Public Health Response to Clusters of Rapid HIV Transmission Among Hispanic or Latino Gay, Bisexual, and Other Men Who Have Sex with Men — Metropolitan Atlanta, Georgia, 2021–2022

Investigation and Results

In February 2021, GDPH identified three HIV clusters among Hispanic MSM using molecular analysis of HIV-1 nucleotide sequence data collected through routine surveillance (1). In Georgia, clusters are inferred using a genetic distance threshold of 0.005 nucleotide substitutions per site among persons with HIV infection diagnosed during the most recent 3 years, with priority clusters defined as those that include four or more diagnoses during the most recent 12 months. This definition is consistent with evidence of rapid HIV transmission (1,3). These were the first priority clusters in Georgia comprising ≥40% Hispanic persons. GDPH analysis of HIV surveillance data demonstrated that during 2014–2019, HIV diagnoses among Hispanic adolescents and adults in four metropolitan Atlanta counties increased from 38.9 to 47.1 per 100,000 persons.

After demonstration of persistent growth of the clusters through early 2021, GDPH reviewed partner services interview data and attempted direct outreach to all persons in clusters, including those previously interviewed. However, response was limited, partly attributed to immigration- and deportation-related concerns and limited numbers of bilingual staff members.

In October 2021, CDC began providing remote assistance in analyzing epidemiologic data for investigation activities, and GDPH initiated review of medical charts of persons in clusters. Among 38 persons with available charts, 10 (26%) were primarily Spanish-speaking, and 12 (32%) were from Latin American countries; five (13%) had mental health diagnoses, including depression, anxiety, or bipolar disorder.

In February 2022, GDPH requested CDC assistance in conducting a qualitative assessment with Hispanic MSM community members and service providers to identify barriers to accessing medical and social services and HIV care, as well as simplifying cluster data synthesis and visualization. CDC provided support during March–July 2022. This activity was reviewed by CDC and conducted consistent with applicable federal law and CDC policy.^§

By June 30, 2022, GDPH detected two additional clusters that included ≥40% Hispanic persons, with additional persons identified among all clusters throughout the investigation period (Figure). The five clusters included 75 persons with HIV, with clusters ranging in size from four to 45 persons. The median age of persons in clusters was 29 years (range = 16–54 years), 56% identified as Hispanic, 96% were assigned male sex at birth, and 81% reported male-to-male sexual contact (Table). Overall, 84% of persons lived in one of the four metropolitan Atlanta counties. Forty percent of diagnoses were from facilities with infectious disease providers who specialize in HIV care, 27% in primary or urgent care settings, 13% in inpatient or emergency department settings, and 11% at health departments. Eighty-five percent of persons in these clusters were virally suppressed^¶; however, new diagnoses continued to be identified throughout the investigation (Figure).

By June 30, 2022, among 52 persons in clusters eligible for partner services interviews,** 34 (65%) were interviewed, 16 (31%) could not be reached, and two (4%) declined. Among those interviewed, 20 (59%) reported meeting partners online, and four (12%) reported ever having taken HIV preexposure prophylaxis (PrEP).

CDC and health department staff members conducted qualitative interviews with 28 Hispanic MSM and one transgender woman in the four counties and 28 individual or group interviews with 65 medical and social service providers who treated persons in clusters or served Hispanic MSM. Community members were recruited by provider referral, social media, and at bars and clubs. Because multiple attempts had already been made to reach persons in clusters for partner services interviews, further attempts to conduct qualitative interviews were not made for persons in clusters.

Interviewed participants identified barriers to accessing medical and social services, including few Spanish-speaking staff members, limited Spanish language materials, and fear of deportation and other immigration-related concerns. Participants also reported barriers to accessing HIV prevention and care, including stigma toward MSM and persons with HIV because of sexuality-related cultural norms, low levels of awareness about HIV and other sexually transmitted infections because of limited primary care access, limited provision of HIV services in primary and urgent care settings, and limited Hispanic MSM-focused community outreach and marketing.

Public Health Response

Response activities have included establishing routine coordination meetings between GDPH and metropolitan Atlanta health districts and presenting reports on the investigation to HIV community advisory boards and planning councils. Health districts disseminated Spanish-language HIV prevention materials emphasizing service availability irrespective of immigration status via social media and at venues in zip codes where persons in clusters reside. GDPH established new partnerships with community-based organizations (CBOs) serving Hispanic communities and developed strategies to increase the number of bilingual staff members, including modifying job postings to prioritize hiring bilingual personnel. Health departments and CBOs partnered with academic institutions to engage in implementation science research and obtained federal funding for a culturally concordant outreach and patient navigation program for status-neutral sexual health services. A status-neutral approach provides persons with and without HIV access to comprehensive medical services, including HIV prevention and treatment, and social services depending on their needs.^†† In addition, in June 2022, the local health districts launched an at-home HIV and sexually transmitted infection self-testing program.^§§ GDPH is continuing to partner with CDC to implement informatics tools to simplify cluster investigations.

Discussion

The detection of multiple HIV clusters among Hispanic MSM in metropolitan Atlanta provided evidence of rapid, ongoing HIV transmission and resulted in a multifaceted response involving health departments, CDC, health care providers, and CBOs. The response identified barriers to accessing HIV services among Hispanic MSM in metropolitan Atlanta. Although most persons in clusters had evidence of viral suppression, which prevents sexual HIV transmission, as of June 30, 2022, the clusters were still expanding. This finding indicates potential ongoing transmission among a larger network, which could include persons with undiagnosed HIV infection.

This investigation highlighted the value of molecular HIV cluster detection and response for identifying gaps in services among networks of MSM. Although most large HIV outbreak responses in the United States have focused on persons who inject drugs, male-to-male sexual contact is the primary mode of HIV transmission in most molecular clusters (4,5). This investigation demonstrated that cluster detection and response can detect rapid HIV transmission and identify population-level gaps in systems involving MSM.

Barriers to accessing HIV services among Hispanic MSM in this investigation included language barriers and immigration- and deportation-related concerns; stigma toward MSM and persons with HIV, often tied to sexuality-related cultural norms; and lack of HIV prevention services in primary and urgent care settings. These findings align with studies identifying access to HIV prevention and care services, language, traditional notions of masculinity, and medical mistrust as barriers to HIV prevention among Hispanic MSM (6,7). When HIV clusters are detected, it is important to gather data to identify gaps in HIV services so that response efforts can strengthen services for affected populations. Although gaps might already be known, collaborative response efforts can clarify the most important gaps and catalyze new efforts to overcome them such as those described in this response.

The findings in this report are subject to at least three limitations. First, qualitative interviews were conducted among Hispanic MSM community members; thus, findings might not directly reflect the experience of persons in the clusters. Second, because HIV testing and diagnoses substantially declined during the COVID-19 pandemic, cluster size might be underestimated (8). Finally, because surveillance and chart review data were incomplete, the proportion of persons in clusters born outside the United States or who were Spanish-speaking might also be underestimated.

This investigation highlights important barriers to and inequalities in HIV prevention services experienced by Hispanic MSM in Georgia because of issues related to language, immigration- and deportation-concerns, and sexuality-related cultural norms. HIV molecular cluster detection has the capability to identify rapid HIV transmission in a new demographic group and advance health equity through expanded and tailored resources for HIV prevention and care.