HIV Risk, Prevention, and Testing Behaviors Among Heterosexually Active Adults at Increased Risk for HIV Infection

Current data release

Key findings

This data release provides descriptive, unweighted data from the 2025 National HIV Behavioral Surveillance (NHBS). The data describe HIV infection, HIV testing, behavioral risk factors, and HIV prevention program participation among 6,591 heterosexually active adults at increased risk for HIV infection. Low socioeconomic status, characterized by educational attainment or household income, is a risk factor for HIV infection in heterosexually active adults1. See technical notes for the definition of "increased risk for HIV infection" and inclusion criteria for the sample. Overall, 2% of sampled heterosexually active adults with a valid NHBS test result tested positive for HIV.

The key findings summarize data from 19 U.S. cities in areas with high HIV prevalence. For complete results, refer to the slide set for figures and to the tables for detailed national- and city-level data. See Technical Notes for information on definitions and data specifications.

Structural factors

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Structural factors refer to societal elements, including economic conditions, policies, laws, and social norms, that can influence health outcomes, including HIV transmission2.

The 2025 data are limited to participants who had low socioeconomic status, overall:

• 38% were unemployed at the time of the interview
• 30% had been homeless in the past 12 months
• 14% had been incarcerated in the past 12 months
• 15% had no current health insurance
• 18% had not visited a health care provider in the past 12 months

HIV testing

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CDC recommends everyone between the ages of 13 and 64 years be tested for HIV at least once as part of routine health care3. Among heterosexually active adults in the sample:

• 79% reported getting an HIV test at least once in their lifetime
• 68% of Hispanic/Latino participants, 74% of White participants, and 83% of Black participants reported getting an HIV test at least once
• 77% of those who received an HIV test in the past 12 months received their most recent test for HIV in a clinical setting

Sexual behaviors

Condomless sex

Condomless sex is a recognized risk factor for HIV infection. Condoms are one way to prevent the spread of HIV, and there are other methods, such as the use of HIV medications (e.g., HIV pre- or post-exposure prophylaxis, or viral suppression among persons living with HIV). Condomless sex in the past 12 months was common among heterosexually active adults in the sample. Overall:

• 90% of females reported condomless vaginal sex, and 24% reported condomless anal sex
• 87% of males reported condomless vaginal sex, and 19% reported condomless anal sex

Unprotected sex

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"Unprotected sex" refers to sex with a partner of different or unknown HIV status without the participant's use of either condoms or HIV medications (i.e., HIV preexposure prophylaxis or HIV antiretroviral treatment) at last sex. The measure assumes the participant does not know if their partner is taking HIV medications. "HIV discordant partner" refers to a sex partner of a different or unknown HIV status. Overall:

• 53% of HIV-negative females reported unprotected sex with an HIV-discordant partner the last time they had sex
• 49% of HIV-negative males reported unprotected sex with an HIV-discordant partner the last time they had sex

Exchange sex

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Giving or receiving money or drugs in exchange for sex is a recognized risk factor for HIV infection. In the sample:

• 12% of females reported receiving money or drugs from a male casual partner in exchange for sex
• 10% of males reported giving money or drugs to a female casual partner in exchange for sex

Preexposure prophylaxis (PrEP) awareness and use

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CDC recommends that all sexually active adults be informed of PrEP4. PrEP can help prevent HIV acquisition; however:

• 34% of heterosexually active adults without HIV were aware of PrEP, ranging by city from 5% to 58%
• 1% of heterosexually active adults without HIV reported taking PrEP, ranging by city from 0% to 3%

Sexually transmitted infections (STIs)

STIs can increase the likelihood of acquiring and transmitting HIV. Overall:

• 7% of sampled heterosexually active adults reported a diagnosis of any bacterial STI (e.g., chlamydia, gonorrhea, or syphilis) in the past 12 months, including 8% of those with HIV and 7% of those without HIV

HIV care and treatment

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CDC recommends that persons with HIV visit a health care provider at least every 6 months and take antiretroviral treatment (ART). Taking ART as prescribed and keeping an undetectable viral load prevents HIV transmission and helps persons with HIV stay healthy, live longer, and have better quality of life5. Among heterosexually active adults who reported that they were living with HIV in the sample:

• 85% reported visiting a health care provider about HIV in the 6 months prior to interview
• 80% reported currently taking ART

Previous data releases

• Previous data releases on CDC Stacks
• CDC Archive
• NCHHSTP Atlas Plus

Technical notes

NHBS conducts rotating cycles of biobehavioral surveys among men who have sex with men (MSM), persons who inject drugs (PWID), and heterosexually active persons (HET) at increased risk for HIV infection6; data are collected in annual cycles from one risk group per year so that each population is surveyed once every 3 years. The same general eligibility criteria are used in each cycle: age 18 years or older, current residence in a participating city, no previous participation in NHBS during the current survey cycle, ability to complete the survey in either English or Spanish, and ability to provide informed consent. In addition to these basic NHBS eligibility criteria, participation in the 2025 NHBS-HET cycle was limited to persons who (1) were aged 18-60 years, (2) reported vaginal or anal sex with an opposite sex partner in the 12 months before the interview, and (3) reported income that does not exceed HHS poverty guidelines or educational attainment not greater than high school. Further, data in this release are from participants who met additional criteria including: (1) never injecting any drugs other than those prescribed for them; and, for male participants, (2) never having oral or anal sex with another male. A standardized questionnaire is used to collect information about behavioral risks for HIV infection, HIV testing, and use of HIV prevention services. The anonymous survey is administered by a trained interviewer using a portable computer or tablet. All participants are offered an anonymous HIV test, which is linked to the survey data through a unique survey identifier.

This activity was reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy78, and by applicable institutional review boards in each participating city.

Participating cities

State and local health departments selected to participate in NHBS are among those whose jurisdictions include a metropolitan statistical area (MSA) or a specified division with the highest number of diagnosed HIV infections reported to CDC during the 3-year period 2017–2019. In 2025, NHBS was conducted in 19 MSAs (see list at the end of the report), which represented approximately 47% of all diagnoses reported to CDC in large MSAs (population ≥ 500,000) in the United States in 20229.

Throughout this report, MSAs and divisions are referred to by the name of the principal city.

Sampling method

Participants in the 2025 NHBS cycle were recruited by using respondent-driven sampling101112. Recruitment started with a limited number of initial participants who were chosen by referrals from people who knew the local population of interest or through outreach to areas where the population could be found. Initial participants who completed the eligibility screener and were deemed eligible were surveyed, and those who completed the survey were asked to recruit up to 5 persons whom they knew personally. Those persons, in turn, completed the survey and were asked to recruit others by using a system of coded coupons. This recruitment process continued until the sample size was reached or the sampling period ended. Participants received incentives for participating in the survey and for recruiting others.

Data collection

Each person who brought a valid coupon to an NHBS field site was escorted to a private area with a trained interviewer for eligibility screening. If the person met eligibility requirements, the interviewer obtained informed consent and conducted the interview. The interview took approximately 30 minutes and consisted of questions concerning participants' demographic characteristics, HIV testing history, sexual and substance use behaviors, hepatitis C (HCV) testing, diagnosis and treatment of hepatitis C infection, sexually transmitted infection (STI) testing and diagnosis, and use of HIV prevention services and programs. In exchange for the time spent taking part in the interview, participants received $25–$50 (amount determined locally).

For participants who consented to HIV testing, blood specimens were collected for rapid testing in the field, followed by rapid or laboratory-based supplemental testing as needed. Participants with a nonreactive rapid test result who did not self-report a previous HIV-positive test result were considered HIV-negative; participants who had a reactive rapid test result were considered HIV-positive if supported by a second rapid test, supplemental laboratory-based testing, or self-report of a previous HIV-positive test result. Participants received $20–$50 for HIV testing (amount determined locally).

Participants who agreed to recruit others received an additional incentive of $10–$25 for each recruit (up to 5) who completed the interview (amount determined locally). The project goal for each participating city was to interview 500 persons who met the NHBS definition of a heterosexually active adult at increased risk for HIV (i.e., of low socioeconomic status [SES], defined as having completed no more than a high school education or having a household income at or below the U.S. Department of Health and Human Services poverty guidelines)13. Sampling was focused on persons of low SES because results of a pilot study indicated that heterosexual adults of low SES were more likely than those of high SES to be infected with HIV1.

Data analysis

This data release presents descriptive data; no statistical tests were performed. In addition, these data are cross-sectional; causal relationships are neither implied nor inferred. Reported numbers fewer than 12, and percentages based on these numbers, should be interpreted with caution because the numbers are considered unreliable.

Data are not weighted. The purpose of this report is to provide a detailed summary of surveillance data collected as part of the NHBS 2025 cycle; unweighted data provide an efficient and transparent way to do so. Further, unweighted analysis allows for detailed reporting of outcomes among small subgroups of the population of interest.

In 2025, 19 MSAs participated in NHBS among heterosexually active adults at increased risk for HIV infection. Among the 19 MSAs, 10,393 persons were recruited to participate; 10,314 persons were screened to participate in NHBS. Of those, 1,728 did not meet NHBS eligibility criteria or did not provide consent and were excluded from the survey. An additional 97 interviews were excluded from this report due to incomplete survey data or survey responses of questionable validity. Finally, an additional 1,898 eligible persons were excluded from this data release because they

• were not classified as low SES (as defined above);
• had any history of injection drug use;
• or, if male, had any history of sex with men.

The full analysis sample for this report includes 6,591 participants from the 2025 NHBS cycle. Additional inclusion criteria were applied for certain analyses of HIV infection and HIV-associated behaviors; details of each analysis sample can be found in the footnotes of each table.

Participating metropolitan statistical areas, 2025

Definitions

Sociodemographic characteristics

• Sex: Male or female
• Age: Calculated from the reported date of birth; age categories were chosen for epidemiologic relevance and consistency of reporting across all 3 National HIV Behavioral Surveillance (NHBS) populations.
• Race/ethnicity: Participants reported 1 or more race categories (American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or other Pacific Islander, and White). Hispanic or Latino ethnicity was asked separately; participants who did not report Hispanic or Latino ethnicity were categorized by race. Hispanic or Latino persons could be of any race.
• Disability: Participants who reported difficulty with hearing, seeing, cognition, ambulation, self-care, or independent living, based on responses to the questions that comprise the US Department of Health and Human Services data standard for disability status1415.
• City: Throughout this report, eligible metropolitan statistical areas (MSAs) and divisions are referred to by the name of the principal city. State and local health departments eligible to participate in NHBS are those in jurisdictions that include an MSA (or a specified division within an MSA) with high prevalence of HIV. This report presents 2025 data in 19 MSAs (see list above).

Structural factors

• Less than high school education: Reported never attending school or having completed less than grade 12.
• Income at or below the federal poverty level: Participants were asked about their combined monthly or yearly household income (in US$) from all sources for the calendar year before interview. Poverty was determined by using the U.S. Department of Health and Human Services poverty guidelines for 2024. These guidelines are issued yearly for the United States and are one of the indicators used for determining eligibility for many federal and state programs. The 2024 guidelines13 were used for participants interviewed in 2025. Because the poverty guidelines are not defined for Puerto Rico, the guidelines for the 48 contiguous states and Washington, D.C., were used for this jurisdiction. Participants were asked to identify the range of their income by selecting from a list of income ranges and the number of dependents on that income. If the participant's income range and household size resulted in an ambiguous determination of poverty level, the participant's household income was assumed to be the low point of the income range.
• Unemployed: Participants who reported their employment status as "unemployed" at the time of the interview.
• Homeless: Living on the street, in a shelter, in a single-room–occupancy hotel, or in a car at any time in the 12 months before interview.
• Incarcerated: Having been held in a detention center, jail, or prison for more than 24 hours in the 12 months before interview.
• No current health insurance: Not having any form of health insurance at the time of the interview.
• Did not visit a health care provider: Did not visit a healthcare provider in the 12 months before interview.

HIV status

HIV testing was performed for participants who consented to testing; blood specimens were collected for rapid testing in the field or supplemental laboratory-based testing.

• HIV-negative: Participants with a negative NHBS HIV test result who did not self-report a previous HIV-positive test result.
• HIV-positive: Participants who had a reactive rapid NHBS HIV test result that was supported by a second rapid test, supplemental laboratory-based testing, or self-report of a previous HIV-positive test result.
• No valid NHBS HIV test result: Participants who did not have a valid positive or negative NHBS HIV test result, including those who did not consent to the HIV test, had an indeterminate laboratory result, discordant rapid test results, or reported a previous HIV-positive test result but had a negative NHBS HIV test result.

HIV testing

• Ever tested: Having had an HIV test during one's lifetime.
• Tested in past 12 months: Having had an HIV test in the 12 months before interview.
• Clinical setting: Participants reported the location of their most recent HIV test as private doctor's office (including health maintenance organization), emergency department, hospital (inpatient), public health clinic or community health center, family planning or obstetrics clinic, correctional facility (jail or prison), or drug treatment program.
• Non-clinical setting: Participants reported the location of their most recent HIV test as HIV counseling and testing site, HIV street outreach program or mobile unit, syringe services program, or home.

Sexual behaviors

• Anal sex: Penis inserted into a partner's anus or butt.
• Vaginal sex: Penis inserted into a partner's vagina.
• Oral sex: Mouth on a partner's penis or vagina.
• Condomless sex: Vaginal or anal sex during which a condom either is not used or is not used throughout the sex act.
• Number of sex partners: Median number of opposite sex partners during the 12 months before interview; first and third quartiles (25th and 75th percentiles) are also reported.
• Exchange sex for males: Refers to giving money or drugs to a female casual partner in exchange for sex.
• Exchange sex for females: Refers to receiving money or drugs from a male casual partner in exchange for sex.
• Casual partner: Person with whom the participant had sex, but to whom he or she does not feel committed or whom he or she does not know very well.
• Unprotected sex with HIV-discordant partner at last sex: "Unprotected sex" refers to sex without the participant's use of either condoms or HIV medications (i.e., HIV preexposure prophylaxis [PrEP] among those without HIV or HIV antiretroviral treatment among those with HIV). "HIV-discordant partner" refers to a sex partner of different or unknown HIV status. The measure assumes the participant does not know if their partner is taking HIV medications.

HIV prevention activities

• Free condoms: Having received free condoms during the 12 months before interview, not including those given by a friend, relative, or sex partner.
• Individual- or group-level intervention: Defined as either one-on-one conversations with an outreach worker, a counselor, or a prevention program worker about ways to prevent HIV, excluding conversations as part of an HIV test, or participating in any organized session that involves a small group of persons discussing ways to prevent HIV infections, excluding informal discussions with friends.
• PrEP awareness: Ever heard of PrEP, an antiretroviral medicine taken for months or years by a person who is HIV-negative to reduce the risk of getting HIV.
• PrEP use: Took PrEP at any point during the 12 months before interview to reduce the risk of getting HIV.

Sexually transmitted infections (STIs)

• Any bacterial STI: Having received a diagnosis of chlamydia, gonorrhea, or syphilis during the 12 months before interview.
• Chlamydia: Having received a diagnosis of chlamydia during the 12 months before interview.
• Gonorrhea: Having received a diagnosis of gonorrhea during the 12 months before interview.
• Syphilis: Having received a diagnosis of syphilis during the 12 months before interview.
• Genital warts: Having received a diagnosis of genital warts during one's lifetime.
• Genital herpes: Having received a diagnosis of genital herpes during one's lifetime.

Noninjection drug use

Participants were asked about their use of drugs (excluding those prescribed for them) during the 12 months before interview and their use of alcohol during the 30 days before interview. Participants were not limited in the number of substances they could report. Participants were considered to have used a substance if they reported using that substance with any frequency other than "never." The use of trade names is for identification only and does not imply endorsement by the Department of Health and Human Services or the Centers for Disease Control and Prevention.

• Any noninjection drug: Used any noninjection drug, excluding alcohol and marijuana, during the 12 months before interview.
• Binge Drinking: Consumed 5 or more alcoholic drinks (males) or 4 or more alcoholic drinks (females) in about 2 hours during the 30 days before interview.
• Cocaine: Used powder cocaine during the 12 months before interview.
• Crack: Used crack cocaine during the 12 months before interview.
• Downer: Used downers (benzodiazepines), such as Klonopin, Valium, Ativan, or Xanax, during the 12 months before interview.
• Ecstasy: Used X or ecstasy during the 12 months before interview.
• Heroin: Used heroin (smoked or snorted) during the 12 months before interview.
• Marijuana: Used marijuana during the 12 months before interview.
• Methamphetamine: Used methamphetamines, including meth, crystal meth, speed, or crank, during the 12 months before interview.
• Prescription opioids: Used pain killers, such as OxyContin, Vicodin, morphine, or Percocet, during the 12 months before interview.

Receipt of HIV care

Participants who self-reported being HIV-positive were asked about their receipt of HIV care. Specifically, participants were asked the date of their first HIV-positive test result; if they had ever visited a doctor, nurse, or other health care provider for a medical evaluation or care related to their HIV infection; the date of their first visit to a health care provider for HIV care after learning they had HIV; the date of their most recent visit to a health care provider for HIV care; and whether they were currently taking any antiretroviral medicines.

• Visited health care provider about HIV, ever: Having ever visited a health care provider for HIV care.
• Visited health care provider about HIV, within 1 month after diagnosis: Having visited a health care provider for HIV care within 1 month after the date of their first HIV-positive test result.
• Visited health care provider about HIV, in the past 6 months: Having visited a health care provider for HIV care during the 6 months before date of interview.
• Currently taking antiretroviral HIV medicines: Taking antiretroviral medicines to treat an HIV infection at the time of interview.

Using these data

Acknowledgments

Atlanta, GA: Genetha Mustaafaa, Jenna Gettings, Timothy Lockhart; Baltimore, MD: Colin Flynn, Danielle German, Molly Gribbin; Chicago, IL: Antonio D. Jimenez, Irina Tabidze, Colleen Leonard; Denver, CO: Alia Al-Tayyib, Megan Duffy, Jessica Forsyth; Detroit, MI: Emily Higgins, Vivian Griffin; Houston, TX: Kirstin Short, Osaro Mgbere, Paige Padgett; Indianapolis, IN: Daniel Hillman, Sherika Sides, Manuel Gonzalez-Carrasco; Los Angeles, CA: Ekow Kwa Sey, Yingbo Ma, Hugo Santacruz; New Orleans, LA: William T. Robinson, Tobas Babilion-Crocket, Polo Orire; New York City, NY: Abdier Benitez Flete, Alexis Rivera, Kristina Rodriguez; Newark, NJ: Afework Wogayehu, Danica Kuncio, Corey Rosmarin-DeStafano; Philadelphia, PA: Kathleen A. Brady, Tanner Nassau, Lyric Kleber; Portland, OR: Lauren Lipira, Pete Singson, Lalaine Sevillano; San Diego, CA: Stephanie Sanz, Nannie Song, Nabeeh Hasan; San Francisco, CA: Erin C Wilson, Willi McFarland; San Juan, PR: Yadira Rolón-Colón, Jesus Vargas-Franco, María Pabón Martínez; Seattle, WA: Sara Glick, Aleks Martin, Courtney Moreno; Virginia Beach, VA: Jennifer Kienzle, Jamell James, Gregg Fordham; Washington, DC: Irene Kuo, Kate Drezner, Sydney Bornstein; CDC: Amy Baugher, Julie Berg, Dita Broz, Janet Burnett, Susan Cha, Johanna Chapin-Bardales, Jacklynn De Leon, Paul Denning, Lyssa Faucher, Jonathan Feelemyer, Teresa Finlayson, Maya Haynes, Rebecca Hershow, Dafna Kanny, Kathryn Lee, Rashunda Lewis, Elana Morris, Evelyn Olansky, Adeolu Orogade, Catlainn Sionean, Anna Teplinskaya, Jeffery Todd, Cyprian Wejnert.

Suggested citation

All material contained in this report is the public domain and may be used and reprinted without special permission; however, citation as to source is appreciated.

Centers for Disease Control and Prevention. HIV Risk, Prevention, and Testing Behaviors Among Heterosexually Active Adults at Increased Risk for HIV—National HIV Behavioral Surveillance, 19 U.S. Cities, 2025. Published October 28, 2026. Accessed [date]. https://www.cdc.gov/hiv-data/nhbs/hiv-risk-prevention-testing-het.html

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