Vital Signs: Status of Human Immunodeficiency Virus Testing, Viral Suppression, and HIV Preexposure Prophylaxis - United States, 2013-2018

Background

Approximately 38,000 new human immunodeficiency virus (HIV) infections occur in the United States each year; these infections can be prevented. A proposed national initiative, Ending the HIV Epidemic: A Plan for America, incorporates three strategies (diagnose, treat, and prevent HIV infection) and seeks to leverage testing, treatment, and preexposure prophylaxis (PrEP) to reduce new HIV infections in the United States by at least 90% by 2030. Targets to reach this goal include that at least 95% of persons with HIV receive a diagnosis, 95% of persons with diagnosed HIV infection have a suppressed viral load, and 50% of those at increased risk for acquiring HIV are prescribed PrEP. Using surveillance, pharmacy, and other data, CDC determined the current status of these three initiative strategies.

Methods

CDC analyzed HIV surveillance data to estimate annual number of new HIV infections (2013–2017); estimate the percentage of infections that were diagnosed (2017); and determine the percentage of persons with diagnosed HIV infection with viral load suppression (2017). CDC analyzed surveillance, pharmacy, and other data to estimate PrEP coverage, reported as a percentage and calculated as the number of persons who were prescribed PrEP divided by the estimated number of persons with indications for PrEP.

Results

The number of new HIV infections remained stable from 2013 (38,500) to 2017 (37,500) (p = 0.448). In 2017, an estimated 85.8% of infections were diagnosed. Among 854,206 persons with diagnosed HIV infection in 42 jurisdictions with complete reporting of laboratory data, 62.7% had a suppressed viral load. Among an estimated 1.2 million persons with indications for use of PrEP, 18.1% had been prescribed PrEP in 2018.

Conclusion

Accelerated efforts to diagnose, treat, and prevent HIV infection are needed to achieve the U.S. goal of at least 90% reduction in the number of new HIV infections by 2030.

Vital Signs: Human Immunodeficiency Virus Testing and Diagnosis Delays - United States

Background

Persons unaware of their human immunodeficiency virus (HIV) infection account for approximately 40% of ongoing transmissions in the United States. Persons are unaware of their infection because of delayed HIV diagnoses that represent substantial missed opportunities to improve health outcomes and prevent HIV transmission.

Methods

Data from CDC’s National HIV Surveillance System were used to estimate, among persons with HIV infection diagnosed in 2015, the median interval (and range) from infection to diagnosis (diagnosis delay), based on the first CD4 test after HIV diagnosis and a CD4 depletion model indicating disease progression and, among persons living with HIV in 2015, the percentage with undiagnosed infection. Data from CDC’s National HIV Behavioral Surveillance were analyzed to determine the percentage of persons at increased risk for HIV infection who had tested in the past 12 months and who had missed opportunities for testing.

Results

An estimated 15% of persons living with HIV in 2015 were unaware of their infection. Among the 39,720 persons with HIV infection diagnosed in 2015, the estimated median diagnosis delay was 3.0 years (interquartile range = 0.7–7.8 years); diagnosis delay varied by race/ethnicity (from 2.2 years among whites to 4.2 years among Asians) and transmission category (from 2.0 years among females who inject drugs to 4.9 years among heterosexual males). Among persons interviewed through National HIV Behavioral Surveillance, 71% of men who have sex with men, 58% of persons who inject drugs, and 41% of heterosexual persons at increased risk for HIV infection reported testing in the past 12 months. In each risk group, at least two thirds of persons who did not have an HIV test had seen a health care provider in the past year.

Conclusions

Delayed HIV diagnoses continue to be substantial for some population groups and prevent early entry to care to improve health outcomes and reduce HIV transmission to others.

Implications for Public Health Practice

Health care providers and others providing HIV testing can reduce HIV-related adverse health outcomes and risk for HIV transmission by implementing routine and targeted HIV testing to decrease diagnosis delays.

Vital Signs: Trends in HIV Diagnoses, Risk Behaviors, and Prevention Among Persons Who Inject Drugs - United States

BACKGROUND

Persons who inject drugs (PWID) are at increased risk for poor health outcomes and bloodborne infections, including human immunodeficiency virus (HIV), hepatitis C virus and hepatitis B virus infections. Although substantial progress has been made in reducing HIV infections among PWID, recent changes in drug use could challenge this success.

METHODS

CDC used National HIV Surveillance System data to analyze trends in HIV diagnoses. Further, National HIV Behavioral Surveillance interviews of PWID in 22 cities were analyzed to describe risk behaviors and use of prevention services among all PWID and among PWID who first injected drugs during the 5 years before their interview (new PWID).

RESULTS

During 2008-2014, HIV diagnoses among PWID declined in urban and nonurban areas, but have leveled off in recent years. Among PWID in 22 cities, during 2005-2015, syringe sharing decreased by 34% among blacks/African Americans (blacks) and by 12% among Hispanics/Latinos (Hispanics), but remained unchanged among whites. The racial composition of new PWID changed during 2005-2015: the percentage who were black decreased from 38% to 19%, the percentage who were white increased from 38% to 54%, and the percentage who were Hispanic remained stable. Among new PWID interviewed in 2015, whites engaged in riskier injection behaviors than blacks.

CONCLUSIONS

Decreases in HIV diagnoses among PWID indicate success in HIV prevention. However, emerging behavioral and demographic trends could reverse this success.

IMPLICATIONS FOR PUBLIC HEALTH PRACTICE

Access to comprehensive prevention services is essential for all PWID. Syringe services programs reduce syringe sharing and can help PWID access prevention and treatment services for HIV and other bloodborne diseases, such as hepatitis C and hepatitis B.

Changes in inpatient psychiatric utilization and quality of care performance measures in a capitated HMO population, 1989-1999

Managed behavioral health care approaches have significantly reduced inpatient utilization and related cost of care, but the relationship between decreased utilization and cost of care to changes in quality of care performance over time remains in question. The trends in utilization and quality of care performance measures over the course of 10 years of the Tufts Health Plan Designated Facility Program, a model health maintenance organization capitated program for inpatient behavioral health care, are presented. The results indicate that substantial decreases in inpatient utilization were sustained while quality of care measures improved over time. The data support the Tufts Health Plan Designated Facility Program as a successful means of balancing cost containment with quality of care.

A program to help staff cope with psychological sequelae of assaults by patients

Mental hospital staff who are assaulted by patients are at risk of developing symptoms associated with posttraumatic stress disorder. The Assaulted Staff Action Program (ASAP), a voluntary program, offers support to staff victims of patient assaults in a state mental hospital. ASAP team members debrief assault victims, assessing the victim's sense of control, social supports, and ability to make sense of the incident. A short-term support group is offered. During the program's first 90 days, the team responded to 67 assaults. Ten days after the assaults, many of the victims had not regained a sense of control, did not have a support network, and were unable to make sense of the incident. These factors put them at risk for PTSD symptoms. The costs of such a program are discussed.