Persons Living With HIV in the United States: Fewer Than We Thought

AIDSVu Cities' Progress Toward HIV Care Continuum Goals: Cross-Sectional Study

BACKGROUND

Public health surveillance data are critical to understanding the current state of the HIV and AIDS epidemics. Surveillance data provide significant insight into patterns within and progress toward achieving targets for each of the steps in the HIV care continuum. Such targets include those outlined in the National HIV/AIDS Strategy (NHAS) goals. If these data are disseminated, they can be used to prioritize certain steps in the continuum, geographic locations, and groups of people.

OBJECTIVE

We sought to develop and report indicators of progress toward the NHAS goals for US cities and to characterize progress toward those goals with categorical metrics.

METHODS

Health departments used standardized SAS code to calculate care continuum indicators from their HIV surveillance data to ensure comparability across jurisdictions. We report 2018 descriptive statistics for continuum steps (timely diagnosis, linkage to medical care, receipt of medical care, and HIV viral load suppression) for 36 US cities and their progress toward 2020 NHAS goals as of 2018. Indicators are reported categorically as met or surpassed the goal, within 25% of attaining the goal, or further than 25% from achieving the goal.

RESULTS

Cities were closest to meeting NHAS goals for timely diagnosis compared to the goals for linkage to care, receipt of care, and viral load suppression, with all cities (n=36, 100%) within 25% of meeting the goal for timely diagnosis. Only 8% (n=3) of cities were >25% from achieving the goal for receipt of care, but 69% (n=25) of cities were >25% from achieving the goal for viral suppression.

CONCLUSIONS

Display of progress with graphical indicators enables communication of progress to stakeholders. AIDSVu analyses of HIV surveillance data facilitate cities' ability to benchmark their progress against that of other cities with similar characteristics. By identifying peer cities (eg, cities with analogous populations or similar NHAS goal concerns), the public display of indicators can promote dialogue between cities with comparable challenges and opportunities.

The Potential Impact of One-Time Routine HIV Screening on Prevention and Clinical Outcomes in the United States: A Model-Based Analysis

BACKGROUND

US guidelines recommend routine human immunodeficiency virus (HIV) screening of all adults and adolescents at least once. The population-level impact of this strategy is unclear and will vary across the country.

METHODS

We constructed a static linear model to estimate the optimal ages and incremental impact of adding 1-time routine HIV screening to risk-based, prenatal, symptom-based, and partner notification testing. Using surveillance data and published studies, we parameterized the model at the national level and for 2 settings representing subnational variability in the rates and distribution of infection: King County, WA and Philadelphia County, PA. Screening strategies were evaluated in terms of the percent of tests that result in new diagnoses (test positivity), cumulative person-years of undiagnosed infection, and the number of symptomatic HIV/acquired immune deficiency syndrome cases.

RESULTS

Depending on the frequency of risk-based screening, routine screening test positivity was maximized at ages 30 to 34 years in the national model. The optimal age for routine screening was higher in a setting with a lower proportion of cases among men who have sex with men. Across settings, routine screening resulted in incremental reductions of 3% to 8% in years of undiagnosed infection and 3% to 11% in symptomatic cases, compared with reductions of 36% to 69% and 41% to 76% attributable to risk-based screening.

CONCLUSIONS

Although routine HIV screening may contribute meaningfully to increased case detection in persons not captured by targeted testing programs in some settings, this strategy will have a limited impact on population-level outcomes. Our findings highlight the importance of a multipronged testing strategy with continued investment in risk-based screening programs.

Calculating Age-Standardized Death Rates Among People With HIV Comparable Across Jurisdictions and Over Time

The Centers for Disease Control and Prevention (CDC) and local health jurisdictions have been using HIV surveillance data to monitor mortality among people with HIV in the United States with age-standardized death rates, but the principles of age standardization have not been consistently followed, making age standardization lose its purpose-comparison over time, across jurisdictions, or by other characteristics.We review the current practices of age standardization in calculating death rates among people with HIV in the United States, discuss the principles of age standardization including those specific to the HIV population whose age distribution differs markedly from that of the US 2000 standard population, make recommendations, and report age-standardized death rates among people with HIV in New York City.When we restricted the analysis population to adults aged between 18 and 84 years in New York City, the age-standardized death rate among people with HIV decreased from 20.8 per 1000 (95% confidence interval [CI] = 19.2, 22.3) in 2013 to 17.1 per 1000 (95% CI = 15.8, 18.3) in 2017, and the age-standardized death rate among people without HIV decreased from 5.8 per 1000 in 2013 to 5.5 per 1000 in 2017.

Impact of an HIV Care Coordination Program on Durable Viral Suppression

BACKGROUND

To assess long-term effectiveness of an intensive and comprehensive Ryan White Part A-funded HIV Care Coordination Program recruiting people living with HIV with a history of suboptimal HIV care outcomes.

METHODS

We merged programmatic data on CCP clients with surveillance data on all adults diagnosed with HIV. Using propensity score matching, we identified a contemporaneous, non-CCP-exposed comparison group. Durable viral suppression (DVS) was defined as regular viral load (VL) monitoring and all VLs ≤200 copies per milliliter in months 13-36 of follow-up.

RESULTS

Ninety percent of the combined cohort (N = 12,414) had ≥1 VL ≤200 during the follow-up period (December 1, 2009-March 31, 2016), and nearly all had routine VL monitoring, but only 36.8% had DVS. Although DVS did not differ overall (relative risk: 0.99, 95% confidence interval: 0.95 to 1.03), CCP clients without any VL suppression (VLS) in the 12-month pre-enrollment showed higher DVS versus "usual care" recipients (21.3% versus 18.4%; relative risk: 1.16, 95% confidence interval: 1.04 to 1.29).

CONCLUSIONS

Enrollment in an intensive intervention modestly improved DVS among those unsuppressed before CCP enrollment. This program shows promise for meeting treatment-as-prevention goals and advancing progress along the HIV care continuum, if people without evidence of VLS are prioritized for CCP enrollment over those with recent evidence of VLS. Low overall DVS (<40%) levels underscore a need for focused adherence maintenance interventions, in a context of high treatment access.

Short-term effectiveness of HIV care coordination among persons with recent HIV diagnosis or history of poor HIV outcomes

The New York City HIV Care Coordination Program (CCP) combines multiple evidence-based strategies to support persons living with HIV (PLWH) at risk for, or with a recent history of, poor HIV outcomes. We assessed the comparative effectiveness of the CCP by merging programmatic data on CCP clients with population-based surveillance data on all New York City PLWH. A non-CCP comparison group of similar PLWH who met CCP eligibility criteria was identified using surveillance data. The CCP and non-CCP groups were matched on propensity for CCP enrollment within four baseline treatment status groups (newly diagnosed or previously diagnosed and either consistently unsuppressed, inconsistently suppressed or consistently suppressed). We compared CCP to non-CCP proportions with viral load suppression at 12-month follow-up. Among the 13,624 persons included, 15∙3% were newly diagnosed; among the 84∙7% previously diagnosed, 14∙2% were consistently suppressed, 28∙9% were inconsistently suppressed, and 41∙6% were consistently unsuppressed in the year prior to baseline. At 12-month follow-up, 59∙9% of CCP and 53∙9% of non-CCP participants had viral load suppression (Relative Risk = 1.11, 95%CI:1.08–1.14). Among those newly diagnosed and those consistently unsuppressed at baseline, the relative risk of viral load suppression in the CCP versus non-CCP participants was 1.15 (95%CI:1.09–1.23) and 1.32 (95%CI:1.23–1.42), respectively. CCP exposure shows benefits over no CCP exposure for persons newly diagnosed or consistently unsuppressed, but not for persons suppressed in the year prior to baseline. We recommend more targeted case finding for CCP enrollment and increased attention to viral load suppression maintenance.

Identifying Spatial Variation Along the HIV Care Continuum: The Role of Distance to Care on Retention and Viral Suppression

Distance to HIV care may be associated with retention in care (RIC) and viral suppression (VS). RIC (≥ 2 HIV visits or labs ≥ 90 days apart in 12 months), prescribed antiretroviral therapy (ART), VS (< 200 copies/mL at last visit) and distance to care were estimated among 3623 DC Cohort participants receiving HIV care in 13 outpatient clinics in Washington, DC in 2015. Logistic regression models and geospatial statistics were computed. RIC was 73%; 97% were on ART, among whom 77% had VS. ZIP code-level clusters of low RIC and high VS were found in Northwest DC, and low VS in Southeast DC. Those traveling ≥ 5 miles had 30% lower RIC (adjusted odds ratio (aOR) 0.71, 95% CI 0.58, 0.86) and lower VS (OR 0.70, 95% CI 0.52, 0.94). Geospatial clustering of RIC and VS was observed, and distance may be a barrier to optimal HIV care outcomes.

Emerging Regional and Racial Disparities in the Lifetime Risk of Human Immunodeficiency Virus Infection Among Men who Have Sex With Men: A Comparative Life Table Analysis in King County, WA and Mississippi

BACKGROUND

Little is known about the lifetime risk of human immunodeficiency virus (HIV) diagnosis among US men who have sex with men (MSM), trends in risk and how risk varies between populations.

METHODS

We used census and HIV surveillance data to construct life tables to estimate the cumulative risk of HIV diagnosis among cohorts of MSM born 1940 to 1994 in King County, Washington (KC) and Mississippi (MS).

RESULTS

The cumulative risk of HIV diagnosis progressed in 3 phases. In phase 1, risk increased among MSM in successive cohorts born 1940 to 1964. Among men born 1955 to 1965 (the peak risk cohort), by age 55 years, 45% of white KC MSM, 65% of black KC MSM, 22% of white MS MSM, and 51% of black MS MSM had been diagnosed with HIV. In phase 2, men born 1965 to 1984, risk of diagnosis among KC MSM declined almost 60% relative to the peak risk cohort. A similar pattern of decline occurred in white MS MSM, with a somewhat smaller decline observed in black MS MSM. In phase 3, men born 1985 to 1994, the pattern of risk diverged. Among white KC MSM, black KC MSM, and white MS MSM, HIV risk increased slightly compared with men born 1975 to 1984, with 6%, 14%, and 2% diagnosed by age 27 years, respectively. Among black MS MSM born 1985 to 1994, HIV risk rose dramatically, with 35% HIV diagnosed by age 27 years.

CONCLUSIONS

The lifetime risk of HIV diagnosis has substantially declined among MSM in KC and among white MSM in MS, but is rising dramatically among black MSM in MS.

Integrating HIV Surveillance and Field Services: Data Quality and Care Continuum in King County, Washington, 2010-2015

OBJECTIVES

To assess how integration of HIV surveillance and field services might influence surveillance data and linkage to care metrics.

METHODS

We used HIV surveillance and field services data from King County, Washington, to assess potential impact of misclassification of prior diagnoses on numbers of new diagnoses. The relationship between partner services and linkage to care was evaluated with multivariable log-binomial regression models.

RESULTS

Of the 2842 people who entered the King County HIV Surveillance System in 2010 to 2015, 52% were newly diagnosed, 41% had a confirmed prior diagnosis in another state, and 7% had an unconfirmed prior diagnosis. Twelve percent of those classified as newly diagnosed for purposes of national HIV surveillance self-reported a prior HIV diagnosis that was unconfirmed. Partner services recipients were more likely than nonrecipients to link to care within 30 days (adjusted risk ratio [RR] = 1.10; 95% confidence interval [CI] = 1.03, 1.18) and 90 days (adjusted RR = 1.07; 95% CI = 1.01, 1.14) of diagnosis.

CONCLUSIONS

Integration of HIV surveillance, partner services, and care linkage efforts may improve the accuracy of HIV surveillance data and facilitate timely linkage to care.

Use of national standards to monitor HIV care and treatment in a high prevalence city-Washington, DC

We sought to benchmark the quality of HIV care being received by persons living with HIV in care in Washington, DC and identify individual-level and structural-level differences. Data from the DC Cohort, an observational HIV cohort of persons receiving outpatient care in DC, were used to estimate the Institute of Medicine (IOM) and Department of Health and Human Services (HHS) quality of care measures. Differences in care by demographics and clinic type were assessed using χ2 tests and multivariable regression models. Among 8,047 participants, by HHS standards, 69% of participants were retained in care (RIC), 95% were prescribed antiretroviral therapy (ART), and 84% were virally suppressed (VS). By IOM standards, 84% were in continuous care; and 78% and 80% underwent regular CD4 and VL monitoring, respectively. Screening for syphilis, chlamydia, and gonorrhea was 51%, 31%, and 26%, respectively. Older participants were 1.5 times more likely to be RIC compared to younger participants (OR: 1.5; 95% CI: 1.3, 1.8). Participants enrolled in community-based clinics were more likely to be RIC (OR: 1.7; 95% CI: 1.4, 2.0) versus those enrolled at hospital-based clinics. Older participants were more likely to achieve VS than younger participants (OR: 1.8; 95% CI: 1.5, 2.2) while Black participants were less likely compared to white participants (OR: 0.4; 95% CI: 0.3, 0.5). Despite high measures of quality of care, disparities remain. Continued monitoring of the quality of HIV care and treatment can inform the development of public health programs and interventions to optimize care delivery.

Continuum of Care Among People Living with Perinatally Acquired HIV Infection in New York City, 2014

OBJECTIVE

The HIV care continuum outlines the steps from HIV infection to diagnosis, linkage to care, and viral suppression among people living with HIV. We examined data for steps along the HIV care continuum among people living with perinatally acquired infection in New York City using surveillance data.

METHODS

This study included data for people who acquired HIV infection perinatally and lived in New York City as of December 31, 2014. We defined "in care" as having ≥1 CD4 or viral load test in 2014, "in continuous care" as having ≥2 CD4 or viral load tests ≥3 months apart in 2014, and "virally suppressed" as having a viral load of #200 copies per milliliter in the most recent test in 2014. We estimated factors associated with viral suppression from a weighted log-binomial regression model that included sex, race/ethnicity, age, and country of birth as independent variables.

RESULTS

As of December 31, 2014, an estimated 1,596 people were living with perinatally acquired HIV infection in New York City. All were diagnosed, 96% were in care, 80% were in continuous care, and 61% were virally suppressed. The multivariable analysis showed significant differences in viral suppression by race/ethnicity and age. Black patients (59%, 534/907) were the least likely of all racial/ethnic groups examined to have a suppressed viral load. By age, compared with 73% (80/109) of children aged 0-12 years who were virally suppressed, 58% (568/987) of adults aged 20-29 years and 56% (54/96) of adults aged 30-39 years were virally suppressed; the adjusted prevalence ratio was 0.80 (95% confidence interval [CI] 0.69, 0.92) for those aged 20-29 years and 0.79 (95% CI 0.63, 0.99) for those aged 30-39 years.

CONCLUSION

The low level of viral suppression among people living with perinatally acquired infection found in this study warrants further exploration to identify the best management strategies to improve viral suppression in this population, especially those transitioning from pediatric to adult health care.

Estimated HIV Incidence in the United States, 2003-2010

OBJECTIVE

To estimate HIV incidence in the United States using a newly developed method.

METHODS

The analysis period (2002-2011) was broken down into 3-year periods with overlaps, and HIV incidence was estimated based on the relationship between number of new diagnoses and HIV incidence in each of these 3-year periods, by assuming that all HIV infections would eventually be diagnosed and within each 3-year period HIV incidence and case finding were stable.

RESULTS

The estimated HIV incidence in the United States decreased from 52,721 (range: 47,449-57,993) in 2003 to 39,651 (range: 35,686-43,617) in 2010, among males from 38,164 (range: 35,051-42,840) to 33,035 (range: 29,088-35,553), and among females from 13,557 (range: 12,133-14,830) to 6616 (range: 5825 to 7120).

CONCLUSIONS

Using a simple and novel method based on the number of new HIV diagnoses, we were able to estimate HIV incidence and report a declining trend in HIV incidence in the United States since 2003.

A Novel Modeling Approach for Estimating Patterns of Migration into and out of San Francisco by HIV Status and Race among Men Who Have Sex with Men

In the early 1980s, men who have sex with men (MSM) in San Francisco were one of the first populations to be affected by the human immunodeficiency virus (HIV) epidemic, and they continue to bear a heavy HIV burden. Once a rapidly fatal disease, survival with HIV improved drastically following the introduction of combination antiretroviral therapy in 1996. As a result, the ability of HIV-positive persons to move into and out of San Francisco has increased due to lengthened survival. Although there is a high level of migration among the general US population and among HIV-positive persons in San Francisco, in- and out-migration patterns of MSM in San Francisco have, to our knowledge, never been described. Understanding migration patterns by HIV serostatus is crucial in determining how migration could influence both HIV transmission dynamics and estimates of the HIV prevalence and incidence. In this article, we describe methods, results, and implications of a novel approach for indirect estimation of in- and out-migration patterns, and consequently population size, of MSM by HIV serostatus and race in San Francisco. The results suggest that the overall MSM population and all the MSM subpopulations studied decreased in size from 2006 to 2014. Further, there were differences in migration patterns by race and by HIV serostatus. The modeling methods outlined can be applied by others to determine how migration patterns contribute to HIV-positive population size and output from these models can be used in a transmission model to better understand how migration can impact HIV transmission.

"Out of Care" HIV Case Investigations: A Collaborative Analysis Across 6 States in the Northwest US

BACKGROUND

HIV care continuum estimates derived from laboratory surveillance typically assume that persons without recently reported CD4 count or viral load results are out of care.

METHODS

We conducted a multistate project (Alaska, Idaho, Montana, Oregon, Washington, and Wyoming) to ascertain the status of HIV cases that appeared to be out of care during a 12-month period. We used laboratory surveillance to identify cases in all states but Idaho, where viral load reporting is not mandatory, requiring us to rely on clinic records. After complete investigation, we assigned each case one of the following dispositions: moved out of state, died, in HIV care, no evidence of HIV care, or data error.

RESULTS

We identified 3866 cases with no CD4 count or viral load result in a ≥12-month period during 2012-2014, most (85%) of which were in Washington or Oregon. A median of 43% (range: 20%-67%) of cases investigated in each state had moved, 9% (0%-16%) had died, and 11% (8%-33%) were in care during the 12-month surveillance period. Only 28% of investigated cases in the region and a median of 30% (10%-57%) of investigated cases in each state had no evidence of care, migration, or death after investigation.

CONCLUSIONS

Most persons living with HIV in the Northwest United States who appear to be out of care based on laboratory surveillance are not truly out of care. Our findings highlight the importance of improving state surveillance systems to ensure accurate care continuum estimates and guide Data to Care efforts.

Data quality shortcomings with the US HIV/AIDS surveillance system

This study investigates some of the data quality challenges facing the HIV surveillance system in the United States. Using the content analysis method, Center for Disease Control annual HIV surveillance reports (1982-2014) are systematically reviewed and evaluated against relevant data quality metrics from previous literature. Center for Disease Control HIV surveillance system has made several key achievements in the last decade. However, there are several outstanding challenges that need to be addressed. The data are unrepresentative, incomplete, inaccurate, and lacks the required granularity limiting its usage. These shortcomings weaken the country's ability to track, report, and respond to the new HIV epidemiological trends. Furthermore, the problems deter the country from properly identifying and targeting the key subpopulations that need the highest resources by virtue of being at the highest risk of HIV infection. Several recommendations are suggested to address these issues.

Racial and socioeconomic disparities in viral suppression among persons living with HIV in New York City

PURPOSE

To examine differences in racial disparities across levels of neighborhood poverty and differences in socioeconomic disparities by race/ethnicity in viral suppression among persons living with HIV (PLWH).

METHODS

Using HIV surveillance data, we categorized and geocoded PLWH who were in care in New York City (NYC). Multilevel binomial regression techniques were used to model viral suppression with a two-level hierarchical structure, by including age, transmission risk, year of diagnosis, race/ethnicity, census tract poverty, and an interaction term of race/ethnicity and census tract poverty in the model.

RESULTS

There were 30,638 Blacks, 22,921 Hispanics, and 11,695 Whites living with HIV and retained in care in NYC, 2014. Compared with Blacks living in the most impoverished neighborhoods (≥30% residents living below the federal poverty level) who had the lowest proportion of viral suppression, with 75% in males and 76% in females, Whites living in the least impoverished neighborhoods (<10% residents living below the federal poverty level) had the highest, with 92% in males (prevalence ratio = 1.16; 95% confidence interval: 1.13, 1.18) and 90% in females (PR = 1.14; 95% CI: 1.09, 1.19).

CONCLUSIONS

By examining racial and socioeconomic disparities simultaneously, we were able to detect both disparities in viral suppression among PLWH in NYC.

Projected demographic composition of the United States population of people living with diagnosed HIV

The transformation of HIV from a fatal disease to lifelong disease has resulted in an HIV-infected population that is growing and aging, placing new and increasing demands on public programs and health services. We used National HIV Surveillance System and US census data to project the demographic composition of the population of people living with diagnosed HIV (PLWDH) in the United States through 2045. The input parameters for the projections include: (1) census projections, (2) number of people with an existing HIV diagnosis in 2013, (3) number of new HIV diagnoses in 2013, and (4) death rate within the PLWDH population in 2013. Sex-, risk group-, and race-specific projections were estimated through an adapted Leslie Matrix Model for age-structured populations. Projections for 2013-2045 suggest that the number of PLWDH in the U.S. will consistently grow, from 917,294 to 1,232,054, though the annual growth rate will slow from 1.8% to 0.8%. The number of PLWDH aged 55 years and older will increase from 232,113 to 470,221. The number of non-Hispanic (NH) African Americans/Blacks and Hispanics is projected to consistently grow, shifting the racial/ethnic composition of the US PLWDH population from 32 to 23% NH-White, 42 to 38% NH-Black, and 20-32% Hispanic between 2013 and 2045. Given current trends, the composition of the PLWDH population is projected to change considerably. Public health practitioners should anticipate large shifts in the age and racial/ethnic structure of the PLWDH population in the United States.

The Lorenz curve: a novel method for understanding viral load distribution at the population level

Existing HIV care cascade metrics fail to capture whether viremia is equally distributed in a population or concentrated within groups. We applied the Lorenz curve, which has been used to describe disparities in the distribution of income and other resources, to the distribution of viremia in a safety-net HIV clinic in 2012. Among 1855 established clinic patients, 1% of the population held 50% of the virus and 10% of the population held 94% of virus.

Conceptualizing Care Continua: Lessons from HIV, Hepatitis C Virus, Tuberculosis and Implications for the Development of Improved Care and Prevention Continua

Background

To examine the application of continuum models to tuberculosis, HIV, and other conditions; to theorize the concept of continua; and to learn lessons that could inform the development of improved care and prevention continua as public health metrics.

Methods

An analytic review of literature drawn from several fields of health care.

Results

The continuum construct is now part of public health evaluation systems for HIV, and is increasingly used in public health and the medical literature. Issues with the comparability and optimal design of care continuum models have been raised, and their methodologic and theoretic underpinnings and scope of focus have been under-addressed. Review of relevant publications suggests that a key limitation of current models is their lack of measures reflecting incidence and mortality. Issues relating to continua data being longitudinal or cross-sectional, definition of numerators and denominators for each step, data sources, measures of timeliness of step completion, theoretic models to facilitate inferences of causes of care continuum gaps, how measures of prevention efforts, reinfection/relapses, and interactions of continua for co-occurring comorbidities should be reflected, and how analyses of differences in retention over time, across geographic regions, and in response to interventions should be conducted are critical to the development of sound care and prevention continuum models.

Conclusion

Lessons learned from the application of continuum models to HIV and other conditions suggest that the application of well-formulated constructs of care and prevention continua, that depict, in well defined, standardized steps, incidence and mortality, along with degrees of and time to screening, engagement in care and prevention, treatment and treatment outcomes, including relapse or reinfection, may be vital tools in evaluating intervention and program outcomes, and in improving population health and population health metrics for a wide range conditions.