with men) ages of 13 through 29 are the only risk group to have had a statistically significant increase in the number of new HIV infections between 2006 and 2009 (CDC, 2011a). Because MMP’s current population of inference is limited to individuals ages 18 and older, however, it cannot be used to monitor health care coverage and utilization of adolescents 13 to 18 years of age. Adolescents have unique HIV care and treatment challenges and many are recently infected. Thus, it is important to monitor their linkage to and engagement in care (CDC, 2011b; Spiegel and Futterman, 2009). It is also crucial to ensure adequate representation of vulnerable populations such as immigrants, people who are homeless or unstably housed, people with mental and substance abuse disorders, and people who flow in and out of the corrections system. These populations are more likely to experience gaps in health coverage and care (Altice et al., 2010; Baillargeon et al., 2010; Chen et al., 2011; Dang et al., 2012; Mellins et al., 2009; Springer et al., 2011).

Expansion of MMP to include new populations such as adolescents and people not in care may generate the need for additional staffing resources, for example, to locate and recruit potential participants. Substantial resources and expertise are also required to achieve adequate response rates from a nationally representative sample of people with HIV, including those from vulnerable populations, and to support data collection, analysis, and dissemination activities. Training and technical support for staff in the 23 MMP project areas will continue to be essential to the success of the project. It is important that funding for MMP is commensurate with these activities.

Recommendation 2. By 2015, the Centers for Disease Control and Prevention (CDC) should improve the Medical Monitoring Project (MMP) to ensure higher response rates and increased sample representativeness. CDC should expand MMP to include representative numbers of HIV-diagnosed individuals not in care, adolescents, and those in the criminal justice system and take particular care to ensure adequate representation of vulnerable populations, including, but not limited to immigrants; individuals who are homeless or unstably housed; and people with mental or substance use disorders.

The committee encourages CDC to continue to test alternative strategies for improving MMP sample completion and representation of vulnerable populations of people with HIV who are not in care, such as using NHSS as the overall sampling frame (as is currently being tested); using a dual-frame approach, combining facility-based sampling to identify individuals in care with NHSS sampling to identify individuals not in care; implementing real-time sampling, rather than list-based sampling, to sample patients within

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