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Many countries with high HIV burden have made substantial progress towards UNAIDS 95-95-95 targets and ending AIDS, but gaps in some sub-populations hinder overall achievement, even as programmes face potentially diminished resources. While certain broad groups defined by age, sex or large geographic regions are commonly labelled as \"high-risk\" for being out of care, most individuals within these groups are in care and virally suppressed. Characteristics beyond age and sex (e.g. behavioural, socio-economic, smaller geographic areas) may differentiate those requiring targeted intervention strategies. Our Closing The Gap project aims to characterize unreached and disengaged sub-populations for targeted HIV interventions across Mozambique, South Africa and Zimbabwe, countries selected for their varied target achievement and diverse populations. We discuss overarching themes from the first Closing The Gap workshop, convening government stakeholders, implementers, researchers and community representatives in February 2025. Key themes emerged from the workshop: (1) the importance of considering absolute sub-population size, alongside percentages, when assessing service gaps; (2) limitations of existing data and analytic paradigms beyond age-and-sex categories, highlighting the need for richer, contextual data linked to care cascade outcomes (e.g. clinical markers, mobility, socio-economic circumstances) and analyses incorporating additional factors for identifying more granular sub-populations; (3) need to identify individuals who do not require differentiated care to better prioritize resources to those not served by existing models; and (4) in the context of decreasing funding, the need to balance the cost and complexity of differentiated interventions with the feasibility and cost-effectiveness of standardized approaches, including self-selection strategies. It is critically important to generate more efficient strategies to close HIV care cascade gaps and sustain positive progress amidst potentially reduced future resources towards HIV. This may need a paradigm shift in service differentiation that specifically identifies sub-populations most-at-risk of suboptimal outcomes, beyond age/sex categories, while efficiently balancing sub-population size and proportionate risk. Data-driven prioritization of cost-effective interventions targeting the unreached and underserved is essential for sustaining progress in the evolving HIV response.

Option B+, an approach that involves provision of antiretroviral therapy (ART) to all HIV-infected pregnant women for life, is the preferred strategy for prevention of mother to child transmission of HIV. Lifelong retention in care is essential to its success. We conducted a discrete choice experiment in Ethiopia and Mozambique to identify health system characteristics preferred by HIV-infected women to promote continuity of care. Women living with HIV and receiving care at hospitals in Oromia Region, Ethiopia and Zambézia Province, Mozambique were shown nine choice cards and asked to select one of two hypothetical health facilities, each with six varying characteristics related to the delivery of HIV services for long term treatment. Mixed logit models were used to estimate the influence of six health service attributes on choice of clinics. 2,033 women participated in the study (response rate 97.8% in Ethiopia and 94.7% in Mozambique). Among the various attributes of structure and content of lifelong ART services, the most important attributes identified in both countries were respectful provider attitude and ability to obtain non-HIV health services during HIV-related visits. Availability of counseling support services was also a driver of choice. Facility type, i.e., hospital versus health center, was substantially less important. Efforts to enhance retention in HIV care and treatment for pregnant women should focus on promoting respectful care by providers and integrating access to non-HIV health services in the same visit, as well as continuing to strengthen counseling.

HIV risk perceptions and behaviors of 236 commercial sex workers from three major Mozambican urban centers were studied using the International Rapid Assessment, Response and Evaluation (I-RARE) methodology. All were offered HIV testing and, in Maputo, syphilis testing was offered as well. Sixty-three of the 236 opted for HIV testing, with 30 (48%) testing positive for HIV. In Maputo, all 30 receiving HIV tests also had syphilis testing, with 6 (20%) found to be positive. Results include interview excerpts and qualitative results using I-RARE methodology and AnSWR-assisted analyses of the interviews and focus group sessions.

Oral pre-exposure prophylaxis (PrEP) is a highly effective option for HIV prevention. To realize the full benefit of PrEP at the population level, uptake must reach those at the greatest risk of HIV acquisition. Guidance published by Centers for Disease Control and Prevention (CDC) suggests that the number of individuals with indications for PrEP is 1.1-1.2 million nationally based on survey data of key populations and local transmission patterns. We applied these estimates at state and county levels to determine the number of individuals who might benefit from PrEP locally and compared our estimates to CDC-published estimates for Colorado. This analysis aimed to produce estimates of key populations with indications for PrEP in Colorado as a whole and by county type. These estimates will be used for public health strategic planning for HIV prevention goals at the state and county jurisdictional levels. Colorado population estimates were obtained from the state demography office, which utilizes US decennial census data and input from county and local agencies to forecast the population. We limited our analysis to adults aged 18-59 years to be consistent with CDC methodology for PrEP estimates. We performed a literature review to define the best population-level percentages to determine numbers of HIV-negative men who have sex with men (MSM) and people who inject drugs (PWID) in Colorado. These percentages were applied to the state and to each county by its rural-urban designation. Finally, CDC-derived percentages of MSM and PWID with indications for PrEP were applied to these estimates to determine numbers of MSM and PWID who may benefit from PrEP use. In 2017, 3,252,648 adults aged 18-59 years were living in Colorado. By applying published estimates of percentages of men who had sex with other men in the past 12 months, we determined that 41,353-49,624 adult males could be considered sexually active MSM. We estimated that 9758-13,011 adults aged 18-59 years were likely to have injected drugs in the past 12 months. By accounting for numbers of people living with HIV in those categories and applying the CDC PrEP percentages of MSM and PWID with indications for PrEP nationally, we estimated that 8792-12,528 MSM and PWID in Colorado had indications for PrEP; this number is smaller than that estimated by CDC, although within the lower CI limit. By employing a simple framework consisting of census data, literature review, population estimates, and national estimates for PrEP indicators, we derived estimates for potential PrEP use in our state. Statewide estimates of key populations by state and county type will enable health officials to set informed goals and track progress toward optimizing PrEP uptake. This formula may be applicable to other states with similar epidemics and resources. .

Evaluating routine HIV testing and treatment and use of services for people who inject drugs (PWID) is critical to curb the ongoing HIV epidemic. We analyzed data from the 2018 National HIV Behavioral Surveillance of PWID aged 18 years or older, recruited using respondent-driven sampling and offered anonymous HIV testing after survey. We performed bivariate and multivariable analyses with log-linked Poisson regression of the generalized linear models to examine the associations between demographics and PWID service use, past-year HIV testing, and current antiretroviral therapy (ART) use. Among 10,311 HIV-negative PWID, 56% reported past-year HIV testing, and of the 553 HIV-positive PWID, 69% reported current ART use. Of the HIV-negative PWID, 64% (2874/4482) in drug treatment and 62% (3386/5440) who used syringe service programs (SSPs) reported past-year HIV testing. Among HIV-positive PWID, 75% (187/248) in drug treatment and 67% (200/298) SSP participants were on ART. In the adjusted multivariable model, past-year HIV testing was associated with drug use treatment (aPR 1.26, 95% CI 1.23–1.31) and SSP participation (aPR 1.19, 95% CI 1.13–1.26) among HIV-negative PWID. Current ART use was associated with drug use treatment (aPR 1.13, 95% CI 1.00–1.28) but the link was not significant probably due to small sample size. Findings support the expansion and improvement of PWID-targeted services, into comprehensive programs, including drug use treatment, SSP, and HIV testing and treatment.

Persons who inject drugs (PWID) and exchange sex face disproportionate HIV rates. We assessed prevalence of exchange sex (receiving money/drugs for sex from ≥ 1 male partner(s) during the past year) among cisgender PWID, separately for women and men with a history of sex with men (MSM). We examined factors associated with exchange sex, including sociodemographic characteristics, sexual and drug use behaviors, and healthcare access/utilization. Over one-third of the 4657 participants reported exchange sex (women: 36.2%; MSM: 34.8%). Women who exchanged sex (WES) were significantly more likely to test HIV-positive than other women. Men who exchanged sex with men (MESM) showed a similar trend. WES and MESM shared many characteristics, including being uninsured, experiencing recent homelessness, condomless sex, polydrug use, and receptive/distributive needle sharing. These findings highlight a need to strengthen prevention interventions and address structural determinants of HIV for WES and MESM, particularly PWID who exchange sex.

The National HIV Behavioral Surveillance (NHBS) is a comprehensive system for biobehavioral surveillance conducted since 2003 in 3 populations disproportionately affected by HIV: gay, bisexual, and other men who have sex with men (MSM); people who inject drugs; and heterosexually active persons at increased risk for HIV infection (HET). This ongoing and systematic collection and analysis of data is needed to identify baseline prevalence of behavioral risk factors and prevention service use, as well as to measure progress toward meeting HIV prevention goals among key populations disproportionately affected by HIV. This manuscript provides an overview of NHBS from 2003 to 2019. NHBS is conducted in rotating, annual cycles; these 3 annual cycles are considered a round. Venue-based, time-space sampling is used for the MSM population. Respondent-driven sampling is used for people who inject drugs and HET populations. A standardized, anonymous questionnaire collects information on HIV-related behavioral risk factors, HIV testing, and use of prevention services. In each cycle, approximately 500 eligible persons from each participating area are interviewed and offered anonymous HIV testing. From 2003 to 2019, 168,600 persons were interviewed and 143,570 agreed to HIV testing across 17 to 25 cities in the United States. In the fifth round (2017 to 2019), over 10,000 (10,760-12,284) persons were interviewed each of the 3 population cycles in 23 cities. Of those, most (92%-99%) agreed to HIV testing. Several cities also conducted sexually transmitted infection or hepatitis C testing. NHBS is critical for monitoring the impact of the Ending the HIV Epidemic in the United States initiative. Data collected from NHBS are key to describe trends in key populations and tailor new prevention activities to ensure high prevention impact. NHBS data provide valuable information for monitoring and evaluating national HIV prevention goals and guiding national and local HIV prevention efforts. Furthermore, NHBS data can be used by public health officials and researchers to identify HIV prevention needs, allocate prevention resources, and develop and improve prevention programs directed to the populations of interest and their communities.

What is already known about this topic? In 2015, the estimated HIV infection prevalence among persons who inject drugs (PWID) in 20 U.S. metropolitan statistical areas was 7%. What is added by this report? In 2018, estimated HIV prevalence among PWID remained unchanged, and although overall syringe service program use did not significantly change, a substantial decrease in their use occurred among Black PWID. What are the implications for public health practice? Low-barrier access is needed to comprehensive and integrated needs-based syringe service programs (where legally permissible) that include provision of sterile syringes and safe syringe disposal, HIV and hepatitis C virus testing and referrals for treatment, HIV preexposure prophylaxis, and treatment for substance use and mental health disorders for PWID.

In 2019, heterosexual sex accounted for 23% of new HIV diagnoses in the United States and six dependent areas (1). Although preexposure prophylaxis (PrEP) can safely reduce the risk for HIV infection among heterosexual persons, this group is underrepresented in PrEP research (2). CDC analyzed National HIV Behavioral Surveillance (NHBS) data to describe PrEP awareness among heterosexually active adults in cities with high HIV prevalence. Overall, although 32.3% of heterosexually active adults who were eligible were aware of PrEP, <1% used PrEP. Racial, ethnic, and gender disparities were identified, with the lowest awareness of PrEP among residents of Puerto Rico (5.8%) and Hispanic or Latino (Hispanic) men (19.5%) and women (17.6%). Previous studies have found that heterosexual adults are interested in taking PrEP when they are aware of it (3); tailoring PrEP messaging, including Spanish-language messaging, to heterosexual adults, might increase PrEP awareness and mitigate disparities in use.

Objectives: Given the national effort to respond to the challenge of terrorism post-9/11, this study examined the organizational structure of state public health preparedness programs across the country, their administration, and the personnel and resources supported through federal cooperative agreements and state funds. Methods: In Fall 2004, the Association of State and Territorial Health Officials surveyed state public health preparedness directors of all 50 states and territories of the United States regarding the organizational structure, administration, personnel, and resources of the state public health preparedness programs. Results: Individuals representing 45 states and the District of Columbia responded to the web-based questionnaire for a response rate of 88.2%. States tended to subdivide their organizations into regions for preparedness purposes. More than half the established preparedness regions (53.8%) were created post-9/11. Preparedness program directors frequently reported directly to either the state health official (40.0%) or a deputy state health official (33.3%). Responsibility for both the Centers for Disease Control and Prevention (CDC) and Health Resources and Services Administration (HRSA) cooperative agreements was predominantly vested in one person (73.3%). Federal resources were found to support needed preparedness workforce (CDC mean=117.1 full-time equivalents [FTEs]; HRSA mean=10.6 FTEs). In addition, 36.6% of the states also contributed to the public health preparedness budget. Conclusions: This study of state public health agency preparedness provides new information about state-level organizational structure, administration, and support of preparedness programs. It offers the first comprehensive insights into the approaches states have adopted to build infrastructure and develop capacity through CDC and HRSA funding streams.