HIV Care Outcomes Among Blacks with Diagnosed HIV — United States, 2014

Since the release of the National HIV/AIDS Strategy (NHAS) (1) and the establishment of the federal Human Immunodeficiency Virus (HIV) Care Continuum Initiative (2), federal efforts have accelerated to improve and increase HIV testing, care, and treatment and to reduce HIV-related disparities in the United States. National HIV Surveillance System (NHSS)* data are used to monitor progress toward reaching NHAS goals,^† and recent data indicate that blacks have lower levels of care and viral suppression than do persons of other racial and ethnic groups (3). Among persons with HIV infection diagnosed through 2012 who were alive at year-end 2013, 68.1% of blacks received any HIV medical care compared with 74.4% of whites (3). CDC used NHSS data to describe HIV care outcomes among blacks who received a diagnosis of HIV. Among blacks with HIV infection diagnosed in 2014, 21.9% had infection classified as HIV stage 3 (acquired immunodeficiency syndrome [AIDS]) at the time of diagnosis compared with 22.5% of whites; 71.6% of blacks were linked to care within 1 month after diagnosis compared with 79.0% of whites. Among blacks with HIV infection diagnosed through 2012 who were alive on December 31, 2013, 53.5% were receiving continuous HIV medical care compared with 58.2% of whites; 48.5% of blacks achieved viral suppression compared with 62.0% of whites. Intensified efforts and implementation of effective interventions and public health strategies that increase engagement in care and viral suppression among blacks (1,4) are needed to achieve NHAS goals.

All states, the District of Columbia, and U.S. territories report cases of HIV infection and associated demographic and clinical information to NHSS. CDC analyzed data for persons aged ≥13 years reported through December 2015 from 33 jurisdictions^§ with complete laboratory reporting.^¶ These jurisdictions accounted for 65.3% of blacks living with diagnosed HIV infection at year-end 2013 in the United States. Stage 3 classification and linkage to care were assessed among blacks living in any of the 33 jurisdictions at the time of HIV diagnosis in 2014. A stage 3 classification was defined as having a CD4 count of <200/µL, CD4 percentage of total lymphocytes of <14, or documentation of an AIDS-defining condition ≤3 months after a diagnosis of HIV infection. Linkage to care was defined as having documentation of ≥1 CD4 count or percentage or viral load (VL) tests ≤1 month after HIV diagnosis. Retention in care and viral suppression were assessed among blacks with HIV diagnosed by December 31, 2012, and who were alive and resided (based on the most recent known address) in any of the 33 jurisdictions as of December 31, 2013 (i.e., persons living with diagnosed HIV). Retention in HIV care, defined as having two or more CD4 or VL tests ≥3 months apart, and viral suppression, defined as a VL of <200 copies/mL at most recent test, were assessed for 2013. Data were statistically adjusted by using multiple imputation techniques to account for missing HIV transmission categories (5).

In the 33 jurisdictions, 12,269 blacks received a diagnosis of HIV infection in 2014. Among these, 21.9% had infections classified as stage 3 at diagnosis (Table 1). Among males, 20.9% had a stage 3 classification, compared with 24.8% of females. The highest percentage of infections classified as stage 3 among different age groups were reported in persons aged ≥55 years (38.2%); stage 3 classifications increased with age group. By transmission category, males with infection attributed to injection drug use (IDU) had the highest percentage (32.5%) of infections classified as stage 3, followed by males with infection attributed to heterosexual contact (32.2%).

Overall, 8,780 (71.6%) of the 12,269 blacks with HIV infection diagnosed during 2014 were linked to care ≤1 month after HIV diagnosis; the percentage of persons linked to care increased with increasing age group (Table 2). Overall, 70.0% of males and 76.2% of females were linked to care. By transmission category and age group, males aged 13–24 years with infection attributed to male-to-male sexual contact and IDU accounted for the lowest percentage of persons linked to care (54.9%), followed by males aged 25–34 years with infection attributed to heterosexual contact (63.0%).

Among 257,316 blacks aged ≥13 years living with diagnosed HIV in 33 jurisdictions on December 31, 2013, approximately half (53.5%) were retained in care (Table 3), including 52.4% of males and 55.6% of females. A lower percentage of persons aged 13–34 years were retained in care (50.3%) than were persons aged ≥35 years (54.4%). By transmission category and age group, males aged 25–34 years with infection attributed to IDU accounted for the lowest percentage retained in care (38.1%), followed by males aged 13–24 years with infection attributed to heterosexual contact (39.4%). VL suppression at the most recent test was achieved by 48.5% of persons (Table 3); a higher percentage of females had suppressed VL (49.8%) than did males (47.9%). Among all age groups, the lowest level of VL suppression was among persons aged 13–24 years (39.7%); VL suppression increased with increasing age group. Females aged 13–24 years with infection attributed to IDU had the lowest level of viral suppression (29.7%), followed by males aged 13–24 years with infection attributed to heterosexual contact (31.2%).

Corresponding author: Andre F. Dailey, ADailey@cdc.gov, 404-639-5478.

¹Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC.

References

1. Office of National AIDS Policy. National HIV/AIDS strategy for the United States: updated to 2020. Washington, DC: Office of National AIDS Policy; 2015. https://www.aids.gov/federal-resources/national-hiv-aids-strategy/nhas-update.pdf
2. Office of National AIDS Policy. National HIV/AIDS strategy improving outcomes: accelerating progress along the HIV care continuum. Washington, DC: Office of National AIDS Policy; 2013. http://hivlawandpolicy.org/resources/national-hivaids-strategy-improving-outcomes-accelerating-progress-along-hiv-care
3. CDC. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas, 2014. HIV Surveillance Supplemental Report 2016; Vol. 21(No. 4). Atlanta, GA: US Department of Health and Human Services, CDC; 2016. https://www.cdc.gov/hiv/library/reports/surveillance/
4. CDC. Compendium of evidence-based interventions and best practices for HIV prevention. Atlanta, GA: US Department of Health and Human Services, CDC; 2014. https://www.cdc.gov/hiv/prevention/research/compendium/ma/index.html
5. Harrison KM, 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. PubMed
6. Hall HI, Tang T, Johnson AS, Espinoza L, Harris N, McCray E. Timing of linkage to care after HIV diagnosis and time to viral suppression. J Acquir Immune Defic Syndr 2016;72:e57–60. CrossRef PubMed
7. Whiteside YO, Cohen SM, Bradley H, Skarbinski J, Hall HI, Lansky A. Progress along the continuum of HIV care among blacks with diagnosed HIV—United States, 2010. MMWR Morb Mortal Wkly Rep 2014;63:85–9. PubMed
8. CDC. HIV prevention in the United States: expanding the impact. Atlanta, GA: US Department of Health and Human Services, CDC; 2014. https://www.cdc.gov/hiv/pdf/policies_NHPC_Booklet.pdf
9. CDC. Secretary’s minority AIDS initiative fund for the Care and Prevention in the United States (CAPUS) Demonstration Project. Atlanta, GA: US Department of Health and Human Services, CDC; 2016. https://www.cdc.gov/hiv/prevention/demonstration/capus

TABLE 1. Number and percentage of HIV infection diagnoses among blacks aged ≥13 years who were stage 3 (AIDS) at the time of diagnosis — National HIV Surveillance System, 33 jurisdictions,* United States, 2014

Abbreviations: AIDS = acquired immunodeficiency syndrome; HIV = human immunodeficiency virus.
* The 33 jurisdictions were Alabama, Alaska, California, District of Columbia, Georgia, Hawaii, Illinois, Indiana, Iowa, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Nebraska, New Hampshire, New Mexico, New York, North Dakota, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.
^† Stage of disease at diagnosis of HIV infection based on first CD4 test performed or documentation of an AIDS-defining condition ≤3 months after a diagnosis of HIV infection.
^§ Data statistically adjusted to account for missing transmission categories.
^¶ Heterosexual contact with a person known to have or to be at high risk for HIV infection.
** Includes persons with diagnosed infection attributed to hemophilia, blood transfusion, perinatal exposure, and risk factors not reported or not identified.

TABLE 2. Linkage to HIV medical care within 1 month after HIV diagnosis,* among blacks aged ≥13 years, by age group and selected characteristics — National HIV Surveillance System, 33 jurisdictions,^† United States, 2014

Abbreviation: HIV = human immunodeficiency virus.
* Data include persons with a diagnosis of HIV infection, regardless of stage of disease at diagnosis.
^† The 33 jurisdictions were Alabama, Alaska, California, District of Columbia, Georgia, Hawaii, Illinois, Indiana, Iowa, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Nebraska, New Hampshire, New Mexico, New York, North Dakota, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.
^§ One or more CD4 or viral load tests performed within 1 month after HIV diagnosis during 2014.
^¶ Data statistically adjusted to account for missing transmission categories.
** Heterosexual contact with a person known to have or to be at high risk for HIV infection.
^†† Includes persons with diagnosed infection attributed to hemophilia, blood transfusion, perinatal exposure, and risk factors not reported or not identified.

TABLE 3. Retention in HIV medical care and viral suppression among blacks aged ≥13 years with HIV infection diagnosed by December 31, 2012,* who were alive on December 31, 2013, by age group and selected characteristics — National HIV Surveillance System, 33 jurisdictions,^† United States, 2014

Abbreviation: HIV = human immunodeficiency virus.
* Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. Data are based on address of residence as of December 31, 2013 (i.e., most recent known address).
^† The 33 jurisdictions were Alabama, Alaska, California, District of Columbia, Georgia, Hawaii, Illinois, Indiana, Iowa, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Nebraska, New Hampshire, New Mexico, New York, North Dakota, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.
^§ Defined as having two or more CD4 or viral load tests performed ≥3 months apart during 2013, among persons diagnosed through December 31, 2012, and alive on December 31, 2013.
^¶ Defined as having a viral load result of ≤200 copies/mL at the most recent viral load test during 2013. The cutoff value of ≤200 copies/mL was based on the U.S. Department of Health and Human Services recommended definition of virologic failure.
** Age at year-end 2013.
^†† Data statistically adjusted to account for missing transmission categories.
^§§ Heterosexual contact with a person known to have or to be at high risk for HIV infection.
^¶¶ Includes persons with diagnosed infection attributed to hemophilia, blood transfusion, perinatal exposure, and risk factors not reported or not identified.