Acceptability of Three Novel HIV Prevention Methods among Young Male and Transgender Female Sex Workers in Puerto Rico

Sex workers need HIV-prevention methods they can control and incorporate easily in their work. We studied the acceptability of three methods: HIV self-test use with clients, oral pre-exposure prophylaxis (PrEP), and rectal microbicide gel. 

Four male and eight transgender female (TGF) sex workers in Puerto Rico completed a baseline survey with a quantitative measure of likelihood of use. From them, one male and four TGF also completed a 12-week study of rectal microbicide placebo gel use prior to receptive anal intercourse with male clients and evaluated via qualitative in-depth interviews and follow-up quantitative assessments how each method could be incorporated into their work. 

Most were interested in a rectal microbicide gel and able to use it covertly with clients. Challenges to using the HIV self-test with clients included the potential for both breach of confidentiality and confronting violent situations. Participants also expressed interest in oral PrEP, but raised concerns about side effects.

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By:  Giguere R1, Frasca T2, Dolezal C2, Febo I3, Cranston RD4, Mayer K5, McGowan I4, Carballo-Diéguez A2.

• 1Division of Gender, Sexuality and Health, HIV Center for Clinical and Behavioral Studies, Columbia University and NY State Psychiatric Institute, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA. giguere@nyspi.columbia.edu.
• 2Division of Gender, Sexuality and Health, HIV Center for Clinical and Behavioral Studies, Columbia University and NY State Psychiatric Institute, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA.
• 3Department of Pediatrics, Gama Project, University of Puerto Rico Medical Sciences Campus, San Juan, PR, USA.
• 4School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
• 5Fenway Health, Fenway Institute, Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA.
• AIDS Behav. 2016 Apr 5. 

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Understanding differences in HIV/HCV prevalence according to differentiated risk behaviors in a sample of PWID in rural Puerto Rico

BACKGROUND:

Blood contained in needles and injection equipment has been identified as a vector for HIV and HCV transmission among people who inject drugs (PWID). Yet, there is often a wide discrepancy in prevalence for both viruses. While microbiological differences between viruses influence prevalence, other variables associated with the way drugs are acquired and used, also play a role.

METHODS:

Respondent-driven sampling (RDS) methods recruited a sample of 315 current intravenous drug users in rural Puerto Rico. Information about type and frequency of use, HIV and HVC risk behaviors (sharing needles, cookers, cotton, and water), sexual behaviors, and alcohol use was collected. HIV and HCV statuses were assessed via rapid antibody tests. T tests compare means of participants who tested positive (reactive) to those who tested negative. Logistic regression analyses were used to validate the association of the risk factors involved.

RESULTS:

Tests showed a significant difference in HIV (6 %) and HCV (78.4 %) prevalence among a population of current PWID. The main riskbehaviors in HCV transmission are the sharing of injection "works", (e.g., cookers, cotton, and water). Sharing works occurred more than twice as often as the sharing of needles, and HCV+ and HCV- individuals reported the same needle sharing habits.

CONCLUSIONS:

Washing and rinsing injection works with water seems to prevent HIV transmission, but it is unable to prevent HCV infection. While education about the need to clean injection equipment with bleach might be beneficial, equipment sharing-and the subsequent risk of HVC-might be unavoidable in a context where participants are forced to pool resources to acquire and use intravenous drugs.

Descriptive statistics

	Mean/%	SD	N
% HIV positive (INSTI Rapid Test)	6.0 %		315
% HCV positive (OraQuick Rapid Test)	78.4 %		315
% Male	90.5 %		315
% Born in Puerto Rico	93.0 %		315
Age (years)	41.8	(10.07)	315
Annual per capita income	$4452	($3200)	311
% Unemployed	85.4 %		314
% Currently homeless	21.9 %		314
% Graduate high school (or higher)	52.4 %		315
% Married or living together as married	22.2 %		315
% Injected 4 or more times per day	39.7 %		315
% Injected 2–3 times per day	39.7 %		315

Full article at:   http://goo.gl/xAXsqk

By:  Abadie R1, Welch-Lazoritz M2, Gelpi-Acosta C3, Reyes JC4, Dombrowski K5.

• 1Department of Sociology, University of Nebraska-Lincoln, 206 Benton Hall, Lincoln, NE, 68588, USA. rabadie2@unl.edu.
• 2Department of Sociology, University of Nebraska-Lincoln, 206 Benton Hall, Lincoln, NE, 68588, USA. mwelch2@unl.edu.
• 3Social Science Department, LaGuardia Community College, 31-10 Thomson Ave., Long Island City, NY, 11101, USA. camilagelpi@gmail.com.
• 4Department of Biostatistics and Epidemiology, University of Puerto Rico, 365067, San Juan, PR, 00936, USA. juan.reyes5@upr.edu.
• 5Department of Sociology, University of Nebraska-Lincoln, 206 Benton Hall, Lincoln, NE, 68588, USA. kdombrowski2@unl.edu.
• Harm Reduct J. 2016 Mar 8;13(1):10. doi: 10.1186/s12954-016-0099-9. 

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HIV-Related Mortality among Adults (≥18 years) of Various Hispanic or Latino Subgroups-United States, 2006-2010

Hispanics or Latinos residing in the USA are disproportionately affected by HIV when compared to whites. Health outcomes for Hispanics or Latinos diagnosed with HIV infection may vary by Hispanic or Latino subgroup. 

We analyzed national mortality data from the National Center for Health Statistics for the years 2006 to 2010 to examine differences in HIV-related mortality among Hispanics or Latinos by sociodemographic factors and by Hispanic or Latino subgroup. After adjusting for age, HIV-related death rates per 100,000 population were highest among Hispanics or Latinos who were male (45.6, 95 % confidence interval [CI], 44.4 to 46.9) compared to female (12.0, 95 % CI 11.4 to 12.6), or resided in the Northeast (75.1, 95 % CI 72.2 to 77.9) compared to other US regions at the time of death. 

The age-adjusted HIV-related death rate was highest among Puerto Ricans (100.9, 95 % CI 97.0 to 104.8) and lowest among Mexicans (16.9, 95 % CI 16.2 to 17.6). Among all deaths, the proportion of HIV-related deaths was more than four times as high among Puerto Ricans (adjusted prevalence ratio = 4.3, 95 % CI 4.1 to 4.5) compared to Mexicans. 

To ensure better health outcomes for Hispanics or Latinos living with HIV in the USA, medical care and treatment programs should be adapted to address the needs of various Hispanic or Latino subgroups.

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By:  Clark H1, Surendera Babu A2, Harris S3, Hardnett F4.

• 1Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, 1600 Clifton Rd. NE, MS E47, Atlanta, GA, 30329, USA. HClark@cdc.gov.
• 2ICF International, Atlanta, GA, USA.
• 3Engility, Chantilly, VA, USA.
• 4Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, 1600 Clifton Rd., NE, MS E48, Atlanta, GA, 30329, USA. 
• J Racial Ethn Health Disparities. 2015 Mar;2(1):53-61. doi: 10.1007/s40615-014-0047-x. Epub 2014 Oct 2.

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Human Papilloma Virus Awareness among Hispanic Females with Inflammatory Bowel Disease

Women with inflammatory bowel disease (IBD) may be at increased risk of human papilloma virus (HPV) infection and HPV-related malignancies, as many are immunocompromised secondary to the use of immunosuppressant agents. 

Several studies have addressed the knowledge about cervical cancer risk factors in different populations, particularly HPV infection and its association with cervical malignancies; most of these studies show poor patient knowledge. 

The purpose of this study is to describe the knowledge of females with IBD about HPV infection and the HPV vaccine. We performed a cross-sectional study in 147 consecutive patients attending the clinics of the University of Puerto Rico Center for IBD from 2009 to 2010. An interviewer-administered questionnaire was used to collect information on demographics, lifestyles, and HPV-related knowledge of participants. Bivariate analysis using the chi-square statistics and Fisher’s exact test was used to examine factors associated with HPV awareness. 

The mean age of participants was 36.6 years (SD = 13.91 years). Three fourth (77 %) of women had awareness of the existence of HPV, and 58 % did know about the existence of HPV vaccines. Among those who had heard about HPV, 79.6 % knew that HPV can cause cervical cancer, and 57.5 % knew that the virus is sexually transmitted. Among those who knew of the vaccine, 75.3 % learned about its existence through the media, while only 15.3 %, through their health-care provider. Only three women within recommended ages (2 %) had been vaccinated against HPV, although 50 % of participants indicated that they would definitely/probably vaccinate against HPV in the future. 

A significant trend was observed, where more educated women were more likely to have heard of HPV (p for trend = 0.0017). Women who were high school graduates/some college (OR = 6.63, 95 % CI = 1.71–25.66) and those with at least an associate degree (OR = 11.69, 95 % CI = 3.05–45.89) were more likely to be aware of the HPV vaccine than women without a high school degree. 

Our study documents poor knowledge of HPV and HPV vaccine in this population of IBD patients in Puerto Rico. Although vaccination coverage is low in this population, women are receptive to the possibility of vaccination in the future. Given that this population may be at an increased risk of HPV infection and related morbidities, education and vaccination programs should be promoted among them.

Full article at:   http://goo.gl/8s8mRk

By:  José E. Rivera-Acosta,* Maysabel Aponte, Irene Villamil, Josefina Romaguera, Ana P. Ortiz, and Esther A. Torres

Division of Gastroenterology, Department of Medicine, University of Puerto Rico School of Medicine, PO Box 365067, San Juan, PR 00936-5067 Puerto Rico

University of Puerto Rico Comprehensive Cancer Center, San Juan, Puerto Rico

José E. Rivera-Acosta, Phone: (787) 598-1555, Email: ude.rpu@021arevir.esoj.

*Corresponding author.

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Late HIV Testing in a Cohort of HIV-Infected Patients Followed in Puerto Rico

Objective

Late HIV testing (LT) defined as an AIDS diagnosis within a year of first positive HIV test is associated with higher HIV transmission, lower HAART effectiveness, and worse outcomes. Latinos represent 36% of LT in the US, yet research concerning LT among HIV cases in Puerto Rico is scarce.

Methods

Multivariable logistic regression analysis was used to identify factors associated with LT and Cochran-Armitage test to describe LT trends in an HIV infected cohort followed at a specialized HIV clinic in Puerto Rico.

Results

From 2000 to 2011, 47% of eligible patients were LT, with lower median CD4 count (54 vs. 420 cells/mm3) and higher median HIV viral load counts (253,680 vs. 23,700 copies/mL), when compared to non-LT patients. LT prevalence decreased significantly, from 47% in 2000 to 37% in 2011. In a mutually adjusted logistic regression model, males, older age at enrolment and past history of IDU significantly increased LT odds whereas history of amphetamine use decreased LT odds. Stratified by mode of transmission, only men who have sex with men (MSM), had a significant reduction in the proportion of LT, from 67% in 2000 to 33% in 2011.

Conclusion

These results suggest a gap in early HIV detection in Puerto Rico that decreased only among MSM. A closer evaluation of HIV testing guideline implementation among non MSM in the Island is needed.

Below:  Distribution of time to AIDS diagnosis (in months) among 377 late testers (LT)

Below:  

Figure 3a: Yearly trends of LT overall and by gender

Figure 3b: Yearly trends of LT by mode of transmission

Figure 3c: Yearly trends of LT for heterosexual mode of transmission by gender

Full article at:  http://goo.gl/uOikx0

By:  Katherine Y. Tossas-Milligan, MS, PhD(c), Robert F. Hunter-Mellado, MD, MS, Angel M. Mayor, MD, MS, Diana M. Fernandez-Santos, EdD, MS, and Mark S. Dworkin, M.D., M.P.H.T.M.

Katherine Y. Tossas-Milligan, Division of Epidemiology and Biostatistics, University of Illinois at Chicago School of Public Health, 1603 W. Taylor Street, M/C 923, Chicago, IL 60612, USA;

Contributor Information.

Corresponding author and reprints requests: Katherine Y. Tossas-Milligan, MS, Division of Epidemiology and Biostatistics, University of Illinois at Chicago School of Public Health, 1603 W. Taylor Street, M/C 923, Chicago, IL 60612, USA, Email: ude.ciu@2assotk phone: 773-590-6231 fax: 312.996.0064

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Persistent HIV Viremia: Description of a Cohort of HIV Infected Individuals with ART Failure in Puerto Rico

The introduction of antiretroviral therapy (ART) has allowed human immunodeficiency virus (HIV) suppression in patients. We present data of a cohort of Puerto Rican patients with HIV who were under treatment with a steady regime of ART across a time horizon of eleven years. 

The time periods were categorized into four year stratums: 2000 to 2002; 2003 to 2005; 2006 to 2008 and 2009 to 2011. Socio-demographic profile, HIV risk factors, co-morbid conditions were included as study variables. One year mortality was defined. The p value was set at ≤0.05. The cohort consisted of 882 patients with 661 subjects presenting with persistent HIV viral load after a self-reported 12 month history of ART use. In this sub-cohort a higher viral load was seen across time (p < 0.05). Illicit drug use, IV drug use, alcohol use, loss of work were associated to having higher viral load means (p < 0.05). HIV viral load mean was lower as BMI increased (p < 0.001). 

It is imperative to readdress antiretroviral adherence protocols and further study ART tolerance and compliance.

Below:  Detectable vs. non-detectable viral load (% patients)

Full article at:  http://www.mdpi.com/1660-4601/13/1/50/htm

By:   Maldonado-Martínez G1, Hunter-Mellado RF2, Fernández-Santos D3, Ríos-Olivares E4.

• 1Data Management and Statistical Research Support Unit, Universidad Central del Caribe, Bayamón 00960, Puerto Rico. geronimo.maldonado@uccaribe.edu.
• 2Internal Medicine Department, Universidad Central del Caribe, Bayamón 00960, Puerto Rico. robert.hunter@uccaribe.edu.
• 3Data Management and Statistical Research Support Unit, Universidad Central del Caribe, Bayamón 00960, Puerto Rico. diana.fernandez@uccaribe.edu.
• 4Microbiology Department, Universidad Central del Caribe, Bayamón 00960, Puerto Rico. eddy.rios@uccaribe.edu. 
• Int J Environ Res Public Health. 2015 Dec 22;13(1). pii: E50. doi: 10.3390/ijerph13010050. 
• 
  
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Impact of ASUMA Intervention on HIV Risk Behaviors among Puerto Rican Adolescents

The purpose of this manuscript is to assess and compare HIV risk behaviors among early adolescents after a three-year pilot study. 

A total of 135 public and private junior high schools students completed the intervention protocol. A self-administered questionnaire was given at baseline and at the end of the third year (fourth measure). Descriptive and inferential analyses were performed using SPSS 20.0.

About 60% of the students were 14 years old at the fourth measure. The proportion of students that did not report at least one HIV risk behavior at baseline and those that reported any risk behavior at the fourth measure was lower in the intervention group (45.0%) than in the control group (54.5%). The proportion of students that reported at least one HIV risk behavior at baseline and those that did not report any HIV risk behavior at the fourth measure was higher in the intervention group than in the control group (33.3% vs. 8.3%). 

The proportion of students engaging in HIV risk behaviors was higher in the control group than in the intervention group at the fourth measure, suggesting that A Supportive Model for HIV Risk Reduction in Early Adolescence (ASUMA) intervention might be a promising initiative to reduce adolescents' engagement in HIV risk behaviors.

Below:  A Supportive Model for HIV Risk Reduction in Early Adolescence (ASUMA) theoretical framework

Full article at:   http://goo.gl/KbkJP9

By:   Fernandez-Santos DM1, Miranda-Diaz C2, Figueroa-Cosme WI3, Ramon RO4, Mayor AM5, Rios-Olivares E6, Hunter-Mellado RF7.

• 1Internal Medicine Department, Universidad Central del Caribe, School of Medicine, PO BOX 60327, Bayamon 00960-6032, Puerto Rico. diana.fernandez@uccaribe.edu.
• 2Internal Medicine Department, Universidad Central del Caribe, School of Medicine, PO BOX 60327, Bayamon 00960-6032, Puerto Rico. christine.miranda@uccaribe.edu.
• 3Internal Medicine Department, Universidad Central del Caribe, School of Medicine, PO BOX 60327, Bayamon 00960-6032, Puerto Rico. wanda.figueroa@uccaribe.edu.
• 4Internal Medicine Department, Universidad Central del Caribe, School of Medicine, PO BOX 60327, Bayamon 00960-6032, Puerto Rico. raul.ramon@uccaribe.edu.
• 5Internal Medicine Department, Universidad Central del Caribe, School of Medicine, PO BOX 60327, Bayamon 00960-6032, Puerto Rico. amayorb@hotmail.com.
• 6Internal Medicine Department, Universidad Central del Caribe, School of Medicine, PO BOX 60327, Bayamon 00960-6032, Puerto Rico. eddy.rios@uccaribe.edu.
• 7Internal Medicine Department, Universidad Central del Caribe, School of Medicine, PO BOX 60327, Bayamon 00960-6032, Puerto Rico. robert.hunter@uccaribe.edu.
• Int J Environ Res Public Health. 2015 Dec 23;13(1). pii: E60. doi: 10.3390/ijerph13010060.

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"That's True Love:" Lived Experiences of Puerto Rican Perinatally HIV-Infected Youth within Their Families' Context

The burden of HIV affects not only HIV-infected patients but also their families and caregivers. It is also known that family support is crucial for people living with HIV. 

A qualitative study was conducted to explore the life experiences, within the family context, of perinatally HIV-infected (pHIV-I) youth in Puerto Rico. Twenty in-depth interviews were performed and audio-recorded. Within the family context, study participants experienced acceptance, love and support but also stigma and discrimination. They reported that family is an essential component in their lives and treatment. Losing one or both parents at a young age was considered more difficult than having HIV. Most participants who lost their parents lived with other family members. This was a challenging situation for both pHIV-I youth and their caregivers. Participants described their healthcare providers as part of their families and would like to keep in touch as they transition to adult care. Despite the challenges, participants expressed a desire to have children. 

Services targeted to this population should stress social support, incorporate family members into the medical process, provide special guidance and support while transitioning to adult care, and provide them with the latest information regarding HIV and reproductive options.

Below:  Patterns and connections among themes that emerge during phenomenological analysis

Full article at:   http://goo.gl/9K8PJt

By:   Silva-Suárez G¹, Bastida E², Rabionet SE³, Beck-Sagué C⁴, Febo I⁵, Zorrilla CD⁶.

¹Department of Sociobehavioral and Administrative Pharmacy, Nova Southeastern University, 00926 San Juan, Puerto Rico. gsilvasuar@nova.edu.

²Department of Health Promotion and Disease Prevention, Florida International University, Miami, FL 33199, USA. ebastida@fiu.edu.

³Department of Sociobehavioral and Administrative Pharmacy, Nova Southeastern University, 33314, Fort Lauderdale, FL &amp; Department of Social Science, School of Public Health, University of Puerto Rico, Medical Sciences Campus, 00921 San Juan, Puerto Rico. rabionet@nova.edu.

⁴Department of Health Promotion and Disease Prevention, Florida International University, Miami, FL 33199, USA. cbecksag@fiu.edu.

⁵Department of Pediatrics, University of Puerto Rico, Medical Sciences Campus, 00921 San Juan, Puerto Rico. irma.febo2@upr.edu.

⁶Department of Obstetrics and Gynecology, University of Puerto Rico, Medical Sciences Campus, 00921 San Juan, Puerto Rico. carmen.zorrilla@upr.edu.

Int J Environ Res Public Health. 2015 Dec 22;13(1). pii: E7. doi: 10.3390/ijerph13010007. 

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Feasibility of Identifying a Female Sex Worker Cohort at High Risk of HIV Infection in the Caribbean for HIV Vaccine Efficacy Trials

Background: Identifying cohorts of Caribbean women with HIV infection rates sufficient for inclusion in HIV vaccine efficacy trials has been challenging. HVTN 907 determined the feasibility of identifying and retaining a cohort of women at high risk for HIV acquisition by focusing recruitment on female sex workers (FSWs).

Methods: HIV uninfected FSWs, residing in Haiti, Dominican Republic, and Puerto Rico, who reported unprotected sex and met previously described more stringent site-specific eligibility criteria, were eligible. Behavioral risk assessment, HIV counseling and testing, and pregnancy testing were performed at baseline, 6, 12, and 18 months.

Results: Among 799 FSWs (264 from Dominican Republic, 334 from Haiti, and 201 from Puerto Rico), the median age was 26 years, with 54% having less than a high school education and 45% having a monthly household income of less than $US 100. Median number of male partners 6 months before screening was 200. Retention at 18 months was 93%. Twelve women became HIV infected, 9 from Haiti. The annualized HIV incidence was 1.07% (95% confidence interval: 0.55% to 1.87%). Pregnancy incidence was 22.5% (95% confidence interval: 21.9% to 29.5%). Statistically significant declines in risk behaviors occurred between screening and the 18-month visit assessment.

Discussion: The HVTN 907 study identified a high-risk cohort of women with excellent retention for all 3 sites, despite major challenges especially in Haiti. These results show that a bridging study of a vaccine shown to be efficacious in other clade settings would be possible among FSWs in the region, particularly in Haiti.

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By:   Deschamps, Marie M. MD^*; Metch, Barbara MA, MS^†; Morgan, Cecilia A. PhD^†; Zorilla, Carmen D. MD^‡; Donastorg, Yeycy MD^§; Swann, Edith PhD, MN^‖; Taina, Dadaille MD^*; Patrice, Joseph MD^*; Pape, William J. MD^*; on behalf of the HVTN 907 Study Team

doi: 10.1097/QAI.0000000000000796 

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Utility of the Static-99 and Static-99R with Latino Sex Offenders

The predictive validity of the Static-99 measures with ethnic minorities in the United States has only recently been assessed with mixed results. We assessed the predictive validity of the Static-99 and Static-99R with a sample of Latino sex offenders (N = 483) as well as with two subsamples (U.S.-born, including Puerto Rico, and non-U.S.-born). 

The overall sexual recidivism rate was very low (1.9%). Both the Static-99 measures were able to predict sexual recidivism for offenders born in the United States and Puerto Rico, but neither was effective in doing so for other Latino immigrants. Calibration analyses (N = 303) of the Static-99R were consistent with the literature and provided support for the potential use of the measure with Latinos born in the United States and Puerto Rico. 

These findings and their implications are discussed as they pertain to the assessment of Latino sex offenders.

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By:   Leguízamo A1, Lee SC2, Jeglic EL3, Calkins C3.

• 1Roger Williams University, Bristol, RI, USA aleguizamo@rwu.edu.
• 2Carleton University, Ottawa, Ontario, Canada.
• 3John Jay College of Criminal Justice, New York, NY, USA. 

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Number of Outcomes of Assisted Reproductive Technology Procedures — United States and Puerto Rico, 2013

Problem/Condition: Since the first U.S. infant conceived with assisted reproductive technology (ART) was born in 1981, both the use of ART and the number of fertility clinics providing ART services have increased steadily in the United States. ART includes fertility treatments in which eggs or embryos are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Women who undergo ART procedures are more likely than women who conceive naturally to deliver multiple-birth infants. Multiple births pose substantial risks to both mothers and infants, including obstetric complications, preterm delivery, and low birthweight infants. This report provides state-specific information for the United States (including Puerto Rico) on ART procedures performed in 2013 and compares infant outcomes that occurred in 2013 (resulting from ART procedures performed in 2012 and 2013) with outcomes for all infants born in the United States in 2013.

Reporting Period Covered: 2013.

Description of System: In 1996, CDC began collecting data on ART procedures performed in fertility clinics in the United States as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (FCSRCA) (Public Law 102–493). Data are collected through the National ART Surveillance System (NASS), a web-based data collection system developed by CDC. This report includes data from 52 reporting areas (the 50 states, the District of Columbia [DC], and Puerto Rico).

Results: In 2013, a total of 160,521 ART procedures (range: 109 in Wyoming to 20,299 in California) with the intent to transfer at least one embryo were performed in 467 U.S. fertility clinics and were reported to CDC. These procedures resulted in 53,252 live-birth deliveries (range: 47 in Alaska to 6,979 in California) and 66,691 infants (range: 61 in Alaska to 8,649 in California). Nationally, the total number of ART procedures performed per million women of reproductive age (15–44 years), a proxy measure of the ART usage rate, was 2,521 (range: 352 in Puerto Rico to 7,688 in DC). ART use exceeded the national rate in 13 reporting areas (California, Connecticut, Delaware, Hawaii, Illinois, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Rhode Island, Virginia, and DC).

Via: http://goo.gl/1WQMM0

By:  Saswati Sunderam, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion. Telephone: 770-488-6356; E-mail: msunderam@cdc.gov.

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