United States Jurisdictions Research Articles

Coverage with Selected Vaccines and Exemption Rates Among Children in Kindergarten - United States, 2023-24 School Year.

In the United States, states and local jurisdictions set vaccination requirements for school attendance, conditions and procedures for exemptions from these requirements, grace periods for submitting documentation, and provisional enrollment for students who need more time to be vaccinated. States annually report data to CDC on the number of children in kindergarten who meet, are exempt from, or are in the process of meeting requirements. Data reported by 49 states and the District of Columbia (DC) for the 2023-24 school year were used for national- and state-level estimates of the following measures: complete vaccination with required doses of measles, mumps, and rubella vaccine (MMR), diphtheria, tetanus, and acellular pertussis vaccine (DTaP), poliovirus vaccine (polio), and varicella vaccine (VAR); exemptions from vaccination; and school attendance while meeting requirements. The 2023-24 kindergarten class became age-eligible to complete most state-required vaccinations during the COVID-19 pandemic, after schools had returned to routine in-person learning. Compared with approximated national coverage levels across all reported vaccines for the 2019-20 (95%) and 2022-23 (93%) school years, coverage dropped below 93% for the 2023-24 school year, ranging from 92.3% for DTaP to 92.7% for MMR. Exemptions increased to 3.3%, compared with those during the 2022-23 (3.0%) and 2021-22 school years (2.6%). Coverage with MMR, DTaP, polio, and VAR decreased in 35, 32, 33, and 36 jurisdictions, respectively, compared with the 2022-23 school year. Exemptions increased in 41 jurisdictions, with 14 reporting that >5% of kindergartners had an exemption from one or more vaccine. Efforts by health departments, schools, and providers are needed to ensure that students begin school fully vaccinated.

Composition of New York State (United States) Disposed Waste and Recyclables in 2021: An Advanced Analysis of Waste Sort Data

Understanding the composition of disposed municipal solid waste (MSW) and recyclables can lead to better waste management. New York State (United States) has never had a state-wide waste characterization sorting program. In 2021, sampling was conducted at 11 locations, representing 25% of the state population outside of New York City. Twenty-three tonnes from 173 discrete samples were sorted into 41 categories. The resulting data were analyzed by single constituent approaches and more novel multivariate distance techniques. The analyses found that disposed MSW was 22.8% paper, 20.5% food, and 16.8% plastics. Recyclable paper and glass–metal–plastic containers were 18.2% (11.7% paper, 6.5% containers) and yard waste was 6.5%, meaning about 25% of the disposed MSW could have been recovered. Multivariate analysis determined that the disposed MSW was similar to that from other United States jurisdictions such as Wisconsin, Pennsylvania, New York City, and Syracuse (NY), and different from California and United States Environmental Protection Agency model data. Recyclables composition was different from disposed MSW composition. Dual-stream recyclables were sorted better than single-stream recyclables. Corrugated cardboard was the most common paper recyclable and plastics were the most common container recyclable. The data are being used to help guide planning for an expected packaging extended producer responsibility law for the State.

Cervical Pap screening among women living with HIV in Puerto Rico and the United States – Medical Monitoring Project, 2018–2021

Our objective was to determine the prevalence of cervical Pap screening among women living with HIV (WLWH) in Puerto Rico (P.R.) and other selected United States (U.S.) jurisdictions. Additionally, we sought to compare selected characteristics of WLWH who underwent cervical Pap screening between P.R. and the other U.S. jurisdictions. We analyzed data from the 2018–2021 cycles of CDC’s Medical Monitoring Project (MMP), a national surveillance system among adults with HIV residing in P.R. (n = 218) and 22 other MMP jurisdictions (n = 3,653). Weighted percentages and 95 % confidence intervals (CIs) for selected characteristics were estimated. Prevalence ratios with predicted marginal means were calculated. An estimated 91.6 % and 84.6 % of WLWH underwent cervical Pap screening in P.R. and the other 22 MMP jurisdictions, respectively (Prevalence Ratio = 1.08, 95% CI = 1.03–1.13). Among WLWH who underwent cervical Pap screening, those in P.R. were more likely to be 50+ years of age, have a household annual income below $20,000, engage in binge drinking, never smoke, and have Medicaid/other public insurance than those in the other 22 MMP jurisdictions (p < 0.05). No differences were found between P.R. and the other 22 MMP jurisdictions in the percentage reporting higher than the median HIV-stigma score, experiencing HIV health care discrimination, and having ≥ 1 sexual partner in the past 12 months. Although cervical Pap screening rates among WLWH were higher in P.R. than in the other 22 MMP jurisdictions, both surpass the Healthy People 2030 target. Future research should assess adherence and compliance with updated cervical cancer screening guidelines.

Wide-bore polyester sutures may create sufficient collagen for cure of prolapse/incontinence: a work in progress.

The main thrust of the Integral Theory Paradigm (ITP) is that inadequate ligament collagen causes pelvic organ prolapses (POP) and pelvic symptoms, a concept validated by multiple publications which cured POP and bladder/bowel/pain dysfunctions by collagen-creating slings. Sling surgery for surgical cure of these conditions was eliminated in the United States, Europe and other regulatory jurisdictions by banning all mesh products (including tapes) in about 2017. The aim of this work was to inform of the progress of a highly promising alternative method for collage creation for ligament repair: wide-bore polyester sutures accurately applied to weak ligaments. The scientific rationale for the wide-bore polyester plication method was a revisit and analysis of prior Instron testing data from a rejected polyester aortic graft from a doctoral thesis. The analysis indicated that the collagen produced by No. 2 polyester sutures would be sufficient to repair weakened pelvic ligaments. The surgical methodology consisted of application of wide-bore No. 2 or No. 3 polyester sutures to existing vaginal surgical techniques such as cardinal/uterosacral ligament (CL/USL) repair in the Fothergill operation, deep transversus perinei (DTP) ligamentous supports of the perineal body (PB) and uniquely, pubourethral ligament (PUL) repair for stress urinary incontinence (SUI). No vaginal tissue was excised. These operations are now being performed in several centres around the world. Because of this, the results detailed below are indicative only, and necessarily incomplete, as they are only from these units. Twelve month data (n=35) for SUI cure (83%) following PUL repair by the urethral ligament plication (ULP) operation has been submitted for publication; POP quantification (POPQ) points Ba, C, Bp, D were significantly improved at 6 weeks postoperative review following repair of CLs (cystocele) and USLs (uterine/apical prolapse) (n=56): deep transverse perinei ligament repair (descending perineal syndrome "DPS") (n=4) were cured at 6-12 months review. Though numbers are few, in the context of DPS being considered incurable, these numbers are significant. Except for the ULP operation, the techniques for cystocele, uterine prolapse, perineocele were essentially evolved versions of the Fothergill and standard PB repairs without any vaginal or ligament excisions. Though promising, more extensive and longer-term results are clearly required before this wide-bore polyester ligament repair method can become mainstream.

Evidence-based post-ban research to inform effective menthol cigarette bans in the United States and other jurisdictions.

Evidence-based post-ban research to inform effective menthol cigarette bans in the United States and other jurisdictions.

Embodied Energy and Carbon Footprint of Concrete Compared to Other Construction Materials

The main objective of infrastructure design codes is to protect the public’s welfare, health, and safety, none of which appear directly related to the current sustainability movement that has focused on protecting the natural environment, conserving resources, and minimizing the toxicity of construction materials and processes. Some United States jurisdictions have adopted language related to sustainability based on the United States Green Building Council to curtail adverse effects of global climate change, minimize environmental impact of new construction of built assets (i.e., buildings and infrastructure), and in some cases, improve air quality in the community. The focus of this paper is to compare the embodied energy and carbon footprint of various construction materials: concrete, steel, timber, masonry, and fiber reinforced composites. To properly compare these materials from a sustainability standpoint, we propose an index that characterizes material ecological properties by dividing strength and stiffness by embodied energy. The index is similar to the structural specific properties index used to characterize the mechanical properties of materials (i.e., strength and stiffness divided by density). Using this ecological index, concrete and steel appear to be the most sustainable materials. As a result of their higher strength and stiffness, concrete and steel require less embodied energy to satisfy specific structural demands. Keywords: embodied energy, carbon footprint, LEED, specific embodied energy

Polysubstance use during pregnancy: The importance of screening, patient education, and integrating a harm reduction perspective

BackgroundSubstance use during pregnancy is associated with poor health outcomes. This study assessed substance use, polysubstance use, and use of select prescription medications during pregnancy. MethodsWe analyzed 2019 data from the Pregnancy Risk Assessment Monitoring System in 25 United States jurisdictions that included questions on prescription medications, tobacco, and illicit substance use during pregnancy. Alcohol and electronic cigarette use were assessed during the last three months of pregnancy, and all other substances and medications were assessed throughout pregnancy. Weighted prevalence estimates and 95% confidence intervals (CIs) were calculated. ResultsNearly one-fifth of respondents who reported use of any substance reported use of at least one other substance during pregnancy. Cigarettes (8.1%; 95% CI 7.6–8.7%) and alcohol (7.4%; 95% CI 6.7–8.1%) were the most frequently reported substances, followed by cannabis (4.3%; 95% CI 3.9–4.7%). Substance use was higher among individuals who reported having depression or using antidepressants during pregnancy compared with those who did not report depression or antidepressant use. Illicit drug use prevalence was low (0.5%, 95% CI 0.4–0.7%); however, respondents reporting heroin use also frequently reported use of illicit stimulants (amphetamines: 51.7%, 95% CI 32.1–71.3% or cocaine: 26.5%, 95% CI 11.9–41.1%). Although prenatal clinician screening for alcohol and cigarette use was approximately 95%, fewer respondents (82.1%) reported being screened for cannabis or illicit substance use during pregnancy. ConclusionsOne in five individuals who reported use of any substance during pregnancy engaged in polysubstance use, highlighting the importance of comprehensive screening and evidence-based interventions including harm reduction.

Planning to Reduce the Health Impacts of Extreme Heat: A Content Analysis of Heat Action Plans in Local United States Jurisdictions.

Objectives. To examine commonalities and gaps in the content of local US heat action plans (HAPs) designed to decrease the adverse health effects of extreme heat. Methods. We used content analysis to identify common strategies and gaps in extreme heat preparedness among written HAPs in the United States from jurisdictions that serve municipalities with more than 200 000 residents. We reviewed, coded, and analyzed plans to assess the prevalence of key components and strategies. Results. All 21 plans evaluated incorporated data on activation triggers, heat health messaging and risk communication, cooling centers, surveillance activities, and agency coordination, and 95% incorporated information on outreach to at-risk populations. Gaps existed in the specific applications of these broad strategies. Conclusions. Practice-based recommendations as well as future areas of research should focus on increasing targeted strategies for at-risk individuals and expanding the use of surveillance data outside of situational awareness. (Am J Public Health. 2023;113(5):559-567. https://doi.org/10.2105/AJPH.2022.307217).

Ethics Considerations in Laws Restricting Incapacitated Patients' Access to ECT.

Electroconvulsive therapy (ECT) is a safe and effective treatment used for numerous psychiatric conditions. While many patients for whom ECT is indicated are able to give voluntary informed consent, some lack decision-making capacity (DMC), at least temporarily. Case reports from numerous countries involving ECT for patients who lack DMC indicate overall positive outcomes and high patient satisfaction with results comparable with those of consenting patients; some patients regain DMC with ECT. Laws and regulations pertaining to ECT vary widely around the world and across the United States. Many United States jurisdictions over-regulate ECT relative to other interventions with comparable risks and potential benefits. While laws restricting whether and under what circumstances patients who lack DMC may receive ECT likely are aimed at protecting incapacitated persons, such laws sometimes undermine important ethics obligations and should be re-evaluated.

Availability of timely methadone treatment in the United States and Canada during COVID-19: A census tract-level analysis

ObjectivesWe sought to compare timely access to methadone treatment in the United States (US) and Canada during the COVID-19 pandemic. MethodsWe conducted a cross-sectional study of census tracts and aggregated dissemination areas (used for rural Canada) within 14 US and 3 Canadian jurisdictions in 2020. We excluded census tracts or areas with a population density of less than one person per square km. Data from a 2020 audit of timely medication access was used to determine clinics accepting new patients within 48 h. Unadjusted and adjusted linear regressions were performed to examine the relationship between area population density and sociodemographic covariates and three outcome variables: 1) driving distance to the nearest methadone clinic accepting new patients, 2) driving distance to the nearest methadone clinic accepting new patients for medication initiation within 48 h, and 3) the difference in the driving distance between the first and second outcome. ResultsWe included 17,611 census tracts and areas with a population density greater than one person per square kilometer. After adjusting for area covariates, US jurisdictions were a median of 11.6 miles (p value <0.001) further from a methadone clinic accepting new patients and 25.1 miles (p value <0.001) further from a clinic accepting new patients within 48 h than Canadian jurisdictions. ConclusionsThese results suggest that the more flexible Canadian regulatory approach to methadone treatment is associated with a greater availability of timely methadone treatment and reduced urban-rural disparity in availability, compared to the US.

United States Federal Emergency Management Agency regional clustering by disaster exposure: a new paradigm for disaster response.

The Federal Emergency Management Agency (FEMA) divides the United States (US) into ten standard regions to promote local partnerships and priorities. These divisions, while longstanding, do not adequately address known hazard risk as reflected in past federal disaster declarations. From FEMA's inception in 1979 until 2020, the OpenFEMA dataset reports 4127 natural disaster incidents declared by 53 distinct state-level jurisdictions, listed by disaster location, type, and year. An unsupervised spectral clustering (SC) algorithm was applied to group these jurisdictions into regions based on affinity scores assigned to each pair of jurisdictions accounting for both geographic proximity and historical disaster exposures. Reassigning jurisdictions to ten regions using the proposed SC algorithm resulted in an adjusted Rand index (ARI) of 0.43 when compared with the existing FEMA regional structure, indicating little similarity between the current FEMA regions and the clustering results. Reassigning instead into six regions substantially improved cluster quality with a maximized silhouette score of 0.42, compared to a score of 0.34 for ten regions. In clustering US jurisdictions not only by geographic proximity but also by the myriad hazards faced in relation to one another, this study demonstrates a novel method for FEMA regional allocation and design that may ultimately improve FEMA disaster specialization and response.

Victim Intoxication and Capacity to Consent in Sexual Assault Statutes across the United States.

Alcohol use is common in cases of sexual assault. These cases raise significant questions about a victim's capacity to consent to sexual intercourse. In many United States jurisdictions, intoxicated victims may be considered mentally incapacitated only if they have been administered alcohol or other substances involuntarily. A recent Minnesota Supreme Court case illustrated why reform is necessary in this area of criminal sexual conduct law. We present this case and the results of a review of felony criminal sexual conduct laws in the fifty states of the United States and the District of Columbia. We find that nearly half of the jurisdictions surveyed require that a victim must be involuntarily intoxicated to be considered incapacitated or impaired. We draw on Minnesota's experience with legislative reform of its sexual assault laws as well as judicially mediated reform mechanisms to present a roadmap for overcoming this voluntary intoxication caveat. Finally, we discuss the implications of these laws for victims of sexual assault and for the practice of forensic psychiatry in cases of criminal sexual conduct involving victim intoxication.

Six-Month Outcomes of Infants Born to People With SARS-CoV-2 in Pregnancy.

To assess the 6-month incidence of laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, postnatal care, hospitalization, and mortality among infants born to people with laboratory-confirmed SARS-CoV-2 infection during pregnancy by timing of maternal infection. Using a cohort of liveborn infants from pregnancies with SARS-CoV-2 infections in the year 2020 from 10 United States jurisdictions in the Surveillance for Emerging Threats to Mother and Babies Network, we describe weighted estimates of infant outcomes from birth through 6 months of age from electronic health and laboratory records. Of 6601 exposed infants with laboratory information through 6 months of age, 1.0% (95% confidence interval: 0.8-1.1) tested positive, 19.1% (17.5-20.6) tested negative, and 80.0% (78.4-81.6) were not known to be tested for SARS-CoV-2. Among those ≤14 days of age, SARS-CoV-2 infection occurred only with maternal infection ≤14 days before delivery. Of 3967 infants with medical record abstraction, breastmilk feeding initiation was lower when maternal infection occurred ≤14 days before delivery compared with >14 days (77.6% [72.5-82.6] versus 88.3% [84.7-92.0]). Six-month all-cause hospitalization was 4.1% (2.0-6.2). All-cause mortality was higher among infants born to people with infection ≤14 days (1.0% [0.4-1.6]) than >14 days (0.3% [0.1-0.5]) before delivery. Results are reassuring, with low incidences of most health outcomes examined. Incidence of infant SARS-CoV-2, breastmilk feeding initiation, and all-cause mortality differed by timing of maternal infection. Strategies to prevent infections and support pregnant people with coronavirus disease 2019 may improve infant outcomes.

Estimating the effects of legalizing recreational cannabis on newly incident cannabis use.

Liberalized state-level recreational cannabis policies in the United States (US) fostered important policy evaluations with a focus on epidemiological parameters such as proportions [e.g., active cannabis use prevalence; cannabis use disorder (CUD) prevalence]. This cannabis policy evaluation project adds novel evidence on a neglected parameter-namely, estimated occurrence of newly incident cannabis use for underage (<21 years) versus older adults. The project's study populations were specified to yield nationally representative estimates for all 51 major US jurisdictions, with probability sample totals of 819,543 non-institutionalized US civilian residents between 2008 and 2019. Standardized items to measure cannabis onsets are from audio computer-assisted self-interviews. Policy effect estimates are from event study difference-in-difference (DiD) models that allow for causal inference when policy implementation is staggered. The evidence indicates no policy-associated changes in the occurrence of newly incident cannabis onsets for underage persons, but an increased occurrence of newly onset cannabis use among older adults (i.e., >21 years). We offer a tentative conclusion of public health importance: Legalized cannabis retail sales might be followed by the increased occurrence of cannabis onsets for older adults, but not for underage persons who cannot buy cannabis products in a retail outlet. Cannabis policy research does not yet qualify as a mature science. We argue that modeling newly incident cannabis use might be more informative than the modeling of prevalences when evaluating policy effects and provide evidence of the advantages of the event study model over regression methods that seek to adjust for confounding factors.

Diagnosis of Abortion Laws in Nigeria and Human Rights Trajectory: Lessons from Great Britain and United States of America

Abortion is the termination of pregnancy before its birth for whatever reason. The present study is concerned with therapeutic abortion which is criminalized in Nigeria been the focus of this study. The Nigerian societal attitude to abortion is one of stereotyped stigmatization notwithstanding the validity of the reasons. The aim of the study is to examine the trajectory between abortion laws and human rights in Nigeria and the lessons Nigeria can learn from Great Britain and United States jurisdictions. The objective is to interrogate the extant abortion laws with a view to locating their inadequacies in the area of both the African and international human rights concerns of sexual and reproductive health of women on abortion rights. Using doctrinal design by reliance on primary and secondary sources analysed through deductive reasoning based on extant statutes and case law, this study interrogated the extant abortion laws in Nigeria in juxtaposition with the British and the United States legal framework on abortion as well as critical examination of the African and international human rights jurisprudences, and found out that the current position of abortion law in Nigeria is not in the same wavelength with both the African and international human rights jurisprudences on sexual and reproductive health rights of females to access safe abortions implicit in the fundamental rights and freedoms of privacy, non-discrimination, right to life, good health and bodily autonomy as it relates to unwanted pregnancies induced by other factors such as rape, incest or severe foetus abnormalities. The study recommended law reform by using the models provided by the British and United States legal framework to allow women access to legal abortion in deserving cases in conformity with African and international human rights treaties.

Naloxone administration among opioid-involved overdose deaths in 38 United States jurisdictions in the State Unintentional Drug Overdose Reporting System, 2019

BackgroundThe majority of drug overdose deaths in the United States involve opioids, and synthetic opioid-involved overdose death rates are increasing. Naloxone is a key prevention strategy yet estimates of its administration are limited. MethodsWe analyzed 2019 data from 37 states and the District of Columbia in CDC’s State Unintentional Drug Overdose Reporting System to estimate the percentage of decedents, by sociodemographic subgroup, who experienced a fatal opioid-involved overdose and had no evidence of naloxone administration. ResultsA total of 77.3% of 33,084 opioid-involved overdose deaths had no evidence of naloxone administration. Statistically significant subgroup differences were observed for all sociodemographic groups examined except housing status. The highest percentages of decedents lacking evidence of naloxone administration were those with highest educational attainment (doctorate or professional degree, 87.0%), oldest (55–64 years, 83.4%; ≥65 years, 87.3%) and youngest ages (<15 years, 87.5%), and single marital status (84.5%). The lowest percentages of no evidence of naloxone administration were observed for non-Hispanic American Indian/Alaskan Native persons (66.2%) and those ages 15–24 years (70.8%). ConclusionsMore than three-quarters of opioid-involved overdose deaths had no evidence of naloxone administration, underscoring the need to ensure sufficient naloxone access and capacity for utilization. While fatal overdose data cannot fully characterize sociodemographic disparities in naloxone administration, naloxone education and access efforts can be informed by apparent inequities. Public health partners can assist persons who use drugs (PWUD) by maintaining naloxone supply and amplifying messages about the high risk of using drugs alone among PWUD and their social networks.

Improving sexually transmitted infection screening, testing, and treatment among people with HIV: A mixed method needs assessment to inform a multi-site, multi-level intervention and evaluation plan

Bacterial sexually transmitted infections (STIs) continue to be a worsening public health concern in the United States (US). Though the national incidence of HIV infection has decreased over recent years, that of chlamydia, gonorrhea, and syphilis have not. Despite national recommendations on prevention, screening, and treatment of these STIs, these practices have not been standardized. Nine Health Resources and Services Administration Ryan White HIV/AIDS Program funded clinics across 3 US jurisdictions (Florida, Louisiana, and Washington, DC), were selected as clinical demonstration sites to be evaluated in this mixed method needs assessment to inform a multi-site, multi-level intervention to evaluate evidence-based interventions to improve STI screening and testing of bacterial STIs among people with or at risk for HIV. These 3 US jurisdictions were selected due to having higher than national average incidence rates of HIV and bacterial STIs. Descriptive statistics and deductive analysis were used to assess quantitative and qualitative needs assessment data. Results indicate the following needs across participating sites: inconsistent and irregular comprehensive sexual behavior history taking within and among sites, limited routine bacterial STI testing (once/year and if symptomatic) not in accordance with CDC recommendations, limited extragenital site gonorrhea/chlamydia testing, limited annual training on STI-related topics including LGBTQ health and adolescent/young adult sexual health, and limited efforts for making high-STI incidence individuals feel welcome in the clinic (primarily LGBTQ individuals and adolescents/young adults). These findings were used to identify interventions to be used to increase routine screenings and testing for bacterial STIs.

Evaluating the effectiveness of problem-solving courts at preventing fatal and non-fatal opioid events: preliminary findings from Indiana

BackgroundFatal and non-fatal events associated with drug misuse are skyrocketing in most United States jurisdictions, including Indiana. Historically, the role of the judiciary is to arrest, impose sanctions and protect society from harm. Adults arrested for drug abuse in Indiana can be sentenced to 1 of 17 correctional facilities. As an alternative, they may be eligible to participate in a problem-solving court (PSC) programme that refers individuals to treatment as a pretrial diversionary strategy. The aim of the study is to determine which interventions offered by PSCs and correctional facilities impact morbidity and mortality. The study began in 2019 and will end in 2023; therefore, the results in this manuscript are preliminary.MethodsThe study cohort included two populations arrested for drug misuse: (1) adults sentenced to Indianan correctional facilities (1 January 2018 to 30 June 2021) and (2) adults participating in an Indiana PSC programme (1 January 2018 to 30 June 2021). The study used a mixed-methods design that integrated qualitative interviews of deputy wardens, PSC team members and service providers with the following quantitative datasets: sentencing information, emergency department visits, inpatient hospitalization admissions, prescription drug monitoring programme data and death records. The individuals will be followed at 2-week, 4-week, 6-month and 1-year intervals post-release. Difference-in-difference and time-to-event analyses will identify impactful interventions. A model will be created to show the effect of impactful interventions in Indiana counties that do not have PSCs.ResultsFindings are preliminary. There is variability amongst correctional facilities regarding programme eligibility, provided services and provision of medication-assisted treatment. All correctional facilities were severely impacted by the COVID-19 pandemic.ConclusionIt is anticipated that the adoption of impactful interventions will lower opioid-related morbidity and mortality rates.

Trends in HIV Care Outcomes Among Adults and Adolescents-33 Jurisdictions, United States, 2014-2018.

With significant improvements in the diagnosis and treatment of HIV, the number of people with HIV in the United States steadily increases. Monitoring trends in HIV-related care outcomes is needed to inform programs aimed at reducing new HIV infections in the United States. The setting is 33 United States jurisdictions that had mandatory and complete reporting of all levels of CD4 and viral load test results for each year during 2014-2018. Estimated annual percentage change and 95% confidence intervals were calculated to assess trends in stage of disease at time of diagnosis, linkage to HIV medical care within 1 month of HIV diagnosis, and viral suppression within 6 months after HIV diagnosis. Differences in percentages were analyzed by sex, age, race/ethnicity, and transmission category for persons with HIV diagnosed from 2014 to 2018. Among 133,477 persons with HIV diagnosed during 2014-2018, the percentage of persons who received a diagnosis classified as stage 0 increased 13.7%, stages 1-2 (early infections) increased 2.9%, stage 3 (AIDS) declined 1.5%, linkage to HIV medical care within 1 month of HIV diagnosis increased 2.3%, and viral suppression within 6 months after HIV diagnosis increased 6.5% per year, on average. Subpopulations and areas that showed the least progress were persons aged 45-54 years, American Indian/Alaska Native persons, Asian persons, Native Hawaiian/other Pacific Islander persons, and rural areas with substantial HIV prevalence, respectively. New infections will continue to occur unless improvements are made in implementing the Ending the HIV Epidemic: A Plan for America strategies of diagnosing, treating, and preventing HIV infection.

A critical assessment of the recent proposals and reports on the regulation of digital mergers

This article examines the recent proposals and reports on the regulation of digital mergers in the European Union, United Kingdom, United States and other jurisdictions, with a particular focus on the proposals for presumptions against mergers. It argues that any intervention in digital mergers needs to calibrate a balance between preventing excessive levels of market concentration and promoting innovation and that any departure from existing laws should be justified. Against this background, this article concludes that the recent arguments for lowering the threshold for blocking digital mergers undermines the risk of chilling innovation and losing significant efficiencies, and does not rely on concrete evidence and sound economic theories.