HIV Testing in 50 Local Jurisdictions Accounting for the Majority of New HIV Diagnoses and Seven States with Disproportionate Occurrence of HIV in Rural Areas, 2016–2017

Marc A. Pitasi, MPH1; Kevin P. Delaney, PhD1; John T. Brooks, MD1; Elizabeth A. DiNenno, PhD1; Shacara D. Johnson, MSPH1; Joseph Prejean, PhD1 (View author affiliations)

View suggested citation

Summary

What is already known about this topic?

Rates of screening for human immunodeficiency virus (HIV) in the United States are low.

What is added by this report?

This analysis of national survey data found that <40% of U.S. adults had ever been tested for HIV, and testing rates varied among jurisdictions comprising the initial focus of the Ending the HIV Epidemic initiative. Within these jurisdictions, rural areas had lower testing percentages and lower HIV diagnosis rates than did urban areas.

What are the implications for public health practice?

Novel HIV screening strategies tailored to meet local needs might be needed to reach segments of the population that have never been tested for HIV and achieve national goals to end the HIV epidemic in the United States.

Article Metrics
Altmetric:
Citations:
Views:

Views equals page views plus PDF downloads

Related Materials

The graphic encourages adults to get tested for human immunodeficiency virus (HIV) at least once and persons at high risk annually.
 
Since 2006, CDC has recommended universal screening for human immunodeficiency virus (HIV) infection at least once in health care settings and at least annual rescreening of persons at increased risk for infection (1,2), but data from national surveys and HIV surveillance demonstrate that these recommendations have not been fully implemented (3,4). The national Ending the HIV Epidemic initiative* is intended to reduce the number of new infections by 90% from 2020 to 2030. The initiative focuses first on 50 local jurisdictions (48 counties, the District of Columbia, and San Juan, Puerto Rico) where the majority of new diagnoses of HIV infection in 2016 and 2017 were concentrated and seven states with a disproportionate occurrence of HIV in rural areas relative to other states (i.e., states with at least 75 reported HIV diagnoses in rural areas that accounted for ≥10% of all diagnoses in the state). This initial geographic focus will be followed by wider implementation of the initiative within the United States. An important goal of the initiative is the timely identification of all persons with HIV infection as soon as possible after infection (5). CDC analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS)§ to assess the percentage of adults tested for HIV in the United States nationwide (38.9%), in the 50 local jurisdictions (46.9%), and in the seven states (35.5%). Testing percentages varied widely by jurisdiction but were suboptimal and generally low in jurisdictions with low rates of diagnosis of HIV infection. To achieve national goals and end the HIV epidemic in the United States, strategies must be tailored to meet local needs. Novel screening approaches might be needed to reach segments of the population that have never been tested for HIV.

BRFSS is an annual cellular and landline telephone survey of the noninstitutionalized U.S. population aged ≥18 years. The median response rate among all participating states and territories was 47.1% (range = 30.7%–65.0%) in 2016 and 45.9% (range = 30.6%–64.1%) in 2017.** Respondents were asked whether they had ever been tested for HIV outside of blood donation; those who answered “yes” were asked for the month and year of their most recent test. Respondents were also asked whether any of the following HIV risk–related situations applied to them in the past year: injected drugs that were not prescribed, received treatment for a sexually transmitted disease, exchanged money or drugs for sex, had anal sex without a condom, or had four or more sex partners. Those who answered “yes” to this question were considered to have reported recent HIV risk.

Data collected in 2016 and 2017 were pooled and used to estimate the percentage and corresponding 95% confidence intervals (CIs) of ever testing for HIV and testing for HIV in the past year overall and for each of the 57 jurisdictions. Nationally and within the seven states with disproportionate rural HIV occurrence, counties were grouped as either mostly urban or mostly or completely rural according to designation by the 2010 U.S. Census.†† Rao-Scott chi-square tests were used to compare testing percentages between mostly urban and mostly or completely rural areas in the United States and in the seven states with disproportionate rural HIV occurrence. All estimates were weighted to account for the complex multistage sampling design. HIV diagnosis rates per 100,000 population among persons aged ≥13 years were calculated from HIV diagnoses reported to CDC’s National HIV Surveillance System during 2016–2017 through December 2018; U.S. Census population estimates for 2016 and 2017 were used for the denominators. HIV diagnosis rates and testing percentages were examined together for each of the 50 local jurisdictions as well as urban and rural areas of the seven states to further characterize these areas with respect to their current HIV morbidity and testing coverage; Pearson’s correlation coefficient was used to assess the correlation between these areas’ testing percentages and HIV diagnosis rates. Although BRFSS testing percentages were calculated among those aged ≥18 years, HIV diagnosis rates were calculated among those aged ≥13 years to be consistent with methodology used to identify the jurisdictions accounting for the majority of new HIV diagnoses and because of limited availability of single-year age population estimates at the municipio (county equivalent) level in Puerto Rico. Analyses were performed using SAS (version 9.4; SAS Institute) and SUDAAN (version 11.0; RTI International).

During 2016–2017, 38.9% of adults aged ≥18 years in the United States had ever been tested for HIV (Table 1). Among 15,701 (3.2%) persons with reported recent HIV risk for whom at least annual rescreening is recommended, 64.8% were ever tested, and 29.2% were tested in the past year. Among all adults, the percentage ever tested (46.9%) was higher among residents of the 50 local jurisdictions that accounted for the majority of diagnoses of HIV infection among persons aged ≥13 years than was the percentage ever tested (35.5%) in the seven states with disproportionate rural HIV occurrence. Among persons with reported HIV risk, the percentage tested in the past year (34.3%) in the 50 local jurisdictions was also higher than that in the seven states (26.2%). Among all adults in these seven states, 32.1% of those residing in mostly rural areas and 37.2% of those residing in mostly urban areas had ever been tested. Among persons with reported HIV risk in these states, 18.4% of those residing in rural areas and 29.0% of those residing in urban areas were tested in the past year.

Testing percentages varied widely by jurisdiction (Table 2). Among the 50 local jurisdictions, the percentage of persons aged ≥18 years ever tested ranged from 36.5% in Maricopa County, Arizona, to 70.7% in the District of Columbia; the percentage tested in the past year (independent of reported recent HIV risk) ranged from 8.1% in Alameda County, California, to 31.3% in Bronx County, New York. Testing percentages were generally low in both urban and rural areas of the seven states with disproportionate rural HIV occurrence. Among the 50 local jurisdictions and seven states, the percentage of persons aged ≥18 years ever tested for HIV generally increased with increasing HIV diagnosis rate among persons aged ≥13 years (r = 0.71; p<0.01) (Figure). Most of the 50 local jurisdictions had higher testing percentages and diagnosis rates than did the seven states.

Discussion

In this analysis, <40% of the U.S. adult population had ever been tested for HIV. Jurisdictions with the highest rates of diagnosis of HIV infection among persons aged ≥13 years generally had higher testing percentages. The converse was also true. Ever testing for HIV was lower in rural areas of the seven states with disproportionate rural HIV occurrence, compared with that in urban areas of these states, the 50 local jurisdictions with the majority of diagnoses of HIV infection, and the United States nationally. Although past-year HIV testing was higher among persons with reported recent HIV risk than among those without such risk, the percentage tested in the past year was far below the 100% coverage recommended for this group (1,2). These findings demonstrate missed opportunities to fully implement HIV screening recommendations in the 57 jurisdictions that will serve as the initial geographic focus of the Ending the HIV Epidemic initiative. The observed variability in both ever and past-year testing by jurisdiction highlights the need for screening strategies that are tailored to local needs. BRFSS is likely the only annual survey with a sufficient sample size to provide jurisdiction-level estimates of HIV testing to monitor long-term progress toward increasing screening coverage in the United States.

HIV screening strategies will likely need to be locally tailored and novel to reach segments of the population that have not been reached by previous efforts. Examples of novel or promising approaches to increase access to HIV testing include routinizing HIV screening in health care settings, integrating HIV screening with sexual health screenings, scaling up partner notification and other strategies (using social network strategy§§ or mobile applications) that offer screening of the social and sexual networks of persons seeking HIV screening, promoting pharmacist-led screening¶¶ as well as screening in other alternative clinical settings such as urgent care, and mass distribution of HIV self-tests*** (610). Further efforts will be needed to identify which approaches are most effective in increasing access to HIV testing in various settings and jurisdictions with different baseline needs. Early diagnosis and effective treatment that suppresses HIV replication not only minimize immune system damage and reduce individual morbidity and mortality but also reduce the risk for transmission to others.††† Delayed diagnosis limits these benefits. HIV screening is a critical entry point to a range of HIV prevention and treatment options. For persons at ongoing risk for HIV infection exposure, annual screening also offers the opportunity to discuss options to reduce risk, including HIV preexposure prophylaxis.§§§

The findings in this report are subject to at least six limitations. First, because the proportion of respondents reporting recent HIV risk was small, testing percentages for this group could not be reported separately in the 57 jurisdictions. Second, self-reported data might be subject to social desirability and recall biases, which might have led to over- or underestimation of testing. Third, BRFSS response rates were low; however, the response rates are comparable with those of other national landline and cellular telephone surveys, and survey weights were designed to ensure generalizable findings. Fourth, the measure of HIV-related risk did not include every behavior that might increase risk for HIV infection, such as unprotected sex with a partner who is known to have HIV or whose HIV status is unknown. Fifth, the assessment of HIV diagnosis rates and HIV testing percentages relied on disparate age ranges (≥13 years and ≥18 years, respectively). Finally, this analysis included data from surveys conducted during 2016–2017 and HIV diagnoses that occurred during the same period. These are the most current data available for these measures but represent a delayed cross-section of the current state of HIV testing and diagnoses for 2019. To monitor progress toward national goals, closer to real-time reporting of select HIV testing activities might be needed.

HIV screening remains suboptimal for persons residing in the 57 jurisdictions that will constitute the initial geographic focus of the Ending the HIV Epidemic initiative. These data provide a baseline from which to measure changes in screening in these jurisdictions and other parts of the United States over time. To achieve national goals and end the HIV epidemic in the United States, innovative and novel screening approaches might be needed to reach segments of the population that have never been tested for HIV.

Acknowledgment

Kim Elmore, PhD, Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC.

Corresponding author: Marc A. Pitasi, mpitasi@cdc.gov, 404-639-6361.


1Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC.

All authors have completed and submitted the ICMJE form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.


References

  1. Branson BM, Handsfield HH, Lampe MA, et al.  Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep 2006;55(No. RR-14). PubMedexternal icon
  2. DiNenno EA, Prejean J, Irwin K, et al. Recommendations for HIV screening of gay, bisexual, and other men who have sex with men—United States, 2017. MMWR Morb Mortal Wkly Rep 2017;66:830–2. CrossRefexternal icon PubMedexternal icon
  3. Pitasi MA, Delaney KP, Oraka E, et al. Interval since last HIV test for men and women with recent risk for HIV infection—United States, 2006–2016. MMWR Morb Mortal Wkly Rep 2018;67:677–81. CrossRefexternal icon PubMedexternal icon
  4. Dailey AF, Hoots BE, Hall HI, et al. Vital signs: human immunodeficiency virus testing and diagnosis delays—United States. MMWR Morb Mortal Wkly Rep 2017;66:1300–6. CrossRefexternal icon PubMedexternal icon
  5. Fauci AS, Redfield RR, Sigounas G, Weahkee MD, Giroir BP. Ending the HIV epidemic: a plan for the United States. JAMA 2019;321:844–5. CrossRefexternal icon PubMedexternal icon
  6. Sullivan PS, Lyons MS, Czarnogorski M, Branson BM. Routine screening for HIV infection in medical care settings: a decade of progress and next opportunities. Public Health Rep 2016;131(Suppl 1):1–4. CrossRefexternal icon PubMedexternal icon
  7. Golden MR, Katz DA, Dombrowski JC. Modernizing field services for human immunodeficiency virus and sexually transmitted infections in the United States. Sex Transm Dis 2017;44:599–607. CrossRefexternal icon PubMedexternal icon
  8. Kachur R, Hall W, Coor A, Kinsey J, Collins D, Strona FV. The use of technology for sexually transmitted disease partner services in the United States: a structured review. Sex Transm Dis 2018;45:707–12. CrossRefexternal icon PubMedexternal icon
  9. Weidle PJ, Lecher S, Botts LW, et al. HIV testing in community pharmacies and retail clinics: a model to expand access to screening for HIV infection. J Am Pharm Assoc 2014;54:486–92. CrossRefexternal icon PubMedexternal icon
  10. Katz DA, Golden MR, Hughes JP, Farquhar C, Stekler JD. HIV self-testing increases HIV testing frequency in high-risk men who have sex with men: a randomized controlled trial. J Acquir Immune Defic Syndr 2018;78:505–12. CrossRefexternal icon PubMedexternal icon
TABLE 1. Ever and past-year testing for human immunodeficiency virus (HIV) among adults aged ≥18 years, by urban-rural classification* — Behavioral Risk Factor Surveillance System, United States, 50 local jurisdictions and seven states, 2016–2017Return to your place in the text
Status Total weighted % (95% CI) Mostly urban counties weighted % (95% CI) Mostly or completely rural counties weighted % (95% CI) p-value§
Ever tested for HIV
United States 38.9 (38.7–39.2) 40.1 (39.8–40.4) 32.0 (31.5–32.4) <0.001
50 local jurisdictions 46.9 (46.3–47.5) 46.9 (46.3–47.5) N/A N/A
Seven states 35.5 (35.0–36.0) 37.2 (36.6–37.8) 32.1 (31.3–32.9) <0.001
Tested for HIV in the past year
United States 10.1 (9.9–10.2) 10.6 (10.4–10.8) 6.7 (6.4–7.0) <0.001
50 local jurisdictions 14.5 (14.0–14.9) 14.5 (14.0–14.9) N/A N/A
Seven states 9.3 (8.9–9.6) 10.1 (9.7–10.5) 7.6 (7.2–8.1) <0.001
Tested for HIV in the past year among those with reported HIV risk
United States 29.2 (27.9–30.6) 30.2 (28.8–31.8) 20.9 (17.7–24.4) <0.001
50 local jurisdictions 34.3 (31.3–37.3) 34.3 (31.3–37.3) N/A N/A
Seven states 26.2 (23.4–29.3) 29.0 (25.5–32.8) 18.4 (14.5–23.2) <0.001

Abbreviations: CI = confidence interval; N/A = not applicable.
* Urban and rural classifications were derived from 2010 U.S. Census. Counties with <50% of the population residing in areas defined as rural were classified as urban counties. Counties with ≥50% of the population residing in areas defined as rural were classified as rural counties.
The 50 local jurisdictions (48 counties, the District of Columbia, and San Juan, Puerto Rico) accounted for the majority of new HIV diagnoses, and the seven states (Alabama, Arkansas, Kentucky, Mississippi, Missouri, Oklahoma, and South Carolina) experienced disproportionate occurrence of HIV in rural areas, as identified from HIV diagnoses made during 2016–2017 and reported to the National HIV Surveillance System through June 2018. Diagnosis data from 2017 were considered preliminary.
§ Rao-Scott chi-square p-values compare testing estimates between mostly urban counties and mostly or completely rural counties.

TABLE 2. Ever and past-year testing for human immunodeficiency virus (HIV) among adults aged ≥18 years — Behavioral Risk Factor Surveillance System, 50 local jurisdictions and seven states,* 2016–2017Return to your place in the text
Jurisdiction No. of respondents Ever tested for HIV weighted % (95% CI) Tested in past year for HIV weighted % (95% CI)
50 local jurisdictions that accounted for the majority of new HIV diagnoses
Arizona
Maricopa County 11,130 36.5 (35.1–37.9) 8.4 (7.6–9.3)
California
Alameda County 740 37.7 (33.3–42.3) 8.1 (5.8–11.2)
Los Angeles County 3,479 43.6 (41.3–45.9) 13.4 (11.9–15.0)
Orange County 1,206 39.8 (36.1–43.6) 10.9 (8.7–13.6)
Riverside County 920 39.6 (35.7–43.7) 10.3 (8.0–13.1)
Sacramento County 952 42.0 (38.1–46.0) 9.1 (7.1–11.7)
San Bernardino County 859 43.0 (38.8–47.2) 12.7 (10.1–15.8)
San Diego County 1,543 45.5 (42.3–48.7) 14.3 (12.1–16.8)
San Francisco County 442 51.8 (45.3–58.3) 14.9 (11.3–19.3)
District of Columbia 7,125 70.7 (69.2–72.1) 26.4 (25.0–27.8)
Florida
Broward County 923 54.0 (49.4–58.5) 19.0 (15.6–23.0)
Duval County 1,502 57.0 (52.9–61.0) 20.3 (16.7–24.4)
Hillsborough County 1,148 52.7 (48.4–56.9) 15.3 (12.3–18.8)
Miami-Dade County 1,377 56.7 (52.4–60.9) 18.5 (15.2–22.3)
Orange County 1,301 48.6 (44.6–52.7) 14.9 (12.2–18.1)
Palm Beach County 911 45.5 (40.9–50.1) 11.1 (8.4–14.4)
Pinellas County 890 41.0 (36.4–45.8) 12.4 (9.0–16.7)
Georgia
Cobb County 576 43.7 (38.9–48.7) 10.1 (7.4–13.6)
DeKalb County 603 57.1 (52.2–61.9) 19.5 (15.6–24.0)
Fulton County 967 56.9 (53.2–60.5) 19.7 (16.8–23.1)
Gwinnett County 563 43.2 (38.4–48.2) 11.8 (8.9–15.5)
Illinois
Cook County 3,807 41.3 (39.3–43.2) 13.5 (12.2–14.9)
Indiana
Marion County 3,248 45.4 (42.9–47.9) 13.0 (11.2–14.9)
Louisiana
East Baton Rouge Parish 664 49.7 (44.3–55.2) 17.0 (13.2–21.6)
Orleans Parish 423 58.2 (51.7–64.4) 24.0 (18.2–31.1)
Maryland
Baltimore City 1,735 62.4 (59.2–65.6) 25.3 (22.3–28.6)
Montgomery County 3,366 44.1 (41.7–46.5) 10.6 (9.2–12.3)
Prince George’s County 2,598 56.3 (53.4–59.1) 22.4 (20.1–24.9)
Massachusetts
Suffolk County 1,495 48.6 (44.7–52.5) 15.2 (12.5–18.2)
Michigan
Wayne County 2,906 45.3 (43.1–47.5) 14.1 (12.5–15.8)
Nevada
Clark County 2,770 40.7 (38.5–42.9) 10.9 (9.5–12.4)
New Jersey
Essex County 1,581 55.0 (51.0–59.0) 17.3 (14.4–20.6)
Hudson County 905 50.2 (45.4–54.9) 15.8 (12.5–19.6)
New York
Bronx County 1,094 70.0 (66.4–73.4) 31.3 (28.1–34.8)
Kings County 2,030 57.0 (54.3–59.7) 21.6 (19.4–23.9)
New York County 1,782 60.0 (57.0–62.9) 22.0 (19.6–24.6)
Queens County 1,568 52.3 (49.2–55.5) 18.0 (15.7–20.6)
North Carolina
Mecklenburg County 753 47.1 (42.9–51.3) 13.5 (10.8–16.8)
Ohio
Cuyahoga County 1,172 44.2 (40.7–47.9) 11.9 (9.6–14.6)
Franklin County 1,749 42.3 (39.4–45.1) 10.1 (8.5–12.1)
Hamilton County 912 41.6 (37.7–45.7) 11.3 (8.9–14.3)
Pennsylvania
Philadelphia County 1,399 57.5 (54.2–60.7) 21.4 (18.8–24.3)
Puerto Rico
San Juan Municipio 1,042 57.2 (52.7–61.6) 17.0 (14.0–20.5)
Tennessee
Shelby County 717 53.4 (49.0–57.8) 22.8 (18.9–27.3)
Texas
Bexar County 784 45.1 (39.9–50.5) 13.7 (10.2–18.1)
Dallas County 623 44.2 (38.7–49.8) 14.4 (10.7–19.2)
Harris County 1,214 45.9 (41.9–50.0) 13.2 (10.8–16.2)
Tarrant County 740 46.0 (40.8–51.4) 11.6 (8.3–16.0)
Travis County 1,855 50.2 (46.2–54.2) 12.3 (9.9–15.3)
Washington
King County 6,101 39.4 (37.9–40.9) 8.4 (7.5–9.3)
Seven states with disproportionate HIV occurrence in rural counties
Alabama, total 12,098 39.4 (38.3–40.6) 11.0 (10.2–11.8)
Urban counties 7,442 40.8 (39.4–42.3) 12.1 (11.1–13.2)
Rural counties 4,656 36.8 (34.8–38.8) 8.8 (7.6–10.2)
Arkansas, total 9,268 33.7 (31.9–35.6) 9.1 (7.9–10.4)
Urban counties 5,206 35.8 (33.4–38.3) 10.6 (8.9–12.5)
Rural counties 4,062 30.9 (28.3–33.6) 7.1 (5.7–8.8)
Kentucky, total 16,937 33.8 (32.6–34.9) 7.2 (6.6–7.9)
Urban counties 8,887 36.3 (34.7–38.0) 8.0 (7.1–9.0)
Rural counties 8,050 29.9 (28.4–31.4) 6.0 (5.3–6.9)
Mississippi, total 8,984 40.2 (38.7–41.7) 12.7 (11.6–13.9)
Urban counties 4,207 44.3 (42.2–46.5) 14.3 (12.7–16.1)
Rural counties 4,777 35.4 (33.4–37.4) 10.9 (9.5–12.4)
Missouri, total 13,446 34.3 (33.1–35.5) 8.3 (7.5–9.1)
Urban counties 9,031 36.4 (34.8–37.9) 9.3 (8.4–10.4)
Rural counties 4,415 29.1 (27.1–31.3) 5.6 (4.5–6.8)
Oklahoma, total 11,952 29.7 (28.6–30.9) 6.8 (6.2–7.6)
Urban counties 7,365 30.7 (29.2–32.2) 7.4 (6.5–8.4)
Rural counties 4,587 27.8 (26.0–29.7) 5.7 (4.8–6.9)
South Carolina, total 19,983 37.4 (36.4–38.3) 10.6 (9.9–11.3)
Urban counties 14,201 37.7 (36.5–38.8) 10.5 (9.8–11.4)
Rural counties 5,782 36.1 (34.3–38.0) 10.9 (9.6–12.4)

Abbreviation: CI = confidence interval.
* Urban and rural classifications were derived from 2010 U.S. Census. Counties with <50% of the population residing in areas defined as rural were classified as urban counties. Counties with ≥50% of the population residing in areas defined as rural were classified as rural counties. The 50 local jurisdictions (48 counties, the District of Columbia, and San Juan, Puerto Rico) accounted for the majority of new HIV diagnoses, and the seven states (Alabama, Arkansas, Kentucky, Mississippi, Missouri, Oklahoma, and South Carolina) experienced disproportionate occurrence of HIV in rural areas, as identified from HIV diagnoses made during 2016–2017 and reported to the National HIV Surveillance System through June 2018. Diagnosis data from 2017 were considered preliminary.
Number of respondents with “yes” or “no” response to question about ever testing for HIV.

Return to your place in the textFIGURE. Percentage of adults aged ≥18 years ever tested for human immunodeficiency virus (HIV) infection and HIV diagnosis rate* among persons aged ≥13 years — Behavioral Risk Factor Surveillance System and National HIV Surveillance System (NHSS), 50 local jurisdictions accounting for the majority of new HIV diagnoses and seven states with disproportionate occurrence of HIV in rural areas, 2016–2017§

* HIV diagnosis rates per 100,000 population among persons aged ≥13 years during 2016–2017 were calculated from HIV diagnoses reported to NHSS through December 2018 and Census population estimates for 2016 and 2017.

The 50 local jurisdictions (48 counties, the District of Columbia, and San Juan, Puerto Rico) accounted for the majority of new HIV diagnoses, and the seven states (Alabama, Arkansas, Kentucky, Mississippi, Missouri, Oklahoma, and South Carolina) experienced disproportionate occurrence of HIV in rural areas, as identified from HIV diagnoses made during 2016–2017 and reported to NHSS through June 2018. Diagnosis data from 2017 were considered preliminary.

§ Pearson’s correlation coefficient = 0.71; p<0.01.


Suggested citation for this article: Pitasi MA, Delaney KP, Brooks JT, DiNenno EA, Johnson SD, Prejean J. HIV Testing in 50 Local Jurisdictions Accounting for the Majority of New HIV Diagnoses and Seven States with Disproportionate Occurrence of HIV in Rural Areas, 2016–2017. MMWR Morb Mortal Wkly Rep 2019;68:561–567. DOI: http://dx.doi.org/10.15585/mmwr.mm6825a2external icon.

MMWR and Morbidity and Mortality Weekly Report are service marks of the U.S. Department of Health and Human Services.
Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.
References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of pages found at these sites. URL addresses listed in MMWR were current as of the date of publication.

All HTML versions of MMWR articles are generated from final proofs through an automated process. This conversion might result in character translation or format errors in the HTML version. Users are referred to the electronic PDF version (https://www.cdc.gov/mmwr) and/or the original MMWR paper copy for printable versions of official text, figures, and tables.

Questions or messages regarding errors in formatting should be addressed to mmwrq@cdc.gov.

View Page In:pdf icon
Page last reviewed: June 27, 2019