Progress Along the Continuum of HIV Care Among Blacks with Diagnosed HIV— United States, 2010

Y. Omar Whiteside, PhD1, Stacy M. Cohen, MPH1, Heather Bradley, PhD1, Jacek Skarbinski, MD1, H. Irene Hall, PhD1, Amy Lansky, PhD1 (Author affiliations at end of text)

The goals of the National HIV/AIDS Strategy are to reduce new human immunodeficiency virus (HIV) infections, increase access to care and improve health outcomes for persons living with HIV, and reduce HIV-related health disparities (1). Recently, by executive order, the HIV Care Continuum Initiative was established, focusing on accelerating federal efforts to increase HIV testing, care, and treatment (2). Blacks are the racial group most affected, comprising 44% of new infections (3) and also 44% of all persons living with HIV infection (4). To achieve the goals of NHAS, and to be consistent with the HIV Care Continuum Initiative, blacks with HIV need high levels of care and viral suppression (5–7). Achieving these goals calls for 85% of blacks with diagnosed HIV to be linked to care, 80% to be retained in care, and the proportion with an undetectable viral load (VL) to increase 20% by 2015 (1). Analysis of data from the National HIV Surveillance System (NHSS)* and the Medical Monitoring Project (MMP)† regarding progress along the HIV care continuum during 2010 for blacks with diagnosed HIV infection indicated that 74.9% of HIV-diagnosed blacks were linked to care, 48.0% were retained in care, 46.2% were prescribed antiretroviral therapy (ART), and 35.2% had achieved viral suppression. Black males had lower levels of care and viral suppression than black females at each step along the HIV care continuum; in addition, levels of care and viral suppression for blacks aged <25 years were lower than those for blacks aged ≥25 years at each step of the continuum. These data demonstrate the need for implementation of interventions and public health strategies that increase linkage to care and consistent ART among blacks, particularly black males and black youths.

Data from NHSS in 2010 reported to CDC through December 2012 were used to determine the numbers of blacks aged ≥13 years newly diagnosed with HIV and living with diagnosed HIV and the numbers and percentages linked to care and retained in care. Nineteen jurisdictions met the criteria for the collection and reporting of CD4+ T-lymphocyte (CD4) and VL test results,§ which are the data needed to assess linkage and retention in care. Linkage to care¶ was calculated among blacks with new HIV diagnoses during 2010 who resided in any of the 19 jurisdictions at diagnosis. Retention in care** was assessed among blacks with HIV diagnosed by December 31, 2009, who resided in any of the 19 jurisdictions at the time of diagnosis, and were alive on December 31, 2010, (i.e., persons living with diagnosed HIV). Data were statistically adjusted for missing HIV transmission categories (8).

Data from MMP were used to estimate ART prescription†† and viral suppression§§ among blacks aged ≥18 years using methods that have been described previously (5). The MMP values are weighted national estimates of the numbers of blacks who received medical care during January–April 2010 and had documentation of ART prescription and viral suppression. Percentages were calculated among blacks whose HIV infection was diagnosed by December 31, 2009, and who were alive on December 31, 2010, in the United States and Puerto Rico (denominators were based on NHSS data). Data analyses were limited to 2010, the most recent year data were available for persons living with HIV infection.

Of the 8,261 blacks with HIV infection diagnosed during 2010 in the 19 jurisdictions, 6,186 (74.9%) were linked to care ≤3 months after HIV diagnosis (Table 1). Among males, 72.3% were linked to care, compared with 81.3% of females. Persons aged 13–24 years had the highest number of diagnoses of any age group, but the lowest percentage of linkage to care (68.8%); linkage increased with age group. By transmission category, males with infection attributed to male-to-male sexual contact had the lowest percentage of linkage to care (71.6%); the highest percentage was among females with infection attributed to injection drug use (82.4%), followed by females with infection attributed to heterosexual contact (81.1%).

Among the 153,581 blacks aged ≥13 years living with diagnosed HIV on December 31, 2010, in 19 jurisdictions, 48.0% were retained in care (Table 2). Of these, a lower percentage of males (46.5%) than females (50.9%) were retained in care. By age group, persons aged 25–34 years had the lowest percentage retained in care (42.8%), followed by persons aged 13–24 years (45.1%). By transmission category, the lowest percentage retained in care was among males with infection attributed to injection drug use (43.9%); the highest percentages were among females with infection attributed to injection drug use (50.9%) and females with infection attributed to heterosexual contact (50.6%).

Of 353,653 blacks aged ≥18 years living with diagnosed HIV on December 31, 2010, in the United States and Puerto Rico, 163,515 (46.2%) had an ART prescription (Table 3). Of these, a higher percentage of females (50.8%) than males (43.7%) had ART prescribed. Prevalence of ART prescription increased with age group; prevalence was 20.8% among blacks aged 18–24 years and 57.4% among those aged ≥55 years. The lowest level of ART prescription by transmission category was among males with infection attributed to injection drug use (34.0%); the highest level was among females with infection attributed to heterosexual contact (51.4%).

Of blacks living with diagnosed HIV in the United States and Puerto Rico, 35.2% achieved viral suppression at their most recent test. Of these persons, a higher percentage of females had suppressed VL (39.8%) than males (32.7%). Persons aged 18–24 years had the lowest level of viral suppression (18.3%) among all age groups. By transmission category, males with infection attributed to injection drug use had the lowest level of viral suppression (22.2%), and females with infection attributed to heterosexual contact had the highest level (41.3%).

Editorial Note

The results of the analysis described in this report indicate that, in 2010, among blacks with HIV diagnoses of all age groups and both sexes, 74.9% were linked to care, 48.0% were retained in care, 46.2% were prescribed ART, and 35.2% had achieved viral suppression. Improving health outcomes for blacks living with HIV infection is necessary to reduce HIV infection in the United States.

Blacks with HIV might not seek, receive, or adhere to HIV care or achieve viral suppression for reasons including lack of health insurance, poverty, and stigma (9). HIV programs that focus on care and treatment for blacks might strengthen efforts to link and retain HIV-infected persons in care and promote adherence to medication to achieve optimal health outcomes. Evidence-based interventions with demonstrated efficacy in scientific studies and effectiveness in practice settings also might be considered (10).

Among black persons with HIV in the United States, males had a lower prevalence than females of linkage to care, retention in care, ART prescription, and viral suppression. The youngest age group among blacks had lower percentages than other age groups of linkage to care, ART prescription, and viral suppression. In addition to interventions to ensure that all persons with HIV receive optimal care to improve health outcomes, targeted strategies for groups such as black males and black youths might be needed to achieve improvements at each step of the continuum.

The findings in this report are subject to at least two limitations. First, analyses based on NHSS data are limited to 19 jurisdictions with complete reporting of all levels of CD4 and VL test results; data from these areas represent approximately 44% of all blacks living with diagnosed HIV on December 31, 2010, in the United States and might not be representative of all blacks in the United States. Second, certain analyses in this study are based on different populations, and the results cannot be compared because linkage to care and retention in care were based on data for persons aged ≥13 years from 19 jurisdictions, whereas ART prescription and viral suppression were based on weighted estimates of persons receiving care aged ≥18 years from the United States and Puerto Rico.

CDC and its partners are pursuing a high-impact prevention¶¶ approach to advance the goals of the National HIV/AIDS Strategy and maximize the effectiveness of current HIV prevention and care methods. Testing is a critical first step of entry into the HIV continuum of care. CDC supports HIV testing projects that focus on blacks. CDC also supports multiple projects to optimize outcomes along the continuum of care, such as the Care and Prevention in the United States*** demonstration project, which seeks to increase linkage to, retention in, and return to care for all HIV-infected persons, including racial and ethnic minorities, with the goal of reducing HIV-related morbidity and mortality by addressing social, economic, clinical, and structural factors influencing HIV health outcomes. The results of the analyses described in this report underscore the need for enhanced linkage to care, retention in care, and viral suppression for blacks, particularly black males and black youths. Focusing prevention and care efforts on populations that bear a disproportionate burden of HIV disease could lead to reductions in HIV incidence and health inequities and help achieve the goals of the National HIV/AIDS Strategy.

1Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC (Corresponding author: Y. Omar Whiteside, ywhiteside@cdc.gov, 404-639-4980)

References

1. Office of National AIDS Policy. National HIV/AIDS strategy for the United States. Washington, DC: Office of National AIDS Policy; 2010. Available at http://aids.gov/federal-resources/national-hiv-aids-strategy/nhas.pdf.
2. Office of the Press Secaretary. Accelerating improvements in HIV prevention and care in the United States through the HIV Care Continuum Initiative. Washington, DC: Office of the Press Secretary, The White House; 2013. Available at http://www.whitehouse.gov/the-press-office/2013/07/15/fact-sheet-accelerating-improvements-hiv-prevention-and-care-united-stat.
3. CDC. Estimated HIV incidence in the United States, 2007–2010. HIV surveillance supplemental report 2012; Vol. 17(No. 4). Atlanta, GA: US Department of Health and Human Services, CDC; 2012. Available at http://www.cdc.gov/hiv/library/reports/surveillance/.
4. CDC. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data: United States and 6 U.S. dependent areas—2011. HIV surveillance supplemental report, 2013. Vol. 18(No. 5). Atlanta, GA: US Department of Health and Human Services, CDC; 2013. Available at http://www.cdc.gov/hiv/library/reports/surveillance.
5. Hall HI, Frazier EL, Rhodes P, et al. Differences in human immunodeficiency virus care and treatment among subpopulations in the United States. JAMA Intern Med 2013;173:1337–4.
6. Valdiserri RO, Forsyth AD, Yakovchenko V, Koh HK. Measuring what matters: development of standard HIV core indicators across the U.S. Department of Health and Human Services. Public Health Rep 2013;128:354–9.
7. Gray KM, Cohen SM, Hu X, Li J, Mermin J, Hall HI. Jurisdiction level differences in HIV diagnosis, retention in care, and viral suppression in the United States. J Acquir Immune Defic Syndr 2014;65:129–32.
8. McDavid HK, Kajese T, Hall HI, Song R. Risk factor redistribution of the national HIV/AIDS surveillance data: an alternative approach. Public Health Rep 2008;123:618–27.
9. Moore RD. Epidemiology of HIV infection in the United States: implications for linkage to care. Clin Infect Dis 2011;52(Suppl 2):S208–13.
10. Mugavero MJ, Amico KR, Horn T, Thompson MA. The state of engagement in HIV care in the United States: from cascade to continuum to control. Clin Infect Dis 2013;57:1164–71.