Marion County Public Health Department, Epidemiology Request DR2370
Prepared by: Tammie L. Nelson, MPH, CPH

The Marion County Public Health Department’s Ryan White Services Program oversees Ryan White Part A, C, and Minority AIDS Initiative grants in the Indianapolis-Carmel Metropolitan Statistical Area (MSA). These programs serve the needs of persons newly infected or living with HIV and out of care and/or uninsured or medically underserved.

HIV Continuum of Care: Engagement in the continuum of care is important in the prevention of secondary transmission and for improving health outcomes and quality of life among people living with HIV (PLWH).^1,2,3 While engagement in care in the MSA is similar to the U.S. overall (see the April 2015 Quality Matters article), disparities are experienced by racial minorities (Figure 1).⁴

Figure 1: HIV Continuum of Care by Race/Ethnicity, Indianapolis-Carmel MSA: 2014

HIV Diagnosis: Overall, about 14% of HIV-positive U.S. residents are undiagnosed and unaware of their status.⁵ When evaluated by race/ethnicity, a higher percentage of minorities are undiagnosed.⁵ Among White PLWH, about 12% are thought to be undiagnosed while the estimate among Blacks and Latinos is 15%. The percentage of undiagnosed PLWH is even higher among other racial/ethnic minorities.

Linkage to Care: Among MSA residents living with HIV, the largest racial disparity is in linkage to care, defined as having attended one’s first HIV primary care visit within 90 days of diagnosis. Of MSA residents newly diagnosed with HIV during 2014, only 68% of Blacks and 78% of Latinos were linked to care within 90 days as compared to 87% of Whites and 100% of other races/ethnicities.

Retention in Care: Although less likely to be linked to care within 90 days of their diagnoses, Blacks and Latinos were more likely to be retained in care, defined by having attended at least one HIV medical visit in each six month period of 2013 and 2014 with at least 60 days between one visit in each period. About 51% of Blacks and 54% of Latinos were retained in care throughout 2013-2014; whereas only 47% of Whites and 46% of others were retained in care.

Prescription of HIV Antiretroviral Medications (ART): Because reporting prescriptions for ART is not mandated in Indiana, and because the percentage of PLWH having suppressed viral loads is much higher than the percentage of ART prescriptions reported, it is assumed that ART prescriptions are grossly under reported. For this reason, disparities in this measure cannot be verified.

Suppressed Viral Load: Among White PLWH in the MSA who received at least one viral load test during 2014, 86% had suppressed viral loads (below 200 copies/mL). Suppressed viral loads were found among 83% of Latinos and those of other races/ethnicities. Among Blacks, however, only 76% had suppressed viral loads.

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Sources:

¹ Branson, et al. (2006) Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings.

² Gardner, et al. (2011). The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection.

³ CDC. (2015). Vital signs: HIV prevention through care and treatment – United States.

⁴ CDC. (2015). Enhanced HIV/AIDS reporting system (eHARS) (as provided by the Indiana State Department of Health).

⁵ CDC. (2014). Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas—2012.

Marion County Public Health Department, Epidemiology Request DR2370
Prepared by: Sara J. Hallyburton and Tammie L. Nelson, MPH, CPH

The Marion County Public Health Department’s Ryan White Services Program oversees Ryan White Part A, C, and Minority AIDS Initiative grants in the Indianapolis-Carmel Metropolitan Statistical Area (MSA). These programs serve the needs of persons newly infected or living with HIV and out of care and/or uninsured or medically underserved.

About LGBT Health: People who identify as lesbian, gay, bisexual, or transgender fall under the umbrella term known as LGBT. While grouped under this acronym, each individual within the LGBT community differs in race, ethnicity, age, socioeconomic status, and identity.¹ They are bound together as social and gender minorities by shared experiences of discrimination and stigma.¹ Individuals within the LGBT community experience social inequality, which can be associated with less than adequate health status and an increased risk for health problems as compared to their heterosexual peers.² The viewpoints and needs of this group should always be considered in public health efforts to improve health and reduce health disparities.²

HIV in Men Who Have Sex with Men (MSM): Although anyone, LGBT or not, can be infected with HIV, MSM are disproportionately affected. According to the Centers for Disease Control and Prevention (CDC), 13-24 year old MSM remain the most heavily affected population with HIV.³ The number of new HIV infections among U.S. MSM increased 12% from 2008 to 2010; with a 22% increase in those ages 13-24.³ While MSM represent roughly 7% of the U.S. male population, they accounted for 78% of new HIV infections in men.³ Not all men who identify as gay and bisexual with HIV are getting the health care they need. Of gay and bisexual men with HIV, only: 77.5% were linked to care (received their first HIV primary care visit within 90 days of diagnosis); 50.9% stayed in care; 49.5% received a prescription for antiretroviral therapy (ART); and, 42% are virally suppressed (Figure 1).

HIV among Transgender People: People who identify as transgender are also considered at high risk for HIV in the U.S.⁴ According to the CDC, transgender women are at high risk for HIV infection, and Black/African American transgender women have the highest HIV positivity rate from among all race/ethnicities.⁴ There have been many challenges in the prevention and treatment of HIV in transgender people. Currently, efforts are being taken to improve the quality of HIV data collected on transgender communities.⁴ In addition, the CDC and its allies are looking into a high-impact prevention approach to promote the goals of the National HIV/AIDS Strategy and increase the success of current HIV prevention approaches among transgender people.⁴ Visit HIV among Transgender People to learn more about what the CDC is doing in this area.

Creating a Welcoming Environment for LGBT Patients: LGBT health care training could be more thorough during medical and nursing school programs. In fact, a recent report stated that an average of only five hours is spent on LGBT issues during clinical training at medical schools in the U.S. and Canada.¹ That said, there are many resources available to aid clinicians in the understanding and care of LGBT patients; some examples follow.¹

Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who Are LGBT, Gender Nonconforming, or Born with DSD: A Resource for Medical Educators – Association of American Medical Colleges (2014)

Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community – The Joint Commission (2014)

The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding – The National Academies of Sciences, Engineering, and Medicine (2011)

The Health of Sexual Minorities Public Health Perspectives on Lesbian, Gay, Bisexual and Transgender Populations – Meyer & Northridge (2007)

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Sources:

¹ Ard, K., & Makadon, H. (n.d.) Improving the health care of lesbian, bisexual and transgender (LGBT) people: Understanding and eliminating health disparities.

² Centers for Disease Control and Prevention. (2014). About LGBT Health.

³ Centers for Disease Control and Prevention. (2015a). HIV incidence – Men who have sex with men.

⁴ Centers for Disease Control and Prevention. (2015b). HIV among transgender people.

Marion County Public Health Department, Epidemiology Request DR2370
Prepared by: Tammie L. Nelson, MPH, CPH

The Marion County Public Health Department’s Ryan White Services Program oversees Ryan White Part A, C, and Minority AIDS Initiative grants in the Indianapolis-Carmel Metropolitan Statistical Area (MSA). These programs serve the needs of persons newly infected or living with HIV and out of care and/or uninsured or medically underserved.

New Evidence Revealed: The National Institute of Allergy and Infectious Diseases (NIAID) recently unveiled the results of a major study on early initiation of HIV antiretroviral treatment (ART).¹ Begun in March 2011, the Strategic Timing of AntiRetroviral Treatment study (START)² was conducted at 215 sites in 35 countries and enrolled 4,685 asymptomatic, ART-naïve, HIV-positive men and women with CD4+ T-cell counts greater than 500. Although START was planned to run through the end of 2016, the benefits of initiating ART, “sooner rather than later,” were so compelling that the results were released early – an action rarely seen.¹

“These findings have global implications for the treatment of HIV.” – NIAID Director, Anthony S. Fauci, M.D.¹

Benefits of Early ART Initiation: START findings provide solid evidence that initiation of ART prior to the decline of CD4+ T-cell count leads to significantly improved health outcomes. In fact, the study showed a 53% reduction in risk for serious illness and death. START findings also support a decrease in secondary HIV transmission resulting from decreased viral load among those for whom ART was initiated early.¹

“This is an important milestone in HIV research.” – Jens Lundgren, M.D., University of Copenhagen and Co-Chair of the START study¹

Guidelines: Current U.S. guidelines recommend ART for all HIV-infected individuals regardless of CD4+ T-cell count.³ In addition, the Ryan White Services Program (RWSP) strives to ensure access to ART for 100% of HIV-infected residents of the MSA. Despite these guidelines and the benefits of the RWSP, only 47.7% (N=1,846) of HIV-infected MSA residents who attended at least one HIV primary care visit during 2014 (N=3,893) had ever received ART.⁴

Expense, complicated regimens, side effects, social stigma, and comorbid conditions (e.g., mental health, substance use) can contribute to a reluctance to begin, or poor adherence to, ART. A summary of recent International Association of Physicians in AIDS Care suggestions may guide practitioners into increasing entry into, and retention in, ART.⁵ In addition, strategies to improve adherence can be found in the guidelines’ Limitations to Treatment Safety and Efficacy: Adherence to Antiretroviral Therapy.

Please keep in mind that it is important to provide your local health department and/or Indiana State Department of Health with information regarding prescription of ART (i.e., patient ID, date, medication name). If this information is not provided then an accurate estimate of the number of HIV-infected MSA residents with access to ART cannot be ascertained. Please take a few moments to report prescriptions of ART to your local health department and/or Indiana State Department of Health.

Note: Some situations may require further consideration prior to ART administration. Always consult current U.S. guidelines for more information.

____________________________

Sources:

¹ National Institute of Allergy and Infectious Diseases: Starting antiretroviral treatment early improves outcomes for HIV-infected individuals: NIH-funded trial results likely will impact global treatment guidelines [Press release, May 27, 2015].

² National Institute of Allergy and Infectious Diseases: NIH study examines best time for healthy HIV-infected people to begin antiretrovirals [Press release, March 7, 2011].

³ U.S. Department of Health and Human Services: Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents.

⁴ Centers for Disease Control and Prevention: Enhanced HIV/AIDS reporting system (eHARS).

⁵ International Association of Physicians in AIDS Care: Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: Evidence-based recommendations from an IAPAC panel.

Marion County Public Health Department, Epidemiology Request DR2370
Prepared by: Tammie L. Nelson, MPH, CPH and Bonny Lewis Van, Ph.D., FACB, HCLD (ABB)

The Marion County Public Health Department’s Ryan White Services Program (RWSP) oversees Ryan White Part A, C, and Minority AIDS Initiative grants in the Indianapolis-Carmel Metropolitan Statistical Area (MSA). These programs serve the needs of persons newly infected or living with HIV and out of care and/or uninsured or medically underserved.

Revised HIV Case Definition: The Centers for Disease Control and Prevention (CDC) and the Council of State and Territorial Epidemiologists (CSTE) revised HIV surveillance case definitions in 2014.¹ Several changes were made, the most important of which were based on an improved HIV test algorithm that allows for earlier detection of HIV during the acute phase of infection; differentiation of HIV-1 and HIV-2; and, creation of a single case definition for individuals of any age.

Updated HIV Test Algorithm Recommendation: Because a span of approximately three months is necessary to develop a detectable HIV antibody response, the recommended algorithm (Figure 1) calls for test one – the Determine – to be an HIV-1/2 antigen/antibody combination immunoassay (HIV-1/2 ag/ab). This test is able to detect an HIV infection within approximately two weeks post-infection. Test two – the Differentiation – is able to confirm an HIV infection within approximately four weeks post-infection. If an individual has HIV but has not yet developed antibodies (seroconverted), then the Differentiation would be reported as indeterminate. In this instance, a third test is performed. Test three in the new algorithm, if necessary, is a nucleic acid test (NAT). The detection window for this test is only one week post-infection. This test is performed only when the Differentiation is indeterminate due to its cost.

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¹ Centers for Disease Control and Prevention & Council of State and Territorial Epidemiologists (2014). Revised surveillance case definition for HIV infection – United States, 2014. MMWR, 63(RR03): 1-10. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6303a1.htm?s_cid=rr6303a1_e

² Branson, B. M., Handsfield, H. H., Lampe, M. A., Janssen, R. S., Taylor, A. W., Lyss, S. B., and Clark, J. E. (2006). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR, 55(RR14): 1-17.

³ Gardner, E. M., McLees, M. P., Steiner, J. F., del Rio, C., and Burman, W. J. (2011). The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis., 52(6): 793-800.

⁴ Centers for Disease Control and Prevention. (2011). Vital signs: HIV prevention through care and treatment – United States. MMWR, 60(47):1621.

⁵ Centers for Disease Control and Prevention & Association of Public Health Laboratories. (2014). Laboratory testing for the diagnosis of HIV infection: Updated recommendations. Retrieved from http://stacks.cdc.gov/view/cdc/23447

Marion County Public Health Department, Epidemiology Request DR2370
Prepared by: Tammie L. Nelson (TNelson@MarionHealth.org)

The Marion County Public Health Department’s Ryan White Services Program (RWSP) oversees Ryan White Part A, C, and Minority AIDS Initiative grants in the Indianapolis-Carmel Metropolitan Statistical Area (MSA). These programs serve the needs of persons newly infected or living with HIV and out of care and/or uninsured or medically underserved.

HIV Continuum of Care: Delayed linkage and poor engagement in care among people living with HIV (PLWH) has been associated with increased transmission, drug resistance, quicker progression to AIDS, decreased quality of life, and increased mortality.^1,2,3 Thus, it is vital to monitor and improve engagement in each step of the HIV continuum of care. The RWSP employs a continuum of care based on common indicators published by the Health Resources and Service Administration’s HIV/AIDS Bureau (HAB). This method encourages similarity in jurisdictional reporting. The measures are used by RWSP staff, Planning Council, and providers to measure program efficacy.

Indianapolis MSA and U.S. Continuum of Care – 2014 vs. 2013: Continuum of care measures were compared between calendar year 2014 and 2013 and MSA versus the U.S. Figure 1 illustrates the differences found. Definitions and data sources for each category can be viewed at [April 2015 definitions attachment].

Figure 1: HAB Continuum of Care Measures among People Living with HIV/AIDS, Indianapolis-Carmel Metropolitan Statistical Area and U.S.: 2014 v. 2013

When examining differences by calendar year for the MSA (Figure 1), decreases in the percentage of people linked to care and prescribed ART were reported. A significant (P<0.05) 23.5% decrease in retention in care is reflected. During the same period, however, a small increase in the percentage with suppressed viral loads was reported.

It makes little sense that suppressed viral loads would have increased while retention in care and prescriptions for ART decreased. This strengthens a previous argument [January article] that, “If it wasn’t documented, then it didn’t happen.” That being said, it is important to provide your clients with regular viral load checks and to provide your local and/or state health department with information regarding all prescriptions for ART (i.e., patient, date, medication).

Note: The 2013 data presented here varies from that published in a past Quality Matters article. Database updates led to revisions in 2013 linkage to care (previously reported as 79.2%), retention in care (previously reported as 62.1%), and prescription of antiretroviral therapy (ART) (previously reported as 47.8%). Percentage of PLWH who have been diagnosed was increased to 86% from 84.2% based upon a revised estimation of the number of PLWH but undiagnosed and unaware of their serostatus by the Centers for Disease Control and Prevention (CDC).⁴ Lastly, a substantial difference is seen in the percent with suppressed viral loads (previously reported as 61.9%). The difference reported is due to a combination of database updates, reporting lag, improved match-merges, and LOINC code changes.

1 Branson, B. M., Handsfield, H. H., Lampe, M. A., Janssen, R. S., Taylor, A. W., Lyss, S. B., and Clark, J. E. (2006). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR, 2006;55(RR14): 1-17.

2 Gardner, E. M., McLees, M. P., Steiner, J. F., del Rio, C., and Burman, W. J. (2011). The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 2011;52(6): 793-800.

3 Centers for Disease Control and Prevention. (2011). Vital signs: HIV prevention through care and treatment – United States. MMWR, 2011;60(47):1621.

4 Centers for Disease Control and Prevention. (2014). Monitoring selected national HIV prevention and care objectives by using HIV surveillance data – United States and 6 dependent areas – 2012. HIV Surveillance Supplemental Report, 19(3).

Source: Marion County Public Health Department, Epidemiology Request DR2370
Prepared by: Tammie L. Nelson (TNelson@MarionHealth.org)

The Marion County Public Health Department’s Ryan White Services Program (RWSP) oversees Ryan White Part A, C, and Minority AIDS Initiative grants in the Indianapolis-Carmel Metropolitan Statistical Area (MSA). These programs serve the needs of persons newly infected or living with HIV and out of care and/or uninsured or medically underserved.

Estimating HIV Prevalence: Estimation of the number of people living with HIV (PLWH) but undiagnosed and unaware of their serostatus is frequently revised. The Centers for Disease Control and Prevention (CDC) recently decreased the estimate from 15.8% to 14% of PLWH ≥13 years of age.¹ Based on this estimate, total prevalence in the MSA on December 31, 2013 is thought to have been 6,223 (5,351 diagnosed and 872 undiagnosed).^2,3

Target: The National HIV/AIDS Strategy (NHAS) goal is to increase the percentage of PLWH who are diagnosed and aware of their serostatus to 90%.⁴

Importance of Early Diagnosis: Diagnosis is the first step in the HIV continuum of care. Early diagnosis and linkage to and retention in care have been associated with delayed progression to AIDS and increases in quality and length of life.^5,6,7 These factors also reduce secondary HIV transmission.^5,8,9 Evidence shows that HIV transmission rate is highest among those undiagnosed, accounting for approximately 30% of new HIV infections.¹⁰ Although early diagnosis is most effective when combined with linkage to and retention in care, diagnosis alone can decrease secondary transmission by decreasing risk factors of transmission (i.e., sex with HIV-discordant partners).^10,11,12,13

Who is Most at Risk: CDC estimates attribute the largest differences in percentage of undiagnosed PLWH to age, where estimates decrease from 51.3% in 13-24 year olds to only 5.1% in those 65 and older.¹ Among youth and young adults, those most at risk are minority males.¹⁴ Table 1 provides estimates of the number and percentage, by age, of undiagnosed PLWH in the MSA calculated using national estimates. Note: Generalizing national estimates to the MSA can produce inaccuracies; thus, Table 1 is meant only to provide approximations of undiagnosed PLWH in the MSA.

Table: Diagnosed and Estimated Undiagnosed HIV in the Indianapolis-Carmel Metropolitan Statistical Area: 31Dec2013^1,2

Overall, a larger percentage of males (14.8%) are thought to be undiagnosed than females (11.5%).¹ A smaller percentage of non-Hispanic White PLWH (11.9%) are thought to be undiagnosed than minorities where 15% of non-Hispanic Black and 15% of Hispanic PLWH are estimated to be undiagnosed.¹

Guidelines for Increasing Diagnosis and Sero-Awareness among PLWH:

Identify and reach out to those most at risk for HIV infection – Identify populations and geographic areas with the greatest HIV burden and design programs to reach them. Populations bearing the greatest burden of HIV in the MSA include MSM, young African American men, and African American women.² Other conditions leading to increased risk of HIV infection in the MSA include IDU, mental illness, former incarceration, and/or homelessness.^{2,14,15,16,17}

Increase readiness of individuals to be tested for HIV – Develop programs to increase awareness of HIV infection and risk reduction methods and strive to decrease stigma related to HIV, sexual identity, substance use, mental health issues, lack of trust in the medical system, and low health literacy.¹⁸ Consider using peer-based outreach programs.¹⁴Design education and risk reduction programs to emphasize the importance of regular HIV screening and early HIV diagnosis.¹⁹ High risk individuals should be tested for HIV at least once annually.¹⁷

Increase access to HIV testing – Consider placing HIV testing sites along bus routes or at non-traditional sites such as community-based organizations, mental health centers, and social service agencies.¹⁸ Eliminate long wait times at testing sites. Provide bilingual staff or language services.¹⁸ Make use of rapid test methods. Consider supporting anonymous testing and home collection kits.¹⁹ Increase testing in health care and correctional facilities.¹⁹

Follow through on those tested – Refer those who test negative to HIV health education and risk reduction programs.¹⁹ Provide post-test counseling for those who test positive. Conduct contact investigations and provide direct partner service notification and testing of sex and needle-sharing partners.¹⁹

Increase routine HIV screening in health care settings – Follow CDC and U.S. Preventive Services Task Force (USPSTF) recommendations of routine HIV screening in: all patients 13-65 years of age (CDC recommends 13-64 year olds be screened and USPSTF recommends 15-65 be screened); younger and older patients who are at increased risk; all pregnant women, including those presenting in labor; and, those seeking treatment for sexually-transmitted disease or tuberculosis.^20,21

Given the strong collaborations and dedication to diagnosing all PLWH in the MSA, the number remaining undiagnosed and unaware of their serostatus should continue to decrease. As you contemplate future programming for your organization, consider employing some of the tactics intended to increase diagnosis. For more information on HIV screening and testing recommendations, visit www.cdc.gov/hiv/guidelines/testing.html.

1 Centers for Disease Control and Prevention. (2014). Monitoring selected national HIV prevention and care objectives by using HIV surveillance data – United States and 6 dependent areas – 2012. HIV Surveillance Supplemental Report, 19(3).

2 Centers for Disease Control and Prevention. (2015). Enhanced HIV/AIDS Reporting System (eHARS).

3 Previously reported as 6,427 (5,411 diagnosed and 1,016 undiagnosed) based on early prevalence reports and 2013 CDC estimation methods. [Nelson, T. L. (2014, December 5). HIV care updates for the Indianapolis-Carmel Metropolitan Statistical Area. MATEC Indiana Newsletter, 65.].

4 The White House Office of National AIDS Policy. (2010). National HIV/AIDS strategy for the United States.

5 Centers for Disease Control and Prevention. (2013). Prevention benefits of HIV treatment.

6 Centers for Disease Control and Prevention. (2012) Linkage to and retention in HIV Medical Care.

7 Chadborn, T. R., Delpech, V. C., Sabin, C. A., Sinka, K., & Evans, B. G. (2006). The late diagnosis and consequent short-term mortality of HIV-infected heterosexuals (England and Wales, 2000–2004). AIDS, 20(18), 2371–2379.

8 Cohen, M. S., Chen, Y. Q., McCauley, M., Gamble, T., Hosseinipour, M. C., Kumarasamy, N., . . . HPTN 052 Study Team. (2011). Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med, 365(6), 493-505.

9 Gardner, E. M., McLees, M. P., Steiner, J. F., del Rio, C., and Burman, W. J. (2011). The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis, 52(6), 793-800.

10 Skarbinski, J., Rosenberg, E., Paz-Bailey, G., Hall, H. I., Rose, C. E., Viall, A. H., . . . Mermin, J. H. (2015). Human immunodeficiency virus transmission at each step of the care continuum in the United States. JAMA Intern Med. doi: 10.1001/jamainternmed.2014.8180.

11 Hall, H. I., Holtgrave, D. R., & Maulsby, C. (2012). HIV transmission rates from persons living with HIV who are aware and unaware of their infection. AIDS, 26(7), 893-896.

12 Marks, G., Crepaz, N., & Janssen, R. S., (2006). Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS, 20(10), 1447-1450.

13 Marks, G., Crepaz, N., Senterfitt, J. W., & Janssen, R. S. (2005). Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: Implications for HIV prevention programs. J Acquir Immune Defic Syndr, 39(4), 446-453.

14 Chen, M., Rhodes, P. H., Hall, H. I., Kilmarx, P. H., Branson, B. M., & Valleroy, L. A. (2012). Prevalence of undiagnosed HIV infection among persons aged ≥13 years — National HIV surveillance system, United States, 2005–2008. MMWR, 61(02), 57-64.

15 Wallace, M. & Nelson, T. (2014). Indianapolis TGA FY 2015 Ryan White Part A HIV Emergency Relief Grant Program – Attachment 5: Co-Morbidities, Cost, and Complexity Table, Indianapolis TGA. Available from Ryan White Services Program, Marion County Public Health Department.

16 Centers for Disease Control and Prevention, Health Resources and Services Administration, National Institutes of Health, & HIV Medicine Association of the Infectious Diseases Society of America. (2003). Incorporating HIV prevention into the medical care of persons living with HIV. MMWR, 52(RR12), 1-24.

17 Centers for Disease Control and Prevention. (2006). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR, 55(RR14), 1-17.

18 U.S. Department of Health & Human Services. (2014). Increasing Access to HIV Care and Treatment.

19 Janssen, R. S., Holtgrave, D. R., Valdiserri, R. O., Shepherd, M., Gayle, H. D., & DeCock, K. M. (2001). The serostatus approach to fighting the HIV epidemic: Prevention strategies for infected individuals. Am J Public Health, 91(7), 1019-1024.

20 Branson, B. M., Handsfield, H. H., Lampe, M. A., Janssen, R. S., Taylor, A. W., Lyss, S. B., & Clark, J. E. (2006). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR, 55(RR14), 1-17.

21 U.S. Preventive Services Task Force. (2013). Final Recommendation Statement: Human Immunodeficiency Virus (HIV) Infection: Screening.