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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

      

HIV

Centers for Disease Control and Prevention
Health Resources and Services Administration

 

Goal

 

Prevent human immunodeficiency virus (HIV) infection and its related illness and death.

 

Overview

In 1981, a new infectious disease, AIDS, or acquired immunodeficiency syndrome, was identified in the United States.[1] Several years later, the causative agent of AIDS—human immunodeficiency virus (HIV)—was discovered. This discovery coincided with the growing recognition of AIDS in the United States as part of a global infectious disease pandemic. 

Currently, HIV/AIDS has been reported in virtually every racial and ethnic population, every age group, and every socioeconomic group in every State and most large cities in the United States.[2] Initially identified among men who have sex with men on the East and West Coasts,[3] the AIDS epidemic is composed of diverse multiple subepidemics that vary by region and community. By the end of 1998, more than 680,000 cases of AIDS had been reported, and nearly 410,800 people had died from HIV disease or AIDS.2

Issues 

Estimates of the number of people infected with HIV in the United States range from 800,000 to 900,000.[4] The HIV/AIDS subepidemics not only vary by region and community but also may vary by population, risk behavior, and geography. Elimination of disparities in the rate of infection among certain racial and ethnic groups, particularly African American and Hispanic populations, remains a challenge. Recently introduced therapies for HIV/AIDS have reduced illness, disability, and death due to HIV/AIDS; however, access to culturally and linguistically appropriate testing and care may limit progress in this area.

In the United States, HIV/AIDS remains a significant cause of illness, disability, and death, despite declines in 1996 and 1997.[5], [6] Current surveillance provides population-based HIV/AIDS data for tracking trends in the epidemic, targeting and allocating resources for prevention and treatment services, and planning and conducting program evaluation activities. Since the early 1980s, surveillance studies have identified four distinct populations and issues that have affected the epidemic in these populations:

·                    n

·                    Men who have sex with men, facilitated by frequent changes of sex partners in highly infected sexual networks and by high-risk sexual practices.

 

·                    n

·                    Injection drug users, facilitated by the shared use of needles and syringes contaminated with HIV-infected blood.

 

·                    n

·                    Heterosexual persons (principally in certain racial and ethnic populations), facilitated by (1) a high rate of HIV among drug-using populations that resulted in heterosexual transmission to some partners, (2) high rates of other sexually transmitted diseases (STDs) that can increase both susceptibility to and transmissibility of HIV infection, (3) high-risk sexual practices (mainly unprotected sex) associated with certain addictive substances, such as crack cocaine, and (4) sex in exchange for drugs.

 

·                    n

·                    Perinatal transmission among infants, caused by undetected or untreated HIV infection in pregnant females (although the number of perinatally infected infants has declined dramatically since the mid-1990s to a point where elimination of perinatal transmission in the United States may be possible).

The proportion of different population groups affected by HIV/AIDS has changed over time. By 1998, 83 percent of the cumulative AIDS cases had occurred in males, 16 percent in females, and 1 percent in children.3 The response to the epidemic reflects these changes:

·                    n

·                    Comparing the 1980s to the 1990s, the proportion of AIDS cases in white men who have sex with men declined, whereas the proportion in females and males in other racial and ethnic populations increased, particularly among African Americans and Hispanics (see Disparities section). AIDS cases also appeared to be increasing among injection drug users and their sexual partners.5

 

·                    n

·                    Increases among women have occurred over time. By the mid-1980s, the majority of AIDS cases had been reported among males, with only 7 percent reported among females in 1983.[7] Reported AIDS cases in females have increased steadily since then and accounted for nearly 23 percent of the cases reported in 1998.3

 

·                    n

·                    Monitoring and tracking of the current HIV/AIDS epidemic remains a challenge. Even though AIDS may occur much later than infection with HIV, only AIDS cases are currently reported by all State health departments. Because tracking HIV is more accurate for tracking the status of the epidemic and because States are making progress in reporting HIV infection, it is anticipated that key baseline data about HIV will be available by the early 2000s.4

 

    

·                    n

·                    Although a test for HIV was developed and made widely available in the early to mid-1980s, the lack of available treatment until 1995, negative implications of treatment (including concerns about lack of confidentiality), and possible discrimination and stigmatization resulted in barriers to the reporting of HIV infection.


HIV graph
 

The lifetime costs of health care associated with HIV, in light of recent advances in diagnostics and therapeutics, have grown from $55,000 to $155,000 or more per person.[8] These costs mean that HIV prevention efforts may be even more cost-effective and even cost-saving to society. Prevention efforts include availability of culturally and linguistically appropriate HIV counseling and testing, partner counseling, and referral systems for individuals at high risk for HIV infection; needle and syringe exchange programs; and information, education, treatment and counseling for injection drug users.

The true extent of the epidemic remains difficult to assess for several reasons, including the following:

·                    n

·                    Because of the long period of time from initial HIV infection to AIDS and because highly active antiretroviral therapy (HAART) has slowed the progression to AIDS, new cases of AIDS no longer provide accurate information about the current HIV epidemic in the United States.4

 

·                    n

·                    Because of a lack of awareness of HIV serostatus as well as delays in accessing counseling, testing, and care services by individuals who may be infected or are at risk of infection, some populations do not perceive themselves to be at risk. As a result, some HIV-infected persons are not identified and provided care until late in the course of their infection.[9]

Trends

HIV infection rates appear to have stabilized since the early 1990s at about 40,000 new infections per year, which represents a slowing from growth rates experienced in the mid-1980s.[10] At least 800,000 persons are estimated to be infected with HIV, with over 200,000 to 250,000 persons who are not aware of their infection.[11] About 335,000 persons are estimated to be in treatment with new antiretroviral treatment therapies, and another 215,000 are not currently in treatment.5, 9, [12]

Significant changes in the epidemic have occurred over time. In 1992, AIDS became a leading cause of death among persons aged 25 to 44 years, but by 1997 had dropped to the eighth leading cause of death in this age group. In 1997, however, HIV/AIDS remained the leading cause of death only for African Americans among persons in this age group.[13], [14] Between 1992 and 1997, the number of persons reported living with AIDS increased in all groups as a result of the 1993 expanded AIDS case definition and, more recently, improved survival rates due to new HAART treatment.

Some of these changes are reflected in the following:

·                    n

·                    Women accounted for just under 14 percent of persons over age 13 years living with AIDS in 1992, compared with 20 percent in 1998.2, [15]

 

·                    n

·                    By the end of 1998, the number of African Americans living with AIDS, which increased from 33 percent of the AIDS population in 1992 to 40 percent in 1998, was almost identical to the number of whites living with AIDS.2

 

·                    n

·                    Persons living in the South accounted for 34 percent of AIDS cases in 1992 and 39 percent in 1998. Persons living in the Northeast accounted for 28 percent in 1992 and 31 percent in 1998. The proportion living in the West declined from 24 percent to 21 percent.2, [16]

 

·                    n

·                    By December 1998, approximately 297,136 persons were reported to be living with AIDS, compared with 269,775 in 1997.2, 6

In late 1982, cases of AIDS attributed to blood transfusions were first reported in the United States.[17], [18] The publication, dissemination, and implementation of specific guidelines and recommendations to prevent HIV infection among health care workers and to test donated blood for HIV[19], [20], [21], [22] have resulted in a reduction in transfusion-related AIDS and increases in safety among health workers.

Another prevention success has been the 66 percent decline in perinatal transmission from 1992 to 1997.[23] With the finding that perinatal HIV transmission rates could be reduced substantially with zidovudine therapy during pregnancy, the U.S. Public Health Service issued guidelines recommending that HIV counseling and voluntary testing become a part of routine prenatal care for all pregnant women.23 This policy ensures that HIV-infected pregnant women have access to important health care for themselves and also have the opportunity to reduce the risk of HIV transmission to their infants. Subsequent declines in new cases of AIDS among children demonstrate that these strategies are showing success in reducing mother-to-infant HIV transmission.[24], [25]

However, initial declines in deaths from AIDS after the availability of treatments have slowed. Deaths from AIDS continued to decline throughout 1997 and 1998 (down 42 percent and 20 percent, respectively, compared to 1996), and the number of persons living with AIDS (AIDS prevalence) in 1997 and 1998 increased by 12 percent and 10 percent, respectively.2, 16 If declines continue in newly diagnosed AIDS cases in the coming years, an increasing number of persons will be living with HIV infection. As HIV surveillance extends to additional States, so will the ability to monitor HIV cases and to direct prevention and treatment services to people with asymptomatic infection or mild illness.

Principal health determinants. Behaviors (sexual practices, substance abuse, and accessing prenatal care) and biomedical status (having other STDs) are major determinants of HIV transmission. Unprotected sexual contact, whether homosexual or heterosexual, with a person infected with HIV and sharing drug-injection equipment with an HIV-infected individual account for most HIV transmission in the United States.[26], [27] Increasing the number of people who know their HIV serostatus is an important component of a national program to slow or halt the transmission of HIV in the United States.

For persons infected with HIV, behavioral determinants also play an important role in health maintenance. Although drugs are available specifically to prevent and treat a number of opportunistic infections, HIV-infected individuals also need to make lifestyle-related behavioral changes to avoid many of these infections. The new HIV antiretroviral drug therapies for HIV infection bring with them difficulties in adhering to complex, expensive, and demanding medication schedules, posing a significant challenge for many persons infected with HIV.

Because HIV infection weakens the immune system, people with tuberculosis (TB) infection and HIV infection are at very high risk of developing active TB disease.[28]

Interventions. Interventions for combating HIV are behavioral as well as biomedical. Recent advances in antiretroviral therapy have been credited with dramatic declines in deaths associated with HIV/AIDS. However, declines in overall AIDS cases, particularly in the early epicenters of the epidemic such as San Francisco and New York City, predate the advent of antiretroviral therapies and support the belief that behavior-based prevention programs are effective. In San Francisco, for example, new cases of AIDS among men who have sex with men began dropping in 1992, suggesting that sustained, comprehensive prevention activities begun in the 1980s succeeded in reducing HIV transmission in this group.[29]

Behavioral interventions to prevent HIV vary depending on the audience for whom the program is designed, who designed it, and funds available. Effective community-level prevention strategies in the United States have included social marketing interventions to increase condom use and messages about safer sex and needle-sharing that rely on popular opinion leaders and role model stories. Effective small and large group interventions have aimed at increasing safer sex practices for high-risk HIV-infected men and women and have tended to employ cognitive behavioral and skill-building methods.29

Several effective individual counseling or education interventions have focused on increasing condom use and other safer sex practices for HIV-infected persons. For example, at the individual level, client-centered HIV counseling and testing appear to be effective in preventing high-risk uninfected persons from becoming infected and in helping HIV-infected persons prevent transmission to uninfected partners. Intervention venues vary and include STD clinic waiting rooms, drug treatment centers, schools, community agencies, street settings, and community settings where HIV-infected and high-risk uninfected persons congregate.29

While HIV testing in STD clinics is an important intervention, detection and treatment of other STDs are also an important biomedical component of an HIV prevention program that should include both behavioral and biomedical interventions. STD prevention programs must address STD concerns and their cofactor role in HIV transmission. Early STD detection and treatment are a biomedical tool for lowering the risk for sexual transmission of HIV infection. Behavioral interventions emphasize reducing the number of sex partners, knowing the serostatus of one’s partner, using condoms consistently and correctly, and avoiding risky sexual behaviors.26, [30], [31]

Disparities

In the United States, African Americans and Hispanics have been affected disproportionately by HIV and AIDS, compared to other racial and ethnic groups. Through December 1998, 688,200 cases of AIDS had been reported among persons of all ages and racial and ethnic groups, including 304,094 cases among whites, 251,408 cases among African Americans, and 124,841 cases among Hispanics. Although 55 percent of the reported AIDS cases occurred among African Americans and Hispanics, these two population groups represent an estimated 13 percent and 12 percent, respectively, of the total U.S. population.2

In 1997, AIDS remained the leading cause of death for all African Americans aged 25 to 44 years—the second leading cause among African American females and the leading cause among African American males.13 In 1996, for the first time, African Americans accounted for a larger proportion of AIDS cases than whites, and this trend has continued. The AIDS case rate among African Americans in calendar year 1998 was 66.4 per 100,000 persons, or eight times the rate for whites (8.2 per 100,000) and over twice the rate for Hispanics (28.1 per 100,000).2

Among women with AIDS, African Americans and Hispanics have been especially affected, accounting for nearly 77 percent of cumulative cases reported among women by 1998. Of the 109,311 AIDS cases in women reported through December 1998, 61,874 cases occurred in African American women and 21,937 occurred in Hispanic women.2

For young adults aged 20 to 24 years, 24,437 cumulative AIDS cases were reported through December 1998. Of this total, 10,107 (41 percent) occurred among African Americans, 8,804 (36 percent) among whites, and 5,203 (21 percent) among Hispanics. Overall, 73 percent (17,797) of the AIDS cases in this age group occurred among males and 27 (6,640) percent among females. Among African Americans in this age group, 63 percent were male, and 37 percent were female. Among Hispanics, 74 percent were male, and 26 percent were female. Because the time from initial infection with HIV to the development of AIDS is long and variable (often 8 to 10 years or more), many of these young adults likely acquired their infections while in their teens.2

Among teenagers aged 13 to 19 years, 3,423 cumulative AIDS cases had been reported through December 1998.2 In this age group, 1,047 cases (31 percent) occurred among whites, 1,654 (48 percent) among African Americans, and 668 (20 percent) among Hispanics. Overall, males accounted for 61 percent of the AIDS cases in this age group, and females accounted for 39 percent. Among African American teenagers with AIDS, 46 percent were male, and 54 percent were female. Among Hispanic teens, 67 percent of those with AIDS were male, and 33 percent were female. Among white teenagers with AIDS, 79 percent were male, and 21 percent were female.2

The disproportionate impact of HIV/AIDS on African Americans and Hispanics underscores the importance of implementing and sustaining effective prevention efforts for these racial and ethnic populations. HIV prevention efforts must take into account not only the multiracial and multicultural nature of society, but also other social and economic factors—such as poverty, underemployment, and poor access to the health care system. These factors affect health status and disproportionately affect African American, Hispanic, Alaska Native, and American Indian populations.

Opportunities

In the 21st century, strategies for reducing HIV transmission will continue to evolve and will require shifts from current efforts.[32] Future strategies should focus on:

·                    n

·                    Continuing to address the disproportionate impact of HIV/AIDS among certain racial and ethnic groups.

 

·                    n

·                    Enhancing prevention strategies for populations that are particularly high risk, such as injection drug users, homeless persons, runaway youth, mentally ill persons, and incarcerated persons. Some of these populations are also difficult to reach.

 

·                    n

·                    Increasing the number of people who learn their HIV status in order to detect HIV infection when the potential for transmission is greatest and the need for prevention, care, and treatment, including HAART, is greatest.

 

·                    n

·                    Reaching high-risk seronegative people to help them to stay uninfected.

 

·                    n

·                    Improving access to HAART, thereby reducing deaths and HIV-associated illness and, possibly, infection of others.

 

·                    n

·                    Increasing efforts and opportunities to provide counseling to prevent transmission and reinfection for all HIV-infected individuals who are receiving medical and supportive care.

 

·                    n

·                    Detecting and treating ulcerative and inflammatory STDs, especially in groups at risk for HIV infection.

 

·                    n

·                    Setting the discovery of a safe and effective HIV vaccine as a reachable goal, as a result of ongoing HIV vaccine testing. The development and testing of candidate microbicides may be important in enhancing prevention efforts until a vaccine is available.

Interim Progress Toward Year 2000 Objectives

Data to assess progress are available for 13 of the 17 Healthy People 2000 HIV objectives. Two objectives have met or exceeded the year 2000 targets. The objective to lower the risk of transfusion-transmitted HIV infection exceeded its target, and the objective to protect workers from exposure to bloodborne infections was met with the Occupational Safety and Health Administration’s bloodborne pathogens standard in December 1991. Data show progress toward the year 2000 targets for objectives to slow the rise in the rate of new AIDS cases, contain the rate of HIV infection, and increase the proportion of sexually active females whose partners used condoms at last sexual intercourse. The objective to increase the proportion of HIV-positive people who know their serostatus is moving away from its target, as are objectives for counseling, outreach, and school-based AIDS education.

Note: Unless otherwise noted,data are from the Centers for Disease Control and Prevention, National Center for Health Statistics, Healthy People 2000 Review, 1998–99.

Healthy People 2010—Summary of Objectives

HIV

Goal: Prevent HIV infection and its related illness and death.

Number

Objective Short Title

13-1

New AIDS cases

13-2

AIDS among men who have sex with men

13-3

AIDS among persons who inject drugs

13-4

AIDS among men who have sex with men and who inject drugs

13-5

New HIV cases

13-6

Condom use

13-7

Knowledge of serostatus

13-8

HIV counseling and education for persons in substance abuse
treatment

13-9

HIV/AIDS, STD, and TB education in State prisons

13-10

HIV counseling and testing in State prisons

13-11

HIV testing in TB patients

13-12

Screening for STDs and immunization for hepatitis B

13-13

Treatment according to guidelines

13-14

HIV-infection deaths

13-15

Interval between HIV infection and AIDS diagnosis

13-16

Interval between AIDS diagnosis and death from AIDS

13-17

Perinatally acquired HIV infection

Healthy People 2010 Objectives

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13-1.

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Reduce AIDS among adolescents and adults.

Target: 1.0 new case per 100,000 persons.

Baseline: 19.5 cases of AIDS per 100,000 persons aged 13 years and older in 1998. Data are estimated; adjusted for delays in reporting.

Target setting method: Better than the best.

Data source: HIV/AIDS Surveillance System, CDC, NCHSTP.

Persons Aged 13 Years and Older, 1998

New AIDS Cases

13-1.
Both
Genders

Females*

Males*

Rate per 100,000

TOTAL

19.5

8.8

30.8

Race and ethnicity

American Indian or Alaska Native

9.4

4.5

14.5

Asian or Pacific Islander

4.3

1.2

7.8

Asian

DNC

DNC

DNC

Native Hawaiian and other
Pacific Islander

DNC

DNC

DNC

Black or African American

DNC

DNC

DNC

White

DNC

DNC

DNC

 

Hispanic or Latino

33.0

13.8

52.2

Not Hispanic or Latino

DNC

DNC

DNC

Black or African American

82.9

48.5

122.9

White

8.5

2.2

15.2

Family income level

Poor

DNC

DNC

DNC

Near poor

DNC

DNC

DNC

Middle/high income

DNC

DNC

DNC

Sexual orientation

DNC

DNC

DNC

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
*Data for females and males are displayed to further characterize the issue.

Historically, AIDS incidence data have served as the basis for assessing needs for prevention and treatment programs. However, because of the effect of potent antiretroviral therapies, AIDS incidence no longer can provide unbiased information on HIV incidence patterns; it is hoped that AIDS will not develop in the growing number of HIV-infected persons as they benefit from these new therapies. Persons reported with AIDS will increasingly represent persons who were diagnosed too late for them to benefit from treatments, persons who either did not seek or had no access to care, or persons who failed treatment. This objective will be modified to track HIV cases as additional States implement HIV surveillance programs as an extension of their current AIDS case surveillance systems.

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13-2.

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Reduce the number of new AIDS cases among adolescent and adult men who have sex with men.

Target: 13,385 new cases.

Baseline: 17,847 new cases of AIDS in 1998 among males aged 13 years and older. Data are estimated; risk is redistributed; adjusted for delays in reporting.

Target setting method: 25 percent improvement.

Data source: HIV/AIDS Surveillance System, CDC, NCHSTP.

In 1998, an estimated 17,847 AIDS cases were diagnosed among men having sex with men. This was a decrease from 1997 and part of a continuing trend. The decline is a result of prevention activities and the impact of and access to potent antiretroviral therapies that are delaying progression to AIDS in many HIV-infected individuals.

However, men who have sex with men (MSM) remains a population at risk for HIV infection, and continued efforts to promote behavioral risk reduction among at-risk youth are needed. Prevention programs for adolescent and adult MSM need to focus on both HIV-infected and uninfected populations. Challenges to HIV prevention programs for MSM include (1) reaching MSM who may not identify themselves as homosexual or bisexual, (2) representing MSM from certain racial and ethnic groups in HIV prevention planning, (3) increasing knowledge about HIV risk, and (4) improving access to HIV testing and health care.[33] Serologic surveys, HIV/AIDS case surveillance, and supplemental research and evaluation studies of MSM from certain racial and ethnic groups and other HIV-infected and at-risk populations also are needed to target intervention programs.4 This objective will be modified when additional States implement HIV infection surveillance as an extension of their current AIDS case surveillance systems.

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13-3.

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Reduce the number of new AIDS cases among females and males who inject drugs.

Target: 9,075 cases.

Baseline: 12,099 new cases of AIDS among injection drug users aged 13 years and older (females, 3,667; males, 8,432) in 1998. Data are point estimates; risk redistributed; adjusted for delays in reporting.

Target setting method: 25 percent improvement.

Data source: HIV/AIDS Surveillance System, CDC, NCHSTP.

In 1998, an estimated 12,099 cases were diagnosed among adult men and women who injected drugs. This was a decrease from the previous year and part of a continuing trend. The decline is a result of prevention activities and the impact of potent antiretroviral therapies that are delaying progression to AIDS in many HIV-infected individuals.

Prevention measures for reducing the occurrence of AIDS associated with injection drug users (IDUs) included: (1) preventing the initiation of injecting-drug use, (2) increasing the number of IDUs in drug treatment, (3) encouraging safer injecting practices among IDUs, and (4) promoting safer sexual behavior among IDUs and their sex partners.[34], [35], [36] Persons who continue to inject drugs should be screened periodically for HIV infection and advised of measures that may reduce risks for infection.

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13-4.

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Reduce the number of new AIDS cases among adolescent and adult men who have sex with men and inject drugs.

Target: 1,592 cases.

Baseline: 2,122 new cases of AIDS among males aged 13 years and older in 1998. Data are point estimates; risk redistributed; adjusted for delays in reporting.

Target setting method: 25 percent improvement.

Data source: HIV/AIDS Surveillance System, CDC, NCHSTP.

In 1998, an estimated 2,122 AIDS cases were diagnosed among adult and adolescent men who have sex with men and who inject drugs. This was a decrease from 1997 and part of a continuing trend. The decline is a result of prevention activities and the impact of potent antiretroviral therapies which are delaying progression to AIDS in many HIV-infected individuals.

Prevention programs for adolescent and adult MSM and IDUs need to focus on both HIV-infected and uninfected populations. Challenges to the design and implementation of HIV prevention programs among MSM and IDUs include: (1) reaching MSM who may not identify themselves as homosexual or bisexual, (2) representing MSM from certain racial and ethnic groups in HIV prevention planning, (3) increasing knowledge about HIV risk, (4) improving access to HIV testing and health care, (5) preventing the initiation of injecting-drug use, (6) increasing the number of IDUs in drug treatment, (7) encouraging safer injecting practices among IDUs, and (8) promoting safer sexual behaviors among IDUs and their sex partners.33, 34, 35, 36 This objective will be modified when additional States implement HIV infection surveillance as an extension of their current AIDS case surveillance systems.

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13-5.

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(Developmental) Reduce the number of cases of HIV infection among adolescents and adults.

Potential data source: HIV/AIDS Surveillance System, CDC, NCHSTP.

Recent advances in HIV treatment have slowed the progression of HIV disease for infected persons on treatment and contributed to a decline in AIDS incidence. These advances in treatment have diminished the ability of AIDS surveillance data to represent trends in HIV incidence or to represent the impact of the epidemic on the health care system. Once HIV case surveillance is implemented nationwide by 2001, the Centers for Disease Control and Prevention (CDC) will be able to report baseline data and progress toward the objective of “reducing the annual incidence of HIV infection.”

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13-6.