HIV Infection — United States, 2008 and 2010

Anna Satcher Johnson, MPH

Linda Beer, PhD

Catlainn Sionean, PhD

Xiaohong Hu, MS

Carolyn Furlow-Parmley, PhD

Binh Le, MD

Jacek Skarbinski, MD

H. Irene Hall, PhD

Hazel D. Dean, ScD

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC

Corresponding author: Anna Satcher Johnson, Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC. Telephone: 404-639-2050; E-mail: ats5@cdc.gov.

Introduction

At the end of 2009, approximately 1.1 million persons in the United States were living with human immunodeficiency virus (HIV) infection (1), with approximately 50,000 new infections annually (2). The prevalence of HIV continues to be greatest among gay, bisexual, and other men who have sex with men (MSM), who comprised approximately half of all persons with new infections in 2009 (2). Disparities also exist among racial/ethnic minority populations, with blacks/African Americans and Hispanics/Latinos accounting for approximately half of all new infections and deaths among persons who received an HIV diagnosis in 2009 (2,3). Improving survival of persons with HIV and reducing transmission involve a continuum of services that includes diagnosis, linkage to and retention in HIV medical care, and ongoing HIV prevention interventions (4).

The HIV analysis and discussion that follows is part of the second CDC Health Disparities and Inequalities Report (CHDIR) and updates information presented in the first CHDIR (5). The 2011 CHDIR (6) was the first CDC report to assess disparities across a wide range of diseases, behavioral risk factors, environmental exposures, social determinants, and health-care access. The topic presented in this report is based on criteria that are described in the 2013 CHDIR Introduction (7). The purposes of this HIV infection report are to discuss and raise awareness of differences in the characteristics of people with HIV infection and to prompt actions to reduce these disparities

Methods

To estimate the number of adults aged ≥18 years who received a diagnosis of HIV infection during 2008 and 2010, CDC analyzed data reported through June 2011 to the National HIV Surveillance System (NHSS). CDC funds and assists state and local health departments to collect case information on persons with an HIV diagnosis. Health departments report deindentified data to CDC, which are compiled for national analyses. Analysis of HIV case surveillance data was limited to the 46 states that had reported HIV cases since at least January 2007 to allow for estimation of diagnoses rates: Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming. Rates per 100,000 population were calculated for 2008 and 2010 by age, sex, and race/ethnicity, with population denominators based on postcensal estimates for 2009 from the U.S. Census Bureau (8). Household income and educational attainment were not calculated because these data are not collected by NHSS. Geographic location was not calculated because estimates of HIV diagnoses among persons in all 50 states and the District of Columbia were unable to be calculated at the time of this analysis. Analysis of transmission categories was limited to all men and MSM because denominator data for transmission categories other than MSM were unavailable (9); the category of all men was used as the referent group. To compute estimated MSM population denominators used for calculating HIV diagnosis rates, CDC applied the estimated proportion of men in the United States who reported ever having male-to-male sex (6.9%; 95% confidence interval [CI]: 5.1%–8.6%) to postcensal estimated populations for men (9). Analyses were adjusted for reporting delays (i.e., the time between diagnosis and report) and for missing risk factor information but not for underreporting (3).

Data from the Medical Monitoring Project (MMP) were used to estimate percentages of adults aged ≥18 years receiving outpatient medical care whose medical record documented that they 1) were prescribed antiretroviral therapy (ART) during the past 12 months, 2) had a suppressed viral load (defined as undetectable or ≤200 copies/mL at their most recent test), and 3) reported receiving prevention counseling in a clinical setting during the 12 months preceding the interview. Nationally representative percentages and associated standard errors were estimated for patients in care in 2009 and interviewed during 2009–2010. MMP collects behavioral and clinical information from a nationally representative sample of adults receiving medical care for HIV infection in outpatient facilities in the United States and Puerto Rico (10–12). A total of 23 project areas were funded to conduct data collection activities for the 2009 MMP data collection cycle: California; Chicago, Illinois; Delaware; Florida; Georgia; Houston, Texas; Illinois; Indiana; Los Angeles County, California; Michigan; Mississippi; New Jersey; the state of New York; New York City, New York; North Carolina; Oregon; Pennsylvania; Philadelphia, Pennsylvania; Puerto Rico; San Francisco, California; Texas; Virginia; and Washington. Patients who received medical care during January–April 2009 at an MMP participating facility were interviewed once during June 2009–April 2010 regarding the 12 months preceding the interview. In addition, patients' medical records were abstracted for documentation of medical care (including prescription of ART and HIV viral load) for the 12 months preceding the interview. All percentages were weighted for the probability of selection and adjusted for nonresponse bias. Standard errors were calculated and account for weighting and complex sample survey design. Associations between variables were assessed using Rao-Scott chi-square tests, with significance set at p<0.05. Detailed methods for MMP have been described previously (10–12).

Data from the 2008 MSM cycle of the National HIV Behavioral Surveillance System (NHBS)§ were used to estimate percentages of MSM aged 18–64 years who 1) engaged in unprotected anal sex with a casual partner, 2) reported testing for HIV during the previous 12 months, and 3) who participated in a behavioral intervention. Men who reported being infected with HIV or who had no male sex partners during the 12 months before interview were excluded from this analysis. NHBS monitors HIV-associated behaviors and HIV positivity within selected metropolitan statistical areas (MSAs) with a high prevalence of acquired immunodeficiency syndrome (AIDS) among three populations at high risk for HIV infection: MSM, injection-drug users, and heterosexual adults at increased risk for HIV infection. Data for NHBS are collected in annual rotating cycles. All NHBS participants must be aged ≥18 years, live in a participating MSA, and be able to complete a behavioral survey in English or Spanish. MSM participants were recruited using venue-based sampling. Detailed methods for NHBS have been described previously (13).

Disparities were measured as the deviations from a referent category rate or prevalence. Absolute difference was measured as the simple difference between a population subgroup estimate and the estimate for its respective reference group. The percentage relative difference was calculated by dividing the difference by the value in the referent category and multiplying by 100 (14).

Results

In the 46 states for which HIV case surveillance data from the NHSS were analyzed, a total of 46,379 adults aged ≥18 years received a diagnosis of HIV in 2008, and 46,381 received an HIV diagnosis in 2010. During 2010, the relative difference in the HIV diagnosis rate among blacks/African Americans compared with whites was eightfold and for Hispanics/Latinos, persons of multiple races, and Native Hawaiians/other Pacific Islanders (NH/OPI), the relative difference was twofold compared with whites (Table 1).

Although the racial/ethnic disparities in rates of HIV diagnoses among men were similar to the disparities observed for the racial/ethnic groups overall, larger differences occurred among women. In 2010, among women, the relative difference in HIV diagnosis rates among black/African American women was twentyfold compared with whites, among women of multiple races was fourfold compared with whites, among Hispanic/Latino women was threefold compared with whites, and among AI/ANs was twofold compared with whites (Table 1). From 2008 to 2010, the relative differences increased for all racial/ethnic groups of women except NH/OPIs and women of multiple races compared with whites. The largest relative difference was observed for MSM compared with all other men (an approximate 46-fold difference) in 2010, as well as the largest change from 2008 to 2010 (763 percentage points).

Among adults aged ≥18 years in MMP, representing persons receiving medical care in 2009, assessment of the data by age group indicated that the percentages of persons who were prescribed ART increased as age increased. Compared with adults aged ≥55 years, a lower percentage of young persons (aged 18–24 years and 25–34 years) were prescribed ART (relative difference: -18% and -16%, respectively). By race/ethnicity, lower percentages of blacks/African Americans were prescribed ART than were whites (relative difference: -7%) (Table 2). A higher percentage of men were prescribed ART than were women, with a relative difference of 5%. Among men, lower percentages of blacks/African Americans were prescribed ART than were whites, with a relative difference of -6%. A similar pattern was observed in the percentage of women prescribed ART, with a lower percentage of blacks/African Americans prescribed ART than whites, (relative difference: -7%).

Among persons prescribed ART in 2009, persons aged 25–34 years and 35–44 years accounted for the lowest percentages of persons with a suppressed viral load. Compared with persons aged ≥55 years, relative differences in viral suppression were -18% for persons aged 25–34 years and -15% for persons aged 35–44 years. By race/ethnicity, lower percentages of blacks/African Americans and Hispanics/Latinos had a suppressed viral load than whites, with relative differences of -15% and −5%, respectively (Table 2). A higher percentage of men had a suppressed viral load at their most recent test than women (relative difference: 10%). Among men, lower percentages of blacks/African Americans and Hispanics/Latinos had a suppressed viral load than whites, with relative differences of -16% and -6%, respectively. Examination of other demographic characteristics indicated that a higher percentage of persons who spoke Spanish with friends and family had a suppressed viral load at their most recent test than English-speaking persons, with a relative difference of 6%. A higher percentage of persons who self-identified as homosexual had a suppressed viral load than persons who self-identified as heterosexual, with a relative difference of 11%. The percentage of persons with a suppressed viral load increased as educational attainment increased.

Of persons receiving HIV care in the United States in 2009, persons in younger age groups reported higher percentages of receipt of HIV prevention counseling than those aged ≥55 years. Higher percentages of blacks/African Americans and Hispanics/Latinos had received HIV prevention counseling from a health-care provider during the 12 months before their interview than whites, with relative differences of 89% and 81%, respectively (Table 2). A lower percentage of men received HIV prevention counseling from a health-care provider than women (relative difference: -15%). Among men, higher percentages of blacks/African Americans and Hispanics/Latinos received HIV prevention counseling than whites, with relative differences of 101% and 84%, respectively. Findings were similar among women; higher percentages of blacks/African Americans and Hispanics/Latinas had received HIV prevention counseling than whites, with relative differences of 49% and 58%, respectively. A higher percentage of persons born outside the United States received HIV prevention counseling than persons born in the United States, with a relative difference of 17%. A higher percentage of persons who spoke Spanish with friends and family had received HIV prevention counseling than English-speaking persons, with a relative difference of 27%. A lower percentage of persons who self-identified as homosexual had received HIV prevention counseling than persons who self-identified as heterosexual, with a relative difference of -21%. The percentage of persons receiving prevention counseling increased as educational attainment decreased. Compared with college graduates, relative differences in the percentage of persons who received HIV prevention counseling were 54% for persons with less than a high school education, 38% for high school graduates, and 19% for persons with some college or the equivalent.

Among MSM in NHBS in 2008, unprotected anal sex with a casual male partner was most common in younger age groups, with relative differences of 38% among MSM aged 25–34 years and 26% among those aged 35–44 years, compared with MSM aged ≥55 years (Table 3). By race/ethnicity, Hispanic/Latino MSM and MSM of multiple races accounted for the largest percentages of MSM who engaged in unprotected anal sex with a casual partner, with relative differences of 14% and 17%, respectively, compared with whites.

The percentages of MSM who had been tested for HIV infection in the 12 months before the interview were higher among younger than older MSM and those who identified as homosexual than those who did not, similar among racial and ethnic groups, and increased with educational attainment (Table 3). Specifically, HIV testing in the 12 months before interview was highest among MSM aged 18–24 and 25–34 years, with relative differences of 37% and 36%, respectively, compared with men aged ≥55 years. The percentage of MSM who reported HIV testing in the 12 months before interview was lowest among MSM with less than a high school education, with a relative difference of -27% compared with MSM who were college graduates.

The percentages of MSM who reported participation in a behavioral HIV intervention in the 12 months before interview were higher among younger than older MSM and among MSM of minority racial/ethnic groups than whites (Table 3). MSM aged 18–24 years accounted for the highest percentage of MSM who participated in a behavioral intervention, with a relative difference of 148% compared with men aged ≥55 years. The percentage of MSM who participated in a behavioral intervention varied by level of educational attainment. Compared with MSM who had graduated from college, the percentage of MSM who had participated in a behavioral intervention was higher among MSM with lower levels of educational attainment, with relative differences of 17%, 29%, and 46% for less than high school, high school graduate, and some college or technical school, respectively.

Discussion

Although the relative difference in HIV infection diagnoses between whites and blacks/African Americans decreased from 2008 to 2010, all racial/ethnic minorities, except Asians, continue to experience higher rates of HIV diagnoses than whites. These differences might reflect HIV incidence, testing patterns, or both. Compared with whites, lower percentages of blacks/African Americans were prescribed ART and lower percentages of both blacks/African Americans and Hispanics/Latinos had suppressed viral loads. Differences in rates of ART prescription and viral suppression might reflect differences in insurance coverage, prescription drug costs, health-care providers' perceptions of patients, or other factors associated with adherence (4). Rates of HIV infection are increasing among MSM, particularly young black/African American MSM (2). However, among MSM, similar percentages of blacks/African American and Hispanic/Latino MSM reported HIV testing compared with white MSM, and higher percentages reported receipt of behavioral interventions than white MSM.

Limitations

The NHSS data presented in this report are subject to at least three limitations. First, data were not available from all states. According to the cumulative estimated number of AIDS diagnoses through 2010, the 46 states with confidential name-based reporting since at least 2007 for which data were used represent approximately 92% of AIDS diagnoses in the 50 states and the District of Columbia. Second, adjustments made to HIV case surveillance data for reporting delays and missing transmission category information are subject to a degree of uncertainty that might result in less stable rates for the most recent years. Finally, although postcensal estimates were used to determine population denominators for women, estimated population denominators were calculated for MSM and other men by applying the estimated proportion of men in the United States who reported ever having male-to-male sex (6.9%; 95% CI: 5.1%–8.6%) to the 2009 postcensal estimated population for men (9). Population denominators for other men were calculated by subtracting the MSM population denominators from the 2009 postcensal estimated population for men.

The MMP data presented in this report are subject to at least three limitations. First, MMP estimates are not representative of all persons with HIV in the United States because only HIV-infected persons in care during the first 4 months of 2009 were eligible for selection into the MMP sample. Second, MMP data might include persons more likely to be retained in care or adhere to ART, leading to overestimation of certain measures. For example, measures might be overestimated because persons in MMP are more engaged in care and adherent to ART use. Finally, documentation of a recent suppressed viral load might not indicate persistent viral suppression over time.

The NHBS data presented in this report are subject to at least two limitations. First, participants in the MSM cycle of NHBS were recruited from venues, primarily bars and clubs, within 21 MSAs with a high AIDS prevalence and might not be representative of MSM who do not attend such venues or of MSM in other areas. Second, NHBS data regarding risk behaviors and use of prevention services are self-reported. Social desirability might lead to underreporting of risk behaviors and overreporting of recent HIV testing and participation in HIV behavioral interventions.

Conclusion

The findings in this report highlight a need for continued expansion of effective HIV prevention efforts for racial/ethnic minorities and MSM. In 2007, CDC initiated the Expanded HIV Testing Initiative, Expanded and Integrated HIV Testing for Populations Disproportionately Affected by HIV, which was expanded in 2010 to include MSM. (Additional information is available at http://www.cdc.gov/hiv/topics/funding/ps10-10138/index.htm.) In addition, the 2010 national HIV/AIDS strategy has goals that include reducing HIV incidence, increasing access to care, improving health outcomes for persons living with HIV, and reducing HIV-related disparities and health inequities. These goals are interdependent (4,15) and also consistent with the Healthy People 2020 goal of achieving health equity, eliminating disparities, and improving the health of all groups. (Additional information available at http://healthypeople.gov/2020/about/default.aspx.) Reducing HIV incidence and improving individual health outcomes require increased access to care and elimination of disparities in the quality of care received (4). CDC is working with health departments throughout the United States to expand efforts in using local data (in accordance with privacy and confidentiality policies, laws, and regulations) to 1) identify HIV-infected persons who are not receiving care and to facilitate efforts to ensure they receive appropriate care and 2) identify populations within their local areas at greatest risk for HIV and with greatest need for prevention services. CDC will continue using its national HIV surveillance systems to monitor HIV incidence and diagnosis in the population and to monitor receipt of ART, risk behaviors, and receipt of prevention services among HIV-infected persons in care to identify opportunities for improvement. Information will be shared with grantees, partners, health-care providers, and other federal agencies (e.g., the Health Resources and Services Administration) to improve delivery of care, treatment, and prevention services for those with HIV infection (4). Behaviors of populations at high risk for HIV infection also will be monitored as part of CDC's comprehensive approach to reducing the spread of HIV infection in the United States.

To reduce the number of new HIV infections, CDC has devoted HIV resources to High-Impact Prevention, a combination of scientifically proven, cost-effective, and scalable interventions that have demonstrated the potential to reduce new HIV infections in the relevant populations and geographic areas to yield a greater reduction in HIV incidence (16). Optimally scaled implementation of the most cost-effective interventions will have the greatest impact on reducing the spread of HIV in the United States.

The progress in HIV prevention since the beginning of the U.S. epidemic is a result of a multisectoral approach to HIV from governmental, non governmental, and community-based organizations, academia, and the business sector. Reducing the higher prevalence of HIV infection in racial/ethnic minority groups and MSM also will require public health interventions and societal actions as a whole that address social, economic, health system, and other environmental factors that play a role in HIV prevalence in these communities (17). These factors might include poverty, which can limit access to health care and HIV testing; stigma and discrimination, which can discourage individuals from seeking testing, prevention, and treatment services; barriers to timely access and use of medical and social services; and higher rates of incarceration, which can disrupt social and safe sexual networks. The results of this report underscore the need for high-priority, carefully targeted HIV prevention efforts in these communities to ensure that individual, social, health system, and other environmental determinants of health are considered in the design and implementation of HIV prevention and care programs.

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