Diagnoses of HIV Infection in the United States and Dependent Areas 2020: Special Focus Profiles

The Special Focus Profiles highlight the distribution of HIV in 6 populations of particular interest to HIV prevention programs in state and local health departments: (1) Gay, Bisexual, and Other Men Who Have Sex With Men, (2) Persons Who Inject Drugs, (3) Transgender Persons, (4) Women, and (5) Persons Aged 13–24 Years, and (6) Children Aged <13 Years. See suggested readings for references and additional information including HIV risk behaviors, barriers to care, and prevention challenges for each population of particular interest.

Gay, Bisexual, and Other Men Who Have Sex With Men

Gay, bisexual, and other men who have sex with men (MSM) are the population most affected by HIV in the United States. Stigma, homophobia, and discrimination make MSM of all races/ethnicities susceptible to multiple physical and mental health problems and can affect whether they seek and receive high-quality health services, including HIV testing, treatment, and other prevention services.

In 2020, MSM accounted for 71% (20,758 MMSC and 1,109 MMSC and IDU) of the 30,692 new HIV diagnoses in the United States and 6 dependent areas (Table 1b). Many Black/African American and Hispanic/Latino MSM with HIV, particularly young MSM, are unaware of their HIV infection. Lack of awareness of HIV status among young MSM may be due to recent infection, not getting tested due to underestimation of personal risk, or fewer opportunities to get tested. Persons who do not know they have HIV do not get medical care or receive treatment and can unknowingly infect others.

Diagnoses of HIV infection among MSM

HIV diagnosis percentages for 2020 were as follows:

• Age group (Figure 12):
  • 13–24 years: 24%
  • 25–34 years: 40%
  • 35–44 years: 17%
  • 45–54 years: 11%
  • ≥55 years: 8%
• Race/ethnicity (Figure 12):
  • American Indian/Alaska Native: 1%
  • Asian: 2%
  • Black/African American: 39%
  • Hispanic/Latino: 31%
  • Native Hawaiian/other Pacific Islander: <1%
  • White: 25%
  • Multiracial: 3%
• Region of residence (Figure 12):
  • Northeast: 13%
  • Midwest: 14%
  • South: 50%
  • West: 23%
  • U.S. dependent areas: 1%

• Age group and race/ethnicity—highest percentages by age group (Figure 13):
  • Aged 13–24 years: Black/African American (54%)
  • Aged >24 years: Black/African American (34%)

• Region of residence and race/ethnicity—highest numbers and percentages by region (Figure 14):
  • Northeast: Black/African American (941; 36%)
  • Midwest: Black/African American (1,323; 47%)
  • South: Black/African American (5,079; 49%)
  • West: Hispanic/Latino (2,199; 47%)
  • U.S. dependent areas: Hispanic/Latino (183; 99%)

• Prevalence and race/ethnicity (Table 16b):At year-end 2020 in the United States and 6 dependent areas, 604,590 MSM were living with diagnosed HIV infection attributed to MMSC. Prevalence by race/ethnicity was as follows:
  • American Indian/Alaska Native: <1%
  • Asian: 2%
  • Black/African American: 31%
  • Hispanic/Latino: 26%
  • Native Hawaiian/other Pacific Islander: <1%
  • White: 36%
  • Multiracial: 5%

Persons Who Inject Drugs

Persons who inject drugs (PWID) can get HIV if they use and share needles, syringes, or other drug injection equipment (e.g., cookers) that someone with HIV has used. In 2020, persons who inject drugs account for about 1 in 15 HIV diagnoses in the United States. In recent years, the opioid (including prescription and synthetic opioids) and heroin crisis has led to increased numbers of PWID. HIV diagnoses among PWID have increased in the 50 states and District of Columbia. IDU in nonurban areas has created prevention challenges and brought attention to populations who would benefit from HIV prevention efforts.

Diagnoses of HIV infection among PWID

In 2020, in the United States and 6 dependent areas, 2,055 diagnoses of HIV infection were attributed to IDU (1,198 among male and 857 among female PWID) (Table 6b).

HIV diagnosis percentages among PWID for 2020 were as follows:

• Age group (Figure 15):
  • 13–24 years: 6%
  • 25–34 years: 32%
  • 35–44 years: 27%
  • 45–54 years: 18%
  • ≥55 years: 17%

  For additional data by 5-year age groups, see Table 6b.

• Race/ethnicity (Figure 15):
  • American Indian/Alaska Native: 1%
  • Asian: 1%
  • Black/African American: 27%
  • Hispanic/Latino: 20%
  • Native Hawaiian/other Pacific Islander: <1%
  • White: 47%
  • Multiracial: 3%
• Region of residence (Figure 15):
  • Northeast: 21%
  • Midwest: 14%
  • South: 44%
  • West: 21%
  • U.S. dependent areas: 1%

• Sex assigned at birth and race/ethnicity—highest percentages (Figure 16):
  • White female: 49%
  • White male: 45%
  • Black/African American female: 29%
  • Black/African American male: 26%

• Region of residence and race/ethnicity—highest numbers and percentages by region (Figure 17):
  • Northeast: White (157; 37%)
  • Midwest: White (152; 53%)
  • South: White (464; 52%)
  • West: White (188; 44%)
  • U.S. dependent areas: Hispanic/Latino (22; 100%)

• Prevalence and race/ethnicity (Table 16b):
  At year-end 2020 in the United States and 6 dependent areas, 118,213 PWID were living with diagnosed HIV infection. Prevalence by race/ethnicity was as follows:
  • American Indian/Alaska Native: <1%
  • Asian: 1%
  • Black/African American: 45%
  • Hispanic/Latino: 27%
  • Native Hawaiian/other Pacific Islander: <1%
  • White: 22%
  • Multiracial: 5%

Transgender Persons

Transgender is an umbrella term that is used to identify persons whose sex assigned at birth does not match current gender identity or expression. Gender identity refers to one’s internal understanding of one’s own gender, or the gender with which a person identifies. Gender expression is a term used to describe people’s outward presentation of their gender. Gender identity and sexual orientation are different facets of identity. Everyone has a gender identity and a sexual orientation, but a person’s gender does not determine a person’s sexual orientation. Transgender persons may identify as heterosexual, homosexual, bisexual, or none of the above. Transgender persons are understudied in HIV prevention (e.g., preexposure prophylaxis [PrEP]) and treatment interventions and face numerous prevention challenges, including social rejection and exclusion and lack of public/provider knowledge about transgender issues.

Diagnoses of HIV infection

In 2020, in the United States and 6 dependent areas, 697 diagnoses of HIV infection were among transgender and AGI persons (Table 4b). Diagnoses of HIV infection among transgender persons accounted for approximately 2% of diagnoses. Transgender women accounted for the highest percentage of diagnoses of HIV infections (92%).

HIV diagnosis percentages among transgender and AGI persons for 2020 were as follows:

• Age group (Figure 18):
  • 13–24 years: 28%
  • 25–34 years: 49%
  • 35–44 years: 13%
  • 45–54 years: 7%
  • ≥55 years: 2%

  For additional data by 5-year age groups, see Table 4b.

• Race/ethnicity (Figure 18):
  • American Indian/Alaska Native: 1%
  • Asian: 2%
  • Black/African American: 47%
  • Hispanic/Latino: 31%
  • Native Hawaiian/other Pacific Islander: <1%
  • White: 13%
  • Multiracial: 5%
• Exposure category (Figure 18):
  • Sexual contact: 89%
  • IDU: <1%
  • Sexual contact and IDU: 6%
  • Other: 5%
• Region of residence (Figure 18):
  • Northeast: 16%
  • Midwest: 15%
  • South: 44%
  • West: 24%
  • U.S. dependent areas: <1%

• Gender and race/ethnicity—highest percentages (Figure 19):
  • Transgender woman: Black/African American (48%)
  • Transgender man: White (38%)
  • AGI: Black/African American (47%)

• Gender and exposure category—highest percentages (Figure 20):
  • Transgender woman: sexual contact (90%)
  • Transgender man: sexual contact (73%)
  • AGI: sexual contact (82%)

Women

More than 5,000 women received an HIV diagnosis in the United States and 6 dependent areas in 2020. One in nine women with HIV are unaware they have it. Because some women may be unaware of their male partner’s risk factors for HIV (such as injection drug use or having sex with men), they may not use condoms or medicines to prevent HIV. Additionally, HIV testing rates within the past year were low among women with sexual behaviors that increase their risk of acquiring HIV and especially low among those who reported anal sex.

Diagnoses of HIV infection

In 2020 in the United States and 6 dependent areas, the rate of diagnoses of HIV infection among females aged ≥13 years was 3.8 (Figure 21).

In 2020 in the United States (Figure 22):

• Black/African American females aged ≥13 years made up 13% of the female population but accounted for 54% of diagnoses of HIV infection among females.
• White females aged ≥13 years made up 62% of the female population and accounted for 24% of diagnoses of HIV infection.
• Hispanic/Latino females aged ≥13 years made up 17% of the female population and accounted for 17% of diagnoses of HIV infection.

HIV diagnosis rates among females aged ≥13 years were as follows:

• Age group (U.S. only) (Figure 23):
  • 13–24 years: 2.9
  • 25–34 years: 7.0
  • 35–44 years: 6.0
  • 45–54 years: 4.9
  • ≥55 years: 1.6

  For additional data by 5-year age groups, see Table 3a.

• • • Disparities by age group:
      • Absolute disparity (rate difference)—If persons aged 25–34 years had the same rate as persons aged ≥ 55 years, 5 cases per 100,000 population would have been prevented.
      • Relative disparity (rate ratio)—Persons aged 25–34 years had a rate that was 4.4 times as high as persons aged ≥ 55 years.
• Race/ethnicity (U.S. only) (Figure 23):
  • American Indian/Alaska Native: 4.2
  • Asian: 1.0
  • Black/African American: 16.4
  • Hispanic/Latino: 3.8
  • Native Hawaiian/other Pacific Islander: 6.0
  • White: 1.5
  • Multiracial: 5.3
    • Disparities by race/ethnicity:
      • Absolute disparity (rate difference)—If Black/African American persons aged ≥13 years had the same rate as White persons aged ≥13 years (1.5), 15 cases per 100,000 population would have been prevented.
      • Relative disparity (rate ratio)—Black/African American persons aged ≥13 years had a rate that was 10.9 times as high as White persons aged ≥13 years.
• Region of residence (U.S. only) (Figure 23):
  • Northeast: 3.6
  • Midwest: 2.5
  • South: 5.5
  • West: 2.4
    • Disparities by region:
      • Absolute disparities (rate difference): if the South had the same rate as the West, 3 cases per 100,000 population would have been prevented.
      • Relative disparities (rate ratio): the South had a rate that was 2.3 times as high as the West.

• Transmission category and race/ethnicity—highest percentages (Figure 24):
  • PWID: American Indian/Alaska Native (47%)
  • Heterosexual contact: Asian (92%)

• Region of residence and race/ethnicity—highest rates (U.S. only) (Figure 25):
  • Northeast: Black/African American (16.3)
  • Midwest: Black/African American (13.8)
  • South: Black/African American (17.2)
  • West: Black/African American (15.9)

• Prevalence and race/ethnicity (Table 16b):
  At year-end 2020 in the United States and 6 dependent areas, 248,819 females aged ≥13 years were living with diagnosed HIV infection. Prevalence by race/ethnicity was as follows:
  • American Indian/Alaska Native: <1%
  • Asian: 1%
  • Black/African American: 57%
  • Hispanic/Latino: 20%
  • Native Hawaiian/other Pacific Islander: <1%
  • White: 16%
  • Multiracial: 5%

Persons Aged 13–24 Years

Persons aged 13–24 years accounted for 20% of the 30,692 diagnoses of HIV infection in 2020 in the United States and 6 dependent areas. They are the least likely of any age group to be aware of their HIV infection, retained in care, or have a suppressed viral load. Lack of awareness of HIV status may be due to recent infection or low rates of HIV testing. Persons who do not know that they have HIV do not get medical care or receive treatment and can unknowingly infect others. In addition, persons aged 13–24 years have high rates of STDs and low rates of condom use, greatly increasing the chance of getting or transmitting HIV. Addressing HIV among persons aged 13–24 years requires that they have access to the information and tools they need to make healthy decisions, reduce their risk factors, get treatment, and stay in care.

Diagnoses of HIV infection

In 2020 in the United States and 6 dependent areas, there were 6,135 diagnoses of HIV infection among persons aged 13–24 years (Figure 26, Table 8b).

The percentage and/or rates of diagnoses of HIV infection among persons aged 13–24 years were as follows:

• Gender (Figure 26):
  • Male: 85%
  • Female: 12%
  • Transgender woman: 3%
  • Transgender man: <1%
  • AGI: <1%
• Age group (Figure 26):
  • 13–14 years: <1%
  • 15–17 years: 5%
  • 18–19 years: 16%
  • 20–21 years: 45%
  • 23–24 years: 35%
• Race/ethnicity (Figure 26):
  • American Indian/Alaska Native: 1%
  • Asian: 1%
  • Black/African American: 54%
  • Hispanic/Latino: 26%
  • Native Hawaiian/other Pacific Islander: <1%
  • White: 15%
  • Multiracial: 3%
• Region of residence (Figure 26):
  • Northeast: 12%
  • Midwest: 15%
  • South: 55%
  • West: 17%
  • U.S. dependent areas: 1%

• Sex assigned at birth and transmission category—highest percentages (Figure 27):
  • Male sex at birth: MMSC (82%)
  • Female sex at birth: heterosexual contact (10%)

• Rates (U.S. only) (Figure 28):
  • Highest: persons aged 23–24 years (24.2)
  • Lowest: persons aged 13–14 years (0.1)
    • Disparities by age group:
      • Absolute disparity (rate difference)—If persons aged 23–24 years had the same rate as persons aged 18–19 years (11.4), 13 cases per 100,000 population would have been prevented.
      • Relative disparity (rate ratio)—Persons aged 23–34 years had a rate that was 2.1 times as high as persons aged 18–19 years.
• Rates (U.S. only) (Figure 28):
  • Highest: Black/African American (46.6)
  • Lowest: Asian (3.1)
    • Disparities by race/ethnicity:
      • Absolute disparity (rate difference)—If Black/African American persons aged 13–24 years had the same rate as White persons aged 13–24 years (3.5), 43 cases per 100,000 population would have been prevented.
      • Relative disparity (rate ratio)—Black/African American persons aged 13–24 years had a rate that was 13.3 times as high as White persons aged 13–24 years.
• Rates (U.S. only) (Figure 28):
  • Highest: South (17.3)
  • Lowest: Midwest (8.3)
    • Disparities by region:
      • Absolute disparity (rate difference): if the South had the same rate as the Midwest, 9 cases per 100,000 population would have been prevented.
      • Relative disparity (rate ratio): the South had a rate that was 2.1 times as high as the Midwest.

Children Aged <13 Years

To make informed decisions about antiretroviral therapy to reduce perinatal transmission of HIV to infants, pregnant women should know their HIV infection status. In 1995, the first recommendations for HIV counseling and voluntary testing for pregnant women were published. In 2006, CDC released revised recommendations for HIV testing which specified that opt-out HIV screening should be included in the routine panel of prenatal screening tests for all pregnant women.

In 2019, 37 areas reported no perinatally acquired infections among infants born. Because of delays in the reporting of births and diagnoses of HIV infection attributed to perinatal exposure, the exclusion of data for the most recent 2 years allowed at least 24 months for data from 2019 to be reported to CDC. Data reflect all infants with diagnosed, perinatally acquired HIV infection who were born in the United States and 6 dependent areas during 2019, regardless of year of diagnosis.

Diagnoses of HIV infection

In the United States and 6 dependent areas, a total of 32 children born during 2019 received a diagnosis of HIV infection attributed to perinatal transmission (Figure 29).

Infected infants (Figure 30): From 2016 through 2019 in the United States and Puerto Rico, among the 193 children born with diagnosed, perinatally acquired HIV infection, time of maternal HIV testing was as follows:

• 45% were born to mothers who were tested before pregnancy
• 19% were born to mothers who were tested during pregnancy
• 8% to mothers tested at the time of birth
• 21% of children with diagnosed, perinatally acquired HIV infection were born to mothers who were tested after the child’s birth
• 7% were born to mothers whose time of maternal HIV testing was unknown

Exposed but not infected (Figure 30): From 2016 through 2019 in the United States and Puerto Rico, among the 11,757 children born who were exposed but not perinatally infected with HIV, time of maternal HIV testing was as follows:

• 82% were born to mothers who were tested before pregnancy
• 15% were born to mothers who were tested during pregnancy
• 1% to mothers tested at the time of birth
• 1% to mothers tested after birth
• 1% were born to mothers whose time of maternal HIV testing was unknown

Note: The number of areas contributing exposure data varied by year. Because not all jurisdictions have exposure reporting in place, the number presented is likely a minimum count of the number of exposed infants in the United States and Puerto Rico.

Diagnoses (Figure 31): In 2020, among children in the United States,

• Black/African American children made up approximately 14% of the population of children but accounted for 56% of diagnoses of HIV infection.
• Hispanic/Latino children made up 26% of the population of children but accounted for 16% of diagnoses.
• White children made up 49% of the population of children but accounted for 21% of diagnoses.

• Prevalence, children (Figure 32):
  • At year-end 2020 in the United States and 6 dependent areas, approximately 1,447 children were living with diagnosed HIV infection.
  • The overall rate of persons living with diagnosed HIV infection was 2.8.

• Prevalence and race/ethnicity, children (Table 16b):
  • American Indian/Alaska Native: <1%
  • Asian: 7%
  • Black/African American: 58%
  • Hispanic/Latino: 13%
  • Native Hawaiian/other Pacific Islander: <1%
  • White: 13%
  • Multiracial: 8%
• Prevalence, perinatally acquired HIV infection (Figure 33):
  • At year-end 2020 in the United States and 6 dependent areas, there were 12,588 persons living with diagnosed, perinatally acquired HIV infection.
  • Data reflect all persons (i.e., children, adolescents, and adults) with diagnosed, perinatally acquired HIV infection who were alive at year-end 2020, regardless of their age at year-end 2020.

• Prevalence and race/ethnicity, perinatally acquired HIV infection (Table 16b):
  • American Indian/Alaska Native: <1%
  • Asian: 1%
  • Black/African American: 57%
  • Hispanic/Latino: 24%
  • Native Hawaiian/other Pacific Islander: <1%
  • White: 11%
  • Multiracial: 7%