Behavioral and Clinical Characteristics of Persons Receiving Medical Care for HIV Infection — Medical Monitoring Project, United States, 2009

Janet M. Blair, PhD

Jennifer L. Fagan, MA

Emma L. Frazier, PhD

Ann Do, MD

Heather Bradley, PhD

Eduardo E. Valverde, MPH

AD McNaghten, PhD

Linda Beer, PhD

Shuyan Zhang, PhD

Ping Huang, MS

Christine L. Mattson, PhD

Mark S. Freedman, DVM

Christopher H. Johnson, MS

Catherine C. Sanders, MA

Kathryn E. Spruit-McGoff, MSN

James D. Heffelfinger, MD

Jacek Skarbinski, MD

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC

Corresponding author: Heather Bradley, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC. Telephone: 404-639-8373; E-mail: [email protected].

Abstract

Problem: As of December 31, 2009, an estimated 864,748 persons were living with human immunodeficiency virus (HIV) infection in the 50 U.S. states, the District of Columbia, and six U.S.-dependent areas. Whereas HIV surveillance programs in the United States collect information about persons with a diagnosis of HIV infection, supplemental surveillance systems collect in-depth information about the behavioral and clinical characteristics of persons receiving outpatient medical care for HIV infection. These data are needed to reduce HIV-related morbidity and mortality and HIV transmission.

Reporting Period Covered: Data were collected during June 2009–May 2010 for patients receiving medical care at least once during January–April 2009.

Description of the System: The Medical Monitoring Project (MMP) is an ongoing surveillance system that assesses behaviors and clinical characteristics of HIV-infected persons who have received outpatient medical care. For the 2009 data collection cycle, participants must have been aged ≥18 years and have received medical care during January–April 2009 at sampled facilities that provide HIV medical care within participating MMP project areas. Behavioral and selected clinical data were collected using an in-person interview, and most clinical data were collected using medical record abstraction. A total of 23 project areas in 16 states and Puerto Rico were funded to collect data during the 2009 data collection cycle. The data were weighted for probability of selection and nonresponse to be representative of adults receiving outpatient medical care for HIV infection in the United States and Puerto Rico. Prevalence estimates are presented as weighted percentages. The period of reference is the 12 months before the patient interview unless otherwise noted.

Results: The patients in MMP represent 421,186 adults who received outpatient medical care for HIV infection in the United States and Puerto Rico during January–April 2009. Of adults who received medical care for HIV infection, an estimated 71.2% were male, 27.2% were female, and 1.6% were transgender. An estimated 41.4% were black or African American, 34.6% were white, and 19.1% were Hispanic or Latino. The largest proportion (23.1%) were aged 45–49 years. Most patients (81.1%) had medical coverage; 40.3% had Medicaid, 30.6% had private health insurance, and 25.7% had Medicare.

An estimated 69.6% of patients had three or more documented CD4+ T-lymphocyte cell (CD4+) or HIV viral load tests. Most patients (88.7%) were prescribed antiretroviral therapy (ART), and 71.6% had a documented viral load that was undetectable or ≤200 copies/mL at their most recent test. Among sexually active patients, 55.0% had documentation in the medical record of being tested for syphilis, 23.2% for gonorrhea, and 23.9% for chlamydia.

Noninjection drugs were used for nonmedical purposes by an estimated 27.1% of patients, whereas injection drugs were used for nonmedical purposes by 2.1% of patients. Overall, 12.9% of patients engaged in unprotected sex with a partner of negative or unknown HIV status.

Unmet supportive service needs were prevalent, with an estimated 22.8% in need of dental care and 12.0% in need of public benefits, including Social Security Income or Social Security Disability Insurance. Fewer than half of patients (44.8%) reported receiving HIV and sexually transmitted disease prevention counseling from a health-care provider.

Interpretation: The findings in this report indicate that most adults living with HIV who received medical care in 2009 were taking ART, had CD4+ and HIV viral load testing at regular intervals, and had health insurance or other coverage. However, some patients did not receive clinical services and treatment in accordance with guidelines. Some patients engaged in behaviors, such as unprotected sex, that increase the risk for transmitting HIV to sex partners, and some used noninjection or injection drugs or both.

Public Health Actions: Local and state health departments and federal agencies can use MMP data for program planning to determine allocation of services and resources, guide prevention planning, assess unmet medical and supportive service needs, inform health-care providers, and help focus intervention programs and health policies at the local, state, and national levels.

Introduction

As of December 31, 2009, an estimated 864,748 persons were living with a diagnosis of human immunodeficiency virus (HIV) infection in the 50 U.S. states, the District of Columbia, and six U.S. dependent areas (1). The estimated number of new HIV diagnoses was 48,283 in 2009 (1). Although the National HIV Surveillance System in the United States collects information about persons with a diagnosis of HIV infection (2), supplemental surveillance systems provide detailed information about care seeking, health-care use, use of supportive services, and other behaviors (3). In 2005, in response to an Institute of Medicine report outlining the need for representative data on persons living with HIV (4), CDC implemented the Medical Monitoring Project (MMP). MMP data from the 2005 and 2007 data collection cycles also have been published (5,6).

Methods

Sample and Areas

MMP is a cross-sectional, nationally representative, population-based surveillance system that assesses clinical and behavioral characteristics among adults with HIV infection receiving outpatient medical care in the United States and Puerto Rico. The MMP sample was selected in three consecutive stages: 1) U.S. states and territories, 2) outpatient facilities providing HIV care, and 3) HIV-infected adults aged ≥18 years who had at least one medical care visit to participating facilities during January–April 2009. A total of 23 areas were funded to collect data for the 2009 cycle (Figure): California (including the separately funded jurisdictions of Los Angeles County and San Francisco), Delaware, Florida, Georgia, Illinois (including Chicago), Indiana, Michigan, Mississippi, New Jersey, New York (including New York City), North Carolina, Oregon, Pennsylvania (including Philadelphia), Puerto Rico, Texas (including Houston), Virginia, and Washington. This report provides unweighted sample sizes and weighted prevalence estimates with 95% confidence intervals (CIs) for selected characteristics. Methods for MMP are described in more detail in this report (Appendix) and have been published previously (3,6,7). Additional information on MMP is available at http://www.cdc.gov/hiv/statistics/systems/mmp/index.html.

Data Collection

Interview

A trained interviewer conducted a computer-assisted personal interview. Two versions of the questionnaire (in English and Spanish) were used in 2009: a standard questionnaire and a short questionnaire. The short questionnaire was administered when a patient was too ill to complete the longer standard interview or when translation to a language other than Spanish was required. Only standard questionnaire data are included in this report.

Persons who agreed to participate were interviewed in a private location (e.g., at home or in a clinic). The standard interview contained 10 modules and took approximately 45 minutes to complete. Participants were reimbursed approximately $40 in a cash equivalent for participation. Reimbursement amounts differed slightly by project area. Modules included questions on demographics, access to and use of health care, met and unmet needs for supportive services, sexual behavior, depression, gynecologic and reproductive history (women only), drug and alcohol use, and use of HIV prevention services.

Medical Record Abstraction

Patients' medical records were abstracted after the patients were interviewed. Medical records were abstracted by MMP staff using an electronic application provided by CDC. Abstracted information included diagnoses of conditions that, when they occur in HIV-infected persons, meet the definition for acquired immunodeficiency syndrome (AIDS); prescription of antiretroviral medications; laboratory results; and health-care use in the 12 months before the interview.

Minimum Data Set

The minimum data set is an adjunct to MMP that includes an extract of National HIV Surveillance System data for sampled patients in MMP. Information for the minimum data set is obtained locally, primarily from the Enhanced HIV/AIDS Reporting System (eHARS) (8), but might include data from other local sources such as participating facilities. The minimum data set provides descriptive information about sampled patients for statistical weighting, including nonresponse adjustment.

Data Weighting

Data used to generate national estimates were weighted for the probability of selection based on known probabilities of selection at each sampling stage. In addition, data were weighted to adjust for nonresponse using predictors of patient-level response, including facility size, race/ethnicity, time since HIV diagnosis, and age group.

Data Management and Statistical Analyses

Data were encrypted and transmitted to CDC through a secure data portal. Statistical software was used for analysis of weighted data to produce prevalence estimates (weighted percentages) and associated CIs (9). Data are not reported for any variables with fewer than five responses or a coefficient of variation of ≥30%. No statistical tests were performed.

The term patients in this report refers to adults living with HIV infection receiving outpatient medical care in the United States and Puerto Rico. The time period referenced is the 12 months before the patient interview unless otherwise noted. Measures used in this report are described in detail (Appendix).

Results

Facility and Patient Response Rates

Of 603 sampled eligible facilities within 23 project areas, 461 participated in MMP; the facility response rate, adjusted for eligibility, was 76%. In total, 9,338 patients were sampled from 461 participating facilities. Of these, 4,217 patients completed interviews using the standard questionnaire and had medical record abstractions, for an adjusted patient response rate of 51% (Table 1). The combined response rate for patients with both an interview and a medical record abstraction was 39% (Combined response rate = Project area response rate × Facility response rate × Adjusted patient response rate).

Sociodemographic Characteristics

The 4,217 respondents represent an estimated 421,186 adults living with HIV who received outpatient medical care in the United States and Puerto Rico during January–April 2009. These 421,186 adults are referred to hereafter as patients. An estimated 71.2% of patients were male, 27.2% were female, and 1.6% were transgender (Table 2). An estimated 50.3% identified themselves as heterosexual or straight; 41.4% as homosexual, gay or lesbian; and 8.3% as bisexual. An estimated 41.4% were black or African American, 34.6% were white, and 19.1% were Hispanic or Latino. Three fourths (75.5%) were aged ≥40 years, and 53.8% had received their HIV diagnosis ≥10 years previously. Half (50.6%) had more than a high school education, and 82.7% were born in the United States. Approximately 9.0% were homeless. An estimated 81.1% had any health coverage, 40.3% had Medicaid, 30.6% had private health insurance, and 25.7% had Medicare. Almost half (43.8%) had household incomes at or below federal poverty guidelines.

Clinical Characteristics

Using the CDC stage of disease classification for HIV (10), an estimated 67.6% of patients had stage 3 disease (Table 3); however, 12.4% of patients had a mean CD4+ T-lymphocyte (CD4+) count of 0–199 cells/µL in the past 12 months (Table 4). The estimated geometric mean CD4+ count was 505 cells/µL, and the median CD4+ count was 460 cells/µL (range: 4–2,388).

Use of Health-Care Services

An estimated 99.7% (CI: 99.5–99.9) of patients had one place in particular, such as a physician's office or clinic, where they received most of their HIV medical care. Patients traveled an estimated average of 34.2 minutes (range:1–480 minutes) to their usual HIV care provider.

An estimated 69.6% of patients had at least three CD4+ or HIV viral load tests documented in the medical record (Table 5). As recommended by guidelines, most patients had at least one viral load test in each 6-month interval (76.5%) and at least one CD4+ test annually (96.8%). Overall, an estimated 88.7% of patients had an ART prescription documented in the medical record, and 71.6% of all patients had an undetectable (≤200 copies/mL) viral load at last measurement.

Among the estimated 17.5% (CI: 16.0–19.1) of patients meeting the clinical criteria for Pneumocystis carinii pneumonia (PCP) prophylaxis, 78.8% (CI: 75.1–82.5) had a prescription for PCP prophylaxis documented in the medical record. Among the estimated 4.8% of patients meeting the clinical criteria for Mycobacterium avium complex (MAC) prophylaxis, 72.3% (CI: 65.7–79.0) had a prescription for MAC prophylaxis documented in the medical record. An estimated 78.5% (CI: 76.0–81.0) of patients received an influenza vaccination. Among sexually active patients, an estimated 23.2% were tested for gonorrhea, 23.9% for chlamydia, 55.0% for syphilis, and 19.7% for all three sexually transmitted diseases (STDs) (Table 6).

An estimated 5.2% of patients were seen in an emergency department or an urgent care center one time, and 1.4% were seen at least five times (Table 7). An estimated 4.5% of patients were admitted to a hospital one time, and 0.4% were admitted at least five times (Table 8).

Self-Reported Antiretroviral Medication Use and Adherence

An estimated 88.2% (CI: 86.8–89.6) of patients were currently taking ART. Among the estimated 6.6% (CI: 5.5–7.7) of patients with no history of ART use, 80% (CI: 74.9–85.1) had never taken ART because a physician advised a delay in treatment, whereas 11.2% (CI: 7.7–14.8) believed medications were unnecessary because they felt healthy or believed their HIV laboratory test results (e.g., CD4+ count and HIV viral load) were good (11.2%, CI: 7.7–14.8).

Among patients currently taking ART, an estimated 63.4% (CI: 61.2–65.7) were never troubled by ART side effects during the past 30 days, whereas 19.0% (CI: 16.9–21.2) were rarely troubled. Patients' ART medications were most commonly paid for by the AIDS Drug Assistance Program (40.1%, CI: 37.4–42.9), Medicaid (33.9%, CI: 29.4–38.4), private health insurance (25.4%, CI: 20.0–30.8), or Medicare (18.3%, CI: 16.2–20.3).

Estimated adherence to dose, schedule, and instructions for taking ART during the past 3 days among patients currently taking ART was 85.6% (CI: 84.1–87.1), 71.7% (CI: 69.3–74.1), and 69.0% (CI: 66.6–71.4), respectively. An estimated 92.8% of patients currently taking ART were very or extremely sure that they could take all of their medication as directed, and 87.4% believed their medication would have a positive effect on their health (Table 9). Among the estimated 61.9% (CI: 58.9–65.0) of patients who were currently taking ART and ever missed a dose, 28.6% missed their last dose because they forgot to take it, and 25.4% missed their last dose because of a change in daily routine (Table 10).

Depression and Substance Use

The estimated prevalence of major depression or other depression using the eight-item Patient Health Questionnaire (PHQ-8) algorithm based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria (11) was 25.6% (CI: 23.8–27.4), including12.4% (CI: 11.2–13.7) with major depression. Using the score-based method (12), an estimated 23.7% (CI: 21.9–25.5) of patients had current moderate or severe depression (a PHQ-8 severity score of ≥10).

An estimated 42.4% (CI: 39.7–45.1) of patients were current smokers, with 35.1% (CI: 32.8–37.3) smoking daily, 3.9% (CI: 2.9–4.8) weekly, 1.2% (CI: 0.8–1.5) monthly, and 2.3% (CI: 1.8–2.8) less than monthly. The estimated prevalence of current alcohol use was 66.4% (CI: 63.7–68.7), with 6.9% (CI: 5.6–8.1) using daily, 18.4% (CI: 17.0–19.7) weekly, 13.6% (CI: 12.2 –15.0) monthly, and 27.5% (CI: 25.7–29.3) less than monthly. An estimated 50.7% (CI: 48.6–52.8) of patients drank alcohol during the past 30 days. Among patients who drank alcohol during the past 30 days, the estimated typical average daily consumption was 3.1 drinks. An estimated 17.8% (CI: 16.4–19.3) of male patients and 12.6% (CI: 10.2–14.9) of female patients engaged in binge drinking during the past 30 days. Among patients who drank alcohol in the past 30 days, the estimated mean number of binge drinking days was 1.8 for male patients and 1.5 for female patients.

An estimated 27.1% (CI: 25.2–28.9) of patients used noninjection drugs for nonmedical purposes. An estimated 22.2% of patients used marijuana, whereas 5.5% used cocaine, 4.8% used crack, and 4.2% used amyl nitrite (Table 11). An estimated 24.0% (CI: 22.1–25.9) of patients drank alcohol before or during sex, whereas 11.9% (CI: 10.3–13.4) used noninjection drugs before or during sex.

An estimated 2.1% (CI: 1.2–2.9) of patients used injection drugs for nonmedical purposes. An estimated 1.1% (CI: 0.4–1.7) used crystal methamphetamine, 0.6% (CI: 0.2–1.0) used heroin, and 0.6% (CI: 0.2–0.9) used cocaine. Of the patients who used injection drugs, an estimated 67.7% (CI: 54.2–81.2) used injection drugs before or during sex.

Gynecologic and Reproductive Health

An estimated 20.9% (CI: 16.4–25.3) of female patients received HIV care at an obstetrics and gynecology clinic, and 77.4% (CI: 73.1–81.8) received a Papanicolaou (Pap) test. An estimated 24.7% (CI: 21.7–27.6) of female patients had been pregnant at least once since testing positive for HIV infection; of these, 80.7% (CI: 75.4–86.0) gave birth to one or more children after learning about their HIV status.

Sexual Behavior

An estimated 47.1% (CI: 42.3–52.0) of patients were men who have sex with men (MSM); 23.8% (CI: 21.2–26.4) were men who exclusively have sex with women (MSW); 26.7% (CI: 23.6–29.8) were women who have sex with men (WSM); 0.7% (CI: 0.4–1.1) were women who exclusively have sex with women (WSW); and 1.6% (CI: 1.1–2.1) were transgender. (Details on classification are provided [Appendix].) An estimated 61.8% (CI: 59.5–64.2) of patients were sexually active, 24.7% (CI: 21.8–27.7) engaged in unprotected sex, and 12.9% (CI: 11.4–14.4) engaged in unprotected sex with a partner with negative or unknown HIV status.

Among MSM, an estimated 69.7% (CI: 66.9–72.5) engaged in anal intercourse or oral sex with at least one man, 31.8% had any unprotected anal intercourse, and 13.7% had unprotected anal intercourse with a partner with negative or unknown HIV status (Table 12). The estimated mean number of sex partners among sexually active MSM during the past 12 months was 5.0 (range: 1–250).

Among MSW, an estimated 57.6% (CI: 53.1–62.0) engaged in oral sex, vaginal intercourse, or anal intercourse with at least one woman; 14.5% had any unprotected vaginal intercourse; and 9.0% had unprotected vaginal intercourse with a partner with negative or unknown HIV status (Table 13). The estimated mean number of female sex partners among sexually active MSW during the past 12 months was 1.5 (range: 1–20).

Among WSM, an estimated 54.7% (CI: 51.8–57.5) engaged in anal intercourse, oral sex, or vaginal intercourse with at least one man, 22.8% had any unprotected vaginal intercourse, and 14.6% had unprotected vaginal intercourse with a partner with negative or unknown HIV status (Table 14). The estimated mean number of male sex partners among sexually active WSM was 1.2 (range: 1–6).

Among WSW, an estimated 65.0% (CI: 44.5–85.4) engaged in sexual activity with at least one woman. The estimated mean number of sex partners among sexually active WSW was 1.2 (range: 1–2). Data on sexual behavior among WSW is not collected by MMP. Among transgender persons, an estimated 49.8% (CI: 35.9–63.7) engaged in any vaginal or anal intercourse with at least one partner. Given the small sample size, the estimate for the mean number of sex partners among transgender persons is not reported here.

Met and Unmet Need for Support Services

An estimated 57.7% of patients received HIV case management services, 57.4% received dental care, 42.0% received counseling about how to prevent the spread of HIV, and 41.9% received medicine through the AIDS Drug Assistance Program (Table 15). An estimated 22.8% of patients had unmet needs for dental care, 12.0% for public benefits such as Social Security Income or Social Security Disability Insurance, 8.6% for transportation services, 8.2% for shelter or housing services, and 7.0% for meal or food services.

Prevention Activities

An estimated 44.8% (CI: 39.8–49.8) of patients received counseling from a physician, a nurse, or another health-care worker about HIV and STD prevention; 30.4% (CI: 26.2–34.5) had a one-on-one conversation with an outreach worker, a counselor, or a prevention program worker about prevention, and 16.2% (CI: 13.2–19.1) participated in an organized session involving a small group of persons (excluding discussions with friends) to discuss prevention of HIV and other STDs. An estimated 54.8% (CI: 51.7–57.9) of patients received free condoms from various organizations; of these, 55.2% (CI: 49.3–61.1) received free condoms from a physician's office or other health clinic, 32.7% (CI: 28.2–37.2) from an HIV/AIDS-focused community-based organizations, 13.6% (CI: 10.9–16.3) from a social venue (i.e., bar, club, bathhouse, gym, or bookstore), 7.0% (CI: 3.7–10.3) from an STD clinic, 4.0% (CI: 2.6–5.4) from a special event, 1.3% (CI: 0.4–2.2) from a family planning clinic, and 1.3% (CI: 0.6–1.9) from an injecting drug use outreach organization (excluding needle exchange programs).

Discussion

Sociodemographic Characteristics

The findings in this report are nationally representative of HIV-infected adults receiving outpatient medical care in the United States and Puerto Rico. Understanding the sociodemographic characteristics of HIV-infected persons who are receiving medical care can be used to develop strategies to improve HIV medical care and to encourage retention in care. Compared with the general U.S. population, HIV-infected persons in medical care are more likely to be male (13), black or African American (14), and, among men, to identify themselves as homosexual or gay (15). In addition, they are less likely to have access to resources that promote health (16). For example, approximately 40% had incomes below the poverty level, and 9% were homeless, whereas only 14% of persons in the general U.S. population had incomes below the poverty level (17), and 0.2% were homeless (18). In addition, some patients did not have health insurance or coverage, which might present extra challenges for accessing and maintaining care (19–21). The data from this report highlight that to improve HIV treatment and prevention in the United States, programs and policies need to be aware of the multiple unique needs of persons living with HIV infection.

Clinical Characteristics

Stage of disease among persons living with HIV infection has been associated with morbidity and mortality (22). Although nearly 68% of patients had received a diagnosis of stage 3 HIV infection, approximately 87% had a mean CD4+ count of ≥200 cells/µL in the past 12 months, suggesting most patients have had CD4+ recovery (23). Stage of disease and current CD4+ count are important indicators of access to and use of medical care.

Use of Health-Care Services

Access to health-care services and treatment is necessary to improve health outcomes among persons living with HIV. By design, MMP samples patients with a usual source of care, and nearly all patients had a source of usual HIV medical care. Treatment guidelines recommend that health-care providers conduct CD4+ and HIV viral load testing every 3–6 months, and for clinically stable patients with suppressed HIV viral load, health-care providers should monitor CD4+ count every 6–12 months (24). These data suggest most patients received CD4+ and HIV viral load testing at regular intervals. In addition, guidelines recommend that ART be considered for all HIV-infected persons (24). Nearly 89% of patients were prescribed ART, and almost 72% had viral suppression at the time of their most recent viral load test. Increasing the number of patients who are prescribed ART and achieve viral suppression is central to reducing HIV morbidity, mortality, and transmission.

Although PCP and MAC infections are AIDS-defining conditions that are preventable with the appropriate use of prophylactic medications, approximately 20% of eligible patients were not receiving guideline-recommended prophylaxis (25). Clinicians should be encouraged to adhere to guidelines for the prevention of opportunistic infections through continuing medical education and targeted campaigns to disseminate updated guidelines (25).

Persons living with HIV have increased risk for developing serious influenza-related complications (26,27), and public health recommendations for HIV-infected persons include yearly influenza vaccination (25). Approximately 78% of patients received the influenza vaccination, which is higher than other reported estimates among HIV-infected persons (28–30) and might be due to possible limitations in accurate recall during self-report, rather than relying on data from medical record abstraction. Clinicians are encouraged to provide annual influenza vaccinations to their HIV-infected patients (31).

The occurrence of STDs among HIV-infected persons indicates ongoing or recurrent high-risk behavior (32). Because many STDs are asymptomatic (32) and can increase HIV transmission risk (33), guidelines for incorporating HIV prevention into the medical care of persons living with HIV recommend that all sexually active, HIV-infected persons be screened at least annually for syphilis, gonorrhea, and chlamydia (34). These findings suggest fewer than 20% of patients were tested for STDs annually. Health-care providers should be reminded of the need to test sexually active HIV-infected patients for STDs annually (34).

Relatively low percentages of MMP patients were hospitalized or used emergency departments or urgent care clinics. This might partially be explained by the expected benefit associated with the receipt of routine medical care, such as viral load and CD4+ monitoring, in settings that follow existing recommendations. Other publications have described higher rates of emergency department visits among HIV-infected persons than in the general population, suggesting a greater use of acute care resources (35). In addition, HIV-infected persons are likely to be hospitalized; a previous study reported that 19.7% of HIV-infected persons had at least one hospital admission annually (36). Clinicians should continue to adhere to extant treatment guidelines (24,25,34,37) to reduce preventable emergency department visits and hospitalizations.

Self-Reported Antiretroviral Medication Use and Adherence

Use of ART has resulted in a major reduction of HIV-related morbidity and mortality (24). In MMP, more than 88% of patients were currently taking ART. The most common reason for not currently taking ART was a physician advising the patient to delay treatment. This finding is likely a result of earlier recommendations to delay the use of ART until a threshold nadir CD4+ count was documented. The 2012 recommendation (24) that ART should be initiated for all HIV-infected persons, regardless of CD4+ count, would not be reflected among these patients receiving HIV care in 2009.

Adherence to ART is necessary for HIV viral suppression, improved health and immune function (24), and prevention of HIV transmission (38). Although dose adherence was relatively high among patients, schedule and instruction adherence were not. Providers can help patients identify barriers and reasons for lack of adherence. Strategies to improve adherence include prescribing less complex regimens (e.g., fewer pills, fewer doses, or both) and using a multidisciplinary team approach to care (e.g., nurses, social workers, pharmacists, and medication managers) (24). Other strategies include the use of pill boxes and medication alarms to remind patients to take medication (39). Adherence should be assessed at clinic visits as part of routine care (24), either through self-report (40,41) or other measures such as pill counts (42). In addition, CDC has identified several medication adherence interventions aimed at improving adherence behaviors and viral suppression (43).

Depression and Substance Use

Among HIV-infected persons, depression can affect quality of life and might lead to treatment nonadherence (44–46), which is associated with increased morbidity, mortality, and HIV transmission risk. Depression also has been associated with substance abuse (44,47,48), which can lead to risky behaviors that might further facilitate HIV transmission. More than 12% of patients experienced major depression, and approximately one fourth experienced some type of depression. Behavioral Risk Factor Surveillance System data from 2006 and 2008 indicate that 4.1% of adults in the general population had current major depression and 9.1% had any current depression (49,50). Medical providers should continue to screen for depression regularly, providing treatment when indicated (37).

Cigarette smoking is the leading cause of preventable death in the United States (51), accounting for approximately 440,000 deaths in the United States each year (52). Approximately 42% of HIV-infected persons smoke cigarettes, compared with an estimated 19% of adults in the U.S. general population (53). HIV-infected persons who smoke are susceptible to respiratory complications (54), including lower respiratory tract infections (55–57), chronic obstructive pulmonary disease, an increased risk for lung cancer (58–61), and death (62). As part of a comprehensive approach to health-care delivery for persons with HIV, providers should assess all patients for tobacco use and promote smoking cessation among current smokers during routine patient encounters (63).

Injection drug use can result in direct transmission of HIV infection. In addition, the use of alcohol (64,65), noninjection drugs (64,66), and injection drugs (67) are associated with risky sexual behaviors and might complicate the management of HIV infection (68–71). Approximately one fourth of patients used noninjection drugs, and 2% used injection drugs. The medical care setting provides an opportunity to assess drug use behavior, communicate prevention messages, positively reinforce changes to safer behavior, and provide referrals for services such as substance abuse treatment (34).

Gynecologic and Reproductive Health

Women living with HIV are at an increased risk for developing cervical cancer (72–74). HIV-infected women should be screened for cervical cancer twice within the first year after initial HIV diagnosis, and if the results are normal, annually thereafter (25,75). The findings in this report are consistent with previous studies showing that 77%–81% of HIV-infected women received cervical cancer screening in the past year (76,77) and suggest that one of five women with HIV were not screened for cervical cancer. Additional efforts should be undertaken to increase the number of health-care providers who provide cervical cancer screening for HIV-infected women (25,75).

Forty-nine percent of all pregnancies in the United States are unintended (78). In general, pregnancy rates among HIV-infected women are lower than that of the general population (79). Data from MMP show that almost one fourth of women had been pregnant since testing positive for HIV, of whom nearly 81% gave birth to one or more children after learning their HIV status. Because many women living with HIV are aware of their HIV status before becoming pregnant, health-care providers who routinely care for HIV-infected women of reproductive age should integrate preconception care into standard medical care visits (80,81).

Sexual Behavior

An estimated 92% of all new HIV infections in the United States are attributed to sexual transmission (1). Previous studies have found that after diagnosis, most persons with HIV infection decrease sexual behaviors that increase the risk for transmission (82). However, some might continue to engage in sexual behaviors that can place others at risk for infection. Nearly 14% of MSM, 9% of MSW, and 15% of WSM engaged in unprotected sex with a partner of negative or unknown HIV status. All groups (MSM, MSW, and WSM) had higher proportions of unprotected sex with main partners than with casual partners. The prevalence of sexual risk behaviors highlights the continued need to incorporate HIV prevention into the medical care of HIV-infected persons (34). The clinical setting offers an opportunity for providers to talk with patients about ways to prevent HIV transmission.

Met and Unmet Need for Supportive Services

Receipt of supportive services has been linked to improved retention in care (83,84), quality of life (85), and ART adherence (86). Unmet need for dental care was particularly high, as has been reported previously (87). These data underscore the continued need for supportive services for persons with HIV infection and can be used to help determine how resources should be allocated.

HIV Prevention Activities

HIV prevention counseling by health-care providers can help to reduce risk behaviors among HIV-infected patients (88–90). Fewer than half of patients were counseled by a health-care provider about HIV and STD prevention. These findings indicate important missed opportunities to engage patients in HIV risk reduction discussions and to refer patients for additional preventive services such as STD screening and partner notification.

Male latex condoms, when used correctly and consistently, are effective in preventing HIV and other STDs (91–93). Over half of patients received free condoms. Previous MMP findings have shown that use of and intention to use condoms are high among HIV-infected patients receiving free condoms (6). Condom distribution programs are an important part of HIV prevention programs in the United States.

Limitations

The findings in this report are subject to at least five limitations. First, because the survey was administered during face-to-face interviews, some responses might have been subject to social response bias, which might have resulted in underreporting of socially undesirable behaviors such as drug use and overreporting of socially desirable behaviors such as adherence to antiretroviral therapy. Second, the combined response rate of 39% is lower than optimal. However, data were adjusted for nonresponse. Third, a potential bias toward favorable outcomes might exist because patients in MMP have a usual source of HIV care and are receiving medical care. Fourth, in certain instances, stratification by certain characteristics produced numbers that were too small for reliable interpretation and were not presented. Finally, although data collection for the 2009 cycle was completed in May 2010, the dissemination of these data was delayed because they were the first to be weighted for national representativeness, and establishing and standardizing the weighting procedures and calculated variables took additional time.

Conclusion

Through ongoing data collection, MMP provides nationally representative estimates of behavioral and clinical characteristics among adults receiving medical care for HIV infection. In addition, MMP monitors risk behaviors, supportive service needs, use of health-care and HIV prevention services, and adherence to clinical care guidelines. These data can be used by local, state, territorial, and federal policymakers to develop strategies for HIV care, treatment, and prevention.

Acknowledgments

This report is based, in part, on contributions by MMP participants, facilities, community and provider advisory boards, and interviewers and abstractors. The MMP principal investigators and project coordinators include Karen Mark, MD, Tyler Arguello, PhD, Robert Flores, III, California Department of Public Health, Sacramento, California; Nanette Benbow, MAS, Alexandra Gagner, MPH, Chicago Department of Public Health, Chicago, Illinois; Robert Vella, MPH, James Dowling, MPH, Delaware Health and Social Services, Dover, Delaware; Rebecca Grigg, PhD, Pam Fillmore, Florida Department of Health, Tallahassee, Florida; Jianglan White, MD, Sarah Loch, MPH, Jennifer Taussig, MPH, Georgia Department of Public Health, Atlanta, Georgia; Salma Khuwaja, MD, DrPH, Adebowale Awosika-Olumo, MD, Osaro Mgbere PhD, Houston Department of Health and Human Services, Houston, Texas; Cheryl Ward, MS, Marti Merritt, Illinois Department of Public Health, Chicago, Illinois; Daniel Hillman, MPH, Jodi Rhynearson, MPA, Indiana State Department of Health, Indianapolis, Indiana; Amy Rock Wohl, PhD, Judy Tejero, MPH, Los Angeles County Department of Public Health, Los Angeles, California; Eve D. Mokotoff, MPH, Meosia Lee-Turner; Michigan Department of Community Health, Detroit, Michigan; Leandro Mena, MD, Arti Barnes, MD, Joseph Grice, MPH, Mississippi State Department of Health, Jackson, Mississippi; Barbara Bolden, PhD, Kidane Meshesha, MPH, New Jersey Department of Health and Senior Services, Trenton, New Jersey; Bridget J. Anderson, PhD, Lou Smith, MD, Michael D. Miele, New York State Department of Health, Albany, New York; Alan Neaigus, PhD, Julie Lulek, MPH, New York City Department of Health and Mental Hygiene, New York City, New York; Delbert Williams, PhD, Ryan Collins, MPH, North Carolina Department of Health, Raleigh, North Carolina; Sean Schafer, MD, Kari Greene, MPH, Oregon Public Health Division, Portland, Oregon; Leequan Ray, PhD, Pennsylvania Department of Health, Harrisburg, Pennsylvania; Kathleen A. Brady, MD, Michael G. Eberhart, MPH, Philadelphia Department of Public Health, Philadelphia, Pennsylvania; Sandra Miranda De León, MPH, Gladys Girona Lozada, MSc, Puerto Rico Department of Health, San Juan, Puerto Rico; Susan Scheer, PhD, Maree Kay Parisi, San Francisco Department of Public Health, San Francisco, California; Sharon K. Melville, MD, Sylvia Odem, MPH, Texas Department of State Health Services, Austin, Texas; Dena Bensen, MPH, Celestine Buyu, MPH, Carmen Roman, Virginia Department of Health, Richmond, Virginia; Maria Courogen, MPH, Washington State Department of Health; Elizabeth Barash, MPH, and Susan Buskin, PhD, Public Health Seattle & King County, Seattle, Washington; the Data Coordinating Center for HIV Supplemental Surveillance at ICF International; and members of the MMP team, Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, Georgia.

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