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were compared between disproportionately (>13%) black and all other (<13% black) counties. Rate ratios were calculated and population attributable fractions (PAF) were estimated using COVID-19 cases and deaths via zero-inflated negative binomial regression model. National maps with countylevel data and an interactive scatterplot of COVID-19 cases were generated. ResultsNearly ninety-seven percent of disproportionately black counties (656/677) reported a case and 49% (330/677) reported a death versus 81% (1987/2,465) and 28% (684/ 2465), respectively, for all other counties. Counties with higher proportions of black people have higher prevalence of comorbidities and greater air pollution. Counties with higher proportions of black residents had more COVID-19 diagnoses (RR 1.24, 95% CI 1.17-1.33) and deaths (RR 1.18, 95% CI 1.00-1.40), after adjusting for county-level characteristics such as age, poverty, comorbidities, and epidemic duration. COVID-19 deaths were higher in disproportionally black rural and small metro counties. The PAF of COVID-19 diagnosis due to lack of health insurance was 3.3% for counties with <13% black residents and 4.2% for counties with >13% black residents.

Emerging epidemiological data suggest that white Americans have a lower risk of acquiring COVID-19. Although many studies have pointed to the role of systemic racism in COVID-19 racial/ethnic disparities, few studies have examined the contribution of racial segregation. Residential segregation is associated with differing health outcomes by race/ethnicity for various diseases, including HIV. This commentary documents differing HIV and COVID-19 outcomes and service delivery by race/ethnicity and the crucial role of racial segregation. Using publicly available Census data, we divide US counties into quintiles by percentage of non-Hispanic white residents and examine HIV diagnoses and COVID-19 per 100,000 population. HIV diagnoses decrease as the proportion of white residents increase across US counties. COVID-19 diagnoses follow a similar pattern: Counties with the highest proportion of white residents have the fewest cases of COVID-19 irrespective of geographic region or state political party inclination (i.e., red or blue states). Moreover, comparatively fewer COVID-19 diagnoses have occurred in primarily white counties throughout the duration of the US COVID-19 pandemic. Systemic drivers place racial minorities at greater risk for COVID-19 and HIV. Individual-level characteristics (e.g., underlying health conditions for COVID-19 or risk behavior for HIV) do not fully explain excess disease burden in racial minority communities. Corresponding interventions must use structural-and policy-level solutions to address racial and ethnic health disparities.

The Medicaid expansion enrolled a population no more likely to be prescribed opioids than the base Medicaid population while significantly increasing uptake of 2 drugs used in medication-assisted treatment.

Background Meeting the contraceptive needs of women living with HIV (WLHIV) has primary health benefits for women, in addition to being a key element to prevent mother-to-child HIV transmission. This analysis will estimate the current number of infant HIV infections prevented by contraception in the era of increased HIV treatment coverage and; 2) model the additional HIV benefits of preventing unintended births to WLHIV. Methods Secondary data analysis was conducted using publicly available data from the United Nations Programme on HIV/AIDS (UNAIDS) and Population Division, Demographic Health Surveys, and peer-review literature. National data from 70 countries, that had a UNAIDS estimate for the number of WLHIV nationally, were combined into country-level models. Models estimated the current number of infant HIV infections averted by contraception annually and potentially averted if unintended births to WLHIV were prevented. Estimates take into account pregnancy and live birth rates, contraceptive coverage, contraceptive method mix and failure rates, and HIV treatment coverage during pregnancy to prevent mother to child transmission. Results Contraception use among WLHIV prevents an estimated 43,559 new infant HIV infections annually across 70 countries. Countries with the largest number of infant infections averted by contraception included South Africa (9441), Nigeria (4195), Kenya (3508), Zimbabwe (2586), and India (2145). Preventing unintended births to WLHIV could avert an additional 43,768 new infant infections per year, with the greatest potential gains to be made in South Africa (12,036), Nigeria (2770), Uganda (2552), and the Democratic Republic of the Congo (2324). Conclusions Contraception continues to play an integral role in global HIV prevention efforts in the era of increasing HIV treatment coverage, especially in sub-Saharan Africa. Broad contraceptive availability, increased contraceptive voluntarism and method mix are key components to preventing unintended births and ending new infant HIV infections worldwide.

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BackgroundThe previously-named Mexico City Policy (MCP) — which prohibited non U.S.-based non-governmental organizations (NGOs) from receiving U.S. family planning (FP) funding if they advocated, provided, counseled, or referred clients for abortions, even with non-U.S. funds — was reinstated and expanded in 2017. For the first time, the expanded MCP (EMCP) applies to HIV funding through the President’s Emergency Plan for AIDS Relief (PEPFAR) in addition to FP funding. Previous, and more limited, iterations of the policy forced clinic closures and decreased contraceptive access, prompting the need to examine where and how the EMCP may impact FP/HIV service integration.MethodsThe likelihood of FP/HIV service de-integration under the EMCP was quantified using a composite risk index for 31 PEPFAR-funded countries. The index combines six standardized indicators from publically available sources organized into three sub-indexes: 1) The importance of PEPFAR for in-country service delivery of HIV and FP services; 2) The susceptibility of implementing partners to the EMCP; and 3) The integration of FP/HIV funds and programming through PEPFAR and USAID.ResultsCountries with the highest overall risk scores included Zambia (3.3) Cambodia (3.2), Uganda (3.1), South Africa (2.9), Haiti (2.8), Lesotho (2.8), Swaziland (2.1), and Burundi (1.5). Zambia’s risk score is driven by sub-index 1, having a high proportion of country HIV expenditures provided by PEPFAR (86.3%). Cambodia and Uganda’s scores are driven sub-index 3, with both countries reporting 100% of PEPFAR supported HIV delivery sites were providing integrated FP services in 2017. South Africa’s risk score is driven by sub-index 2, where roughly 60% of PEPFAR funding is to non U.S.-based NGOs. Of the countries with the highest risk scores, Swaziland, Lesotho, and South Africa, are also in the top quartile of PEPFAR countries for HIV prevalence and unintended pregnancies among young women.ConclusionThis analysis highlights where and why the EMCP may have the greatest impact on FP/HIV service integration. The possible disruption of service integration in countries with generalized HIV epidemics highlights significant risks. Researchers, national governments, and non-U.S. funders can consider these risk factors to help target their responses to the EMCP and mitigate potential harms of the policy.

BackgroundUNAIDS estimates global HIV investment needs in low- and middle-income countries (LMICs) at $26 billion per year in 2020. Yet international financing for HIV programs has stagnated amidst despite the increasing number of people requiring and accessing treatment. Despite increased efficiencies in HIV service delivery, evaluating programs for greater efficiencies remains necessary. While HIV budgets have been under scrutiny in recent years, indirect costs have not been quantified for any major global HIV program, but may constitute an additional avenue to identify program efficiencies. This analysis presents a method for estimating indirect costs in the President’s Emergency Plan for AIDS Relief (PEPFAR).MethodsUtilizing PEPFAR country operational plan (COP) funding data from 2007 to 2016 for international organizations (IOs) and universities and standard regulatory cost bases, we calculated modified total direct costs on which indirect cost rates may be applied by partner and funding agency. We then apply a series of plausible indirect cost rates (10%–36.28%) to develop a range for total indirect costs that have accrued over the period.FindingsOf $37.01 billion in total COP funding between 2007 and 2016, $22.24 billion (60.08%) was identifiably allocated to IOs ($17.95B) and universities ($4.29B). After excluding funding for sub-awards ($1.92B) and other expenses ($3.89B) to which indirect rates cannot be applied, $16.44B remained in combined direct and indirect costs. From this, we estimate that between $1.85B (8.30% of total international partner funding) and $4.34B (19.51%) has been spent on indirect costs from 2007–2016, including $157-$369 million in 2016.InterpretationTo our knowledge, this is the first analysis to quantify the indirect costs of major implementing partners of a global HIV funder. However, lack of transparency in the indirect cost rates of non-University international partners creates an opaque layer of programmatic costs. Given the current funding environment and evolution of HIV programming in PEPFAR countries, the findings motivate a re-examination of the current policies and the return on investment in indirect cost recovery across the PEPFAR program.