Behavioral and Clinical Characteristics of Persons with Diagnosed HIV Infection—Medical Monitoring Project, United States 2020 Cycle (June 2020–May 2021): Commentary

At year-end 2019, an estimated 1,061,482 persons in the United States and 6 dependent areas were living with diagnosed HIV infection, and in 2019, the number of new HIV diagnoses was 36,801 [1]. Although the National HIV Surveillance System (NHSS) collects information about persons with diagnosed HIV infection [1], other surveillance systems provide more detailed information about care seeking, health care use, use of ancillary services, and key behaviors among people at risk for, and with, diagnosed HIV [2,3]. In 2005, in response to an Institute of Medicine (IOM) report outlining the need for representative data on persons with HIV [4], the Centers for Disease Control and Prevention (CDC) implemented the Medical Monitoring Project (MMP), which from 2009 to 2014 collected data from a 3-stage probability sample of adults receiving HIV medical care [5]. In 2015, in response to recommendations stemming from an IOM review of national HIV data systems [6], MMP sampling and weighting methods were revised to include all adults with diagnosed HIV infection, regardless of HIV care status. MMP is a cross-sectional, nationally representative, complex sample survey that assesses the behavioral and clinical characteristics of adults with diagnosed HIV infection in the United States. MMP also provides information on behaviors and clinical outcomes affecting the risk of HIV transmission, morbidity, and mortality that are critical for achieving the goals of the National HIV/AIDS Strategy [7] and the Ending the HIV Epidemic in the U.S. (EHE) initiative [8], which seek to reduce new HIV infections in the United States by 90% by 2030.

The 2020 MMP data were collected from a 2-stage probability sample. During the first stage, 16 U.S. states and Puerto Rico were selected from all U.S. states, the District of Columbia, and Puerto Rico. A total of 23 project areas from 16 states, including 6 separately funded jurisdictions within these states, and Puerto Rico were funded to conduct data collection for the 2020 cycle (Table 1). In the second stage, simple random samples of persons aged ≥18 years with diagnosed HIV infection who were reported to NHSS as of December 31, 2019 were selected from each participating jurisdiction [9].

This report presents unweighted frequencies and weighted prevalence estimates with 95% confidence intervals for all characteristics. The estimates describe the characteristics of adults with diagnosed HIV infection who are living in the United States, hereafter referred to as persons with diagnosed HIV or persons. The period referenced for estimates is the 12 months before the participants’ interviews and medical record abstractions unless otherwise noted. Statistical software (SAS, version 9.4) was used for analysis of weighted data [10]. Data are not reported for estimates derived from a denominator size < 30 or for estimates with a coefficient of variation ≥ 0.30. Estimates with an absolute confidence interval width ≥ 30, estimates with an absolute confidence interval width between 5 and 30 and a relative confidence interval width > 130%, and estimates of 0% or 100% are marked with an asterisk and should be interpreted with caution. No statistical tests were performed. Estimates presented in this report may have been affected by the COVID-19 pandemic. Additional information on MMP is available at https://www.cdc.gov/hiv/statistics/systems/mmp/.

Highlights of Analyses

Response Rates

All 16 states, including 6 separately funded jurisdictions within those states, and the 1 territory sampled for MMP participated (Figure 1). In total, 9,700 persons were sampled from NHSS and 3,710 participated (Table 1). Adjusted for eligibility, the response rate was 40% (shown in footnotes of Table 1).

Figure 1. Participating Medical Monitoring Project Sites, Including 16 States and 6 Separately Funded Jurisdictions—United States, 2020

Figure 1. For the 16 states and territory selected in the first stage of sampling, 23 individual jurisdictions were funded to conduct data collection for the 2020 cycle, including 16 states, Puerto Rico, and 6 independent surveillance jurisdictions within the selected states.

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Selected Characteristics, Including Demographic Characteristics and Social Determinants of Health

An estimated 75% of persons were cisgender male, 23% were cisgender female, and 2% were transgender (Figure 2; Table 2). Nearly three-quarters (74%) were aged at least 40 years. An estimated 43% identified themselves as heterosexual or straight; 45% as lesbian or gay; 9% as bisexual; and 3% as another sexual orientation. An estimated 42% were Black or African American, 29% were White, and 24% were Hispanic or Latino.

Figure 2. Distribution of Gender, Age, Sexual Orientation, and Race/Ethnicity Among Adults with Diagnosed HIV—Medical Monitoring Project, United States, 2020

Figure 2a 2b 2c 2d: An estimated 75% of persons were male, 23% were female, and 2% were transgender (defined as either self-identifying as transgender or reporting a gender identity that was different from their reported sex assigned at birth). Nearly three-quarters (74%) of persons were at least 40 years of age. Approximately 43% of persons identified themselves as heterosexual or straight; 45% as lesbian or gay; 9% as bisexual; and 3% as another sexual orientation. An estimated 42% of persons were Black or African American and 29% were White. Additionally, 24% of all persons were Hispanic or Latino (Hispanics and Latinos can be of any race) and 6% were American Indian/Alaska Native, Asian, Native Hawaiian/Other Pacific Islander, or multiracial. Data presented were from the 2020 cycle of the Medical Monitoring Project, a surveillance system monitoring clinical outcomes and behaviors of adults with diagnosed HIV infection in the United States. Demographic data were collected using in-person or telephone interviews. For more details on MMP methods, see here: https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-special-report-number-29.pdf.

Note. Transgender persons defined as those who self-identified as transgender or who reported a gender identity different from sex assigned at birth. “Other” race/ethnicity defined as persons who were American Indian/Alaska Native, Asian, Native Hawaiian/Other Pacific Islander, or multiracial. Hispanics or Latinos can be of any race.

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Over half (60%) had more than a high school education and 83% were born in a U.S. state or territory (Table 2). The estimated prevalence of homelessness or other forms of unstable housing among all people with diagnosed HIV was 17% (data not shown in table). The estimated prevalence of homelessness was 8%. Many people experienced other forms of unstable housing: approximately 12% had moved in with other people because of financial problems, 8% moved 2 or more times, and 2% had been evicted from housing during the past 12 months. Nearly 4% were incarcerated >24 hours. Approximately 16% went without food due to lack of money, 41% were unemployed, and 36% had household incomes at or below the federal poverty threshold. An estimated 15% received Supplemental Security Income (SSI) and 19% received Social Security Disability Insurance (SSDI). An estimated 98% had health insurance or coverage for care or medications (including antiretroviral therapy [ART] medications): 47% had coverage through the Ryan White HIV/AIDS Program, 43% had Medicaid, 28% had Medicare, and 40% had private health insurance (Figure 3). An estimated 40% had a disability. Overall, 72% perceived their general health as good, very good, or excellent, and 68% had received an HIV diagnosis at least 10 years earlier.

Figure 3. Prevalence of Selected Social Determinants of Health Among Adults with Diagnosed HIV—Medical Monitoring Project, United States, 2020

Figure 3a: During the 12 months prior to interview, an estimated 8% experienced homelessness, 4% were incarcerated, 16% experienced food insecurity, 41% were unemployed, and 36% were in households living at or below the federal poverty level.   Data presented were from the 2020 cycle of the Medical Monitoring Project, a surveillance system monitoring clinical outcomes and behaviors of adults with diagnosed HIV infection in the United States. Data on social determinants of health were collected using in-person or telephone interviews. For more details on MMP methods, see here: https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-special-report-number-29.pdf.
Figure 3b: An estimated 15% received Supplemental Security Income (SSI) benefits, and 19% received Social Security Disability Insurance (SSDI) benefits during the 12 months prior to interview.  Data presented were from the 2020 cycle of the Medical Monitoring Project, a surveillance system monitoring clinical outcomes and behaviors of adults with diagnosed HIV infection in the United States. Data on SSI benefits and SSDI benefits were collected using in-person or telephone interviews. For more details on MMP methods, see here:  https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-special-report-number-29.pdf.
Figure 3c: 47% of persons had health insurance or coverage for care or medications (including antiretroviral medications) through the Ryan White HIV/AIDS Program (RWHAP), 43% had Medicaid, 28% had Medicare, and 40% had private health insurance. People could report more than one type of health insurance or coverage.  Data presented were from the 2020 cycle of the Medical Monitoring Project, a surveillance system monitoring clinical outcomes and behaviors of adults with diagnosed HIV infection in the United States. Data on types of health insurance or coverage for care or antiretroviral medications were collected using in-person or telephone interviews. For more details on MMP methods, see here:  https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-special-report-number-29.pdf.

Abbreviations: SSI, Supplemental Security Income; SSDI, Social Security Disability Insurance; RWHAP, Ryan White HIV/AIDS Program.
Note. Healthcare insurance/coverage types not mutually exclusive; people could report >1 type of coverage.

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Clinical Characteristics

According to the CDC stage of disease classification for HIV infection [11], an estimated 54% of persons ever had stage 3 (AIDS) disease (Table 3). An estimated 7% of persons had a geometric mean CD4 T-lymphocyte (CD4) count of 0–199 cells/µL. The estimated average geometric mean CD4 count among all persons was 659.3 cells/µL, and the median geometric mean CD4 count was 635.8 cells/µL (range, 0–2,920) (data not shown in table).

An estimated 63% of persons had a viral load that was undetectable or < 200 copies/mL at the most recent measurement, while 59% had viral loads that were undetectable or <200 copies/mL at all measurements during the past 12 months (sustained viral suppression) (Figure 4; Table 3).

Figure 4. Percentage of Adults with Diagnosed HIV Who Were Virally Suppressed During the 12 Months Before Interview—Medical Monitoring Project, United States, 2020

Figure 4. An estimated 63% of persons had an undetectable HIV viral load (<200 copies/mL or undetectable) at the most recent test, and 59% of persons had sustained viral suppression, defined as having all viral load tests in the past 12 months <200 copies/mL or undetectable in the 12 months prior to the interview. Data presented were from the 2020 cycle of the Medical Monitoring Project, a surveillance system monitoring clinical outcomes and behaviors of adults with diagnosed HIV infection in the United States. HIV viral load data were collected using medical record abstractions. Abstraction of medical records occurred at the facility where the participant received most of their HIV care in the 12 months prior to the interview. Medical records were only abstracted at one clinic regardless of how many clinics the participant visited. For more details on MMP methods, see here: https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-special-report-number-29.pdf.

*Viral load <200 copies/mL or undetectable based on most recent test in the past 12 months.
†Sustained viral suppression defined as having all viral load tests in the past 12 months <200 copies/mL or undetectable.

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Use of Health Care Services

Overall, 95% had received outpatient HIV care during the past 12 months (Figure 5; Table 4). An estimated 72% were retained in care during the past 12 months, while 56% were retained in care during the past 24 months. An estimated 79% of persons had an ART prescription documented in the medical record during the 12 months before interview. Of persons who met the clinical criteria for Pneumocystis pneumonia (PCP) prophylaxis, 42% had a prescription for PCP prophylaxis documented in the medical record.

Figure 5. Receipt of HIV Care and Antiretroviral Therapy Prescription During the 12 Months Before Interview Among Adults with Diagnosed HIV—Medical Monitoring Project, United States, 2020

Figure 5. In all, 95% of persons received some form of outpatient HIV care in the 12 months prior to the interview. Outpatient HIV care was defined as any documentation of the following: encounter with an HIV care provider, viral load test result, CD4 test result, HIV resistance test or tropism assay, ART prescription, PCP prophylaxis, or MAC prophylaxis. Approximately 72% were retained in care in the 12 months prior to the interview. Retention in care was defined as at least two elements of outpatient HIV care at least 90 days apart in each 12-month period. Overall, an estimated 79% of persons had an antiretroviral therapy prescription documented in the medical record. Data presented were from the 2020 cycle of the Medical Monitoring Project, a surveillance system monitoring clinical outcomes and behaviors of adults with diagnosed HIV infection in the United States. Clinical care data were collected using medical record abstractions. Abstraction of medical records occurred at the facility where the participant received most of their HIV care in the 12 months prior to the interview. Medical records were only abstracted at one clinic regardless of how many clinics the participant visited. Additionally, a self-reported encounter with an HIV care provider met the criteria for receipt of outpatient HIV care. For more details on MMP methods, see here: https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-special-report-number-29.pdf.

 *Outpatient HIV care was defined as any documentation of the following at the most frequent source of HIV care: encounter with an HIV care provider (could be self-reported), viral load test result, CD4 test result, HIV resistance test or tropism assay, ART prescription, PCP prophylaxis, or MAC prophylaxis.
†Two elements of outpatient HIV care at least 90 days apart during the 12 months prior to interview.

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Among sexually active persons, an estimated 47% were tested for gonorrhea, 48% for chlamydia, 61% for syphilis, and 41% for all 3 sexually transmitted infections (STIs) (Figure 6; Table 5).

Figure 6. Percentage of Sexually Active Adults with Diagnosed HIV Who Tested for Gonorrhea, Chlamydia, or Syphilis During the 12 Months Before Interview—Medical Monitoring Project, United States, 2020

Figure 6. Among sexually active persons, an estimated 47% were tested for gonorrhea, 48% for chlamydia, 61% for syphilis, and 41% for all 3 sexually transmitted diseases (STDs), for screening or diagnostic purposes. Percentages for gonorrhea and chlamydia include testing at any anatomical site. Data presented were from the 2020 cycle of the Medical Monitoring Project, a surveillance system monitoring clinical outcomes and behaviors of adults with diagnosed HIV infection in the United States. STD screening data were collected using medical record abstractions. Abstraction of medical records occurred at the facility where the participant received most of their HIV care in the 12 months prior to the interview. Medical records were only abstracted at one clinic regardless of how many clinics the participant visited. For more details on MMP methods, see here: https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-special-report-number-29.pdf.

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An estimated 38% of persons were seen in an emergency department at least once, and 4% were seen at least 5 times (Figure 7; Table 6). An estimated 16% of persons were admitted to a hospital for an illness at least once.

Figure 7. Percentage of Adults with Diagnosed HIV Who Had At Least One Visit to the Emergency Room Or At Least One Hospital Admission During the 12 Months Before Interview—Medical Monitoring Project, United States, 2020

Figure 7. In all, 38% of persons had at least 1 visit to an emergency department in the 12 months prior to the interview and 16% were admitted to the hospital in the 12 months prior to the interview. Data presented were from the 2020 cycle of the Medical Monitoring Project, a surveillance system monitoring clinical outcomes and behaviors of adults with diagnosed HIV infection in the United States. Emergency department and hospital admissions data were collected using in-person or telephone interviews. For more details on MMP methods, see here: https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-special-report-number-29.pdf.

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Self-reported ART Medication Use and Adherence

An estimated 99% of persons had ever taken ART and 95% of persons were currently taking ART, based on self-report (Table 7). Among those with a history of ART use but who were not currently taking ART, 37% were not taking ART due to money or insurance problems, 29% were not taking ART because the person’s health care provider never discussed restarting ART with them, and 20% were not taking ART because the person thought ART would make them feel sick or harm them.

Among persons taking ART, 78% had never been troubled by ART side effects during the past 30 days; 12% had rarely been troubled (Table 8). Among persons taking ART, 62% took all of their ART doses in the past 30 days. Among persons who had ever missed a dose, the most common reasons given for not taking one’s most recently missed ART dose were forgetting (65%), a change in one’s daily routine or being out of town (39%), or falling asleep early or oversleeping (37%) (Figure 8).

Figure 8. Reasons for Missing Last Antiretroviral Therapy Dose Among Adults with Diagnosed HIV Who Have Ever Missed a Dose*—Medical Monitoring Project, United States, 2020

Figure 8. Among persons who were currently taking antiretroviral therapy (ART) and ever missed a dose, 65% reported that the reason for their most recently missed dose was because they forgot, 39% reported it was because of a change in daily routine or being out of town, 37% reported the reason was because they fell asleep early or overslept, 17% had a problem getting a prescription or refill for HIV medicine, and 16% because they felt depressed or overwhelmed. Data presented were from the 2020 cycle of the Medical Monitoring Project, a surveillance system monitoring clinical outcomes and behaviors of adults with diagnosed HIV infection in the United States. Adherence data were collected using in-person or telephone interviews. For more details on MMP methods, see here: https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-special-report-number-29.pdf.

*Participants may report more than one reason for last missed dose.

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Clinical Characteristics by Selected Populations

The estimated prevalence of ART prescription documented in a medical record was 79% among cisgender males and 79% among cisgender females (Table 9). Approximately 76% of bisexual persons and 79% of lesbian or gay persons were prescribed ART, compared with 80% of heterosexual or straight persons. An estimated 76% of Black or African American persons were prescribed ART, compared with 81% of Hispanic or Latino persons and 81% of White persons. The estimated prevalence of ART prescription was 74% among persons aged 18–29 years and 81% among those aged ≥50 years.

ART dose adherence in the past 30 days was 63% among both cisgender males and cisgender females. An estimated 57% of bisexual persons and 62% of lesbian or gay persons were ART dose adherent, compared with 64% of heterosexual or straight persons. Approximately 60% of Black or African American persons and Hispanic or Latino persons were ART adherent, compared with 66% of White persons. An estimated 37% of persons aged 18–29 years were ART adherent, compared with 69% of persons aged ≥50 years.

The estimated prevalence of sustained viral suppression was 58% among cisgender males and 59% among cisgender females. Approximately 58% of bisexual persons and 60% of lesbian or gay persons, compared with 57% of heterosexual or straight persons had sustained viral suppression. An estimated 54% of Black or African American persons, had sustained viral suppression, compared with 63% of Hispanic or Latino persons and 62% of White persons. The estimated prevalence of sustained viral suppression was 48% among persons aged 18–29 years and 62% among those aged ≥50 years.

Depression and Substance Use

The estimated prevalence of symptoms indicative of major or other depression in the past 2 weeks based on the Patient Health Questionnaire (PHQ-8) algorithm [12] was 14%, including 7% with major depression (Figure 9; Table 10). Based on the total PHQ-8 symptom score (see the appendix), an estimated 11% of persons had symptoms of moderate or severe depression. The estimated prevalence of mild, moderate, or severe symptoms of generalized anxiety disorder in the past 2 weeks based on the Generalized Anxiety Disorder Scale (GAD-7) [13] was 18%, including 6% with severe anxiety.

Figure 9. Percentage of Adults with Diagnosed HIV Who Experienced Symptoms of Major or Other Depression* and Generalized Anxiety Disorder† During the Two Weeks Before Interview—Medical Monitoring Project, United States, 2020

Figure 9a. 7% of adults with diagnosed HIV reported symptoms of major depression, and 7% reported symptoms of other depression, during the past 2 weeks. Responses to the items on the PHQ-8 were used to define "major depression" and "other depression", according to criteria from the DSM-IV. "Major depression" was defined as having at least 5 symptoms of depression; "other depression" was defined as having 2–4 symptoms of depression. The PHQ-8 classification "other depression" comprises the DSM-IV categories of dysthymia and depressive disorder, not otherwise specified, which includes minor or subthreshold depression. Data presented were from the 2020 cycle of the Medical Monitoring Project, a surveillance system monitoring clinical outcomes and behaviors of adults with diagnosed HIV infection in the United States. Data on symptoms of depression were collected using in-person or telephone interviews. For more details on MMP methods, see here: https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-special-report-number-29.pdf.
Figure 9b. Of all adults with diagnosed HIV, 5% reported symptoms of mild anxiety, 7% reported symptoms of moderate anxiety, and 6% reported symptoms of severe anxiety in the past 2 weeks. Responses to the GAD-7 were used to define "mild anxiety", "moderate anxiety", and "severe anxiety", according to criteria from the DSM-IV. "Severe anxiety" was defined as having a score of >=15; "moderate anxiety" was defined as having a score of 10–14; and "mild anxiety" was defined as having a score of 5–9. Data presented were from the 2020 cycle of the Medical Monitoring Project, a surveillance system monitoring clinical outcomes and behaviors of adults with diagnosed HIV infection in the United States. Anxiety data were collected using in-person or telephone interviews. For more details on MMP methods, see here: https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-special-report-number-29.pdf.

*Responses to the items on the PHQ-8 were used to define “major depression” and “other depression” according to criteria from the DSM-IV. “Major depression” was defined as having at least 5 symptoms of depression; “other depression” was defined as having 2–4 symptoms of depression. The PHQ-8 classification “other depression” comprises the DSM-IV categories of dysthymia and depressive disorder, not otherwise specified, which includes minor or subthreshold depression.

†Responses to the GAD-7 were used to define “mild anxiety,” “moderate anxiety,” and “severe anxiety,” according to criteria from the DSM-IV. “Severe anxiety” was defined as having a score of ≥ 15; “moderate anxiety” was defined as having a score of 10–14; and “mild anxiety” was defined as having a score of 5–9.

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The estimated prevalence of current smoking was 29%: 24% of persons smoked daily, 3% weekly, 1% monthly, and 2% less than monthly (Figure 10; Table 11). The estimated prevalence of alcohol use was 63%: 7% of persons drank alcohol daily, 19% weekly, 12% monthly, and 25% less than monthly (Figure 10; Table 12). An estimated 15% of persons engaged in binge drinking during the past 30 days.

Figure 10. Percentage of Adults with Diagnosed HIV Who Smoked Cigarettes and Drank Alcohol During the 12 Months Before Interview—Medical Monitoring Project, United States, 2020

Figure 10a. The estimated prevalence of cigarette smoking in the past 12 months was 29%. An estimated 24% of persons smoked daily, 3% weekly, 1% monthly, and 2% less than monthly. Data presented were from the 2020 cycle of the Medical Monitoring Project, a surveillance system monitoring clinical outcomes and behaviors of adults with diagnosed HIV infection in the United States. Smoking data were collected using in-person or telephone interviews. For more details on MMP methods, see here: https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-special-report-number-29.pdf.
Figure 10b. The estimated prevalence of any alcohol use in the past 12 months was 63%. An estimated 7% of persons reported drinking alcohol daily, 19% weekly, 12% monthly, and 25% reported less than monthly in the 12 months before the interview. An estimated 15% of persons engaged in binge drinking, defined as 5 or more alcoholic beverages in one sitting (4 or more alcoholic beverages for women), during the past 30 days. Data presented were from the 2020 cycle of the Medical Monitoring Project, a surveillance system monitoring clinical outcomes and behaviors of adults with diagnosed HIV infection in the United States. Alcohol use data were collected using in-person or telephone interviews. For more details on MMP methods, see here: https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-special-report-number-29.pdf.

*Persons who drank ≥5 alcoholic beverages in a single sitting (≥4 for women) during the 30 days before interview.

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An estimated 33% of persons used noninjection drugs for nonmedical purposes (Table 13). In total, an estimated 29% used marijuana, 8% used poppers (amyl nitrite), 6% used methamphetamines, 5% used cocaine, 4% used club drugs, 3% used crack, 3% used prescription tranquilizers, and 2% used prescription opioids. An estimated 3% of persons used injection drugs for nonmedical purposes (Table 14). In total, an estimated 2% injected methamphetamines and 1% injected heroin.

Characteristics Related to Gynecologic and Reproductive Health

Among females, 85% reported receiving a Papanicolaou (Pap) test in the past 3 years (Figure 11; Table 15). An estimated 28% of females reported being pregnant at least once since receiving an HIV diagnosis.

Figure 11. Percentage of Cisgender Female Adults with Diagnosed HIV Who Had a Papanicolaou Test During the Three Years Before Interview or Became Pregnant Since Receiving an HIV Diagnosis—Medical Monitoring Project, United States, 2020

Figure 11. An estimated 85% of all women received a Pap test in the past 3 years. An estimated 28% of women had been pregnant at least once since receiving an HIV diagnosis. Data presented were from the 2020 cycle of the Medical Monitoring Project, a surveillance system monitoring clinical outcomes and behaviors of adults with diagnosed HIV infection in the United States. Gynecologic and reproductive health services data were collected using in-person or telephone interviews. For more details on MMP methods, see here:  https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-special-report-number-29.pdf.

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Sexual Behavior

An estimated 61% of cisgender men engaged in vaginal or anal sex; approximately 18% engaged in vaginal sex, 35% had receptive anal sex with cisgender men, and 32% had insertive anal sex with cisgender men (Table 16). An estimated 39% of cisgender men did not have vaginal or anal sex. Among cisgender women, an estimated 50% engaged in vaginal or anal sex. Approximately 50% had vaginal sex and 6% had receptive anal sex. An estimated 50% did not have vaginal or anal sex. Among transgender persons, 75% had vaginal or anal sex (Table 17).

Among cisgender men who had sex with cisgender men (MSM), an estimated 9% engaged in high-risk sex, compared with 8% of cisgender men who had sex only with cisgender women (MSW) and 7% of cisgender women who had sex with cisgender men (WSM) (Figure 12; Table 18).

Figure 12. Percentage of Adults with Diagnosed HIV Who Engaged in Sex Without Using an HIV Prevention Strategy* During the 12 Months Before Interview by Sexual Behavior/Orientation—Medical Monitoring Project, United States, 2020

Figure 12. Among cisgender men who had sex with cisgender men (MSM), an estimated 9% engaged in sex without using an HIV prevention strategy, compared with 8% for cisgender men who only had sex with cisgender women (MSW), and 7% for cisgender women had sex with cisgender men (WSM). Sex without using an HIV prevention strategy was defined as having vaginal or anal sex in the past 12 months with at least 1 partner with an HIV-negative or unknown status while not having sustained viral suppression (all viral load tests in the past 12 months <200 copies/mL or detectable), when a condom was not used, and the partner was not known to be taking pre-exposure prophylaxis (PrEP). Data presented were from the 2020 cycle of the Medical Monitoring Project, a surveillance system monitoring clinical outcomes and behaviors of adults with diagnosed HIV infection in the United States. Data on sex without using an HIV prevention strategy were collected using in-person or telephone interviews. For more details on MMP methods, see here: https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-special-report-number-29.pdf.

Note. MSM, cisgender men who have sex with cisgender  men; MSW, cisgender men who have sex only with cisgender women; WSM, cisgender women who have sex with cisgender men.
*Vaginal or anal sex with at least 1 HIV-negative or unknown status partner while not having sustained viral suppression (all viral load measurements in the past 12 months undetectable or < 200 copies/mL), when a condom was not used, and the partner was not known to be taking preexposure prophylaxis (PrEP)

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Sexually active persons used a variety of HIV prevention strategies. For instance, an estimated 62% of MSM engaged in sex and had sustained viral suppression, 55% had condom-protected sex, 22% had condomless sex with a partner on preexposure prophylaxis (PrEP), and 54% had sex with a person with HIV (Figure 13; Table 18). Among sexually active MSW, 50% engaged in sex and had sustained viral suppression, 57% had condom-protected sex, 5% had condomless sex with a partner on PrEP, and 24% had sex with a person with HIV. Among sexually active WSM, 58% engaged in sex and had sustained viral suppression, 51% had condom-protected sex, 4% had condomless sex with a partner on PrEP, and 28% had sex with a person with HIV.

Figure 13. Prevention Strategies Used During the 12 Months Before Interview Among Sexually Active Men Who Have Sex with Men, Men Who Have Sex with Only Women, and Women Who Have Sex with Men with Diagnosed HIV—Medical Monitoring Project, United States, 2020

During the past 12 months, an estimated 62% of sexually active cisgender men with diagnosed HIV who had sex with cisgender men engaged in sex and had viral suppression. An estimated 55% of persons had condom-protected sex; 22% had condomless sex with a partner on PrEP; and 54% had sex with a person with HIV. During the past 12 months, an estimated 50% of sexually active cisgender men with diagnosed HIV who only had sex with cisgender women engaged in sex and had viral suppression. An estimated 57% of persons had condom-protected sex; 5% had condomless sex with a partner on PrEP; and 24% had sex with a person with HIV. During the past 12 months, an estimated 58% of sexually active cisgender women with diagnosed HIV who had sex with cisgender men engaged in sex and had viral suppression. An estimated 51% of persons had condom-protected sex; 4% had condomless sex with a partner on PrEP; and 28% had sex with a person with HIV. Data presented were from the 2020 cycle of the Medical Monitoring Project, a surveillance system monitoring clinical outcomes and behaviors of adults with diagnosed HIV infection in the United States. Prevention services data were collected using in-person or telephone interviews. For more details on MMP methods, see here: https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-special-report-number-29.pdf.

Note. MSM, cisgender men who have sex with cisgender men; MSW, cisgender men who have sex only with cisgender women; WSM, cisgender women who have sex with cisgender men.

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Met and Unmet Need for Ancillary Services

Overall, 94% of people with diagnosed HIV received at least one ancillary service; 72% received at least one HIV support service, 68% received at least one non-HIV medical service, and 51% received at least one subsistence service. Overall, 41% had an unmet need for at least one ancillary service; 14% had an unmet need for at least one HIV support service, 27% had an unmet need for at least one non-HIV medical service, and 20% had an unmet need for at least one subsistence service (not shown in tables or figures).

Among all HIV support services, the most commonly reported service received in the 12 months before interview was HIV case management (52%); estimated unmet need for HIV case management services was 6% (Figure 14; Table 19). Of all non-HIV medical care services, the most commonly reported service received was dental care (56%); 21% reported an unmet need for dental care. Among all subsistence services, the most commonly reported services received were obtained through the Supplemental Nutrition Assistance Program (SNAP) or Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (37%); unmet need for SNAP or WIC services was 10%.

Figure 14. Percentage of Adults with Diagnosed HIV Who Received, or Who Needed but Did Not Receive, Ancillary Services Related to (a) HIV Support, (b) Non-HIV Medical Services, and (c) Subsistence During the 12 Months Before Interview—Medical Monitoring Project, United States, 2020

Figure 14a. For HIV support services, an estimated 52% of persons received HIV case management services, 48% received medicine through Ryan White/ADAP, 30% received ART adherence support services, 14% received patient navigation services, and 10% received HIV peer support services. In total, 6% of persons had unmet needs for HIV case management, 3% had unmet needs for medicine through Ryan White or ADAP, 1% had unmet needs for adherence support services, 4% had unmet needs for patient navigation services, and 6% had unmet needs for HIV peer support services. Data presented were from the 2020 cycle of the Medical Monitoring Project, a surveillance system monitoring clinical outcomes and behaviors of adults with diagnosed HIV infection in the United States. Data on unmet needs for ancillary services were collected using in-person or telephone interviews. For more details on MMP methods, see here: https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-special-report-number-29.pdf.
Figure 14b. For non-HIV medical care services, an estimated 56% of person received dental care, 29% received mental health services, and 6% received drug or alcohol counseling or treatment. In total, 21% had unmet needs for dental care, 8% had unmet needs for mental health services, and 2% had unmet needs for drug or alcohol counseling or treatment. Data presented were from the 2020 cycle of the Medical Monitoring Project, a surveillance system monitoring clinical outcomes and behaviors of adults with diagnosed HIV infection in the United States. Data on unmet needs for ancillary services were collected using in-person or telephone interviews. For more details on MMP methods, see here: https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-special-report-number-29.pdf.
Figure 14c. For subsistence services, an estimated 37% received SNAP or WIC, 24% received meal or food services, 20% received transportation assistance, and 15% received shelter or housing services. In total, 10% had unmet needs for SNAP or WIC, 5% had unmet needs for meal or food services, 6% had unmet needs for transportation assistance, and 8% had unmet needs for shelter or housing services. Data presented were from the 2020 cycle of the Medical Monitoring Project, a surveillance system monitoring clinical outcomes and behaviors of adults with diagnosed HIV infection in the United States. Data on unmet needs for ancillary services were collected using in-person or telephone interviews. For more details on MMP methods, see here: https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-special-report-number-29.pdf.

*ADAP, AIDS Drug Assistance Program
†ART, Antiretroviral therapy

*SNAP: Supplemental Nutrition Assistance Program; WIC: Special Supplemental Nutrition Program for Women, Infants, and Children
†Includes services such as soup kitchens, food pantries, food banks, church dinners, or food delivery services.

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Physical Violence and Forced Sex

An estimated 26% of persons had ever been physically hurt by a romantic or sexual partner, including 4% who experienced this in the past 12 months (Figure 15; Table 20). An estimated 16% of persons had ever been threatened with harm or physically forced to have unwanted sex, including 1% who experienced this in the past 12 months.

Figure 15. Percentage of Adults with Diagnosed HIV Who Experienced Physical Violence by an Intimate Partner or Forced Sex During Their Lifetime or the 12 months Before Interview—Medical Monitoring Project, United States, 2020

Figure 15. Over one-quarter (26%) of persons were ever slapped, punched, shoved, kicked, choked, or otherwise physically hurt by a romantic or sexual partner and 4% of persons experienced this in the 12 months prior to the interview. In all, 16% were ever threatened with harm or physically forced to have unwanted vaginal, anal, or oral sex and 1% of persons experienced this in the 12 months prior to the interview. Data presented were from the 2020 cycle of the Medical Monitoring Project, a surveillance system monitoring clinical outcomes and behaviors of adults with diagnosed HIV infection in the United States. Data on intimate partner violence and sexual violence were collected using in-person or telephone interviews. For more details on MMP methods, see here: https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-special-report-number-29.pdf.

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Prevention Activities

An estimated 56% of persons received counseling from a physician, nurse, or other health care worker about HIV and STD risk reduction; 27% had a one-on-one conversation with an outreach worker, a counselor, or a prevention program worker about prevention; and 10% participated in a small-group session (excluding discussions with friends) to discuss the prevention of HIV and other STDs (Figure 16; Table 21). An estimated 42% of persons received free condoms from various organizations.

Figure 16. Receipt of HIV and Sexually Transmitted Disease Prevention Services During the 12 Months Before Interview—Medical Monitoring Project, United States, 2020

Figure 16. During the past 12 months, an estimated 56% of persons received counseling from a physician, nurse, or other healthcare worker about HIV and sexually transmitted disease (STD) prevention; 27% had a one-on-one conversation with an outreach worker, a counselor, or a prevention program worker about HIV and STD prevention; and 10% participated in a small-group session (excluding discussions with friends) to discuss the prevention of HIV and other STDs in the past 12 months. An estimated 42% of persons received free condoms. Data presented were from the 2020 cycle of the Medical Monitoring Project, a surveillance system monitoring clinical outcomes and behaviors of adults with diagnosed HIV infection in the United States. Data on receipt of HIV and STD prevention services were collected using in-person or telephone interviews. For more details on MMP methods, see here: https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-special-report-number-29.pdf.

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National Indicators

The estimated prevalence of homelessness was 8% among all persons with diagnosed HIV and persons who received outpatient HIV care in the past 12 months (Table 22). The median HIV stigma score (see the appendix for more details on how the score was derived and its validity) among all persons was 35. When the personalized stigma dimension was limited to the past 12 months, the median HIV stigma score was 28. An estimated 8% of persons engaged in sex without using an HIV prevention strategy.

References

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