 2008 and 2011 supports this hypothesis.
Among MSM participating in the National HIV Behavioral Surveillance System (NHBS) in 2011, 18% were HIV-positive (5). Awareness of HIV-positive status among HIV-infected MSM increased from 56% in 2008 to 66% in 2011 in the 20 cities participating in NHBS (5). However, one third of HIV-positive MSM in NHBS did not know that they were infected with HIV (5), and a high percentage of them reported recent unprotected discordant anal sex with a partner of HIV-negative or unknown status. CDC found that MSM who were HIV-positive but unaware were more than two times more likely to engage in unprotected discordant anal sex, compared with HIV-positive aware or HIV-negative MSM. Persons aware of their infection are less likely to transmit the virus (6), and HIV testing is an essential first step in the care and treatment of those who are HIV-positive. HIV treatment can lower viral load, improving health outcomes and reducing the likelihood of HIV transmission. About eight transmissions would be averted for every 100 persons newly aware of their infection as a result of HIV treatment and reductions in risk behavior (6). CDC recommends that persons at high-risk for HIV, such as sexually active MSM, be tested at least annually (7,8). However, in this analysis one third of MSM had not tested for HIV in the past 12 months. Increased use of HIV testing and more frequent testing among sexually active MSM might reduce the number of men unaware of their HIV status and reduce HIV transmission.
The findings in this report are subject to at least two limitations. First, NHBS data are from MSM who were recruited at venues in large cities. Thus, results might not be generalizable to all MSM. Second, except for HIV testing results, analyses were based on self-reported data and might be subject to social desirability and recall bias.
Sexually active MSM should be tested at least annually for HIV and other sexually transmitted infections. Sexually active MSM can take steps to make sex safer such as choosing less risky behaviors, using condoms consistently and correctly if they have vaginal or anal sex, reducing the number of sex partners, and if HIV-positive, letting potential sex partners know their status (2). For some MSM at high risk, taking preexposure or postexposure prophylaxis can reduce risk (9). Health-care providers and public health officials should work to ensure that 1) sexually active, HIV-negative men are tested for HIV at least annually (providers may recommend more frequent testing, for example every 3–6 months); 2) HIV-negative MSM who engage in unprotected sex receive risk-reduction interventions; and 3) HIV-positive MSM receive HIV care, treatment, and prevention services. Reducing the burden of HIV among MSM is fundamental to reducing HIV infection in this country.

References

1. CDC. Diagnoses of HIV infection in the United States and dependent areas, 2011. HIV surveillance report. Vol. 23. Atlanta, GA: US Department of Health and Human Services, CDC; 2013. Available at http://www.cdc.gov/hiv/library/reports/surveillance/2011/surveillance_report_vol_23.html.
2. CDC. Gay and bisexual men's health: HIV/AIDS: serosorting among MSM. Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Available at http://www.cdc.gov/msmhealth/serosorting.htm.
3. Smith D, Herbst JH, Zhang X, Rose C. Condom efficacy by consistency of use among MSM. Presented at the 20th Conference on Retroviruses and Opportunistic Infections; March 3–6, 2013; Atlanta, GA. Abstract 32.
4. Hart GJ, Elford J. Sexual risk behaviour of men who have sex with men: emerging patterns and new challenges. Curr Opin Infect Dis 2010;23:39–44.
5. Wejnert C, Le B, Rose C, et al. HIV infection and awareness among men who have sex with men—20 cities, United States, 2008 and 2011. PLoS One 2013;8:e76878.
6. Hall HI, Holtgrave DR, Maulsby C. HIV transmission rates from persons living with HIV who are aware and unaware of their infection. AIDS 2012;26:893–6.
7. CDC. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR 2006;55(No. RR-14).
8. CDC. Sexually transmitted diseases treatment guidelines, 2010. MMWR 2010;59(No. RR-12).
9. CDC. Interim guidance: preexposure prophylaxis for the prevention of HIV infection in men who have sex with men. MMWR 2011;60:65–8.

* Estimated numbers of HIV diagnoses resulted from statistical adjustment that accounted for reporting delays and missing transmission category but not for incomplete reporting. Diagnoses data are used to describe the geographic distribution of the HIV burden among MSM.

† NHBS monitors HIV-associated behaviors and HIV prevalence within selected metropolitan statistical areas (MSAs) with high acquired immunodeficiency syndrome (AIDS) prevalence among three populations at high risk for HIV infection: MSM, injection drug users, and heterosexual adults at increased risk for HIV infection. Data for NHBS are collected in annual rotating cycles. All NHBS participants must be aged ≥18 years, live in a participating MSA, and be able to complete a behavioral survey in English or Spanish. MSM participants were recruited using venue-based sampling. The first MSM cycle of NHBS in 2003–2005 (referred to as 2005 in this report) included the following cities: Atlanta, Georgia; Baltimore, Maryland; Boston, Massachusetts; Chicago, Illinois; Denver, Colorado; Fort Lauderdale, Florida; Houston, Texas; Los Angeles, California; Miami, Florida; Newark, New Jersey; New York City, New York; Philadelphia, Pennsylvania; San Diego, California; San Francisco, California; and San Juan, Puerto Rico. The second MSM cycle of NHBS in 2008 included all the cities in the first cycle except Fort Lauderdale, Florida; plus the following cities: Washington, DC; Dallas, Texas; Detroit, Michigan; New Orleans, Louisiana; Nassau-Suffolk, New York; St. Louis, Missouri; and Seattle, Washington. The third MSM cycle of NHBS included all the cities in the second cycle except for St. Louis.

§ Unprotected anal sex was defined as sex without a condom with a male partner at least once in the 12 months before the survey interview. The outcome is reported for self-reported HIV-positive and self-reported HIV-negative or unknown-status MSM. Self-reported negative and unknown-status MSM are grouped together to represent the group "at risk" for HIV infection based on self-reported status. Persons of unknown status include: last HIV test results were indeterminate, did not receive test results, did not know the results, or had never been tested. The analysis included all MSM participating in NHBS irrespective of whether they had an HIV test through NHBS. Men who consented to and completed the survey and reported having a male sex partner in the past year were included in the analyses. All cities that participated in any of the three cycles of NHBS among MSM were included. Because the studies used different geographic eligibility criteria with slightly different cities participating in each cycle, a sensitivity analysis limited to the 14 cities that participated in all three cycles was conducted and found similar results.

¶ Generalized estimating equations using a robust variance estimate and assuming a Poisson model were used to test if a linear trend exists between 2005, 2008, and 2011 in the percentage of MSM that had unprotected anal sex at least once with a male partner in the past 12 months. All models included year, age, race/ethnicity, and city and interactions for year × age and year × race. Year was treated as a continuous variable. P-values for the 2005 to 2011 trend were calculated (Table 1); p<0.05 was considered statistically significant.

** Data from 2008 and 2011 for MSM with a valid HIV test result (positive or negative) were used to describe unprotected discordant anal sex, defined as not using a condom at last sex with a male partner of opposite or unknown HIV status. Based on HIV-test results, the analysis subgroups for the first outcome (self-reported positive and self-reported negative or unknown status MSM) are further divided into HIV-positive aware, HIV-positive unaware, and HIV-negative MSM. HIV-positive aware MSM are defined as self-reported HIV-positive MSM with a confirmed positive HIV test result in the NHBS survey. HIV-positive unaware MSM are defined as MSM with a confirmed positive HIV test result in the NHBS survey who reported their last HIV test result was negative, indeterminate, did not receive test results, did not know the results, or had never been tested. HIV-negative MSM are defined as self-reported negative or unknown HIV status participants with an HIV-negative test result in the NHBS survey. Data from 2005 were excluded from this analysis since HIV testing was only conducted in five cities.

†† Because no statistically significant difference (p<0.05) was found in the percentage engaging in unprotected discordant sex between years, a multivariate analysis was not conducted for this outcome (Table 2).

§§ Respondents with a confirmed positive HIV test result in NHBS who reported having previously tested positive for HIV were considered to be aware of their infection. Those with a confirmed positive HIV test result in NHBS, who reported previously testing negative, not knowing their last test result or never testing, were considered unaware of their HIV status.

¶¶ Generalized estimating equations using a robust variance estimate and assuming a Poisson model were used to determine the associations between unprotected discordant sex and HIV status (using HIV-positive unaware as the reference category) after adjusting for race/ethnicity, age, and city.

What is already known on this topic?

Although men who have sex with men (MSM) are a small proportion of the population, MSM represent the majority of persons diagnosed with human immunodeficiency virus (HIV) in the United States.

What is added by this report?

Unprotected anal sex increased among MSM from 2005 to 2011; unprotected discordant anal sex was the same in 2008 and 2011. In 2011, one third of HIV-positive MSM who did not know they were infected with HIV reported recent unprotected anal sex with a partner of HIV-negative or unknown status, compared with 13% of HIV-positive aware and 12% of HIV-negative MSM. Only 67% of sexually active MSM reported getting an HIV test in the past year.

What are the implications for public health?

Expanded efforts are needed to reduce HIV risk behaviors and to promote at least annual HIV testing among MSM. Health-care providers and public health officials should work to ensure that 1) sexually active, HIV-negative MSM are tested for HIV at least annually (providers may recommend more frequent testing, for example every 3–6 months); 2) HIV-negative MSM who engage in unprotected sex receive risk-reduction interventions; and 3) HIV-positive MSM receive HIV care, treatment, and prevention services.

FIGURE 1. Estimated percentage of persons diagnosed with HIV with infection attributed to male-to-male contact or male-to-male contact and injection drug use, by area of residence — National HIV Surveillance System, United States, 2011

Alternate Text: The figure above shows the estimated percentage of persons diagnosed with HIV with infection attributed to male-to-male contact or male-to-male contact and injection drug use, by area of residence, in the United States in 2011. In 2011, men who have sex with men accounted for at least half of persons diag¬nosed with HIV in all but two states.

TABLE 1. Number and percentage of men who have sex with men who reported unprotected* anal sex with a male partner in the past 12 months, by self-reported human immunodeficiency virus (HIV) status — National HIV Behavioral Surveillance System, United States, 2005, 2008, and 2011†
Characteristic	2005			2008			2011			p-value§
	No. in sample	No.	(%)	No. in sample	No.	(%)	No. in sample	No.	(%)
Self-reported HIV-positive
Overall	1,441	796	(55)	1,101	623	(57)	1,244	769	(62)	0.054
Race/Ethnicity
Black, non-Hispanic	296	140	(47)	269	137	(51)	417	235	(56)	0.026
Hispanic¶	285	146	(51)	228	124	(54)	262	156	(60)	0.198
White, non-Hispanic	744	446	(60)	526	320	(61)	488	332	(68)	0.051
Other/Multiple races**	103	59	(57)	78	42	(54)	72	43	(60)	0.771
Age group (yrs)
18–24	49	26	(53)	79	41	(52)	143	78	(55)	0.776
25–29	98	64	(65)	123	77	(63)	167	116	(69)	0.246
30–39	569	342	(60)	326	207	(63)	316	227	(72)	0.002
≥40	725	364	(50)	573	298	(52)	618	348	(56)	0.092
Self-reported HIV-negative or unknown status††
Overall	10,016	4,693	(47)	8,152	4,394	(54)	8,009	4,546	(57)	<0.001
Race/Ethnicity
Black, non-Hispanic	1,732	697	(40)	1,919	952	(50)	2,068	1,003	(49)	0.113
Hispanic¶	2,677	1,265	(47)	2,004	1,138	(57)	2,145	1,340	(62)	<0.001
White, non-Hispanic	4,506	2,235	(50)	3,498	1,921	(55)	3,177	1,840	(58)	<0.001
Other/Multiple races**	993	443	(45)	725	380	(52)	600	350	(58)	<0.001
Age group (yrs)
18–24	2,186	996	(46)	1,992	1,133	(57)	2,209	1,302	(59)	<0.001
25–29	1,813	912	(50)	1,588	944	(59)	1,583	965	(61)	<0.001
30–39	3,310	1,646	(50)	2,236	1,232	(55)	1,874	1,119	(60)	0.003
≥40	2,707	1,139	(42)	2,336	1,085	(46)	2,343	1,160	(50)	<0.001
Total	11,457	5,489	(48)	9,253	5,017	(54)	9,253	5,315	(57)	<0.001
* Neither the respondent nor his sex partner used a condom all the time. † Percentages might not add to 100 because of rounding; numbers might not add to total because of missing data. § Adjusted p-values for the 2005 to 2011 trend; all models include year, age, race/ethnicity, and city and interactions for year × age and year × race/ethnicity. Interactions for year × age and year × race/ethnicity were not statistically significant, suggesting that no overall difference in trend existed between race/ethnicity categories, likewise for age categories. P<0.05 is considered statistically significant. ¶ Respondents of Hispanic ethnicity might be of any race. ** Other races include American Indian/Alaska Native, Asian, Native Hawaiian/other Pacific Islander, and mixed race. †† Includes respondents who reported their last HIV test result was negative, indeterminate, did not receive test results, did not know the results, or had never been tested.

TABLE 2. Number and percentage of men who have sex with men who reported unprotected* anal sex at last sex with a male partner of human immunodeficiency virus (HIV) discordant or unknown status, by HIV status of the participant — National HIV Behavioral Surveillance System, United States, 2008 and 2011†
Characteristic	2008			2011			p-value§
	No. in sample	No.	(%)	No. in sample	No.	(%)
Self-reported HIV-positive
HIV-positive aware¶ with a partner of HIV-negative or unknown status
Overall	882	139	(16)	1,032	139	(13)	0.16
Race/Ethnicity
Black, non-Hispanic	219	36	(16)	357	47	(13)	0.28
Hispanic**	190	29	(15)	216	41	(19)	0.32
White, non-Hispanic	410	69	(17)	394	42	(11)	0.01
Other/Multiple races††	63	5	(8)	60	9	(15)	0.22
Age group (yrs)
18–24	62	8	(13)	123	15	(12)	0.89
25–29	95	15	(16)	139	26	(19)	0.56
30–39	256	50	(20)	254	39	(15)	0.21
>40	469	66	(14)	516	59	(11)	0.21
Self-reported HIV-negative or unknown status
HIV-positive unaware§§ with a partner of HIV-negative or unknown status
Overall	676	201	(30)	521	174	(33)	0.18
Race/Ethnicity
Black, non-Hispanic	314	82	(26)	307	97	(32)	0.13
Hispanic**	163	44	(27)	124	44	(35)	0.12
White, non-Hispanic	138	52	(38)	65	24	(37)	0.92
Other/Multiple races††	61	23	(38)	24	8	(33)	0.71
Age group (yrs)
18–24	135	33	(24)	129	41	(32)	0.18
25–29	128	40	(31)	104	29	(28)	0.58
30–39	212	65	(31)	127	51	(40)	0.07
≥40	201	63	(31)	161	53	(33)	0.75
HIV-negative with partner of HIV-positive or unknown status
Overall	6,591	734	(11)	6,867	806	(12)	0.27
Race/Ethnicity
Black, non-Hispanic	1,346	164	(12)	1,551	198	(13)	0.64
Hispanic**	1,676	249	(15)	1,885	260	(14)	0.37
White, non-Hispanic	2,959	271	(9)	2,879	291	(10)	0.22
Other/Multiple races††	605	49	(8)	538	53	(10)	0.30
Age group (yrs)
18–24	1,691	196	(12)	1,930	236	(12)	0.56
25–29	1,306	143	(11)	1,382	141	(10)	0.53
30–39	1,761	187	(11)	1,597	191	(12)	0.22
≥40	1,833	208	(11)	1,958	238	(12)	0.44
Total	8,149	1,074	(13)	8,420	1,119	(13)	0.83
* Neither the respondent nor his sex partner used a condom all the time. † Percentages might not add to 100 because of rounding; numbers might not add to total because of missing data. § Chi-square p-value for comparison of 2008 and 2011 percentages. P<0.05 is considered statistically significant. ¶ Respondents with a confirmed positive HIV test result in the survey who reported having previously tested positive for HIV. ** Respondents of Hispanic ethnicity might be of any race. †† Other races include American Indian/Alaska Native, Asian, Native Hawaiian/other Pacific Islander, and mixed race. §§ Includes respondents with a confirmed positive HIV test result in the survey who reported their last HIV test result was negative, indeterminate, did not receive test results, did not know the results, or had never been tested.

FIGURE 2. Time since last human immunodeficiency virus (HIV) test among men who have sex with men who reported negative or unknown HIV status,* — National HIV Behavioral Surveillance System, United States, 2011†

* Includes respondents who reported their last HIV test result was negative, indeterminate, did not receive test results, did not know the results, or had never been tested.

† N = 7,312; excludes 76 respondents missing data for time of HIV test.

Alternate Text: The figure above shows the time since last HIV test among men who have sex with men (MSM) who reported negative or unknown HIV status in the United States in 2011. Among HIV-negative or unknown status MSM, 67% reported testing for HIV in the past 12 months. A higher percentage tested in the past ≤3 months (31%) than in the past 4-6 months (17%) or in the past 7-12 months (19%).

FIGURE 3. Percentage who were human immunodeficiency virus (HIV)-positive unaware among men who have sex with men who reported negative or unknown HIV status, by time since last HIV test — National HIV Behavioral Surveillance System, United States, 2011*

* N = 7,312; excludes 76 respondents missing data for time of HIV test. Bars represents percentage testing positive in the survey among men who have sex with men who reported having had an HIV test at each time interval.

Alternate Text: The figure above shows the percentage of HIV-positive unaware among men who have sex with men who reported negative or unknown HIV status, by time since last HIV test, in the United States in 2011. The percentage HIV-positive but unaware was 5% among those who tested in the past 12 months: 4%, 5%, and 7% among those tested ≤3, 4-6, and 7-12 months ago, respectively.

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