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AbstractIntroductionHIV testing is an essential prerequisite for accessing treatment with antiretroviral therapy or prevention using pre‐exposure prophylaxis. Internet distribution of HIV self‐tests is a novel approach, and data on the programmatic cost of this approach are limited. We analyse the costs and cost‐effectiveness of a self‐testing programme.MethodsMen who have sex with men (MSM) reporting unknown or negative HIV status were enrolled from March to August 2015 into a 12‐month trial of HIV self‐testing in the United States. Participants were randomly assigned either to the self‐testing arm or the control arm. All participants received information on HIV testing services and locations in their community. Self‐testing participants received up to four self‐tests each quarter, which they could use themselves or distribute to their social network associates. Quarterly follow‐up surveys collected testing outcomes, including number of tests used and new HIV diagnoses. Using trial expenditure data, we estimated the cost of implementing a self‐testing programme. Primary outcomes of this analysis included total programme implementation costs, cost per self‐test completed, cost per person tested, cost per new HIV diagnosis among those self‐tested and cost per quality adjusted life year (QALY) saved.ResultsA total of 2665 men were assigned either to the self‐testing arm (n = 1325) or the control arm (n = 1340). HIV testing was reported by 971 self‐testing participants who completed a total of 5368 tests. In the control arm, 619 participants completed 1463 HIV tests. The self‐testing participants additionally distributed 2864 self‐tests to 2152 social network associates. Testing during the trial identified 59 participants and social network associates with newly diagnosed HIV infection in the self‐testing arm; 11 control participants were newly diagnosed with HIV. The implementation cost of the HIV self‐testing programme was $449,510. The cost per self‐test completed, cost per person tested at least once, and incremental cost per new HIV diagnosis was $61, $145 and $9365 respectively. We estimated that self‐testing programme potentially averted 3.34 transmissions, saved 14.86 QALYs and nearly $1.6 million lifetime HIV treatment costs.ConclusionsThe HIV self‐testing programme identified persons with newly diagnosed HIV infection at low cost, and the programme is cost saving.

For the past three decades, legislative approaches to prevent HIV transmission have been used at the national, state, and local levels. One punitive legislative approach has been enactment of laws that criminalize behaviors associated with HIV exposure (HIV-specific criminal laws). In the USA, HIV-specific criminal laws have largely been shaped by state laws. These laws impose criminal penalties on persons who know they have HIV and subsequently engage in certain behaviors, most commonly sexual activity without prior disclosure of HIV-positive serostatus. These laws have been subject to intense public debate. Using public health law research methods, data from the legal database WestlawNext© were analyzed to describe the prevalence and characteristics of laws that criminalize potential HIV exposure in the 50 states (plus the District of Columbia) and to examine the implications of these laws for public health practice. The first state laws were enacted in 1986; as of 2011 a total of 67 laws had been enacted in 33 states. By 1995, nearly two-thirds of all laws had been enacted; by 2000, 85 % of laws had been enacted; and since 2000, an additional 10 laws have been enacted. Twenty-four states require persons who are aware that they have HIV to disclose their status to sexual partners and 14 states require disclosure to needle-sharing partners. Twenty-five states criminalize one or more behaviors that pose a low or negligible risk for HIV transmission. Nearly two-thirds of states in the USA have legislation that criminalizes potential HIV exposure. Many of these laws criminalize behaviors that pose low or negligible risk for HIV transmission. The majority of laws were passed before studies showed that antiretroviral therapy (ART) reduces HIV transmission risk and most laws do not account for HIV prevention measures that reduce transmission risk, such as condom use, ART, or pre-exposure prophylaxis. States with HIV-specific criminal laws are encouraged to use the findings of this paper to re-examine those laws, ...

INTRODUCTION: Preventing tuberculosis (TB) disease requires treatment of latent TB infection (LTBI) as well as prevention of person-to-person transmission. We estimated the LTBI prevalence for the entire United States and for each state by medical risk factors, age, and race/ethnicity, both in the total population and stratified by nativity. METHODS: We created a mathematical model using all incident TB disease cases during 2013–2017 reported to the National Tuberculosis Surveillance System that were classified using genotype-based methods or imputation as not attributed to recent TB transmission. Using the annual average number of TB cases among US-born and non-US-born persons by medical risk factor, age group, and race/ethnicity, we applied population-specific reactivation rates (and corresponding 95% confidence intervals [CI]) to back-calculate the estimated prevalence of untreated LTBI in each population for the United States and for each of the 50 states and the District of Columbia in 2015. RESULTS: We estimated that 2.7% (CI: 2.6%–2.8%) of the U.S. population, or 8.6 (CI: 8.3–8.8) million people, were living with LTBI in 2015. Estimated LTBI prevalence among US-born persons was 1.0% (CI: 1.0%–1.1%) and among non-US-born persons was 13.9% (CI: 13.5%–14.3%). Among US-born persons, the highest LTBI prevalence was in persons aged ≥65 years (2.1%) and in persons of non-Hispanic Black race/ethnicity (3.1%). Among non-US-born persons, the highest LTBI prevalence was estimated in persons aged 45–64 years (16.3%) and persons of Asian and other racial/ethnic groups (19.1%). CONCLUSIONS: Our estimations of the prevalence of LTBI by medical risk factors and demographic characteristics for each state could facilitate planning for testing and treatment interventions to eliminate TB in the United States. Our back-calculation method feasibly estimates untreated LTBI prevalence and can be updated using future TB disease case counts at the state or national level.