Anna Satcher Johnson

Trends in diagnoses of HIV infection in the United States, 2002-2011.

Trends in Diagnoses of HIV Infection in the United States, 2002-2011 There has been increasing emphasis on care and treatment for persons with human immunodeficiency virus (HIV) in the United States during the past decade,1,2 including the use of antiretroviral therapy for increasing survival and decreasing transmission.1 Accurate HIV diagnosis data recently became available for all states,3 allowing for the first time an examination of long-term national trends. These data can be used to monitor awareness of serostatus among persons living with HIV, primary prevention efforts, and testing initiatives. We examined trends in HIV diagnoses from 2002-2011 in the United States using data from the National HIV Surveillance System of the US Centers for Disease Control and Prevention (CDC).

Epidemiologic Differences Between Native-Born and Foreign-Born Black People Diagnosed with HIV Infection in 33 U.S. States, 2001-2007

Objective. Few studies have examined the extent to which foreign-born people contribute to the human immunodeficiency virus (HIV) epidemic among non-Hispanic black people in the U.S. We sought to determine differences in the epidemiology of HIV infection among native- and foreign-born black people, using data from the national HIV surveillance system of the Centers for Disease Control and Prevention. Methods. We estimated the number of HIV infections among black adults and adolescents diagnosed from 2001 to 2007 in 33 U.S. states. We compared annual HIV diagnosis rates, distributions of demographic characteristics and HIV-transmission risk factors, late diagnoses of HIV infection, and survival after an acquired immunodeficiency syndrome (AIDS) diagnosis for native- and foreign-born black people. Results. From 2001 to 2007, an estimated 100,013 black adults and adolescents were diagnosed with HIV infection in 33 U.S. states, for which country-of-birth information was available. Of these, 11.7% were foreign-born, with most from the Caribbean (54.1%) and Africa (41.5%). Annual HIV diagnoses decreased by 5.5% per year (95% confidence interval [CI] −5.9, −5.0) among native-born black people. Decreases were small among foreign-born black people (–1.3%; 95% CI −2.6, −0.1), who were more likely to be female, have HIV infection attributable to high-risk heterosexual contact, be diagnosed with AIDS within 12 months of HIV diagnosis, and survive one year and three years after an AIDS diagnosis. Conclusions. The epidemiology of HIV infection differs for foreign-born black individuals compared with their native-born counterparts in the U.S. These data can be used to develop culturally appropriate and relevant HIV-prevention interventions.

HIV viral suppression among persons with varying levels of engagement in HIV medical care, 19 US jurisdictions.

Background:Ongoing HIV medical care is vital in achieving and maintaining viral suppression. We examined viral suppression applying retention in care definitions used by various federal agencies. Methods:Using National HIV Surveillance System data from 19 US jurisdictions with complete CD4 and viral load reporting, we determined viral suppression among persons who met the National HIV/AIDS Strategy retention in care definition (≥2 visits ≥3 months apart; “retained in continuous care”) and among those who had evidence of care but did not meet the definition (“engaged in care”). We also examined viral suppression among persons who met the Health and Human Services Core Indicator definition for retention. Results:Of 338,959 persons living with diagnosed HIV infection in 19 areas in 2010, 63.7% received any care; of these, 19.7% were “engaged in care” and 80.3% were “retained in continuous care.” Of those “engaged in care,” 47.7% achieved viral suppression compared with 73.6% of persons “retained in continuous care.” Significant differences were evident for all subpopulations within each care category; younger persons and blacks/African Americans had lower levels of viral suppression than their counterparts. Persons “engaged in care,” regardless of sex, age, race/ethnicity, and transmission category, had significantly lower percentages of viral suppression than persons “retained in continuous care.” Similar patterns of viral suppression were found for persons meeting the Health and Human Services definition compared with persons “retained in continuous care.” Conclusions:Higher levels of engagement in care, including more frequent monitoring of CD4 and viral load, were associated with viral suppression.

The Status of the National HIV Surveillance System, United States, 2013

The burden of HIV disease in the United States is monitored by using a comprehensive surveillance system. Data from this system are used at the federal, state, and local levels to plan, implement, and evaluate public health policies and programs. Implementation of HIV reporting has differed by area, and for the first time in early 2013, estimated data on diagnosed HIV infection were available from all 50 states, the District of Columbia, and six U.S. dependent areas. The newly available data for the entire U.S. as well as several other key changes to the surveillance system support the need to provide an updated summary of the status of the National HIV Surveillance System.

Sex With Bisexual Men Among Black Female Students at Historically Black Colleges and Universities

BACKGROUND Human immunodeficiency virus (HIV) disproportionately affects black women. Nearly two-thirds of all female HIV cases reported to the CDC are black, and HIV is the leading cause of death among black women aged 25 to 34 years. The greatest HIV transmission risk among black women is sexual intercourse with a man, although the role of bisexual men is not clear. METHODS The CDC and collaborating partners conducted behavioral surveys at 7 historically black colleges and universities from January 2005 to April 2007. RESULTS Of the 2705 black female students aged 18 to 29 years who were surveyed, 2040 (75%) reported being sexually active in the previous 12 months and, among sexually active women, 291 (14%) reported having sex with a bisexual man in the previous 12 months. Women who reported sex with a bisexual man were more likely than women who did not to report having at least 2 sex partners in the previous 12 months, having male and female sex partners, not using a condom at last intercourse, being in a committed relationship, never or infrequently attending church, and believing they were at increased risk for HIV infection. CONCLUSION Heterosexually active black women who have engaged in sexual intercourse with bisexual men have a different HIV risk profile than other heterosexually active black women.

Differences in Selected HIV Care Continuum Outcomes Among People Residing in Rural, Urban, and Metropolitan Areas—28 US Jurisdictions

PURPOSE The HIV care continuum is used to monitor success in HIV diagnosis and treatment among persons living with HIV in the United States. Significant differences exist along the HIV care continuum between subpopulations of people living with HIV; however, differences that may exist between residents of rural and nonrural areas have not been reported. METHODS We analyzed the Centers for Disease Control and Preventions National HIV Surveillance System data on adults and adolescents (≥13 years) with HIV diagnosed in 28 jurisdictions with complete reporting of HIV-related lab results. Lab data were used to assess linkage to care (≥1 CD4 or viral load test ≤3 months of diagnosis), retention in care (≥2 CD4 and/or viral load tests ≥3 months apart), and viral suppression (viral load <200 copies/mL) among persons living with HIV. Residence at diagnosis was grouped into rural (<50,000 population), urban (50,000-499,999 population), and metropolitan (≥500,000 population) categories for statistical comparison. Prevalence ratios and 95% CI were calculated to assess significant differences in linkage, retention, and viral suppression. FINDINGS Although greater linkage to care was found for rural residents (84.3%) compared to urban residents (83.3%) and metropolitan residents (81.9%), significantly lower levels of retention in care and viral suppression were found for residents of rural (46.2% and 50.0%, respectively) and urban (50.2% and 47.2%) areas compared to residents of metropolitan areas (54.5% and 50.8%). CONCLUSIONS Interventions are needed to increase retention in care and viral suppression among people with HIV in nonmetropolitan areas of the United States.

Estimated HIV Incidence, Prevalence, and Undiagnosed Infections in US States and Washington, DC, 2010-2014.

Introduction: The burden of HIV infection and health outcomes for people living with HIV varies across the United States. New methods allow for estimating national and state-level HIV incidence, prevalence, and undiagnosed infections using surveillance data and CD4 values. Methods: HIV surveillance data reported to the Centers for Disease Control and Prevention and the first CD4 value after diagnosis were used to estimate the distribution of delay from infection to diagnosis based on a well-characterized CD4 depletion model. This distribution was used to estimate HIV incidence, prevalence, and undiagnosed infections during 2010–2014. Estimated annual percentage changes (EAPCs) were calculated to assess trends. Results: During 2010–2014, HIV incidence decreased 10.3% (EAPC = −3.1%) and the percentage of undiagnosed infection decreased from 17.1% to 15.0% (EAPC = −3.3%) in the United States; HIV prevalence increased 9.1% (EAPC = 2.2%). Among 36 jurisdictions with sufficient data to produce stable estimates, HIV incidence decreased in 3 jurisdictions (Georgia, New York, and District of Columbia) and the percentage of undiagnosed HIV infections decreased in 2 states (Texas and Georgia). HIV prevalence increased in 4 states (California, Florida, Georgia, and Texas). In 2014, southern states accounted for 50% of both new HIV infections and undiagnosed infections. Conclusion: HIV incidence and undiagnosed infection decreased in the United States during 2010–2014; however, outcomes varied by state and region. Progress in national HIV prevention is encouraging but intensified efforts for testing and treatment are needed in the South and states with high percentages of undiagnosed infection.

A Census Tract–Level Examination of Social Determinants of Health among Black/African American Men with Diagnosed HIV Infection, 2005–2009—17 US Areas

Background HIV disproportionately affects black men in the United States: most diagnoses are for black gay, bisexual, and other men who have sex with men (collectively referred to as MSM). A better understanding of the social conditions in which black men live and work may better explain why HIV incidence and diagnosis rates are higher than expected in this population. Methods Using data from the National HIV Surveillance System and the US Census Bureaus American Community Survey, we examined the relationships of HIV diagnosis rates and 5 census tract–level social determinants of health variables for 21,948 black MSM and non-MSM aged ≥15 years residing in 17 areas in the United States. We examined federal poverty status, marital status, education level, employment status, and vacancy status and computed rate ratios (RRs) and prevalence odds ratios (PORs), using logistic regression with zero-inflated negative binomial modeling. Results Among black MSM, HIV diagnosis rates decreased as poverty increased (RR: 0.54). At the time of HIV diagnosis, black MSM were less likely than black non-MSM to live in census tracts with a higher proportion below the poverty level (POR: 0.81) and with a higher proportion of vacant houses (POR: 0.86). In comparison, housing vacancy was positively associated with HIV diagnosis rates among black non-MSM (RR: 1.65). HIV diagnosis rates were higher for black MSM (RR: 2.75) and non-MSM (RR: 4.90) whose educational level was low. Rates were significantly lower for black MSM (RR: 0.06) and non-MSM (RR: 0.26) as the proportion unemployed and the proportion married increased. Conclusions This exploratory study found differences in the patterns of HIV diagnosis rates for black MSM and non-MSM and provides insight into the transmission of HIV infection in areas that reflect substantial disadvantage in education, housing, employment, and income.

HIV Care Outcomes Among Hispanics or Latinos with Diagnosed HIV Infection — United States, 2015

Data from CDCs National HIV Surveillance System (NHSS)* are used to monitor progress toward achieving national goals set forth in the Division of HIV/AIDS Preventions Strategic Plan (1) and other federal directives† for human immunodeficiency virus (HIV) testing, care, and treatment outcomes and HIV-related disparities in the United States. Recent data indicate that Hispanics or Latinos§ are disproportionately affected by HIV infection. Hispanics or Latinos living with diagnosed HIV infection have lower levels of care and viral suppression than do non-Hispanic whites but higher levels than those reported among blacks or African Americans (2). The annual rate of diagnosis of HIV infection among Hispanics or Latinos is three times that of non-Hispanic whites (3), and a recent study found increases in incidence of HIV infection among Hispanic or Latino men who have sex with men (4). Among persons with HIV infection diagnosed through 2013 who were alive at year-end 2014, 70.2% of Hispanics or Latinos received any HIV medical care compared with 76.1% of non-Hispanic whites (2). CDC used NHSS data to describe HIV care outcomes among Hispanics or Latinos. Among male Hispanics or Latinos with HIV infection diagnosed in 2015, fewer males with infection attributed to heterosexual contact (34.6%) had their infection diagnosed at an early stage (stage 1 = 12.0%, stage 2 = 22.6%) than males with infection attributed to male-to-male sexual contact (60.9%: stage 1 = 25.2%, stage 2 = 35.7%). The percentage of Hispanics or Latinos linked to care after diagnosis of HIV infection increased with increasing age; females aged 45-54 years with infection attributed to injection drug use (IDU) accounted for the lowest percentage (61.4%) of persons linked to care. Among Hispanics or Latinos living with HIV infection, care and viral suppression were lower among selected age groups of Hispanic or Latino males with HIV infection attributed to IDU than among males with infection attributed to male-to-male sexual contact and male-to-male sexual contact and IDU. Intensified efforts to develop and implement effective interventions and public health strategies that increase engagement in care and viral suppression among Hispanics or Latinos (3,5), particularly those who inject drugs, are needed to achieve national HIV prevention goals.

HIV Incidence, Prevalence, and Undiagnosed Infections in U.S. Men Who Have Sex With Men

Infection with HIV, as well as its burden, is a major health issue for the United States. Each year, about 40000 persons receive an HIV diagnosis, and more than 1 million are living with the virus (1, 2). Testing for HIV, linkage to and engagement in care, and receipt of antiretroviral therapy are critical to prevent disease progression. Persons who are aware of their HIV infection also may reduce risk behavior and, with successful treatment, achieve viral suppression, which greatly reduces the risk for transmitting the virus (35). Some successes of treatment and prevention efforts are reflected in recent decreases in HIV diagnoses among women and persons who inject drugs (2). However, progress in reducing infections among men who have sex with men (MSM) has been limited. National goals include increasing the percentage of persons who are aware of their HIV infection and reducing the number of new infections. To meet these objectives, targets must be met for all high-risk populations in the United States, particularly gay, bisexual, and other MSM of all racial/ethnic groups (6). Although MSM represent approximately 2% of the U.S. population, they made up 67% of persons who received an HIV diagnosis in 2015 (2, 7). Assessing HIV outcomes nationally as well as among MSM is important for guiding prevention efforts and monitoring progress toward national goals. We updated and extended our model estimating HIV incidence and prevalence and the percentage of undiagnosed HIV infections (8) for additional years2008 to 2015for sex and transmission categories, and for MSM by race/ethnicity and age. Methods Using data from the National HIV Surveillance System (NHSS) of the Centers for Disease Control and Prevention (CDC) on the first CD4 value after HIV diagnosis, we modeled HIV incidence and prevalence and the percentage of undiagnosed HIV infections from 2008 through 2015 for persons aged 13 years and older (812). We used information on persons living with diagnosed HIV infection by the end of 2007 to estimate HIV prevalence and the percentage of undiagnosed HIV infections. All states, the District of Columbia, and 6 U.S. territories report cases of HIV infection and associated demographic and clinical information to the CDC without personal identifiers. Although cases of stage 3 HIV infectionthat is, AIDShave been reportable in all jurisdictions since the early 1980s, implementation of confidential, name-based HIV reporting was staggered over time, with all jurisdictions reporting by 2008. The first CD4 test result after an HIV diagnosis is a required data element on the HIV case report form. In addition, as of December 2016, all but 6 states had implemented mandatory laboratory reporting of all CD4 values, and 37 states and the District of Columbia reported complete data to the NHSS, representing 72% of persons living with an HIV diagnosis in the United States (1). Cases are routinely deduplicated within and between jurisdictions (13). Deaths are ascertained by linking HIV surveillance data to vital records. Death ascertainment for a given year of death typically is completed within 12 to 18 months; therefore, we used data that allowed at least 18 months for reporting each diagnosed case. Using the first CD4 value after HIV diagnosis, we first estimated the time from HIV infection to diagnosis at the individual level on the basis of a well-characterized CD4 depletion model commonly used in the literature (9, 10): where t is the duration of infection at the date of the CD4 test and ai and bi are model parameters specific to the U.S. HIV population groups (sex, age, and transmission category) in which most HIV infections are subtype B (8). The t estimates among persons in an HIV population group may be used to estimate the distribution of diagnosis delay (time from HIV infection to diagnosis) in the group. These estimates in turn may be used to approximate HIV incidence and prevalence and the percentage of undiagnosed HIV infections (812). Because not everyone with an HIV diagnosis had a CD4 test administered or reported, persons with a CD4 test result were assigned a weight to account for those without a result. This weight is the inverse of the probability that a person with an HIV diagnosis has a CD4 test after diagnosis. This probability is estimated by using the proportion of cases with a CD4 test result reported to the NHSS. Considering the heterogeneity in the availability of CD4 data, the population is stratified on the basis of the year of HIV diagnosis, sex, race/ethnicity, transmission category, age at diagnosis, and disease status at the end of the study periodthat is, whether the person had HIV infection never classified as AIDS, died without the infection ever having been classified as AIDS, or had infection that progressed to AIDS. Because we report results for persons aged 13 years and older, if a person had an estimated date of infection before age 13, the date of infection was set to the date the person reached 13 years of age. The distribution of diagnosis delay (time from HIV infection to diagnosis) was then used to estimate annual HIV incidence, which represents persons with diagnosed or undiagnosed HIV infection. The prevalence of HIV, which represents the number of persons with diagnosed or undiagnosed HIV infection who were alive at the end of a given year, was estimated by subtracting the cumulative number of deaths from the cumulative number of infections. The number of persons with undiagnosed HIV infection was estimated by subtracting the cumulative number of diagnoses from the cumulative number of infections. The proportion of undiagnosed HIV infections was estimated by dividing the number of undiagnosed infections by the total HIV prevalence for each year. More details are provided in the Appendix. All analyses were carried out by using SAS/STAT, version 9.4 (SAS Institute). Approximately 30% of HIV infection cases are reported to the CDC without an identified risk factor (2). To provide case counts by transmission categorya summary classification of the single risk factor most likely to have been responsible for transmissionmultiple imputation was used to handle missing values (14). Multiple imputation is a statistical approach in which each missing transmission category is replaced with a set of plausible values that represent the uncertainty about the true, but missing, value. Variables in the imputation model included age at HIV diagnosis, race/ethnicity, birth country origin, stage of disease at HIV diagnosis, type of HIV diagnosis facility, year of HIV diagnosis, and delay between HIV diagnosis and reporting of the case. Multiple imputation was performed separately for males and females because each sex had different numbers of transmission categories. Ten imputation values were generated to achieve a 95% relative efficiency based on the proportion of missing data. Several data sets with imputed values were analyzed by using standard statistical procedures, and the results were combined (15, 16). To account for model uncertainty, results were rounded to the nearest hundred for estimates greater than 1000 and the nearest ten for those less than or equal to 1000. We examined trends during 2008 to 2015 by using the estimated annual percentage change (EAPC) and its associated 95% CIs. We used Poisson regression with a log link function to calculate EAPC. The EAPC for diagnosed proportions was calculated by using the logarithm of the estimated prevalence that served as offset in the Poisson regression model (17). We compared incidence estimates for 2014 and 2015 by using a simple Z test. Rates per 100000 population were calculated for estimates of HIV incidence and prevalence (18). Rates for transmission categories were calculated by using published population size estimates as denominators (7, 19, 20). Role of the Funding Source This study used data collected as part of routine public health surveillance and was not funded. Results United States HIV Incidence In the United States, the estimated annual number of HIV infections, or HIV incidence, decreased 14.8%, from 45200 infections in 2008 to 38500 in 2015 (EAPC, 2.6% [95% CI, 3.2% to 2.1%]) (Figure; for all years, 2008 to 2015, see Appendix Table 1). The incidence of HIV attributed to heterosexual contact, injection drug use, and male-to-male sexual contact and injection drug use decreased by 6.3% (CI, 7.4% to 5.2%), 10.7% (CI, 12.8% to 8.6%), and 4.3% (CI, 6.9% to 1.6%) per year, respectively. The decreasing trend for persons who inject drugs may have been leveling off since 2014, with stable incidence in 2014 and 2015 (P= 0.22). The incidence decreased among both male and female adults and adolescents with infection attributed to heterosexual contact or injection drug use, with the reduction potentially leveling off among both males and females who inject drugs after 2014 (stable incidence in 2014 and 2015; P= 0.32 and P= 0.47, respectively) (Appendix Table 1). The incidence of HIV among MSM remained relatively stable, with 26700 infections in 2008 and 26200 in 2015. Men who have sex with men had the highest annual rates of HIV incidence each year, with a 2015 rate (513.7 [CI, 443.7 to 583.7] per 100000) 16 times that of persons with infection attributed to injection drug use (32.1 [CI, 20.3 to 43.8] per 100000) and 135 times that of persons with infection attributed to heterosexual contact (3.8 [CI, 3.3 to 4.2] per 100000) (Table 1). Figure. Estimated HIV incidence among persons aged 13 years or older, by transmission category (adjusted for missing transmission category), United States, 2008 to 2015. Shown are the estimated annual percentage changes and associated 95% CIs. Appendix Table 1. Estimated HIV Incidence Among Persons Aged 13 Years, by Sex and Transmission Category*United States, 20082015 Table 1. Estimated HIV Incidence and Prevalence and the Percentage of Undiagnosed HIV Infections Among Persons Aged 13 Years or Older, b